Exercise Requirements –

The legal staff of the facility should review and approve of all consent and waiver forms before beginning this program.  Here are some successful suggestions which are included in the back of your manual.

1. Description of the Program
2. A Facility application/Hippa release form if applicable to your program
3. Medical Clearance to participate in the Parkinson’s Cycling Program from  the Neurologist and other personal physicians.
4. Parkinson’s Cycling Screening Form
5. General release of liability
6. Training heart rate zones

Collect the facility application, Hippa release form,  liability release, medical clearance form, and then review the Parkinson’s Cycling screening form with the participant and his or her support group. At this time it will be a perfect opportunity to begin to create the accepting and welcoming atmosphere that will encompass and support these individuals as the program begins and moves forward.

**These suggested forms are included at the back of your manual.**

It will be necessary to screen each participant on an individual basis.  The heart rate training zones will be determined during the initial visit. The Parkinson’s Cycling Coach will collect and review all other documents listed. It is extremely important to have all the documents completed and in the hands of the coach before any activity begins.

Initial visit

The participants….

Parkinson’s Cycle Coach Program will be an asset to any facility. Nearly one million people in the United States are living with Parkinson’s Disease. As our population gets “older”, this number will only get larger.
The National Parkinson Foundation states that exercise is an important protocol for individuals diagnosed with Parkinson’s Disease. Exercise can encourage better balance, gait, flexibility and enhance an overall feeling of well being. Group exercise provides that opportunity in a safe uplifting way.

It is now time to “screen” or talk with each participant. Getting to know the future cyclists with questions like:

• when were you diagnosed?

• what are your symptoms?

• how is your general health?

• have you exercised recently?

Use the Parkinson’s Cycling Screening form. This opens the door to discuss any other health issues that are important.

The Center for Disease Control states that 80% of older adults have one chronic condition, and 50% have at least two. The participants in the Parkinson’s Cycling Program may have other health issues like diabetes or high blood pressure. The health screening questionnaire should be completed by the lead coach for the Parkinson’s Cycling class. He/she will ask important health questions of the participant about his/her general health status and medications.  It is imperative that any secondary health issues have been identified and addressed before allowing the Parkinson’s participant to take part in the Parkinson’s Cycling Program.

For example:

If a participant is currently under the care of a cardiologist or any other specialist it is also a good idea to have a signed release from the doctor stating the participant is safe to exercise. If any conditions are set by a doctor, especially a cardiologist, the coach will follow those specific guidelines.

Your Parkinson’s Cycling screening questions will help you establish parameters for individual success. Please refer to the Parkinson’s Cycling Health Screening Questionnaire in the back of your manual. Feel free to use this form or incorporate your own screening questions and forms for your participants.

Observations

Other important factors about your future cyclists are important to your success as well as the riders.
During the initial visit or conversation, be aware of these observations.

• Flexibility issues? Are they standing with rounded shoulders?

• Do they shuffle?

• Do they need a walker or cane to stay safe and upright?

• Do they need to sit during your conversation?

• Did they come to the facility alone, or with a support person or persons?

Always encourage the initial 1:1 to be in person or face to face. A lot of fact gathering is done at this time that can be very important for the coach’s and the rider’s success.

It sounds a bit taxing and challenging.  Fact gathering is certainly that.  Attention to the details will help achieve success.  The more the coach talks with and observes the participants during this 1:1 meeting,  the better the coach becomes at anticipating the rider’s  needs.  This creates a smoother beginning and builds mutual respect between the Parkinson’s Cycling Rider and the Parkinson’s Cycling Coach.

Communication

The rapport between the Parkinson’s Cycling Coach and rider is important. Communication is important too. Effective communication allows people to build personal and professional relationships.

Most people with Parkinson’s Disease do not have any cognitive impairment. But conversation might be challenging. Here are some tips for holding great conversations.

