Treadmill exercise tests in persons with Parkinson's disease: responses and disease severity

Refining Maximal Heart Rate Estimation to Enhance Exercise Recommendations for Persons With Parkinson Disease

OBJECTIVE

To derive and evaluate an alternative equation to estimate maximal heart rate in persons with Parkinson disease (PD) in the absence of structured exercise testing using observed maximal heart rate data from a maximal cardiopulmonary exercise test (CPET) and basic demographic and clinical data.

DESIGN

Baseline data from a randomized controlled trial.

SETTING

Academic Medical Center.

PARTICIPANTS

Eighty-two persons with mild-to-moderate PD who completed a CPET.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A linear regression model was fit to maximal heart rate from CPET using the relaxed least absolute shrinkage and selection operator (lasso) and 7 readily clinically accessible candidate covariables. Model fit was assessed by leave-one-out cross-validation. Maximal heart rates from the CPET were compared with estimates from the regression model and from 2 traditional age-based maximal heart rate estimators: (220 - age) and [208 - (0.7 × age)].

RESULTS

The regression-based heart rate estimator was [166 - (1.15 × age) + (0.60 × resting heart rate)] and most closely fit the observed maximal heart rate from the CPET. The (220 - age) and [208 - (0.7 × age)] equations overestimated maximal heart rate for 88% and 94% of the participants, respectively. The mean square error of the regression-based estimator was 63% and 75% lower than those of the 2 traditional age-based estimators, respectively.

CONCLUSIONS

Overestimating maximal heart rate generates prescribed target heart rate zones that are likely unachievable during aerobic exercise. The proposed regression-based maximal heart rate estimator most closely fit observed maximal heart rates from the CPET. Adoption of this estimator, based on both age and resting heart rate, may improve estimated maximal heart rate accuracy and thus provide more appropriate and achievable exercise heart rate zones for persons with PD in the absence of a CPET.

The effect of chronotropic incompetence on physiologic responses during progressive exercise in people with Parkinson's disease

PURPOSE

Heart rate (HR) response is likely to vary in people with Parkinson's disease (PD), particularly for those with chronotropic incompetence (CI). This study explores the impact of CI on HR and metabolic responses during cardiopulmonary exercise test (CPET) in people with PD, and its implications for exercise intensity prescription.

METHODS

Twenty-eight participants with mild PD and seventeen healthy controls underwent CPET to identify the presence or absence of CI. HR and metabolic responses were measured at submaximal (first (VT1) and second (VT2) ventilatory thresholds), and at peak exercise. Main outcome measures were HR, oxygen consumption (VO2), and changes in HR responses (HR/WR slope) to an increase in exercise demand.

RESULTS

CI was present in 13 (46%) PD participants (PDCI), who during CPET, exhibited blunted HR responses compared to controls and PD non-CI beyond 60% of maximal workload (p ≤ 0.05). PDCI presented a significantly lower HR at VT2, and peak exercise compared to PD non-CI and controls (p ≤ 0.001). VO2 was significantly lower in PDCI than PD non-CI and controls at VT2 (p = 0.003 and p = 0.036, respectively) and at peak exercise (p = 0.001 and p = 0.023, respectively).

CONCLUSION

Although poorly understood, the presence of CI in PD and its effect on HR and metabolic responses during incremental exercise is significant and important to consider when programming aerobic exercises.

Assessment of cardiorespiratory fitness in Chinese patients with early to mid-stage Parkinson's disease

PURPOSE

To evaluate cardiorespiratory fitness in patients with early to mid-stage Parkinson's disease by cardiopulmonary exercise test (CPET) on a stationary cycle ergometer.

METHODS

To compare the differences in each index of the cardiopulmonary exercise test between the two groups of subjects; general data such as disease duration, medication use and exercise habits were also collected.

