Exercises for Postural Instability and Gait Disorders in Parkinson's disease

Help for Balance,Tight Muscles and Sore Joints of PD

The success of exercise comes from the willingness of the person with Parkinson's (PwP) to help himself or herself. Going through the motions but not applying yourself will not produce enough positive results.

One of the early symptoms Steve developed many months before his diagnosis was Postural Instability. It is frightening not to know where your vertical or center is. We take this marvel for granted and don't realize its importance until it's gone. For those who have suffered from dizziness or vertigo, you know.

If possible, get other friends or family members to lead you or your person with PD in exercises to vary the routine. I do not make the best exercise leader for my husband because I want him to push and that feels like work to him. I am too emotionally invested and therefore have a higher frustration level; I don't always have the patience he requires. My sister is a great exercise leader because she is patient as she moves from step to step.

In the past Steve didn't do more than go through the motions especially after his Exercise Therapist told him that he didn't need to push through. Steve loved the idea; I hated it! Great therapist but for that bad idea - you do need to give exercise your all once you have learned the motions. Like dancing. And I propose rhythmic music to make your routine feel less like a regimen and more like a dance.

I do posture exercises regularly but I don't plan them. I sneak them in before I get out of bed or when I'm sitting at the computer or about to stand and cook. Mongo and Blakey stretch all the time - they know intuitively how important it is to jump successfully to all of those forbidden places.



             Chair exercises should begin with back stretching followed by body twisting.

             Back stretches help to strengthen those muscles responsible for posture

             as well as reducing stiffness and promoting flexibility (range of motion)

             And it wouldn't hurt to stretch your arms as well as your hands and fingers.

   

                                  Back Stretch:

1. Raise arms to shoulder height in front of you
2. Bend the elbows and bring palms together in front of face with fingers pointing towards ceiling - press hands first gently together and breathe through the nose - in slowly, then hold, then out.
3. Press hands firmly together while sitting up as straight as possible - you will feel this in the arms and the front of the chest and abdominal areas
4. Next open arms wide - moving them apart with fingers now pointing at the walls - feel the stretch across the chest and shoulders - even in the wrists
5. Now comes the tricky part - the idea is that with arms stretched in an open position, they push backwards so that the shoulder blades are pushed together as closely as possible. The stretch will be felt in the shoulders, the shoulder blades and the neck and even the chin.
6. Repeat this exercise 10 times and relax

                                                       Twist the Body for Balance

1. Sit up in the chair - do not lean back - arms straight down, palms towards your body
2. Still sitting as erect as possible, slowly bring arms up to shoulder level forming a cross – fingers separated. You should already feel a pull in the shoulder area.
3. Now bend your arms and bring your hands to your shoulders - it may only be possible to have finger-tip contact
4. Now slowly turn/twist the upper torso to the right, let your head follow the motion as you try to look over your right shoulder
5. Slowly return to face forward - hands still at shoulders
6. Next slowly turn the body from the waist to the left, again let the head follow to look over the left shoulder.
7. Slowly return to a forward position - check posture: are you still sitting tall ?
8. Stretch arms out - keeping them parallel with the shoulders and rotate arms in a small circle with the movement coming from the shoulders.
9. Slowly breathe in and out through your nose and
10. Repeat this exercise 9 more times

Note: I had hoped to have photos of Steve doing these exercises. Unfortunately he is not willing to pose for photos at this time. I will add them later.

Marching in Place whether sitting or standing is an excellent exercise for freezing, balance, walking. You can march in place while holding on to the back of a chair or even your walker as long as the brakes are on or the walker is braced against immovable furniture. It is easier to get going from a march gait than a walk. You can march while at your desk or as a passenger in a car - don't try it while you are driving, however.

The back is as straight as possible in a march. Just play a Sousa march and you'll feel yourself sitting taller. The movement doesn't come as much from the spine, shoulders and hips as a walk but rather from the knee to the hips. Feet land squarely on the floor. It is easier than a walk in some ways. So march away.

