Therapeutic value of exercise training in Parkinson's disease

Responsiveness of respiratory function in Parkinson's Disease to an integrative exercise programme: A prospective cohort study

INTRODUCTION

Respiratory disorders are the most common cause of death in Parkinson's Disease (PD). Conflicting data exist on the aetiology of respiratory dysfunction in PD and few studies examine the effects of exercise-based interventions on respiratory measures. This study was conducted to better understand respiratory dysfunction in PD and to identify measures of dysfunction responsive to an integrative exercise programme.

OBJECTIVES

The objectives were to compare baseline respiratory measures with matched, published population norms and to examine immediate and longer-term effects of a 12-week integrated exercise programme on these measures.

DESIGN

Twenty-three people with mild PD (median Hoehn & Yahr = 2) self-selected to participate in this exploratory prospective cohort study. Evaluation of participants occurred at three time points: at baseline; following the 12-week exercise programme and at 4-month follow-up.

OUTCOME MEASURES

Outcome measures included: Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 second (FEV1), FEV1/FVC ratio, Peak Expiratory Flow (PEF), Inspiratory Muscle Strength (MIP), Expiratory Muscle Strength (MEP), Peak Cough Flow (PCF), and Cardiovascular Fitness measures of estimated VO2 max and 6-Minute Walk Test (6MWT).

RESULTS

Compared to published norms, participants had impaired cough, reduced respiratory muscle strength, FEV, FVC, PEF and cardiovascular fitness. Post exercise intervention, statistically significant improvements were noted in MEP, cardiovascular fitness, and PEF. However only gains in PEF were maintained at 4-month follow-up.

CONCLUSIONS

Significant respiratory dysfunction exists, even in the early stages of PD. Metrics of respiratory muscle strength, peak expiratory flow and cardiovascular fitness appear responsive to an integrative exercise programme.

Cognitive and executive impairments in Parkinson's disease psychosis: a Bayesian meta-analysis

BACKGROUND

Cognitive and executive deficits lead to worsening of quality of life and are a risk factor for developing dementia in people with Parkinson's disease (PD) with psychosis (PDP). However, which key cognitive domains are differentially affected in PDP compared with those without (PDnP), remains unclear. Here, we examined this using a Bayesian meta-analytical approach.

METHODS

Searches were conducted on PubMed, Web of Science, SCOPUS, Medline and PsycINFO. Hedges' g effect-size estimates were extracted from eligible studies as a measure of standard mean differences between PDP and PDnP participants. Meta-analyses were conducted separately for each cognitive domain and subdomain, we examined the effect of age, PD medications, PD duration and severity, depression and psychosis severity for all major domains with meta-regressions.

RESULTS

Effect-size estimates suggest worse performance on all major domains (k=105 studies) in PDP compared with PDnP participants, with global cognition (k=103 studies, g=-0.57), processing speed (k=29 studies, g=-0.58), executive functions (k=33, g=-0.56), episodic memory (k=30 studies, g=-0.58) and perception (k=34 studies, g=-0.55) as the most likely affected domains. Age, depression and PD duration had moderating effects on task-related performance across most of the major nine domains.

CONCLUSIONS

We report extensive deficits across nine domains as well as subdomains in PD psychosis, with global cognition, processing speed and executive functions as the most likely impaired. The presence of depression may influence task-related performance in PDP, alongside age and PD duration, but not dose of dopamine replacement treatments.

Effect of Long-term Exercise Therapy on Motor Symptoms in Parkinson Disease Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVES

The aims of the study were to assess the effectiveness of long-term exercise therapy (≥12 wks) for patients with Parkinson disease and to derive specific suggestions on how the motor symptom improvements can be optimized by exercise type and exercise dose.

DESIGN

The PubMed, Web of Science, Cochrane Central Register, Embase, Scopus, and CNKI databases were searched up to January 2021 for randomized controlled trials focusing on the effects of long-term exercise for Parkinson disease. Two researchers independently evaluated the quality of papers using the PEDro scale. Twenty-six studies with a total of 1243 participants were included.

RESULTS

Tai Chi, resistance training, and dance provide significant improvements in physical function and functional mobility. Furthermore, Tai Chi and dance result in balance benefits. However, walking capacity outcomes did not improve after Tai Chi and resistance training but did improve after dance. With an increase in the intervention duration or length of each session, the effect sizes of exercise on these outcomes increased; higher benefits of exercise on these outcomes were observed at a frequency of 2 times/wk.

CONCLUSIONS

Long-term exercise therapy is an effective treatment for improving motor symptoms, with dance being an ideal exercise choice.

TO CLAIM CME CREDITS

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CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Recognize that long-term exercise slows clinical progression of motor symptoms in patients with Parkinson disease; (2) Acquire knowledge regarding the effectiveness of long-term exercise therapy on motor symptoms in Parkinson disease; and (3) Incorporate specific suggestions on dose-response relationships of different exercise therapy on motor symptoms in Parkinson disease.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

I Feel Like I Am Flying and Full of Life: Contemporary Dance for Parkinson's Patients

Parkinson’s is a neurodegenerative disease characterized by motor and non-motor symptoms which are strongly associated with patients’ quality of life, affecting social skills and support. It strikes not only the motor abilities but may harm cognitive and emotional functioning. For the past 15 years, contemporary dance has been employed as an intervention to help people diagnosed with Parkinson’s disease cope physically and mentally by way of motor, vestibular, and sensory stimulation as well as social interaction. In this study we aimed to examine psychological flexibility, creative self-efficacy and quality of life of Parkinson’s patients participating in contemporary dance sessions. To obtain this goal we conducted a cross-sectional comparative study of 50 Parkinson’s patients aged 50–87 years, half of which had been participating for at least 3 months once a week, in contemporary dance classes, and the matched controls participated in a verbal support group. Study participants completed questionnaires after participating in a dance class (Intervention) or in a support group (control). Participants in the intervention group were also asked to answer three open-ended questions that examined the experience of participating in contemporary dance classes. We found that psychological flexibility and quality of life were significantly higher in the dance class participants. Participants reported positive changes that occur in their overall feeling and quality of life following their participation in dance classes. Since PD patients’ experiences are deeply embedded in the body, it is significant to explore the use of movement in treatment. The importance of the study is in its potential to highlight the relationship between psychological flexibility and quality of life and to increase awareness of clinicians treating Parkinson’s patients to the importance of incorporating dance as an inherent part of a multidisciplinary team effort.