RESULTS

(1) Finally, 36 Parkinson's disease patients and 12 healthy controls successfully completed the cardiopulmonary exercise test without any adverse events. (2) The V'O2peak, Metspeak, RERpeak, MVVpeak, Wpeak, HRpeak, HRpeak/pre, percentage of HRR-1 min decay > 12 bpm, SBPpeak in the Parkinson's disease group were lower than those in the control group (p < .05, each). Detailed data: V'O2peak (15.7 ± 4.5vs21.5 ± 3.6 ml/kg/min, p < .01), Metspeak (4.5 ± 1.3 vs 6.1 ± 1.0, p < .01), RERpeak (1.04 ± 0.10 vs 1.15 ± 0.10, p = .001), MVVpeak (37.22 ± 11.58 vs 53.00 ± 16.85L/min, p = .009), Wpeak (49.17 ± 29.72 vs 49.17 ± 29.72W, p < .01), HRpeak (111.08 ± 16.67 vs 111.08 ± 16.67bpm, p < .01), HRpeak/pre (71.19 ± 10.06 vs 96.00 ± 21.13, p = .002), percentage of HRR-1min decay > 12bpm (33.3% vs 100%, p < .01), systolic blood pressure (155.81 ± 31.83 vs 175.83 ± 17.84 mmHg, p = .01). (3) Divided Parkinson's disease patients into high V'O2peak group (V'O2peak ≥ 15 mL/kg/min) and low V'O2peak group (V'O2peak < 15 mL/kg/min). The age of patients, Hoehn-Yahr grade and incidence of symptom fluctuation in high V'O2peak group were lower (p < .05, respectively), percentage of males and percentage of HRR-1 min decay > 12 bpm were higher (p < .05, respectively); p < .05 is considered a statistically significant difference. Detailed data: age of patients(61.05 ± 6.93 vs 68.57 ± 7.99 years, p = .005), Hoehn-Yahr grade(1.75 ± 0.48 vs 2.18 ± 0.64, p = .028), incidence of symptom fluctuation (59.1 vs 92.9%, p = .03), percentage of males (77.7 vs 42.9%, p = .041), percentage of HRR-1 min decay > 12 bpm (50 vs 7.1%, p = .008).

CONCLUSIONS

Cardiopulmonary exercise test was safe to perform and the cardiorespiratory fitness is significantly reduced in patients with early and middle stage Parkinson's disease. Patients with Parkinson's disease presented blunted heart rate and systolic blood pressure responses to exercise test. Females, older age, fluctuating symptoms, high H-Y staging and higher activities of daily living may be associated with lower oxygen uptake.

Exercise increases arterial stiffness independent of blood pressure in older Veterans

BACKGROUND

Exercise-induced changes in arterial function could contribute to a hypertensive response to exercise (HRE) in older individuals. We performed the present analysis to define the acute arterial stiffness response to exercise in ambulatory older adults.

METHODS

Thirty-nine Veterans (>60 years old), without known cardiovascular disease, participated in this study, including 19 Veterans who were hypertensive (70.8 ± 6.8 years, 53% women) and 20 Veterans who were normotensive (72.0 ± 9.3 years, 40% women). Arterial stiffness parameters were measured locally with carotid artery ultrasound and regionally with carotid-femoral pulse wave velocity (cfPWV) before and during the 10 min after participants performed a Balke maximal exercise treadmill stress test.

RESULTS

The arterial stiffness response to exercise was similar for control and hypertensive participants. At 6 min postexercise, cfPWV was significantly increased (Δ1.5 ± 1.9 m/s, P  = 0.004) despite mean blood pressure (BP) having returned to its baseline value (Δ1 ± 8 mmHg, P  = 0.79). Arterial mechanics modeling also showed BP-independent increases in arterial stiffness with exercise ( P  < 0.05). Postexercise cfPWV was correlated with postexercise SBP ( r  = 0.50, P  = 0.004) while baseline cfPWV ( r  = 0.13, P  = 1.00), and postexercise total peripheral resistance ( r  = -0.18, P  = 1.00) were not.

CONCLUSION

In older Veterans, exercise increases arterial stiffness independently of BP and the arterial stiffness increase with exercise is associated with increased postexercise SBP. BP-independent increases in arterial stiffness with exercise could contribute to a HRE in older adults.

Graded peak cycle ergometer test for cognitively impaired patients with Parkinson's disease: a pilot study

BACKGROUND

Cognitive decline affects up to 50% of patients with Parkinson's disease (PD) in the course of the disease and may be amenable to exercise interventions. To accurately set adequate training intensities, standardized exercise testing is required but such testing takes considerable time and effort. The aim of this pilot study was to investigate the feasibility of a graded peak cycle ergometer exercise test in cognitively impaired patients with Parkinson's Disease (PD), and to define whether age-predicted maximal heart rate (HRmax) matched measured HRmax.