For more exercises and to read about Forced Exercise to relieve PD symptoms:

Chair Exercises

More Shoulder Exercises

Forced Exercise and other links for Dr Alberts' work

March Music you can choose your own at You Tube. Clicking on the link will open your sound track in a new window. Yes, Sousa marches are fast.. As a child, my Grandfather played many of them on the piano but slower and they work well that way.

But pop over to the Regimental Marches of the Foot Guards for slow marches and work your way up to Sousa.

Postural Instability and Gait Disturbances in Parkinson's Disease

PIGD not helped by current PD medications but there is hope for treatments

Steve had several PD precursor symptoms for years. Some motor symptoms appeared early but did not interfere with lifestyle. Postural Instability appeared about a year prior to his diagnosis.  The appearance was subtle. He would climb a ladder to perform some honeydo chore and come back down saying that he felt uncomfortable, unsteady, not right about being on a ladder. And this was inside the house. He felt that the sensation was real - as his wife I had some doubts. He was right; I wish he'd been wrong. He was exhibiting one of the Big 4 Parkinson's symptoms.

What is Postural Instability? To my eyes it is the failure to be able to identify the vertical but really it is much more. It occurs when reflexes are unable to adjust or compensate for sway, vertical, horizontal and diagonal and environmental changes. Gait Disturbances such as freezing or the loss of the natural rhythms which initiate and maintain gait, the rhythm aids in turning and in stride length are interrupted or short circuited.

An easy way to identify how a PwP might sense the problem is to visualize a set of steps which do not  conform to the normal rise and/or tread depth. Imagine (feel) walking up or down the stairs where the next step you take is not the same height difference as the previous step so that the spacing rhythm is disrupted. Perhaps one riser is the code max of 7.75" while another is 8" or 8.5". You automatically reach for the next step and it isn't where it is supposed to be. I've seen it when an amateur cuts a step stringer and it can kill you. Your body has a natural rhythm when descending or ascending a flight of stairs. You can simulate this by placing a magazine on one step, two on the next, none after that. You'll feel very disconcerted and off balance. You grab for the handrail. What should come naturally doesn't. That's just a part of Postural Instability and Gait Disturbance.  

We recently received an email asking for information about a procedure known as ExAblate®. The writer wanted to know if there was hope for Parkinson's patients with Postural Instability after she had seen the Diane Sawyer segment on ABC World News in which a ET patient of  Dr William Jeff Elias discussed her Essential Tremor life before and after this unique targeted laser procedure. Although there may be a genetic link between some cases of ET and some cases of PD, the targeting will be different.

ExAblate® is a procedure done using Magnetic Resonance guided Focused Ultrasound *MRgFUS) technology developed by a Swiss company, InSightec. Although there is a study underway for Parkinson's patients, it will only take place at the Center of Ultrasound Functional Neurosurgery in Solothurn, Switzerland.  The studies being conducted by Dr William Jeff Elias in the US are directed to Essential Tremor as the specific brain targets have been identified. 

The Parkinson's study by Insightec is geared towards long-term chronic, therapy-resistant movement disorders. Perhaps there will be some surprise results as Postural Instability (PI) or Postural Instability and Gait Disturbances (PIGD) are inadvertently addressed as well. We can only hope.

There is some research in progress. In 2009 the Michael J Fox Foundation awarded five research grants totaling $2 million for research addressing Postural Instability and Gait Disorders. 

Over the last few years there has been research into a part of the brain stem known as the pedunculoponitine nucleus (PPN) which is a bi-lateral target for stimulation to address gait freezing. We plan to write more about it. The PPN processes sensory and behavioral data, is related to arousal, attention. learning, locomotion rewards and voluntary limb movement. While the PPN gets input from several areas of the brain, it sends but does not receive information from the substantia nigra pars compacta. Autposies of PD brains show degeneration of the pedunculopontine nucleus. Researchers identifed the PPN as a target for Deep Brain Stimulation and the first PPN DBS surgeries have shown promise. The point is that the PPN seems to be very significant in Parkinson's disease. 