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.

Evidence Supports PA Prescription for Parkinson's Disease: Motor Symptoms and Non-Motor Features: A Scoping Review

Parkinson’s disease (PD) is a prevalent neurodegenerative disorder, which relates to not only motor symptoms, but also cognitive, autonomic, and mood impairments. The literature suggests that pharmacological or surgical treatment has a limited effect on providing relief of the symptoms and also restricting its progression. Recently, research on non-pharmacological interventions for people living with PD (pwPD) that alleviate their motor and non-motor features has shown a new aspect in treating this complex disease. Numerous studies are supporting exercise intervention as being effective in both motor and non-motor facets of PD, such as physical functioning, strength, balance, gait speed, and cognitive impairment. Via the lens of the physical profession, this paper strives to provide another perspective for PD treatment by presenting exercise modes categorized by motor and non-motor PD symptoms, along with its effects and mechanisms. Acknowledging that there is no “one size fits all” exercise prescription for such a variable and progressive disease, this review is to outline tailored physical activities as a credible approach in treating pwPD, conceivably enhancing overall physical capacity, ameliorating the symptoms, reducing the risk of falls and injuries, and, eventually, elevating the quality of life. It also provides references and practical prescription applications for the clinician.

Machine learning-based motor assessment of Parkinson's disease using postural sway, gait and lifestyle features on crowdsourced smartphone data

OBJECTIVES

Remote assessment of gait in patients' homes has become a valuable tool for monitoring the progression of Parkinson's disease (PD). However, these measurements are often not as accurate or reliable as clinical evaluations because it is challenging to objectively distinguish the unique gait characteristics of PD. We explore the inference of patients' stage of PD from their gait using machine learning analyses of data gathered from their smartphone sensors. Specifically, we investigate supervised machine learning (ML) models to classify the severity of the motor part of the UPDRS (MDS-UPDRS 2.10-2.13). Our goals are to facilitate remote monitoring of PD patients and to answer the following questions: (1) What is the patient PD stage based on their gait? (2) Which features are best for understanding and classifying PD gait severities? (3) Which ML classifier types best discriminate PD patients from healthy controls (HC)? and (4) Which ML classifier types can discriminate the severity of PD gait anomalies?

METHODOLOGY

Our work uses smartphone sensor data gathered from 9520 patients in the mPower study, of whom 3101 participants uploaded gait recordings and 344 subjects and 471 controls uploaded at least 3 walking activities. We selected 152 PD patients who performed at least 3 recordings before and 3 recordings after taking medications and 304 HC who performed at least 3 walking recordings. From the accelerometer and gyroscope sensor data, we extracted statistical, time, wavelet and frequency domain features, and other lifestyle features were derived directly from participants' survey data. We conducted supervised classification experiments using 10-fold cross-validation and measured the model precision, accuracy, and area under the curve (AUC).

RESULTS

The best classification model, best feature, highest classification accuracy, and AUC were (1) random forest and entropy rate, 93% and 0.97, respectively, for walking balance (MDS-UPDRS-2.12); (2) bagged trees and MinMaxDiff, 95% and 0.92, respectively, for shaking/tremor (MDS-UPDRS-2.10); (3) bagged trees and entropy rate, 98% and 0.98, respectively, for freeze of gait; and (4) random forest and MinMaxDiff, 95% and 0.99, respectively, for distinguishing PD patients from HC.

CONCLUSION

Machine learning classification was challenging due to the use of data that were subjectively labeled based on patients' answers to the MDS-UPDRS survey questions. However, with use of a significantly larger number of subjects than in prior work and clinically validated gait features, we were able to demonstrate that automatic patient classification based on smartphone sensor data can be used to objectively infer the severity of PD and the extent of specific gait anomalies.

ReadySteady intervention to promote physical activity in older adults with Parkinson's disease: Study design and methods

The main motor impairments of gait and balance experienced by people with Parkinson's disease (PD) contribute to a sedentary lifestyle, resulting in poor physical conditioning, loss of functional independence, and reduced quality of life. Despite the known benefits of physical activity in PD, the majority of older adults with PD are insufficiently active. Few studies incorporate behavioral change approaches to promoting physical activity in PD. The main goal of this research is to foster community mobility in older adults with PD by promoting physical activity and improving gait patterns using a theory-based behavioral change intervention. The ReadySteady intervention combines wellness motivation theory with polestriding physical activity, which has been shown to be beneficial for people with PD. The intervention will be tested using a randomized controlled design, including inactive older adults diagnosed with PD. Participants will be randomly assigned the 12-week ReadySteady intervention, 12-week polestriding, and education intervention, or 12-week education intervention. Thirty-six older adults with PD will participate in each of the interventions. Level of physical activity, clinical scores, quantitative measures of gait and balance control, and motivational variables for each intervention will be measured at three time points: pre-intervention, post-intervention (12 weeks), and follow-up (24 weeks). If the intervention is beneficial, it may serve as a sustainable addition to current practice in health promotion efforts serving the PD population.

