When I first worked with people with neurological conditions, I was a relatively new studio teacher. I benefitted greatly from mentors who guided me thoughtfully and by immersing myself in the science of human movement available through Body Harmonics’ extensive Continuing Education program, and beyond. Eighteen years later, as director of our NeuroFit program at Body Harmonics, I am so proud of the work we do and the clients we serve, including people with Parkinson’s disease. Most importantly, our program meshes biomechanics and functional outcomes with a commitment to helping people build confidence and movement competency regardless of their level of activity, ability or stage of Parkinson’s disease.
So, the purpose of this writing is to share some of the wisdom I’ve gained from building NeuroFit and from working with so many people with different needs over the years. My aim is to provide a template to guide your work with this population—one that is both an evidence-based resource and springboard for your creativity.
The rules of thumb I follow to improve quality of life for my clients with PD
- Always observe client responses to determine what works and what doesn’t; try to choose exercises that provide enough challenge to lead to mastery
- Create a dialogue with clients so they are active in determining the exercises that serve them best at any stage and on different days; find out how they want to feel and what they want to be able to do outside of sessions
- Use knowledge and skills about neurological challenges, biomechanics and human behaviour to deliver whole-person programming for clients living with PD
What you’ll find in the class plans
Below are two class plans designed for more able-bodied clients with PD who have relatively good stamina. What does relatively good stamina mean? You will notice people can focus well and follow instructions with consistency, their coordination is basically “normal” and they have energy to spare at the end of the class. For those who are more compromised in their movements and cognition, fewer exercises at a slower tempo usually work better.
You will notice that each plan includes only a few positions. This helps to keep a class moving and flowing without time spent on positional changes and resets. The exercises in these plans build on one another and flesh out the chosen goals. Some exercises are repeated in the class to assist the learning process. Do the exercises with the participants so they can mirror you as it facilitates their ability to move freely. Execute approximately 8-10 repetitions of each exercise.
But before you dive in, let’s recap the exercise goals to consider when developing a class or one-on-one session for people with PD (per Part 2 of our PD series). They are based on counteracting and/or delaying the onset of typical PD symptoms:
- Postural stability
- Sensory, mind-body & breathwork for neuromuscular connection
- Balance, agility, big reciprocal movements
- Dual tasking
- Flexibility/mobility—spine and ankles especially become stiff
- Muscular strength & endurance
- Voice projection—speech is quieted by PD
- Cardiovascular fitness
Let these goals inform your planning process for classes or sessions. When you are new to working with people with PD, I advise choosing two goals from this list to start, based on your assessment of their most pressing needs. Depending on the individual’s response, you may choose to focus exclusively on one goal, or several in a session. As you observe what clients’ needs are and how they respond, add more goals gradually. Keep notes to chart what works best and what does not.
Class plan for mobility and stability – 30 minutes
Seated on a chair
- Shoulder shrugs and circles
- ½ roll down (start with a forward head nod and then curl forward to the base of the ribs; hold a chair for support as needed)
- Spine rotation with hugging arms (start with a hug and then turn spine side to side)
- Drawing circles with elbows
- Windmill arms (start the windmill motion with elbows then progress to fully extended arms)
- Foot slides
- Psoas isometric (press thigh and hand into each other)
- Open & close knees with arms hugging an imaginary tree
- Bowing with hand slides (1/2 roll down)
- Hugging thoracic rotation
- Squats with arms slides
- Split stance rock forward and back from foot to foot (multifidi rock)
- Hugging Thoracic rotation
Seated on a chair
- Psoas isometric (press thigh and hand into each other)
- Windmill arms
- Shoulder shrugs
Check out the video
Preserving and Improving Mobility & Stability for People With Parkinson’s Disease
In this class for people with PD, Nancy McKinnon leads you through a series of seated and standing exercises that focus on mobility and stability—a winning combination that helps to improve posture and overall strength for everyday activities. Ideal for participants and teachers.