1. Hold the conversation at eye level making eye contact at all times. Sit down if the person with Parkinson’s is sitting and assume a relaxed posture to convey patience and a willingness to listen. Be clear and coherent with any questions and allow adequate time for the response. There may not be any cognitive difficulty but due to the muscle and nerve involvement, ability to speak clearly can be compromised.
2. Avoid finishing sentences for someone who has Parkinson’s disease unless requested. Maintain good body language by nodding a “yes” and saying “I see” when understanding of a point that is made. If understanding is not made clear or is not coherent, feel free at that point to ask for clarification or repetition. This will help avoid any misunderstandings.

3.  Email communication or equivalent with each person can be established at this initial visit. The Parkinson’s Cycling Coach will be able to use this to keep the participant/rider involved and validated on their personal achievements and successes. This class is a behavioral change for many of the participants. The updates on their progress over the first month will encourage these riders to make this exercise habit a priority.
Sending encouraging messages such as:
“Great job today Frank! I really liked the way you drank your water today!
“Fantastic ride today, Carol! How did you feel during the ride? Your heart rate was right on target during the work intervals. ”

This email communication goes both ways. The participant or even their significant other/ support person sometimes finds it easier to ask personal questions through email. Once again, this solidifies the relationship when the communication is both ways.
It keeps them coming back for more!

Initial Baseline Testing

After achieving the correct bike setup for your new rider, begin the individual assessment.

Most of the Parkinson participants will be aerobically challenged or deconditioned.  Aerobically deconditioned means that an aerobic base is not present.  Aerobic refers to the energy created using the cardiovascular system.  These riders will need to slowly build an aerobic base.  An aerobic base is needed to use oxygen efficiently during exercise.   This base can be built in approximately 6-12 weeks of aerobic exercise by adding more duration to the interval rides.

The benefits of a strong aerobic base are many.  Some of these benefits which relate to the Parkinson’s Cycling Program are:

1.  Better performance- Aerobic exercise provides a more productive and efficient  use of oxygen.

2. Increased energy by reducing fatigue-  The more efficient the heart is, the better the pumping action of oxygen to the muscles of the body.  More efficiency results in more energy and less fatigue.

3. Aid in sleeping and less tension-  Exercise can create better balance in the body.  This creates a better environment for the release of tension, rest and sleep.

4.  Overall better stamina- As the heart becomes stronger and more efficient the blood and oxygen are pumped without adding any more energy to the process.  Everyday activities become easier.

5. Psychological benefits- Research has documented that as little as 30 minutes of exercise per day can result in less anxiety, stress, and depression.

6.  Lowered risk of heart disease- Aerobic exercise has been shown to favorably impact serum cholesterol and blood pressure.

 

It is important to monitor the Parkinson’s rider’s  first “personalized assessment test” closely. This will be the baseline for his/her success in the Parkinson’s Cycling Program.

Baseline testing of the participant is to determine initial RPM’s, working heart rate, maximum sustainable power, and time interval for work effort.

The initial baseline testing takes approximately 20 minutes.

The Initial Baseline Testing Protocol

The instructor stands beside the rider as he/she begins to pedal. Briefly describe the assessment test to the rider explaining what will take place over the next 20 minutes.  Allow them to ask any questions or express concerns at this time.  Most of these riders have never performed an assessment test or used a stationary bike.  Some have never been to a gym or fitness facility.  The coach’s job will be crucial here.  The coach provides the instructions to the rider and the encouragement needed.  At the same time the coach will be assessing  the rider’s physical abilities.  Record all results in the Data Entry Binder.

Initial Baseline Testing Protocol

1. Set up the Parkinson’s Cycling Participant correctly on the bike.

2. The Parkinson’s coach promotes diaphragmatic breathing  ( allowing the belly then the chest to expand) or “nose” breathing during the warm up and throughout the ride.