The Effects of Physical Activity in Parkinson's Disease: A Review

BACKGROUND

Physical activity (PA) is increasingly advocated as an adjunct intervention for individuals with Parkinson's disease (PD). However, the specific benefits of PA on the wide variety of impairments observed in patients with PD has yet to be clearly identified.

OBJECTIVE

Highlight health parameters that are most likely to improve as a result of PA interventions in patients with PD.

METHODS

We compiled results obtained from studies examining a PA intervention in patients with PD and who provided statistical analyses of their results. 868 outcome measures were extracted from 106 papers published from 1981 to 2015. The results were classified as having a statistically significant positive effect or no effect. Then, outcome measures were grouped into four main categories and further divided into sub-categories.

RESULTS

Our review shows that PA seems most effective in improving Physical capacities and Physical and cognitive functional capacities. On the other hand, PA seems less efficient at improving Clinical symptoms of PD and Psychosocial aspects of life, with only 50% or less of results reporting positive effects. The impact of PA on Cognitive functions and Depression also appears weaker, but few studies have examined these outcomes.

DISCUSSION

Our results indicate that PA interventions have a positive impact on physical capacities and functional capacities. However, the effect of PA on symptoms of the disease and psychosocial aspects of life are moderate and show more variability. This review also highlights the need for more research on the effects of PA on cognitive functions, depression as well as specific symptoms of PD.

Current Treatment Options for Alzheimer's Disease and Parkinson's Disease Dementia

Alzheimer's disease (AD) and Parkinson's disease (PD) are the two most common neurodegenerative disorders encountered in clinical practice. Whilst dementia has long been synonymous with AD, it is becoming more widely accepted as part of the clinical spectrum in PD (PDD). Neuropsychiatric complications, including psychosis, mood and anxiety disorders, and sleep disorders also frequently co-exist with cognitive dysfunctions in AD and PDD patients. The incidence of such symptoms is often a significant source of disability, and may aggravate pre-existing cognitive deficits. Management of AD and PDD involves both pharmacological and non-pharmacological measures. Although research on pharmacological therapies for AD and PDD has so far had some success in terms of developing symptomatic treatments, the benefits are often marginal and non-sustained. These shortcomings have led to the investigation of non-pharmacological and novel treatments for both AD and PD. Furthermore, in light of the diverse constellation of other neuropsychiatric, physical, and behavioural symptoms that often occur in AD and PD, consideration needs to be given to the potential side effects of pharmacological treatments where improving one symptom may lead to the worsening of another, rendering the clinical management of these patients challenging. Therefore, the present article will critically review the evidence for both pharmacological and non-pharmacological treatments for cognitive impairment in AD and PD patients. Treatment options for other concomitant neuropsychiatric and behavioural symptoms, as well as novel treatment strategies will also be discussed.

Metabolic syndrome: an important risk factor for Parkinson's disease

Metabolic syndrome is becoming commoner due to a rise in obesity rates among adults. Generally speaking, a person with metabolic syndrome is twice as likely to develop cardiovascular disease and five times as likely to develop diabetes as someone without metabolic syndrome. Increasing oxidative stress in metabolic syndrome and Parkinson's disease is mentioned in the comprehensive articles; however, the system review about clear relation between metabolic syndrome and Parkinson's disease is deficient. In this review, we will focus on the analysis that the metabolic syndrome may be a risk factor for Parkinson's disease and the preventions that reduce the incident of Parkinson's disease by regulating the oxidative stress.

Treatment of psychosis and dementia in Parkinson's disease

OPINION STATEMENT

Parkinson's disease (PD) has been increasingly recognized as having a multitude of nonmotor symptoms including psychosis, cognitive impairment and dementia, mood disturbances, fatigue, apathy, and sleep disorders. Psychosis and dementia, in particular, greatly affect quality of life for both patients and caregivers and are associated with poor outcomes. Safe and effective treatment options for psychosis and dementia in PD are much needed. Antipsychotics with dopamine-blocking properties can worsen parkinsonian motor features and have been associated with increased morbidity and mortality in elderly, dementia patients. For treating PD psychosis, a first step would be eliminating confounding variables, such as delirium, infections, or toxic-metabolic imbalances, followed by simplifying parkinsonian medications as tolerated. If additional treatment is warranted after such interventions, clozapine or quetiapine can be implemented at the low dose levels typically needed by PD patients. Although quetiapine is easy-to-use in clinical settings, does not require blood count monitoring like clozapine, and is anecdotally beneficial, it remains "investigational" in evidence-based medicine reviews. Though not currently available, the novel 5-HT2a inverse agonist, pimavanserin has shown promise in the treatment of PD psychosis. Current treatments for PD dementia are mostly derived from those utilized in Alzheimer's disease, focusing mainly on cholinesterase inhibitors and memantine, a NMDA receptor antagonist. Rivastigmine, the only Food and Drug Administration approved medication for PD dementia, is a reasonable first choice. Other cholinesterase inhibitors and memantine have not yet achieved recommendation status in evidence-based medicine reviews but are well tolerated in studies of PD dementia patients. At present, there are no approved treatments for mild cognitive impairment in PD, but rasagiline, a selective MAO-B inhibitor, and atomoxetine, a serotonin norepinephrine reuptake inhibitor, have been recently studied. Nonpharmacological interventions, including cognitive therapy, physical activity, music and art therapy, and noninvasive brain stimulation techniques, may be promising options for PD cognitive impairment but await rigorous study.