Required props: Chair
Level: All levels
Length: 25 minutes
Class plan for balance and sensory/neuromuscular integration – 30 minutes
- Stimulate the feet (roll foot over soup can; dorsi & plantar flexion; slide foot for sensation on the floor)
- Toe press, lift and wobble heel
- Toe curls
- Stimulate the hands (hand flicks; wrist motions; hand pull & flash)
- Cross body arm series
- Conductor arms
- Hairbrush combing legs and arms
- Cross body arm & leg motion – open & close
- Foot stimulation with hairbrush or soup can
Standing Quadruped with hands on seat of chair
- Stand in a slight squat position while flexing and extending (cat/cow)
- Stand with feet wider than hip distance apart while side bending left and right
- Hands on chair, tall on one arm as other hand taps seat
- With hands on chair seat, alternate lifting and lowering heels
- Squat with hands on legs alternating heel bumps
Alternate Limb lifts
- Lift opposite foot and hand simultaneously and switch (like a minute march)
- Hands on seat of chair – wipe feet on floor as if trying to clean off bottoms of shoe (one foot at a time)
- Step back and slightly to one side and gesture as if presenting something
- Hold a split stance lunge position and pump the back heel up and down (hold the back of a chair)
- Make a wide parallel stance and move as if swinging a golf club
- March while tapping hands to opposite thighs (as one knee lifts, tap that thigh with opposite hand)
- Hold stride stance while turning head side to side
- Arm sweeps/throws from up top to down low
Check out the video
Priming the Balance and the Sensory Systems for People with Parkinson’s Disease
In this seated and standing class for people with PD, the focus is on building better balance, first by stimulating neural pathways, then by targeting key muscles to leave you standing and sitting taller. Join Nancy McKinnon for this feel-great routine. Ideal for participants and teachers.
Required props: light weight (can be a canned product), hair brush, chair
Level: All levels
Length: 35 minutes
Tip #1: Cluster exercises around one goal for coordination and mastery
If the goal is to enhance mobility…
Teach three mobility exercises in three different body zones: Start by choosing three distinct exercises for three different body zones. For example, pelvic tilting, ankle plantar and dorsiflexion, and lateral arm arcs. Teach each exercise separately and repeat the sequence if you like.
Teach three mobility exercises in one body zone: Focus on one body zone like the ankles and do three mobility exercises. For example, ankle plantar and dorsiflexion, circles and side to side foot sweeps. Change the body zone to the shoulders and teach three mobility exercises for that zone. If we use shoulders as the example, try figure-8 conductor arms, bent elbow shoulder abduction like wing flapping and soldier arms.
Tip #2: Make cues visual and tactile rather than cerebral – don’t rely on words too much
Use hand gestures.
Offer hands-on feedback or ask people to touch their own body parts.
Tip #3: Choose exercises that are accessible – ascertain individual needs
This can be a tricky balancing act. We want to stimulate and challenge while respecting limitations and movements that make people feel uncoordinated. Your choice may not always work, but if you watch and listen carefully to client responses, you’ll know when it is time to switch gears for more or less challenge.
Never underestimate the subtle nuances of this.
Tip #4: Focus on doable tasks to encourage a sense of accomplishment and minimize frustration
The emphasis here is on “tasks.” Choose exercises where you can focus on the task at hand rather than how to execute certain movements. For example, if teaching squats, have people practise sitting down and standing up from a chair without using their arms (if appropriate). The task is to sit down and stand up from the chair.
Tip #5: Infuse fun, play and socializing through interactive exercises
How do you do this? One way is by using props like two small squishy balls and ask people to be in a circle. Pass a ball around, person to person. Periodically, someone has to stand and sit back down while holding the ball. In essence, people play a game rather than focus on their movements.
Beneficial exercises for people with PD
The following list is a compilation of accessible movements. They are grouped by position, but otherwise, are in no particular order. Examples or benefits are provided beside some of the exercises for clarity. This is not an exhaustive list.
How you choose to teach an exercise (as is, modified or embellished) will depend on your client’s needs, age, mobility and level of enthusiasm. Keep a record of what works well and what does not as you build your own repertoire of effective movements for your clients.