 While there don't seem to be medications which work effectively to address Postural Instability, there are some exercises which might help if done on a regular basis. We covered marching in place as a chair exercise a few years ago. Shoulder exercises are important for posture and range of motion. This week we'll post two more excellent exercises.

Additional reading - just click the links while holding the shift key:

Michael J Fox Foundation grant awards 

Pedunculopontine nucleous stimulation for gait freezing in Parkinson's disease

Cerebral blood flow changes induced by pedunculopontine nucleus stimulation in patients with advanced PD

PPN as a target for DBS 

Topical organization of the pedunculopontine nucleus by Christina Martiniz-Gonzalez, J Paul Bolan and Juan Mena-Segovia from the Medical Research Council Anatomical Neuropharmacology Unit, Dept of Pharmaacology, University of Oxford, Oxford, UK 

If It's Not Parkinson's, It's Something Else

PD, Arthritis and Ligaments - Will Yoga Help?

Well over a year ago I started Aqua and Dry Land physical therapy after being diagnosed with Osteoarthritis to accompany my Parkinson's disease.  I'm now the patient of a different doctor and he thinks it's not the arthritis but rather the ligaments which are causing the knee problems. I'm going in soon for Xrays which will hopefully give him enough information to make a new diagnosis.  This could mean the difference between knee replacement or arthroscopic surgery.  Since he also wants an MRI, to which I am averse (spelled claustrophobic), I have been motivated to research ligament issues and to find ways to improve their strength.

As it happens, a few weeks ago I signed up for a series of Yoga classes which started yesterday at the physical therapy center where I am a member. The classes will run through the winter.  So far it is just me and many women being led by a therapist from the execise center.  The other men don't know what they're missing.

This is just what I need to strengthen the muscles around my knees and possibly avoid either of the operations I mentioned. The Wellness Center is part of a Senior Center. Because they were tight for space on our first class day, we were assigned the room used for the sanctuary.which is a beautiful spiritual space in which to learn yoga.

To accommodate the predominatly elderly demographic, the yoga poses that we were taught were performed on mats on the floor or sitting in chairs depending on individual flexibility and ability to move down to the floor and back.

I was a chair person but by the time the class was over I was starting to feel less rigid. I usually limit my walking because if I walk too far my knee becomes painful or sometimes just gives out.  Inspired by the class, I walked all the way from the synagogue building beck to the aquatic center through about a quarter mile of walkways.  It was certainly easier because the surface was level and not slippery. But mainly I think that I was less tense - more relaxed...confident.

Another important issue is the possibility that there may be some relief of this pain in my future.  It is often important to have another medical opinion.

       ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

FYI: November is National Caregiver month and the Parkinson's Disease Foundation (PDF) will be providing tips and resources for care partners and family members on Tuesday, November 17th at 1:00 pm ET.  You can watch online of call the toll-free number to listen in.  The phone number will be provided after registration.  You can get more information at PDF.

According to the The National Health Calendar of Observances:

November 2009 observes:

*   American Diabetes Month
*   Diabetic Eye Disease Month
*   National adoption Month
*   National Family Caregivers Month
*   National Hospice Palliative Care Month
*   Pulmonary Hypertension Awareness Month
*   World COPD Day - November 18th
*   National Suicide Survivors of Suicide Day - November 21st         

The 2010 Health Observances Calendar sans an April mention of Parkinson's disease.

Fly with Me

More Chair Exercises for Parkinson's Disease

Shoulder Exercise - Trapezius Stretch
Sitting upright - head up - eyes forward - hands at rest in your lap or on your knees
Raise your ribcage so that you free up your diaphragm for breathing
Slowly raise your arms in front of you and to a full upright position over your head
Arms as close to your ears as possible
Try to grasp your thumbs to help with the stretch.

Depending upon the chair armed or armless - pick one
Armed: bring your arms down slowly in front of you and return your hands to your knees, thighs or lap
Armless: Move your arms to the side-parallel to the floor, bring your arms down and slowly return them to the starting position.