Therapeutic effects of tai chi in patients with Parkinson's disease

Objective. The purpose of the study was to investigate the effects of a 12-week program of therapeutic Tai Chi on the motor function and physical function of idiopathic Parkinson's disease patients (PDs). Methods. The participants were 22 clinically stable PDs in Hoehn-Yahr stages 1-2 randomly assigned to a therapeutic Tai Chi group (TTC, N = 11) or a control group (CON, N = 9). Two subjects in control group did not complete the study for personal reasons. TTC was performed three days a week (60 min/session). Motor symptoms by the UPDRS were assessed, and tests of physical function were administered before and after the 12-week trial. Results. The TTC group, as compared to the CON group, showed changes in the mentation, behavior, mood, and motor scales of the UPDRS (P < 0.05, P < 0.01, resp.), with no significant main effects on the activities of daily living scale (ADL). However, there was a significant interaction between the time and intervention group on ADL (P < 0.05). There were no significant main effects for any of the physical function variables. There were significant interaction effects in balance and agility (P < 0.05, resp.). Conclusions. This study showed that TTC training had modest positive effects on the functional status of Parkinson's disease patients.

Role of movement in long-term basal ganglia changes: implications for abnormal motor responses

Abnormal involuntary movements (AIMs) and dyskinesias elicited by drugs that stimulate dopamine receptors in the basal ganglia are a major issue in the management of Parkinson’s disease (PD). Preclinical studies in dopamine-denervated animals have contributed to the modeling of these abnormal movements, but the precise neurochemical and functional mechanisms underlying these untoward effects are still elusive. It has recently been suggested that the performance of movement may itself promote the later emergence of drug-induced motor complications, by favoring the generation of aberrant motor memories in the dopamine-denervated basal ganglia. Our recent results from hemiparkinsonian rats subjected to the priming model of dopaminergic stimulation are in agreement with this. These results demonstrate that early performance of movement is crucial for the manifestation of sensitized rotational behavior, indicative of an abnormal motor response, and neurochemical modifications in selected striatal neurons following a dopaminergic challenge. Building on this evidence, this paper discusses the possible role of movement performance in drug-induced motor complications, with a look at the implications for PD management.

Effect of different exercise programs on the psychological and cognitive functions of people with Parkinson's disease

The purpose of this study was to analyze the effect of different exercise programs on the psychological and cognitive functions in patients with Parkinson's disease (PD). Forty-five patients with PD participated in the study. The participants were randomized in three intervention programs: Group-1 (n=15, cognitive-activities), Group-2 (n=15, multimodal exercise) and Group-3 (n=15, exercises for posture and gait). The clinical, psychological and cognitive functions were assessed before and after 4 months of intervention. Univariate analysis did not reveal significant interactions between groups and time (p>0.05). However, univariate analysis for time revealed differences in stress level and memory. Participants showed less physical stress (p<0.01) and overall stress (p < 0.04) and higher performance in episodic declarative memory (p < 0.001) after exercise. These findings suggest that group work with motor or non-motor activities can improve cognitive and psychological functions of patients with PD.

Influência do fortalecimento muscular no equilíbrio e qualidade de vida em indivíduos com doença de Parkinson

Esse estudo teve como objetivo avaliar o efeito do fortalecimento muscular no equilíbrio, mobilidade e na qualidade de vida (QV) de indivíduos com doença de Parkinson (DP), e verificar a correlação entre fortalecimento muscular e qualidade de vida. Participaram do estudo nove sujeitos, de ambos os sexos, com diagnóstico médico de DP. Eles, inicialmente, passaram por avaliação do equilíbrio e da mobilidade funcional por meio da Escala de Equilíbrio de Berg (EEB) e teste Timed Up and Go (TUG) e da QV pelo questionário Parkinson's Disease Questionnaire (PDQ-39). Os sujeitos realizaram ainda o teste de determinação de carga máxima (1 RM) para os grupos musculares treinados. Depois de verificadas a normalidade e homogeneidade dos dados, foram realizados o teste t de Student e o teste de correlação de Spearman. Foi considerado nível de significância de p<0,05. Foi verificada melhora no equilíbrio (p=0,008) e na QV (p=0,013), e correlação negativa entre equilíbrio e QV (avaliação r=-0,65 e p=0,05; e na reavaliação r=-0,82 e p=0,005). O fortalecimento muscular foi eficaz na melhora no equilíbrio e na qualidade de vida de indivíduos com doença de Parkinson.

Efeitos da fisioterapia aquática na qualidade de vida de sujeitos com doença de Parkinson

A doença de Parkinson (DP) é uma doença degenerativa e progressiva do sistema nervoso central, e seus sintomas podem proporcionar um declínio da qualidade de vida (QV) dos pacientes, que pode ser influenciada positivamente pela fisioterapia aquática (FA). A FA é um recurso fisioterapêutico que utiliza os efeitos físicos, fisiológicos e cinesiológicos advindos da imersão do corpo em piscina aquecida. O questionário da doença de Parkinson 39 (PDQ-39) é o instrumento mais apropriado para a avaliação da QV do paciente com DP. O objetivo deste estudo foi avaliar os efeitos da FA na QV de pacientes com DP nos estágios de leve a moderado, utilizando-se do PDQ-39. Foram incluídos 13 pacientes com DP, com idade entre 45 e 74 anos, entre os estágios 1 a 3 da doença (Hoehn-Yahr). Os pacientes foram submetidos a 16 sessões de FA, duas vezes por semana, com duração de uma hora, em piscina terapêutica aquecida. A percepção da QV foi mensurada por meio do PDQ-39, antes e depois da FA. Depois da FA, ocorreu uma redução estatisticamente significativa (p<0,0001) tanto no escore total do PDQ-39 quanto em todos os seus domínios (p=0,032). A QV foi mais afetada em maiores estágios da doença. Antes da FA, a QV era pior no estágio mais avançado da doença, e apesar da melhora dos escores de QV depois da FA, o estágio mais avançado continuou apresentando pior percepção da QV. A FA proporcionou uma melhora na qualidade de vida dos pacientes com doença de Parkinson neste estudo.

