Exercise As Medicine For The Signs And Symptoms of Parkinson's Disease To Move Or Not To Move - That Is The Question

Parkinson's Disease and Exercise

The primary cardinal sign of Parkinson's disease is bradykinesia, slowness of movement. Parkinson's disease cannot be diagnosed in the absence of bradykinesia. At a very fundamental level, it is self-evident that if a disease causes slowness of movement as well as less overall movement (number of steps per day, for example), a primary treatment should involve increasing movement. Despite this self-evident truth, this has not been the case until very recently.

The flagship journal of Movement Disorders specialists is the Journal of Movement Disorders. Between 1986 and 2000, there were no published articles in Movement Disorders related to movement, exercise, physical activity or physical therapy. People with Parkinson's disease who had a parent with Parkinson's disease will sometimes reflect that their parent took part in little or no physical activity and did not present as being healthy. Please see film "SPARX3 Recruitment Short" in https://www.sparx3pd.com. In 2002, Deane and colleagues published a systematic review of "paramedical therapies" for PD (physiotherapy, occupational therapy, and speech and language therapy) and found no conclusive evidence of the effectiveness for any form of paramedical therapy that would warrant recommendation in routine clinical practice.1 A similar conclusion was drawn in a supplement published by Movement Disorders in 2002.2

Over the next 25 years, Movement Disorders published at least 100 articles related to physical activity and exercise for people with PD. These and other articles laid the foundation for current physical activity and exercise recommendations for people with PD. Exercise and activity are now one of the four treatments for Parkinson's disease: 1) exercise/physical activity, 2) medication, 3) deep brain stimulation, and 4) avoidance of toxins (See WPC blog of Professor Tanner).3,4

What motor and non-motor systems does movement and exercise benefit in people with Parkinson's disease?

There is now increasing evidence for the benefits of movement, physical activity and exercise in PD across motor and non-motor symptoms. Exercise, physical activity and physical therapy have been shown to have symptomatic benefits,5,6 improve physical function,7 VO2 peak,8 which is the single best measure of disability, cognition,9 sleep,10 bone density,11 mood,12 and gastrointestinal health.13 It is easier to ask the question, what organ systems and measures of health span does exercise not benefit?

How does exercise work?

The simple answer is that we really do not know although thousands of articles have been written about how exercise works. There are lots and lots of potential candidate mechanisms. As people age, there is a reduction in blood flow through the brain. This may reduce access to both oxygen and nutrients to neurons. Exercise probably increases blood flow.14 Inflammation is often increased in people with Parkinson's disease and exercise decreases inflammation. Brain-derived neurotrophic factor (BDNF) is a vital protein that supports the survival, growth, and adaptation of neurons in the central and peripheral nervous systems. Exercise increases BDNF levels in people with Parkinson's disease. Parkinson's disease is associated with abnormalities in the endocrine system including elevated levels of cortisol. Exercise can reduce levels of cortisol. The comprehensive effects of exercise on blood derived biomarkers have recently been summarized by Luthra and colleagues.15 It is a good thought exercise to ask whether there will ever be a pill which can do so much?

What exercises should I do?

There are four categories of exercise: aerobic (also known as cardiorespiratory and endurance), resistance training (weight training), stretching, and neuromotor. Neuromotor exercises are designed specifically to target balance, agility and multitasking (BAM). All four categories are very important and should all be performed since they target different biological systems and mitigate the effects of the signs and symptoms of Parkinson's disease in different ways. Aerobic exercise targets the heart and lungs but also has a potent effect on the brain. Resistance exercise targets skeletal muscle and also has a potent effect on the brain. It increases cortical thickness and improves executive function. Rigidity is a primary motor symptom in Parkinson’s disease (PD) that causes increased muscle stiffness, reduced range of motion, and resistance to movement. Stretching enables muscles to stay flexible and healthy, and this is needed to maintain range of motion in the joints. When a person loses flexibility and they want to move volitionally, they are unable to extend their joint all the way. That puts a person at risk for joint pain, strains, and muscle damage. Finally, people with Parkinson's disease have a much higher risk of falling and the consequences of falling, such as fractures, are greater than people without Parkinson's disease. Exercises that focus on balance are therefore an essential part of the exercise prescription and part of any fall prevention program. Dance, Tai Chi, Yoga and boxing are also all very beneficial.

Does exercise delay disease progression

Since 2018, three studies have provided strong evidence that aerobic exercise can delay disease progression.16-18 In contrast, no drug has provided evidence of disease modification. The common feature of all 3 high intensity aerobic studies is that one should exercise 3-4 times per week with a heart rate or close to 80% of one's peak heart rate for 30 minutes with a warm-up and cool down. The best way to make sure the dosage of one's heart rate prescription is accurate is with a heart rate monitor. The three studies have been done using a treadmill, bicycle, and brisk walking. However, it is very likely that it does not matter which exercise modality (treadmill, cycle, walking/running, rowing, elliptical, stepping machine, swimming) is used to elevate heart rate. The key variable is targeting a heart rate at 80%-85% peak. There is also a benefit in using more than one exercise modality to limit overuse injuries. The primary outcome in each study was the MDS UPDRS which assesses disease severity. The reason we think the actual disease process has been affected is based on a wealth of research on animal models suggests exercise is neuroprotective,19,20 and two studies on humans that have shown that high intensity aerobic exercise can increase the striatal specific binding ratio in the striatum.

