To the Editor:

Parkinson’s disease (PD) is the second most common neurodegenerative disorder, affecting more than ten million people worldwide [1]. Some patients, despite the use of drug therapy, experience motor fluctuations and dyskinesias that affect their quality of life. The need to manage these symptoms encouraged the development of research on therapeutic exercise, widely developed but lacking a concise and organized training plan [2]. The exercise offers multiple benefits to treat PD; however, they are not fully exploited by patients due to their typically sedentary behavior [3]. Consequently, a proposal for a multimodal and weekly training plan has been devised, alongside implementation strategies, to facilitate the medical prescription of exercises and their long-term adherence.

The proposed training plan (Table 1) was prepared based on eight relevant studies [2,3,4,5,6,7,8,9]. It is aimed at patients with PD in the first and third Hoehn and Yahr (H&Y) stages during the “on” medication state and consists of the following types of training: aerobic, endurance (anaerobic) and flexibility. Gross motor exercises were added, considering that patients with PD are characterized by coordination disorders [10], and with the aim of improving balance and optimizing their abilities [11]. Its medical prescription was made in accordance with the guidelines of the American College of Sports Medicine (ACSM) [12], with the FITT principle (frequency, intensity, type, and time) [2, 7], and the five fundamental principles that ensure its clinical impact: specificity, overload, progression, variance and reversibility.

Table 1 Multimodal and weekly physical training plan proposed for patients with PD in the first and third Hoehn and Yahr (H&Y) stages, applied according to intensity level
Full size table

Regarding the fundamental principles, specificity was applied with types of training focused on muscle groups of limbs; and overload, with the distribution of exercises according to the intensity level (to avoid a dropout rate greater than 20% due to the burden of symptoms and clinical deterioration). Similarly, progression was considered by increasing the difficulty of activities in a staggered manner (to improve adherence and reach the recommended 30 min of daily activity) [2]; and variance, by interspersing muscle groups and types of training, with the possibility of choosing different activities during the week. Finally, reversibility was included with daily partial rest to preserve the individual’s physical form. Regarding the FITT principle, intensity was established as the basis of the prescription levels (mild, moderate, advanced), determined by the frequency of exercise, its time, and type; each of these associated with their respective advantages in PD.

As implementation strategies, people with more advanced PD can perform the exercises while sitting or using body weight support6. Also, it is recommended to take the medication between 45 and 60 min before or during the session [9] (the latter only if necessary). Furthermore, exercise caution after changing drug therapy or dosage, as drug reactions can produce unpredictable responses to exercise. It is suggested to opt for group sessions accompanied by music and visual cues to improve adherence; as well as limiting the number of transitions from decubitus to standing, removing obstacles that could cause falls, and ensuring the use of supportive footwear [8]. In patients with thermoregulatory deficiencies, the training place should be kept at a temperature of 20–22 °C, with available water and good air flow [13].

The proposed model is based on collective studies that constitute a starting point and can be considered as a standard guide to facilitate and promote the prescription of exercise in PD, especially by the general practitioner. However, as far as possible, an individualized prescription by specialist physiotherapists is preferred, considering the patient’s physical, genetic, and environmental factors [2, 4]. This management by condition can enhance the effects of exercise and avoid possible complications, even though, so far, no study shows deterioration after its execution [4]. Routine visits with advice oriented to physical activity and recommendations that avoid sedentary lifestyle should be promoted. The use of telerehabilitation is suggested for optimal exercise supervision in the domestic environment, particularly in times of pandemic as it is a protective factor against COVID-19. Besides, the importance of exercise its now greater than ever, since the confinement influences its lower practice and, therefore, greater symptomatic deterioration.