Improved clinical status, quality of life, and walking capacity in Parkinson's disease after body weight-supported high-intensity locomotor training

OBJECTIVE

To evaluate the effect of body weight-supported progressive high-intensity locomotor training in Parkinson's disease (PD) on (1) clinical status; (2) quality of life; and (3) gait capacity.

DESIGN

Open-label, fixed sequence crossover study.

SETTING

University motor control laboratory.

PARTICIPANTS

Patients (N=13) with idiopathic PD (Hoehn and Yahr stage 2 or 3) and stable medication use.

INTERVENTIONS

Patients completed an 8-week (3 × 1h/wk) training program on a lower-body positive-pressure treadmill. Body weight support was used to facilitate increased intensity and motor challenges during treadmill training. The training program contained combinations of (1) running and walking intervals, (2) the use of sudden changes (eg, in body weight support and speed), (3) different types of locomotion (eg, chassé, skipping, and jumps), and (4) sprints at 50 percent body weight.

MAIN OUTCOME MEASURES

The Movement Disorders Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS), Parkinson's Disease Questionnaire-39 items (PDQ-39), and the six-minute walk test were conducted 8 weeks before and pre- and posttraining.

RESULTS

At the end of training, statistically significant improvements were found in all outcome measures compared with the control period. Total MDS-UPDRS score changed from (mean ± 1SD) 58±18 to 47±18, MDS-UPDRS motor part score changed from 35±10 to 29±12, PDQ-39 summary index score changed from 22±13 to 13±12, and the six-minute walking distance changed from 576±93 to 637±90m.

CONCLUSIONS

Body weight-supported progressive high-intensity locomotor training is feasible and well tolerated by patients with PD. The training improved clinical status, quality of life, and gait capacity significantly.

Efficacy of a multimodal cognitive rehabilitation including psychomotor and endurance training in Parkinson's disease

Mild cognitive impairment, especially executive dysfunction might occur early in the course of Parkinson's disease. Cognitive training is thought to improve cognitive performance. However, transfer of improvements achieved in paper and pencil tests into daily life has been difficult. The aim of the current study was to investigate whether a multimodal cognitive rehabilitation programme including physical exercises might be more successful than cognitive training programmes without motor training. 240 PD-patients were included in the study and randomly allocated to three treatment arms, group A cognitive training, group B cognitive training and transfer training and group C cognitive training, transfer training and psychomotor and endurance training. The primary outcome measure was the ADAS-Cog. The secondary outcome measure was the SCOPA-Cog. Training was conducted for 4 weeks on a rehabilitation unit, followed by 6 months training at home. Caregivers received an education programme. The combination of cognitive training using paper and pencil and the computer, transfer training and physical training seems to have the greatest effect on cognitive function. Thus, patients of group C showed the greatest improvement on the ADAS-Cog and SCOPA-COG and were more likely to continue with the training programme after the study.

Facilitação neuromuscular proprioceptiva na doença de Parkinson: relato de eficácia terapêutica

INTRODUÇÃO: A Facilitação Neuromuscular Proprioceptiva (FNP) está entre as várias opções de tratamento fisioterapêutico para que o paciente com doença de Parkinson (DP) possa atingir uma função motora eficiente, porém poucos estudos exploram os efeitos dessa abordagem nessa população. OBJETIVOS: Com base no exposto, o presente estudo teve como objetivo explorar os efeitos de uma intervenção fisioterapêutica baseada na FNP em sujeitos DP. MATERIAIS E MÉTODOS: Foram estudados quatro sujeitos com DP, com idade média de 65,25 ± 10,11 anos, nos quais foram aplicadas as avaliações antes do início do tratamento baseado na FNP e após dois meses de sua aplicação. Foram utilizadas a Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF), a Escala Unificada de Avaliação da Doença de Parkinson (Unified Parkinson's Disease Rating Scale - UPDRS), o questionário de qualidade de vida SF36 e o software de avaliação postural (SAPO). RESULTADOS: Os resultados revelam que o tratamento baseado na FNP proporcionou melhora nos quatro sujeitos investigados, especialmente nos aspectos cinéticos funcionais e na execução das atividades de vida diária. CONCLUSÃO: Todos os ganhos observados podem ser relacionados à terapia baseada na FNP, que englobou atividades corporais totais facilmente incorporadas às atividades cotidianas.

Long-term group exercise for people with Parkinson's disease: a feasibility study

BACKGROUND AND PURPOSE

Aerobic and strengthening exercises have been shown to benefit people with Parkinson's disease (PD) on the basis of highly structured, short-term, clinical protocols. This study extended previous research by investigating feasibility of an ongoing, community-based, group exercise program for people with PD on the basis of short-term (10 weeks) and long-term (14 months) data.

METHODS

Twenty people with PD (Hoehn and Yahr stages I to III) participated in at least one of four 10-week sessions. Classes were held twice weekly for 1 hour and included strength, flexibility, and balance and walking exercises. Evaluations were done 1.5 hours after medication intake 1 week before and 1 week after each session. Gait speed, 6-Minute Walk test (6MWT), "Timed Up and Go" test, and grip strength were used to assess physical function. Analysis of short-term results were based on 18 participants (2 dropped out prior to posttest), and long-term results were based on 8 participants who started in the first session continued through the 14-month period.

RESULTS

Attendance rates were moderate to high (73% overall). No injuries were reported. Wilcoxon signed ranks tests based on each participant's first 10-week session demonstrated significant improvements in 6MWT, and grip strength. Long-term participants showed significant improvements in grip strength, and a trend toward improved 6MWT. Gait speed and Timed Up and Go test did not change significantly in the short or long terms.

DISCUSSION/CONCLUSIONS

Our community-based group exercise program was safe, feasible, and appears to be effective. While some measures showed no improvement, there was no evidence of decline. This is an important outcome for persons with progressive neurological disorders, and suggests community-based group exercise is a promising option for people with PD.