Seated exercises with a vertical spine
- Shoulder shrugs/rolls/shimmy
- Swimming arms
- Heel bumps (avoid with dyskinesia)
- Foot slides (sagittal, or wavy line, or adducted for cross body movement)
- Foot pivots (helpful to secure thighs with ball between knees)
- Ankle dorsiflexion (foot taps)
- Open and close knees with feet flat on floor
- Psoas isometric (hand presses into thigh as toes press down and heel lifts)
- Marching (lift heel of one foot + opposite arm forward)
- Cross body gestures (self-hug, pulling a sash across the body, head turns with arm reaches across the body, crossing and uncrossing ankles)
- Cervical rotation (ask people to look at big objects in the room as they turn their heads)
- Hands sliding alternately on thighs with thoracic rotation – no head/neck movement
- Pulling reins (for shoulder girdle movement)
- Windmill arms
- Kayaking arms
- Bow and arrow arms
Standing exercises with a vertical spine
- Split stance forward/backward rocking (to activate multifidi)
- Hula hoop hip circles with feet wider than hip distance
- Figure 8 hips with feet wider than hip distance
- Pedaling feet (stand parallel, lift one heel while the other stays down; add speed as appropriate)
- Hip hinge or bowing (ask people to hinge over a table for a more accurate hinge at the hips)
- Hold and turn a steering wheel – use a resistance ring (e.g. Magic Circle™) or a small stability ball to simulate an actual steering wheel
- Arm slides, circles, rainbow, figure 8 on a wall
- Step-touch side to side
- March like a soldier
- Step back and open to the side with arm and foot as if presenting something
- Backward steps (start parallel, step back with one foot, return to parallel and repeat on other side)
- Lunges (pump back heel up and down to move front and back leg)
- Golf swing rotations
Exercises for somatosensory input to feet, hands, face
- Move eyes – helps to manage fixation and stimulates visual cortex
- Breathe (cues: grow torso bigger on the inhale and smaller on the exhale to free thoracic spine)
- Vocalize (ask people to make audible sounds on the exhale; have… you make sounds too)
- Place a ball between knees to help maintain alignment and tracking of the thigh and leg bones
- Hold a resistance ring to activate upper body muscles from hands to chest and upper back
- Use a chair for supports – lean against the back, press “sitz bones” (pointy parts of distal pelvis) into the seat of the chair
- Place a balance cushion (e.g. SitFit™) under feet for stimulation of the foot proprioceptors
Interactive exercises done in partners, seated
- Face each other and hold a ball together; then ask them to move the ball together in different directions
- Face each other while touching one or both hands together; ask them to start moving as if they are mirroring each other
- Sit back-to-back and press into each other to sit taller; ask them to side bend or turn side to side without losing contact; you could also ask them to link arms as they move
Interactive exercises done in partners, standing
- Waltzing – assume the dance position for waltzing, take a step in the same direction together while holding hands and then take a step the opposite way
- Face-to-face mirroring movements – press palms together, move arms in various planes
- Side-by-side arm swings – hold hands and move arms in forward and backward sweeps
- Face-to-face mimicking of exaggerated facial expressions
- Face-to-face “call and answer” – one person asks a question and the answers (use big voices)
- Face-to-face pedalling or pony feet – press hands gently together while moving the feet
- Hip glides (squat)
- Hand tapping, foot tapping in time with each other
In the supine position it is more difficult to see demonstrations. Try standing beside the person at a 45º angle. If you are teaching online, avoid the supine position, or ensure that a family member or friend is willing to provide the demonstration.
- Sagittal arm arcs while holding a prop like a balance cushion, resistance ring or small ball
- Figure 8 arms while holding a prop like a balance cushion, resistance ring or small ball
- Leg slides (add unstable prop under pelvis if applicable to client)
- Open/close knees (include opposite arm leg coordination too for cross body effect)
Do any of the above with a balance cushion under the pelvis as long as the person is able to stay on the unstable surface and not fall off.