Finally, the first Phase 3 clinical trial on exercise in Parkinson's disease is underway (SPARX3).21 Results will be published in 2029 at the 8th World Parkinson Congress in Québec. Through exclusive enrollment of de novo participants, the use of DaTscan to screen out people who are classified as SWEDDS (scans without evidence of dopamine deficit), and quantification of the striatal specific binding ratio as a key secondary outcome measure, SPARX3 is designed to test the hypothesis that high intensity aerobic exercise (80-85% of peak heart rate compared to 60-65%) can slow disease progression as measured both by the MDS-UPDRS part 3 and a reduction in the decline of the striatal specific binding ratio.21

Summary

There is now clear evidence that it is both possible to have Parkinson's disease and live a healthy, active lifestyle and have a fulfilling life.

Selected references

  1. Deane KH, Ellis-Hill C, Jones D, Whurr R, Ben-Shlomo Y, Playford ED, Clarke CE. Systematic review of paramedical therapies for Parkinson's disease. Mov Disord. 2002;17(5):984-91. doi: 10.1002/mds.10197. PubMed PMID: 12360547.
  2. Goetz CG, Koller WC, Poewe W, Rascol O, Sampaio C, Brin MF, Lees AJ, LeWitt P, Lozano A, Mizuno Y, Nutt JG, Öertel W, Olanow CW, Tolosa E. Physical and occupational therapy in Parkinson's disease. Movement Disord. 2002;17(SUPPL. 4):S156-S9. doi: 10.1002/mds.5576.
  3. Corcos DM, Lamotte G, Luthra NS, McKee KE. Advice to People with Parkinson's in My Clinic: Exercise. J Parkinsons Dis. 2024;14(3):609-17. doi: 10.3233/JPD-230277. PubMed PMID: 38189710; PMCID: PMC11091645.
  4. Corcos DM, Munoz MJ, Mehta N, McKee KE. Physical Activity and Exercise for People with Parkinson's Disease: The Past, Present, and Future. Mov Disord. 2026;41(8):2014-21. Epub 20260614. doi: 10.1002/mds.70396. PubMed PMID: 42290029; PMCID: PMC13518266.
  5. Goldman JG, Volpe D, Ellis TD, Hirsch MA, Johnson J, Wood J, Aragon A, Biundo R, Di Rocco A, Kasman GS, Iansek R, Miyasaki J, McConvey VM, Munneke M, Pinto S, St Clair KA, Toledo S, York MK, Todaro R, Yarab N, Wallock K. Delivering Multidisciplinary Rehabilitation Care in Parkinson's Disease: An International Consensus Statement. J Parkinsons Dis. 2024;14(1):135-66. doi: 10.3233/JPD-230117. PubMed PMID: 38277303; PMCID: PMC10836578.
  6. Ernst M, Folkerts AK, Gollan R, Lieker E, Caro-Valenzuela J, Adams A, Cryns N, Monsef I, Dresen A, Roheger M, Eggers C, Skoetz N, Kalbe E. Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis. Cochrane Database Syst Rev. 2024;4(4):CD013856. Epub 20240408. doi: 10.1002/14651858.CD013856.pub3. PubMed PMID: 38588457; PMCID: PMC11001292.
  7. Ellis TD, Colon-Semenza C, DeAngelis TR, Thomas CA, Hilaire MS, Earhart GM, Dibble LE. Evidence for Early and Regular Physical Therapy and Exercise in Parkinson's Disease. Semin Neurol. 2021;41(2):189-205. Epub 20210319. doi: 10.1055/s-0041-1725133. PubMed PMID: 33742432; PMCID: PMC8678920.
  8. Shulman LM, Katzel LI, Ivey FM, Sorkin JD, Favors K, Anderson KE, Smith BA, Reich SG, Weiner WJ, Macko RF. Randomized clinical trial of 3 types of physical exercise for patients with Parkinson disease. JAMA Neurol. 2013;70(2):183-90. doi: 10.1001/jamaneurol.2013.646. PubMed PMID: 23128427; PMCID: PMC4574905.
  9. David FJ, Robichaud JA, Leurgans SE, Poon C, Kohrt WM, Goldman JG, Comella CL, Vaillancourt DE, Corcos DM. Exercise improves cognition in Parkinson's disease: The PRET-PD randomized, clinical trial. Mov Disord. 2015;30(12):1657-63. Epub 20150706. doi: 10.1002/mds.26291. PubMed PMID: 26148003; PMCID: PMC4609235.
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  11. Amato A, Baldassano S, Vasto S, Schiro G, Davi C, Drid P, Dos Santos Mendes FA, Caldarella R, D'Amelio M, Proia P. Effects of a Resistance Training Protocol on Physical Performance, Body Composition, Bone Metabolism, and Systemic Homeostasis in Patients Diagnosed with Parkinson's Disease: A Pilot Study. Int J Environ Res Public Health. 2022;19(20). Epub 20221011. doi: 10.3390/ijerph192013022. PubMed PMID: 36293598; PMCID: PMC9602560.