Progressive resistance exercise and Parkinson's disease: a review of potential mechanisms

This paper reviews the therapeutically beneficial effects of progressive resistance exercise (PRE) on Parkinson's disease (PD). First, this paper discusses the rationale for PRE in PD. Within the first section, the review discusses the central mechanisms that underlie bradykinesia and muscle weakness, highlights findings related to the central changes that accompany PRE in healthy individuals, and extends these findings to individuals with PD. It then illustrates the hypothesized positive effects of PRE on nigro-striatal-thalamo-cortical activation and connectivity. Second, it reviews recent findings of the use of PRE in individuals with PD. Finally, knowledge gaps of using PRE on individuals with PD are discussed along with suggestions for future research.

Impact of elliptical trainer ergonomic modifications on perceptions of safety, comfort, workout, and usability for people with physical disabilities and chronic conditions

BACKGROUND

The popularity of elliptical training has grown in rehabilitation, fitness, and home settings as a means for improving fitness and walking, yet many people with physical disabilities and chronic conditions experience difficulties when trying to use elliptical trainers.

OBJECTIVE

The purpose of this study was to compare, for people with disabilities and chronic conditions, perceptions of safety, comfort, workout, and usability of 4 elliptical trainers before and after the development of a set of low-cost adaptations.

DESIGN

This study was a quasi-experimental repeated-measures investigation.

METHODS

Twenty adults with diverse medical conditions and functional abilities evaluated 4 elliptical trainers for safety, comfort, workout, and usability. Barriers to the use of the elliptical trainers and solutions to improve the use of the trainers were identified. Prototype modifications were designed, and participants reassessed the same features after the modifications were made.

RESULTS

An integrated system (steps, bench, side rails, center rail or handle, deeper foot wells, and 1-handed heart rate monitor) was developed. Although at least 25% of participants required physical assistance to get on or off the elliptical trainers before modification, only one required this after modification. Before modification, only 1 participant was able to mount each device independently; after modification, 6 to 8 participants were able to do so. Up to 25% of participants continued to require assistance to initiate or sustain pedal movement. Compared with participants' ratings of the elliptical trainers before modification, those after modification were higher for safety (55% increase in visual analog scale ratings), comfort (43% higher), ability to achieve a good workout (23% greater), and usability (24% increase).

LIMITATIONS

To date, only 4 elliptical trainers have been studied with a small sample of convenience.

CONCLUSIONS

Elliptical trainers posed access challenges to people with disabilities, chronic conditions, or both. Implementation of low-cost modifications successfully reduced barriers and the need for assistance, enabling greater access for people who could benefit from using the devices for functional training and fitness.

The influence of Nordic Walking training on sit-to-stand transfer in Parkinson patients

Neurodegenerative processes in Parkinson's disease (PD) particularly affect activities of daily living (ADL). Problems of patients with PD in sit-to-stand (STS) performance have been verified before, but not the effects of training on biomechanical measures of STS function. This pilot study aimed to analyse effects of 12 weeks of Nordic Walking training and severity of PD: healthy controls (CO), least (UPDRS A) and more severe (UPDRS B) affected PA on selected functional outcome measures. We expected improvements in PD similar to CO, with better performance of the unstable second phase and faster execution of the entire movement with higher velocities of centre of gravity (COG). 3D kinematics of 22 PD and 18 CO subjects before and after training, were recorded using a motion analysis system (Vicon, Oxford). We compared five outcome measures for STS in 11 PD and 11 CO, matched according to age, gender, height, and weight. Effects of Nordic Walking training were not statistically significant but indicated different patterns which depended on the values of patient's UPDRS score (part III, motor functions). Time required for STS performance increased and horizontal and vertical velocity of COG decreased in UPDRS B, which could be due to progression of PD during the training period. In contrast, UPDRS A showed similar effects as CO. The effects of Nordic Walking as an easy, economic and low-risk intervention on STS in PD depend on the degree of PD. Our findings may help scientists, patients, and therapists to adjust sport-physiological interventions.

Neuroprotective effects and mechanisms of exercise in a chronic mouse model of Parkinson's disease with moderate neurodegeneration

The protective impact of exercise on neurodegenerative processes has not been confirmed, and the mechanisms underlying the benefit of exercise have not been determined in human Parkinson's disease or in chronic animal disease models. This research examined the long-term neurological, behavioral, and mechanistic consequences of endurance exercise in experimental chronic parkinsonism. We used a chronic 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-induced mouse model of Parkinson's disease with moderate neurodegeneration and examined the effects of treadmill exercise on movement and balance coordination, changes in dopamine neuron biomarkers, mitochondrial functions, and neurotrophic factor activities in the nigrostriatal system. The exercise results were compared with those of the control and sedentary chronic parkinsonian animals. After 18 weeks of exercise training in the chronic parkinsonian mice, we observed a significant deterrence in the loss of neuronal dopamine-producing cells and other functional indicators. The impaired movement and balance incoordination in the chronic parkinsonian mice were also markedly reduced following exercise. Mechanistic investigations revealed that the neuronal and behavioral recovery produced by exercise in the chronic parkinsonian mice was associated with an improved mitochondrial function and an increase in the brain region-specific levels of brain-derived and glial cell line-derived neurotrophic factors. Our findings indicate that exercise not only produces neuronal and mitochondrial protection, it also boosts nigrostriatal neurotrophic factor levels in the chronic parkinsonian mice with moderate neurodegeneration. Therefore, modifying lifestyle with increased exercise activity would be a non-pharmacological neuroprotective approach for averting neurodegenerative processes, as demonstrated in experimental chronic parkinsonism.

