to the editor: We read with great interest the article by Dr. Rao and colleagues on Parkinson disease, especially the section on nonpharmacologic interventions such as exercise. Historically, physicians did not think that exercise had an effect on Parkinson disease. Rao and colleagues cite a 2001 Cochrane meta-analysis on physical therapy and exercise for Parkinson disease¹ that is consistent with this view and conclude that “non-pharmacological interventions do not improve the cardinal symptoms of Parkinson's disease.”² More recent studies suggest that exercise improves some of the cardinal features of this disease that often resist pharmacologic intervention, including gait, posture, and dysarthria.^3–5 Animal studies on aerobic exercise for Parkinson disease suggest that exercise does provide a protective effect on the Parkinson disease brain.⁶ These animal studies have been replicated and a large National Institutes of Health human trial on exercise and Parkinson disease is forthcoming.

Family physicians are often the first to diagnose and treat patients with Parkinson disease. Given the current evidence supporting exercise as a treatment for this disease and its impact on other associated conditions, including heart disease and depression, we strongly suggest that physicians encourage exercise in all patients with Parkinson disease.

Anecdotally, we saw a patient who was diagnosed with idiopathic Parkinson disease in 2001 at 49 years of age who lost his insurance when he became unemployed in 2006. As a result, he decided to wean himself off his medications while continuing an intense exercise program. His main symptoms were stiffness and tremor in his left leg and hand. He was an avid athlete, participating in activities such as weight lifting, biking, running on a treadmill, water aerobics, stretching and flexibility, and jumping rope throughout his life for at least two hours per day, six times a week. At baseline, he was receiving amantadine (Symmetrel) 100 mg, and ropinirole (Requip) three times daily. He went to taking one dose of ropinirole at night for six months and then stopped all medications for more than two months. His symptoms remained stable, but he reported increased lower extremity rigidity within 24 hours if he did not exercise.

We believe that exercise should be considered in the treatment regimen for all patients with Parkinson disease who do not have specific contraindications.

editor's note: This letter was sent to the authors of “Parkinson's Disease: Diagnosis and Treatment,” who declined to reply.