3.  Encourage water consumption.

4.  The coach should encourage the rider to increase the cadence or Rpms approximately 10% every minute.

5. Resistance or power can be added but typically Rpm seems to be sufficient in achieving the goal here.

6.  Monitor and record heart rate and RPM every minute. If power is used, record the wattage.

7. Record the observations made during this Assessment test.

The assessment test begins with:

1. 1-10 minutes- Warm up with Voluntary RPM. Most riders will be at a 55-60 RPM. Encourage the rider to stay at the cadence that he or she is most comfortable. The coach will encourage conversation and allow the rider to talk comfortably.
2. 10-11 minutes @ 66RPMs
3. 11-12 mins- 72 RPMs
4. 12-13 mins- 79 RPMs
5. 13-14 mins- 86 RPMS
6. 14-20 minutes- 90 RPMs

Assessment Test is Complete

Make sure the rider is recovered fully before stepping off the bike.

20 minutes is a good indicator to determine the aerobic threshold for the participant at that time.  If a participant can not complete the assessment for any reason, the assessment is complete. This does not preclude them from participating in the program. You will have enough information to help coach the participants towards success.

This baseline test can and should be done again in 2 weeks after the program begins and every 2 weeks as the aerobic base is being established.  It can be done during the class itself by the instructor or in another 1:1 meeting. The results are usually slightly improved and very encouraging to the rider. Improvement in flexibility is apparent and work effort is stronger after a few weeks of consistently coming to the Parkinson’s Cycling Program.

Does your facility have indoor cycles that include Power/Wattage meters?

Training with a power meter is the current gold standard for measuring improvement in performance and goal setting for Parkinson’s Cycling riders.  The power meters help the riders “dial in” their fitness.

Benefits of Power meters over Heart Rate Monitors

At the onset of the Parkinson’s Cycling Program, the use of cadence and heart rate is sufficient to achieve the goals of the program.  However as the fitness of the participant improves power training can offer a much more accurate and instant measure of how hard the participant is working. Heart rate monitors measure the body’s reaction or response to physical activity whereas a power meter measures the actual activity itself. In addition there is often a time interval between excretion and the hearts response.  This time interval does not exist when using power meters.  The wattage shows immediately.   This has a powerful effect on the rider because it shows immediate feedback.  The wattage numbers solidify the improvement of the Parkinson’s Cycling rider.  It encourages the rider and the coach that positive advancement is taking place.

In the Parkinson’s Cycling Program power or wattage can be used efficiently and effectively when the following guidelines are implemented.
The typical Parkinson’s Cycling rider is above the age of 60. Therefore small increments of power are possible but no more that 10 or 15% at a time.
Example:
If the initial wattage or power is 50, do not expect more that 5-7 increases in power or wattage every week.

Heart Rate Training for Parkinson’s Cycle Classes

1. Build on your existing knowledge of heart rate training.
2. Learn why we discourage using age predicted formulas to identify training zones or specific heart rate BPM’s that are some percentage of Maximum heart rate.
3. Understand the concept of the Aerobic Threshold and how it compares to the more commonly used Anaerobic Threshold (AT).
4. Learn how you will use the two of the three Zoning heart rate training zones (Easy Blue & Moderate Yellow) to guide the intensity of your Parkinson’s Cycling Class participants.
5. Learn how to conduct an Aerobic Threshold assessment to discover the heart rate BPM where your participant reaches Aerobic Threshold.

What we don’t recommend

I’d like to begin by explaining what we do not recommend using any age predicted formulas to determine a Maximum heart rate. They are many and include:

• 220 – your age = MAX HR
• Karvonen Formula

Age predicted maximum heart rate, while commonly used in fitness, is a poor predictor of actual maximum heart rate. While these formulas may be correct for a few people, they’ve been shown not to be an accurate method of determining heart rate BPM for the purpose of creating training zones for all people, regardless of age and/or level of fitness.

So what will you use?

Instead of working off of an age based formula, we will be using a simple field assessment to discover each participant’s training heart rates based on their Aerobic Threshold – not to be confused with the Anaerobic Threshold (AT) or Lactate Threshold (LT) you might be familiar with.