METHODS

A convenience sample of seven patients with PD (Hoehn and Yahr: 2-4, and cognitive impairment (Montreal Cognitive Assessment (MoCA) ≤ 26) completed a graded peak cycle ergometer test to voluntary exhaustion. Borg Rating of Perceived Exertion was used to record the individual's perception of exertion. Pre-defined age-predicted HRmax (calculated as 208-(0.7 × age) was compared with the measured HRmax using Bland-Altman plot and a two-one-sided test.

RESULTS

All PD patients completed the graded exercise test between 8-12 minutes, showing therefore 100% compliance to the test protocol. No adverse events occurred. Predicted HRmax and measured HRmax did not differ.

CONCLUSION

We demonstrate feasibility of graded peak cycle ergometer testing in PD patients with cognitive impairment. The good correspondence of age-predicted HRmax equation with measured HRmax, in this small sample, may in the future provide clinicians with a tool to define training intensities in cognitively impaired PD, without cardiac disease. However, further research is needed to confirm these results.

Oxygen uptake efficiency slope: A submaximal test evaluation tool that provides cardiopulmonary reserve data in individuals with Parkinson's disease

BACKGROUND

Oxygen uptake efficiency slope (OUES) is a method for investigating cardiorespiratory fitness and is proposed as an alternative to overcome the limitations of traditional measures such as peak oxygen consumption (VO_2peak) for patients who do not achieve a maximum response, such as in Parkinson's disease (PD).

OBJECTIVE

To assess the performance of individuals with PD during the six-minute walk test (6MWT) using the OUES.

METHODS

This is an observational cross-sectional study including 12 individuals with PD and 12 healthy controls. Participants performed the 6MWT along with an analysis of exhaled gas kinetics. The OUES was determined from the last 16 s of the walk test. Multiple linear regression analyses were computed to explore associations between the independent (OUES) and the dependent variables (VO_2peak) controlled by group.

RESULTS

The OUES was associated to VO_2peak on the 6MWT (β=0.24, p<0.01) in individuals with PD. The PD group had low performance on the 6MWT with a shorter distance walked (mean difference: -113.1 m; 95% CI: -203.2, -59.1) and worse cardiopulmonary condition with lower OUES values (mean difference: -0.52 [l/minO₂]/[l/minVE]; 95% CI: -0.83, -0.21) found in this same group.

CONCLUSIONS

Our results suggest that OUES is related to VO_2peak during the 6MWT, and therefore it could be used as a submaximal test evaluation tool which provides cardiopulmonary reserve data in individuals with PD.

Guidelines on exercise testing and prescription for patients at different stages of Parkinson's disease

BACKGROUND

Exercise is highly recommended in patients with Parkinson's disease (PD). Exercise-induced amelioration of motor, non-motor, and drug-induced symptoms are widely known. However, specific guidelines on exercise testing and prescription in PD are lacking.

OBJECTIVE

This study reviews the literature on exercise-based approaches to the management of symptoms at each stage of the disease and evaluate: (1) the most suitable clinical exercise testing; (2) training programs based on testing outcomes and PD stage; (3) the effects of exercise on antiparkinsonian drugs and to suggest the most effective exercise-medication combination.

METHODS

A systematic search was conducted using the databases MEDLINE, Google Scholar and, Cochrane Library using "Parkinson's Disease AND Physical therapy", "Training AND Parkinson", "Exercise", "Exercise AND Drug" as key words. In addition, references list from the included articles were searched and cross-checked to identify any further potentially eligible studies.

RESULTS

Of a total of 115 records retrieved, 50 (43%) were included. From these, 23 were included under the rubric "exercise testing"; 20 focused on the effectiveness of different types of exercise in PD motor-functional symptoms and neuroprotective effects, throughout disease progression, were included under the rubric "training protocol prescription"; and 7 concern the rubric "interaction between exercise and medication", although none reported consistent results.

CONCLUSIONS

Despite the lack of standardized parameters for exercise testing and prescription, all studies agree that PD patients should be encouraged to regularly train according to their severity-related limitations and their personalized treatment plan. In this manuscript, specific guidelines for tailored clinical testing and prescription are provided for each stage of PD.