Repeat your stretch 4 more times.
Make sure that your can breathe by raising-opening the rib cage as you sit in an upright position

Flap Your Wings
Sitting upright - head up - looking ahead
Make fists and turn them thumbs to the sky
Bend your arms - and anchor your hands at the front of your rib cage - thumbs up
Flap your arms from the elbows.
Moving your arms back is more important than front move for this flap.
Can you feel the stretch?
Repeat a few times

Bodybuilders Posture without the shoulder drop or body twist

Same position - same fists at ribcage
Elbows lead - wrists may follow the arms forward
Resist the impulse to bend into the movement - try to remain erect.
Repeat 4 times to feel the shoulder (trapezius) stretch and the stretch of the triceps.

We will continue to add other chair exercises as they are developed.
Please feel free to contact us if you have questions or comments.

Concerning the weaker side of the body:
We have found that often during these exercises it is necessary for the assistant/the reader to hold the strong side so that the weaker side can exercise. Sometimes it is necessary to guide the weaker side once as an example. Do not be upset if there is additional tremor. That is not surprising because these motions can be intense for stiff muscles.

Previously posted chair exercises:
http://parkinsonsfocustoday.blogspot.com/2009/02/shakin-all-over.html
http://parkinsonsfocustoday.blogspot.com/2009/02/arm-swing-exercise-for-parkinsons.html

Let's Do the Parkinson's Swing

Arm Swing Exercise for Parkinson's Disease

Since PD patients are often stiffer and weaker on one side in the earlier stages of PD, one of the things that suffers is gait which is somewhat dependent upon the arms for balance. If the arms don't swing, the stride usually shortens to compensate for the lack of shoulder and arm movement as well as the leg stiffness on the "bad" side. And of course, balance also becomes problematic.

Just telling yourself to swing your arms is not going to do it. You have to practice through exercise...regularly!

Sit in a chair - preferably a chair without arms - or one narrow enough that your arms can hang over the sides

Can you swing both arms? Together? In opposition?
If you can't, here's the exercise. You might need an assistant.
This is pretty simple but not necessarily easy.

If you have trouble, your assistant should hold the stronger arm in place while you work the weaker side.
Don't let the stronger side arm move. Just hold while the weaker-stiffer side performs the exercise once.
After the shoulder raises - the Shrug - is completed and the Forward and Back is also performed - release the arm

Get the shoulders moving first - we've done this before - the shoulders will help to propel you as well as provide balance.

Sit tall - head up - eyes forward
Raise the shoulders - let fall - raise both shoulders and let fall
Now alternate: raise the right shoulder only - let fall
Then the left shoulder: rise and fall
Together up and down - up and down
Shake it out

Sitting erect in your chair - head up - eyes forward
Swing your right arm front to back - reach back - swing forward
The shoulder will assist as it rises and falls with the swing.
Now repeat with the left arm

Next you will try alternate arm swing using both arms
Get the weaker side going first: forward-back-forward
Now the stronger side: forward-back
Keep the shoulders involved with the swing.

Now we're going to march in place with the arms swinging.
Sit erect - knees and feet comfortable apart for your march
(March them out now to that place)

Just as your assistant held your strong arm in place, if you have a problem raising the leg from the hip,
the strong leg should be held in place while you raise the weaker leg a few times. Release the leg

Lets March in Place.
Get the march going by raising first one leg from the hip, stepping down (heel first) and repeating with the other leg
Add the arm swing.

Music Maestro:
http://www.dws.org/sousa/works.htm
We're going to suggest the slower Wedding March for this exercise.
You might also like Riders for the Flag, Washington Post or the familiar Stars and Stripes Forever.

When you have completed your march with your arms swinging it is time to stand by leaning forward, rise from the chair
and march or walk down the hall or around the room.
Your stride goal is the one foot steps down a full foot length or more in front of the other.
If you have a freeze issue, your assistant must be ready with your key words to break the freeze and prevent a fall.