  12. Reynolds GO, Otto MW, Ellis TD, Cronin-Golomb A. The Therapeutic Potential of Exercise to Improve Mood, Cognition, and Sleep in Parkinson's Disease. Movement Disord. 2016;31(1):23-38. doi: 10.1002/mds.26484.
  13. Wu YP, Wu IC, Lu MK. Effects of daily walking exercise on constipation in patients with Parkinson's disease. BMJ Open Sport Exerc Med. 2026;12(1):e002696. Epub 20260313. doi: 10.1136/bmjsem-2025-002696. PubMed PMID: 41853800; PMCID: PMC12993353.
  14. Wilson AC, Pountney DL, Khoo TK. Therapeutic Mechanisms of Exercise in Parkinson’s Disease. International Journal of Molecular Sciences. 2025;26(10):4860. PubMed PMID: doi:10.3390/ijms26104860.
  15. Luthra NS, Mehta N, Munoz MJ, Fantuzzi G, Lamotte G, Haus JM, McFarland NR, Tansey MG, Gonzalez-Latapi P, Caraveo G, Kang UJ, Corcos DM. Aerobic exercise-induced changes in fluid biomarkers in Parkinson's disease. NPJ Parkinsons Dis. 2025;11(1):190. Epub 20250701. doi: 10.1038/s41531-025-01042-8. PubMed PMID: 40595707; PMCID: PMC12215721.
  16. Schenkman M, Moore CG, Kohrt WM, Hall DA, Delitto A, Comella CL, Josbeno DA, Christiansen CL, Berman BD, Kluger BM, Melanson EL, Jain S, Robichaud JA, Poon C, Corcos DM. Effect of High-Intensity Treadmill Exercise on Motor Symptoms in Patients With De Novo Parkinson Disease: A Phase 2 Randomized Clinical Trial. JAMA Neurol. 2018;75(2):219-26. doi: 10.1001/jamaneurol.2017.3517. PubMed PMID: 29228079; PMCID: PMC5838616.
  17. van der Kolk NM, de Vries NM, Kessels RPC, Joosten H, Zwinderman AH, Post B, Bloem BR. Effectiveness of home-based and remotely supervised aerobic exercise in Parkinson's disease: a double-blind, randomised controlled trial. Lancet Neurol. 2019;18(11):998-1008. Epub 20190911. doi: 10.1016/S1474-4422(19)30285-6. PubMed PMID: 31521532.
  18. Mak MKY, Wong-Yu ISK. Six-Month Community-Based Brisk Walking and Balance Exercise Alleviates Motor Symptoms and Promotes Functions in People with Parkinson's Disease: A Randomized Controlled Trial. J Parkinsons Dis. 2021;11(3):1431-41. doi: 10.3233/JPD-202503. PubMed PMID: 33967056.
  19. Ahlskog JE. Aerobic Exercise: Evidence for a Direct Brain Effect to Slow Parkinson Disease Progression. Mayo Clin Proc. 2018;93(3):360-72. doi: 10.1016/j.mayocp.2017.12.015. PubMed PMID: 29502566.
  20. Rodriguez TN, Smeyne RJ, Smeyne M. Neurobiology of exercise in Parkinson's disease. J Parkinsons Dis. 2026:1877718X261452869. Epub 20260520. doi: 10.1177/1877718X261452869. PubMed PMID: 42159410; PMCID: PMC13442943.
  21. Patterson CG, Joslin E, Gil AB, Spigle W, Nemet T, Chahine L, Christiansen CL, Melanson E, Kohrt WM, Mancini M, Josbeno D, Balfany K, Griffith G, Dunlap MK, Lamotte G, Suttman E, Larson D, Branson C, McKee KE, Goelz L, Poon C, Tilley B, Kang UJ, Tansey MG, Luthra N, Tanner CM, Haus JM, Fantuzzi G, McFarland NR, Gonzalez-Latapi P, Foroud T, Motl R, Schwarzschild MA, Simuni T, Marek K, Naito A, Lungu C, Corcos DM, Investigators SP. Study in Parkinson's disease of exercise phase 3 (SPARX3): study protocol for a randomized controlled trial. Trials. 2022;23(1):855. Epub 20221006. doi: 10.1186/s13063-022-06703-0. PubMed PMID: 36203214; PMCID: PMC9535216.

Daniel M. Corcos, PhD, is an Exercise Neuroscientist in Chicago, Illinois and is in the Department of Physical Therapy and Human Movement Science at Northwestern University. He spoke at the exercise plenary session at the 7th World Parkinson Congress in Phoenix.

Ideas and opinions expressed in this post reflect that of the author(s) solely. They do not necessarily reflect the opinions or positions of the World Parkinson Coalition®

Basic ScienceDaniel M. Corcos, PhDeleven, Parkinson's Disease, Excercise