Do any of the above while lying on a foam roller as long as the person is able to stay on the unstable surface and not fall off. Alternatively, place the roller under the knees, feet, head or thoracic spine.
Side lying exercises
- Lie on side, facing a wall; slide straight or bent arm up and down a wall; switch sides
- Hip abduction with knees bent and a pillow between knees (ask clients to press into the pillow to deflate it and then lighten the pressure to inflate it)
- Leg circles
- Side kick (forward and back leg sweep with extended knee; add flexed knee)
- Pelvic rotation (innominate rocks forward and back to move innominate, femur and spine)
- Side bridge
Positions that work and ones that don’t
In a group class it is important to determine which positions participants are able to do beforehand (where possible) to help with planning. A group class experience requires cohesive flow to avoid having to teach one-on-one sessions within a group. How? Choose positions based on the majority of participants’ abilities to help manage multiple needs at once. Avoid changing positions too often in a group. Stick with one for several exercises and maximize it.
For one-on-one sessions, body positions can be adapted moment to moment based on an individual’s needs, but it is important to start upright (seated or standing) to build rapport.
- Seated – easy to get into, minimizes fatigue, can watch teacher clearly
- Standing – may need to hold something for balance, weight bearing, opens hips & uses feet
- Standing quadruped – hands on table, or chair seat (if tolerable)
- Supine – dependent on comfort (not suitable for all)
- Side lying – dependent on comfort (not suitable for all)
- Prone – awkward for some, impedes ability to watch teacher
- Quadruped – uncomfortable for wrists, impedes ability to watch teacher (standing alternative)
The list could include pillows, balance cushions, foam rollers, a wobble board, spiky pods, swivel discs, soft balls. Consider how to use unstable props safely to assist with your objectives for your clients. Unstable surfaces provide somatosensory stimulation but should not be so unstable as to be unsafe. Do no, for example, ask people with PD to stand on a wobble board without anything to hold on to. Instead, ask them to sit on a chair with one foot on top of the wobble board so as to stimulate the proprioceptors in their feet. Simplicity is key. If the unstable surface is difficult for a person to navigate, don’t use it!
Closed chain props (hands or feet are fixed)
Props like a chair, the wall, the floor, a foam roller, walking poles, a resistance ring, balance cushions or soft balls can all be used to create a closed chain environment for clients. Use these props to provide a stability challenge and tune into your client(s) agility, control and interest. For example, a roller under feet while seated on a chair may be helpful for one person but awkward for another.
Open chain props (hands or feet are free to move and not fixed)
Props like free weights or resistance bands (e.g. TherabandTM) are excellent resistance tools, but are inherently less stable and more difficult to use than props that provide a closed chain environment.
Troubleshooting for success
When faced with challenges in teaching people with PD, be sure to implement one or more strategies from this checklist to help the client process information better and to increase movement accessibility for them. Start with one, then incorporate more as needed. Progress gradually.
- Emphasize large, visual movements and avoid micro movements
- Use mirroring and mimicking – show, don’t tell and get people to follow you
- Break movements down – use progressive sequences to make movements accessible
- Include opposite limb and cross-body movements for hemispheric brain coordination
- Include touch from you, from themselves, or a combination to help people make sense of a movement or movement sequence
- Use unstable surfaces to possibly subdue tremors (this is based on in-studio evidence)
- Choose closed chain exercises whenever possible for co-contraction of muscles around multiple joints
- Reduce verbal cues, speed and complexity if signs of confusion or freezing emerge
- If people seem despondent ask them if they know what they need – allow ample response time
Build your program based on the following:
- Client goals and aspirations (what do they want to do and why)
- Goals for PD programming
- Duration of class – avoid overwhelm and exhaustion by determining an appropriate duration (30, 45, 60 mins) and a number of exercises that leave clients feeling strong, able and motivated
- Energy level and/or age of your clients
- Postural needs (e.g. kyphotic t-spine)
- Symptoms identified by the clients