What we are doing with this exercise is similar to both the nautilus work favoring the weak side and the swim therapy marching with knees up and arms swinging except no equipment and no water.

The thing about Parkinson's is that unlike recovering from an injury or surgery, the body will stiffen again. These exercises must be done at least 3 times a week.

Did you know that 5-6 hours of vigorous exercise a week will raise the endorphin and dopamine levels? That should help ease some of your Parkinson's disease symptoms, however briefly.

Note: This is another in the series of exercises I designed to help Steve with his short stride. You will find that they are more strenuous than they might appear at first glance.
Marge

Shakin' All Over

Chair Exercises for Parkinson's Disease

Not only is it hard to find space to exercise on the floor, it is difficult to get to the floor when you have Parkinson's disease. Okay, sometimes not so difficult but sometimes hard to get up. Balance is an issue so you often need a spotter; but not as much so with chair exercises. And you can do these at work or anyplace.

The exercises are designed to help balance, walking stride, leg and ankle flexibility, posture (spine), neck and shoulder muscles, throat muscles and breathing; Parkinson's disease symptoms.

So begin by sitting down and then sitting tall. You may use a chair with arms as long as it isn't too tight a fit to move your arms. A desk chair should work just fine.

Remember head and gaze "up" or following the direction of your body. Your spine will follow the direction of your gaze. If you look down when your body should be erect, your spine will curve following the gaze. You horseback riders know what I mean. If you look down, that message will be conveyed through your spine/seat to the horse and your mount will follow that direction and shorten stride.

All of these exercises except the last will be done in a sitting position without leaving your chair.

note: I prefer to close my eyes so that I can focus and feel. You might not. Your call
If you have a partner who will read these to you, so much the better
If you are working with a partner and cannot complete the motion, the partner should move that limb or joint. This should be done with two hands, one to stabilize and the other to perform the motion. Feel that motion.
If you have a full length mirror, use it - eyes open

Shoulders Down and Up
Let your arms drop to your sides - body erect
Begin by pushing your shoulders down firmly. Head up.
You should feel the pull in your shoulders and neck.
Relax your shoulders.
Repeat three times.
If you cannot tell if your shoulders are down - put a hand on the opposite shoulder or have your exercise partner help move your shoulders into position once or twice.

Raise your shoulders, ignore the spine cracking and try to touch your ears with your shoulders - no cheating - don't drop your head!
Relax your shoulders. Repeat three times.

Now alternate between shoulders raised and shoulders down. Sit Straight. Repeat three times
Shake your arms to loosen up

Shoulders forward and back
Instead of a shoulder roll which may be difficult to coordinate, let's do a "simple" shoulders forward and back.
Sit straight, eyes forward, hands in your lap.
Move your shoulders forward and then back to the original erect position.
Move your shoulders back and return to the original position.

Next combine the shoulders forward and back but this time bring your straight arms with you so that the hands almost touch in forward position when your elbows bend.
The arms will come back with the shoulders but will bend and the hands will form fists which help propel the shoulders back.

Forward - Middle - Back - Middle and repeat three times
Try not to move your torso - shoulders and arms only - moving as smoothly and as strongly as possibly.

You should feel the last combination in your shoulders, spine, arms and in your lats (latissimus dorsi)

Chin PressesSitting erect, look straight ahead.
Now lower your chin to your upper chest.
Do not alter your straight posture. Eyes looking straight ahead.
You should feel tension in eyelids and brows as you force your eyes to look straight ahead - not down.
And relax.
Repeat three times.
You should feel this one at the back of the neck, the spine, the jaw muscles and even your eyes as you look ahead.

Say AH
Staying in an erect posture tilt your head back as far as you can while still maintaining your balance.
Say "AH"
Louder, I can't hear you.
"AHHHHHHH" as deeply and as loudly as you can.
Better: "AHHHHHHHHHHHHHHHHHHHHH"
Straighten your head, inhale from the diaphragm through the chest - HOLD IT and slowly exhale "AHHHHHHHH" as the air moves from your lungs.
Take some shallow breaths and repeat once more.