Heart Rate training experts like Sally Edwards and the American Council on Exercise (ACE ) both recommend using a simple three zone system, built around two thresholds:

1. VT1 – the first ventilatory  or Aerobic Threshold.  This is also called the “crossover” point where lactic acid begins to accumulate in the blood. The body’s need for oxygen is usually met primarily through deep breathing and not respiratory rate.
2. VT2 – the second ventilatory or Anaerobic Threshold.   This threshold is accompanied by an increase in respiration and is an important marker.  It represent the highest sustainable level of exercise intensity.

Sally Edwards’ Zoning program is based on the three zones; Easy, Moderate and Hard as pictured in this chart. Note how each zone is based on the participant’s ability to talk, while exercising. You will be using the (Easy Blue & Moderate Yellow) to guide the intensity of your Parkinson’s Cycling Class participants.

Assessing Training Zones for Parkinson’s Cycling Classes

The simple “Talk Test”, designed and *validated by Dr. Karl Foster of the University of Wisconsin, has been shown to accurately identify both thresholds in both conditioned and unconditioned populations.

Have you noticed how your class gets quiet, as the intensity goes up? Over the year’s, I’ve taken to calling the blue/easy zone the “Chatty Zone”. When everyone is working at a comfortable pace and breathing easily, they want to talk… and many do! Increase their effort just a little and they’ll magically stop talking, as they cross into the yellow/moderate zone – that’s another variation of the talk test.

Conducting an Aerobic Threshold assessment / Talk Test

This short video from ACE does a good job demonstrating a simple graded exercise assessment (I don’t like to call it a test) to discover the two thresholds.

Please note that all of the training we’re doing in a Parkinson’s Cycling Class is Aerobic and we’re only using Zones 1 & 2. Intensities near, at or above VT2 are not recommended for this population. 

Conducting the assessment is as follows:

• With a heart rate monitor on and working, have the participant spend 7-10 minutes warming up @ 80 -90 RPM but little resistance.
• Just before you’re ready to begin, engage in a conversation to assess their ability to speak.
• While maintaining a constant pedal speed, ask them to add a noticeable amount of resistance. After two minutes have them recite the alphabet and then ask; “can you talk comfortably? As the observer, you’ll quickly learn to spot when someone’s over their aerobic threshold.  
• If they are still able to speak comfortably have then add additional resistance while keeping their cadence at 80 RPM or above and after another two minutes ask again.
• Repeat this process until the answer is; No, I can no longer talk comfortably.
• Note their heart rate BPM and record it on their chart or enter it into their profile if you’re using a rider display & data management system.

Additional Notes:

• If you encounter someone who has difficulty speaking, as a result of their PD, here’s an alternative method you can try.  Instead of asking if they can talk comfortably, ask if they can breath comfortably through just their nose, with their mouth closed. Although not clinically proven, years of successfully teaching with this technique has me offering it to you as a possible solution.
• It’s our suggestion that you re-assess your participants often. Through experience, your participants may become more aware of the feelings of reaching their Aerobic Threshold, resulting in a more accurate number.
• There’s no reason you don’t include this assessment as a part of every class. It’s a great way to have everyone get in tune with their fitness and get them focused on the class.

Homework: please try this assessment on yourself so you have an understanding of what you’re trying to communicate to your participants and what they will be experiencing. 

Additional resources:

At Age 91, He Rides at 149 bpm – an article by Sally Edwards demonstrating the myth that Maximum heart rates decrease with age.

ACE IFT Model for Cardiorespiratory Training – comprehensive article from ACE explaining the science behind their recommended Three Heart Rate Zone training system.

*Validating the Talk Test as a Measure of Exercise Intensity – from acefitness.org

Problem Solved – Two Threshold / Three Zone Heart Rate Training – a discussion about Zoning with Chuck Cali from Zoning Fitness.