Fatigability and Cardiorespiratory Impairments in Parkinson's Disease: Potential Non-Motor Barriers to Activity Performance

Parkinson's disease (PD) is the second most common neurodegenerative condition after Alzheimer's disease, affecting an estimated 160 per 100,000 people 65 years of age or older. Fatigue is a debilitating non-motor symptom frequently reported in PD, often manifesting prior to disease diagnosis, persisting over time, and negatively affecting quality of life. Fatigability, on the other hand, is distinct from fatigue and describes the magnitude or rate of change over time in the performance of activity (i.e., performance fatigability) and sensations regulating the integrity of the performer (i.e., perceived fatigability). While fatigability has been relatively understudied in PD as compared to fatigue, it has been hypothesized that the presence of elevated levels of fatigability in PD results from the interactions of homeostatic, psychological, and central factors. Evidence from exercise studies supports the premise that greater disturbances in metabolic homeostasis may underly elevated levels of fatigability in people with PD when engaging in physical activity. Cardiorespiratory impairments constraining oxygen delivery and utilization may contribute to the metabolic alterations and excessive fatigability experienced in individuals with PD. Cardiorespiratory fitness is often reduced in people with PD, likely due to the combined effects of biological aging and impairments specific to the disease. Decreases in oxygen delivery (e.g., reduced cardiac output and impaired blood pressure responses) and oxygen utilization (e.g., reduced skeletal muscle oxidative capacity) compromise skeletal muscle respiration, forcing increased reliance on anaerobic metabolism. Thus, the assessment of fatigability in people with PD may provide valuable information regarding the functional status of people with PD not obtained with measures of fatigue. Moreover, interventions that target cardiorespiratory fitness may improve fatigability, movement performance, and health outcomes in this patient population.

Effects of Fatigue on Balance in Individuals With Parkinson Disease: Influence of Medication and Brain-Derived Neurotrophic Factor Genotype

BACKGROUND AND PURPOSE

Because falls can have deleterious consequences, it is important to understand the influence of fatigue and medications on balance in persons with Parkinson disease (PD). Thus, the purpose of this study was to investigate the effects of fatigue on balance in individuals with PD. Because brain-derived neurotrophic factor (BDNF) has been shown to be related to motor performance, we also explored its role.

METHODS

A total of 27 individuals (age = 65.4 ± 8.1 years; males = 14, females = 13) with neurologist-diagnosed PD with 13 genotyped for BDNF as Val66Val, 11 as Val66Met, 2 as Met66Met (1 refused). Participants were tested both on and off medication, 1 week apart. On both days, they completed a pre- and posttest separated by a fatiguing condition. Factorial analyses of variance were performed for the following balance domains: (1) anticipatory postural responses; (2) adaptive postural responses; (3) dynamic balance; (4) sensory orientation; and (5) gait kinematics. For BDNF, t-tests were conducted comparing genotype for the pre-post difference scores in both the on and off medication states.

RESULTS

There were no interactions between time (pre- and postintervention) and medication for any of the domains (Ps ≥ 0.187). Participants with BDNF Met alleles were not significantly different from Val66Val participants in balance (Ps ≥ 0.111) and response to a fatiguing condition (Ps ≥ 0.070).

DISCUSSION AND CONCLUSIONS

Fatigue does not appear to have a detrimental effect on balance, and there was not a differential effect of medication in individuals with PD. These results also indicate that participants with a BDNF Met allele did not have a greater decay in function after a fatiguing condition.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A196).

Acute Cardiometabolic Responses to Three Modes of Treadmill Exercise in Older Adults With Parkinson's Disease

The purpose of this study was to compare acute cardiometabolic responses to 3 modes of treadmill exercise in adults diagnosed with Parkinson's disease (PD). Eight elderly adults with PD (67.9 ± 3.0 yr) completed 1 session each on a land, aquatic, and antigravity treadmill at 50% body weight. Participants walked from 1 to 3 mph in 0.5-mph increments at 0% grade for 5 min at each speed. Heart rate, energy expenditure, blood pressure, and rating of perceived exertion were measured at rest and during exercise. All variables except diastolic blood pressure increased with speed on all treadmills (p < .001). At all speeds except 1.5 mph, heart rate was higher on the land treadmill than the antigravity treadmill (p < .05). Exercising on an aquatic or antigravity treadmill elicits similar submaximal physiologic responses to exercise on a land treadmill in adults with PD.