Eficácia de tratamento fisioterapêutico no equilíbrio estático e dinâmico de pacientes com doença de Parkinson

Distúrbios de equilíbrio são um dos sinais mais prevalentes na doença de Parkinson (DP), que contribuem para a perda da independência funcional dos sujeitos acometidos. O objetivo deste trabalho foi verificar a eficácia de um programa de treinamento fisioterapêutico específico sobre o equilíbrio estático e dinâmico de pacientes com DP. Vinte e três pacientes com DP idiopática, divididos em dois grupos, experimental e controle, foram avaliados pela escala de equilíbrio funcional de Berg e pelo teste de levantar e caminhar cronometrado (timed up & go). O grupo experimental foi submetido a uma seqüência de exercícios fisioterapêuticos de estimulação motora e cognitiva, com freqüência de três atendimentos semanais durante seis meses. Após o tratamento, foi constatada uma melhora significativa do equilíbrio dos pacientes do grupo experimental em relação ao controle (p<0,05) em ambos os instrumentos. O protocolo fisioterapêutico proposto, de estimulação motora e cognitiva, foi pois eficaz ao promover importante melhora no equilíbrio estático e dinâmico dos sujeitos com doença de Parkinson.

Client and therapist views on exercise programmes for early-mid stage Parkinson's disease and Huntington's disease

PURPOSE

Physiotherapists frequently prescribe home exercise programmes for individuals with Parkinson's disease (PD) and Huntington's disease (HD); however, little is known about clients' perceptions of such programmes and any barriers that may affect participation and compliance.

METHOD

A qualitative design was used to capture the attitudes and experiences of people with early-mid stage HD and PD, and with physiotherapists who have experience in neurodegenerative diseases. Two focus groups were conducted for physiotherapists (n = 8); individual interviews were conducted for clients with HD and PD (n = 10). Conversations were digitally recorded and transcribed, and transcriptions were analysed using grounded theory and validated through researcher triangulation. Concepts were categorised according to emerging themes and findings were verified by participants.

RESULTS

Both groups cited several barriers to engagement in exercise programmes, which included disease-specific impairments, individual safety and the location at which exercising takes place. Therapists felt that a client's cognition could affect their ability to participate in an exercise programme. Therapists and clients offered a number of strategies to overcome barriers to exercise.

CONCLUSIONS

Therapists should work in collaboration with clients to evaluate their individual considerations, identify barriers to exercise and design a client-specific programme that is acceptable and feasible for the client.

Comparison of the effects of a physiotherapist-supervised exercise programme and a self-supervised exercise programme on quality of life in patients with Parkinson’s disease

Objectives: To compare the effects of a physiotherapist-supervised exercise programme in an exercise unit and self-supervised home exercise programme on quality of life in patients with Parkinson’s disease.

Design: Assessor-blinded, quasi-randomized trial (alternate allocation).

Setting: An outpatient exercise unit; home settings.

Participants: Thirty patients with idiopathic Parkinson’s disease, Hoehn & Yahr I—III, stable medication use.

Interventions: Patients were included in the physiotherapist-supervised or home group. The exercise programme was performed for 10 weeks, three times/week either under the supervision of a physiotherapist or at home without supervision.

Main outcome measures: Parkinson’s Disease Quality of Life Questionnaire (PDQLQ), Nottingham Health Profile (NHP), Unified Parkinson’s Disease Rating Scale (UPDRS), Beck Depression Inventory (BDI).

Results: Patients in the supervised physiotherapy group improved more than the home exercise group in Parkinson’s Disease Quality of Life Questionnaire (total score, Parkinson’s symptoms, emotional function), Nottingham Health Profile total, Unified Parkinson’s Disease Rating Scale (all domains) and Beck Depression Inventory scores.

Conclusions: The exercise programme under physiotherapist supervision was found to be more effective at improving activities of daily living, motor, mental, emotional functions and general health quality in patients with Parkinson’s disease compared with a self-supervised home programme.

Similarity of joint kinematics and muscle demands between elliptical training and walking: implications for practice

BACKGROUND

People with physical disabilities often face barriers to regaining walking ability and fitness after discharge from rehabilitation. Physical therapists are uniquely positioned to teach clients the knowledge and skills needed to exercise on functionally relevant equipment available in the community, such as elliptical trainers. However, therapeutic use is hindered by a lack of empirical information.

OBJECTIVE

The purpose of this study was to examine joint kinematics and muscle activation recorded during walking and elliptical training to provide evidence-based data to guide clinical decision making.

DESIGN

This was a prospective, controlled laboratory study using a repeated-measures design.

METHODS

Twenty adults free from impairments that might hinder gait participated. After familiarization procedures, subjects walked and trained on 4 elliptical devices while kinematic, electromyographic (EMG), and stride characteristic data were recorded.

RESULTS

Movement similarities between elliptical training and walking were supported by the documentation of relatively high coefficients of multiple correlation for the hip (.85-.89), thigh (.92-.94), knee (.87-.89) and, to a lesser extent, the ankle (.57-.71). Significantly greater flexion was documented at the trunk, pelvis, hip, and knee during elliptical training than during walking. One of the elliptical trainers most closely simulated sagittal-plane walking kinematics, as determined from an assessment of key variables. During elliptical training, gluteus maximus and vastus lateralis muscle activation were increased; medial hamstring, gastrocnemius, soleus, and tibialis anterior muscle activation were decreased; and gluteus medius and lateral hamstring muscle activation were relatively unchanged compared with muscle activation of those muscles in walking. On the basis of EMG findings, no elliptical trainer clearly emerged as the best for simulating gait.

LIMITATIONS

To date, only 4 elliptical trainers have been studied, and the contributions of the upper extremities to movement have not been quantified.

CONCLUSIONS

Although one of the elliptical trainers best simulated sagittal-plane walking kinematics, EMG analysis failed to identify one clearly superior device. This research provides evidence-based data to help guide clinical decision making related to the use of elliptical trainers across the health care continuum and into the community.