Shake out your shoulders and roll your head if possible. Not too fast, just enough so that those muscles don't stay tensed.
Smile - and breathe.

Next we're going to target those stiff legs including the feet and ankles.

Sitting straight but comfortably, cup (support) your knees with your hands. If you have finger curl in one hand, help that hand get a grip and then position the stronger hand.

Heel lifts and toe raisesRaise your toes and the balls of your feet from the floor by rocking your feet back on your heels. Foot back down. Repeat three times.

Raise your heels from the floor by lifting with the balls of your feet. HOLD. Heels slowly down. Repeat three times.

Next we will combine toe lifts and heel lifts. Raise toes - down - lift heels - down and repeat
If possible do alternate moves with each foot at the same time: lift the heel of one foot while raising the toes and ball of the other foot.
This is difficult for PD patients and may not be possible at this time-No matter-Do the combined with both feet: heel lift followed by toe raise.
The important thing is to involve the foot and the ankle in an exaggerated walking position.

If you have a problem with getting a good lift and rock, move your feet closer to the chair (and your body)

Side to side on your heels and toesWith your heels raised, move your feet from side to side. Just wiggle them right and left.
Repeat with your toes raised - weight on your heels. Just shake them all around.
Obviously this one is about your ankles
Shake it out - arms, feet and sit erect and get ready to march

Marching in place
(see: below if you'd like some march music for audio accompaniment)

This exercise is to encourage lifting the leg so that the foot steps down rather than slides along the floor.
Try this exercise with the knees and feet at various distances apart.
Begin with your feet and knees only a few inches apart.
Remain comfortably erect - eyes forward (remember marching band?)
Hands and arms may be on the arms of your chair or arms crossed in front of you close to shoulder height or at the sides of your hips or thighs.
Lift from the hip and alternate between the left and the right leg. March in place.
Move or better yet march your feet and knees apart by several more inches - which will open the hips as well. March in place, coming down firmly.
Remember that even in the march, the heel lands on the floor a millisecond before the balls of the feet and the toes.

If you are in an armless chair, try to add arm swing to your march. Arms going forward and back to your march.

Touching your toesThis is a stretching exercise which will involve as much of your body as you can.
Begin in a erect posture
Head up - eyes forward
Hands resting on your knees
Legs at the knees approximating a 55-60o angle
Knees at least 12" apart which will position your Feet about 12"-15" apart.
Your bend will be from your hips - your upper torso, neck and head will follow because the hinge is your hip

Slide your hands down the front of your legs as far as they will go.
How far is enough? When you can feel the slight pain in the back of your thighs
Your gaze will focus ahead - don't follow your fingertips unless you are reaching well beyond your toes.
Hold
Slowly straighten, drawing your arms and hands back to their original position on your thighs as your body returns to an open, erect posture.
Repeat 5 times slowly.

Cooling down
Sit erect, raise your arms in front of you and then over your head - stretch - inhale and exhale - slowly return your arms to your thighs.
Repeat three times.
Shake your chest from your waist and hips.
Holds your arms out and shake arms, wrists and hands.

Out of the chair
Stand and walk down a hall or someplace which offers you unobstructed room to walk.
Try to walk with as much of your body as possible.
The walking step should be such that one foot clears the other at least completely (more is better in this case.)
Stride or march up and down the hall - head up - eyes up.
You may find that marching is more effective than walking since there is a helpful rhythm to marching.

You were terrific!
Thank you
Marge

Notes: These I designed these exercises for Steve to address some of the problems he has walking. Since he also has arthritis in his knees, they had to be low impact. Because he has Parkinson's they had to assist in helping PD issues of stiffness, shuffle, breathing and using both sides of the body.

If you have a problem printing this article, just Contact Us; we'll email you a copy of the chair exercises or any of the exercise sets in the other articles. Just be sure to specify the title and date of the article.

March Music link: http://www.dws.org/sousa/works.htm  Hold the shift key down while clicking the link to open the music in another window so that you can march to the music.