Forced, Not Voluntary, Exercise Improves Motor Function in Parkinson's Disease Patients

Background. Animal studies indicate forced exercise (FE) improves overall motor function in Parkinsonian rodents. Global improvements in motor function following voluntary exercise (VE) are not widely reported in human Parkinson's disease (PD) patients. Objective. The aim of this study was to compare the effects of VE and FE on PD symptoms, motor function, and bimanual dexterity. Methods. Ten patients with mild to moderate PD were randomly assigned to complete 8 weeks of FE or VE. With the assistance of a trainer, patients in the FE group pedaled at a rate 30% greater than their preferred voluntary rate, whereas patients in the VE group pedaled at their preferred rate. Aerobic intensity for both groups was identical, 60% to 80% of their individualized training heart rate. Results. Aerobic fitness improved for both groups. Following FE, Unified Parkinson's Disease Rating Scale (UPDRS) motor scores improved 35%, whereas patients completing VE did not exhibit any improvement. The control and coordination of grasping forces during the performance of a functional bimanual dexterity task improved significantly for patients in the FE group, whereas no changes in motor performance were observed following VE. Improvements in clinical measures of rigidity and bradykinesia and biomechanical measures of bimanual dexterity were maintained 4 weeks after FE cessation. Conclusions. Aerobic fitness can be improved in PD patients following both VE and FE interventions. However, only FE results in significant improvements in motor function and bimanual dexterity. Biomechanical data indicate that FE leads to a shift in motor control strategy, from feedback to a greater reliance on feedforward processes, which suggests FE may be altering central motor control processes.

Parkinson's disease and resistive exercise: rationale, review, and recommendations

Individuals with Parkinson's disease (PD) are not only burdened with disease-specific symptoms (i.e., bradykinesia, rigidity, and tremor), but are also confronted with age-associated progressive loss of physical function, perhaps to a greater extent than neurologically normal adults. Suggestions for the inclusion of resistive exercise into treatment to attenuate these symptoms were made over 10 years ago, yet very few well controlled investigations are available. The objective of this review is to establish a clear rationale for the efficacy of resistance training in individuals with PD. Specifically, we highlight musculoskeletal weakness and its relationship to function as well as potential training-induced adaptive alterations in the neuromuscular system. We also review the few resistance training interventions currently available, but limit this review to those investigations that provide a quantitative exercise prescription. Finally, we recommend future lines of inquiry warranting further attention and call to question the rationale behind current exercise prescriptions. The absence of reports contraindicating resistive exercise, the potential for positive adaptation, and the noted benefits of resistance training in other populations may provide support for its inclusion into a treatment approach to PD.

Gazing into the future: Parkinson's disease gene therapeutics to modify natural history

PD gene therapy clinical trials have primarily focused on increasing the production of dopamine (DA) through supplemental amino acid decarboxylase (AADC) expression, neurotrophic support for surviving dopaminergic neurons (DAN) or altering brain circuitry to compensate for DA neuron loss. The future of PD gene therapy will depend upon resolving a number of important issues that are discussed in this special issue. Of particular importance is the identification of novel targets that are amenable to early intervention prior to the substantial loss of DAN. However, for the most part the etiopathogenesis of PD is unknown making early intervention a challenge and the development of early biomarker diagnostics imperative.

Efeitos do exercício físico sobre o estado redox cerebral

A atividade física é conhecida por promover saúde e bem-estar. O exercício também é responsável por aumentar a produção de Espécies Reativas de Oxigênio (ERO) pelo acréscimo do consumo de oxigênio mitocondrial nos tecidos. O desequilíbrio entre a produção de EROs e as defesas oxidantes dos tecidos pode provocar danos oxidativos a proteínas, lipídios e DNA. O dano oxidativo cerebral é um mecanismo etiopatológico comum da apoptose e da neurodegeneração. O fator de crescimento cérebro-derivado desempenha um importante papel neste contexto. Nesta revisão, apresentamos os resultados de diferentes modelos de exercício físico no metabolismo oxidativo e neurotrófico do Sistema Nervoso Central (SNC). Também revisamos estudos que utilizaram suplementação antioxidante para prevenir danos oxidativos exercício-induzido ao SNC. Os modelos de exercício físico mais comuns foram as rodas de correr, a natação e a esteira com configurações de treinamento muito diferentes como a duração e a intensidade. Os resultados do treinamento físico no tecido cerebral são muito controversos, mas geralmente demonstram ganhos na plasticidade sináptica e na função cognitiva com exercícios de intensidade moderada e baixa.

The patient with Parkinson's disease: part I-treating the motor symptoms; part II-treating the nonmotor symptoms

PURPOSE

This two-part article provides the nurse practitioner (NP) with information on the developments in the pathophysiology and expanded treatment options in the motor and nonmotor symptoms of Parkinson's disease (PD). The discussion provides treatment strategies that may offer improved ability to manage the disabling symptoms of this neurodegenerative disorder.

DATA SOURCES

Review of scientific literature from PubMed search for English language articles on PD from 1998 to 2005 and books or chapters in textbooks published on the disease in the same time frame provided the data source for this article. The content reflects our clinical judgments and experience from clinical practice in the Movement Disorder Clinic at Mayo Clinic Arizona.

CONCLUSIONS

The high prevalence of the disease and important advances in its management means that the NP needs to have knowledge of the disorder and the combination of multiple treatment options available for both the motor and the nonmotor symptoms.

IMPLICATIONS FOR PRACTICE

PD is a progressive neurodegenerative disease affecting 1% of persons over the age of 60 in the United States. As prevalence increases with age, so does the need for early accurate diagnosis and proper treatment of the PD by the clinician. Advances in the treatment for the motor and nonmotor symptoms of PD provide the clinician with increased options to improve the patient's quality of life.