Abstracts supporting the benefits of exercise for Parkinson’s symptoms

PUBMED http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed

Bergen JL, et al. Aerobic exercise intervention improves aerobic capacity and movement initiation in Parkinson’s disease patients. NeuroRehabilitation 2002; 17:161-8.
Abstract: Parkinson’s Disease (PD) is a progressive neurologic disorder, which includes an inability to activate appropriate muscle activity. Very little research has analyzed aerobic exercise for PD patients. The purpose of this study was to investigate the effect of a 16 week aerobic exercise intervention on aerobic capacity and movement initiation (MI) time for PD patients. With 8 PD subjects (Hoehn & Yahr stage 2), 4 completed the exercise intervention. Peak VO2 scores significantly improved (26%) following the intervention. Choice MI improved from 532 ms to 415 ms, while simple MI improved from 285 ms to 261 ms. The improvement in aerobic capacity suggests that PD patients may benefit from exercise just as much as a normal population. The change in MI indicates that aerobic exercise may reduce the detrimental effects of neuromuscular slowing within PD patients, by improving the subjects’ ability to initiate and perform appropriate movement patterns.

Hirsch MA, Toole T, Maitland CG, Rider RA. The effects of balance training and high-intensity resistance training on persons with idiopathic Parkinson’s disease. Arch Phys Med Rehabil 2003;84:1109-17.
Objective: To assess immediate and near-term effects of 2 exercise training programs for persons with idiopathic Parkinson’s disease (IPD). Design: Randomized control trial. Setting: Public health facility and medical center.
Participants: Fifteen persons with IPD. Intervention: Combined group (balance and resistance training) and balance group (balance training only) underwent 10 weeks of high-intensity resistance training (knee extensors and flexors, ankle plantar flexion) and/or balance training under altered visual and somatosensory sensory conditions, 3 times a week on nonconsecutive days. Groups were assessed before, immediately after training, and 4 weeks later. Main Outcome Measures: Balance was assessed by computerized dynamic posturography, which determined the subject’s response to reduced or altered visual and somatosensory orientation cues (Sensory Orientation Test [SOT]). Muscle strength was assessed by measuring the amount of weight a participant could lift, by using a standardized weight-and pulley system, during a 4-repetition-maximum test of knee extension, knee flexion, and ankle plantar flexion. Results: Both types of training improved SOT performance. This effect was larger in the combined group. Both groups could balance longer before falling, and this effect persisted for at least 4 weeks. Muscle strength increased marginally in the balance group and substantially in the combined group, and this effect persisted for at least 4 weeks. Conclusion: Muscle strength and balance can be improved in persons with IPD by high-intensity resistance training and balance training.

Treadmill and body weight:
Miyai I, Fujimoto Y, Ueda Y, Yamamoto H, Nozaki S, Saito T, Kang J. Treadmill training with body weight support: its effect on Parkinson’s disease. Arch Phys Med Rehabil 2000;81:849-52.
Objective: To test whether body weight–supported treadmill training (BWSTT) is effective in improving functional outcome of patients with Parkinson’s disease. Design: Prospective crossover trial. Patients were randomized to receive either a 4-week program of BWSTT with up to 20% of their body weight supported followed by 4 weeks of conventional physical therapy (PT), or the same treatments in the opposite order. Medications for Parkinsonism were not modified throughout the study. Setting: Inpatient rehabilitation unit for neurologic diseases. Subjects: Ten patients (5 men, 5 women) with Hoehn and Yahr stage 2.5 or 3 Parkinsonism; mean age 67.6 years, mean duration of Parkinson’s disease 4.2 years. Main Outcome Measures: The Unified Parkinson’s Disease Rating Scale (UPDRS), ambulation endurance and speed (sec/10m), and number of steps for 10-meter walk. Results: The mean total UPDRS before/after BWSTT was 31.6/25.6, and before/after PT was 29.1/28.0. Analysis of covariance for improvement of UPDRS demonstrated a significant effect of type of therapy (F(1, 16) 5 42.779, p , .0001) but not order of therapy (F(1, 16) 5 0.157, p 5 .6971). Patients also had significantly greater improvement with BWSTT than with PT in ambulation speed (BWSTT, before/after 5 10.0/8.3; PT, 9.5/8.9), and number of steps (BWSTT, 22.3/19.6; PT, 21.5/20.8). Conclusions: In persons with Parkinson’s disease, treadmill training with body weight support produces greater improvement in activities of daily living, motor performance, and ambulation than does physical therapy.

Treadmill Home-based training:
Canning CG, Allen NE, Dean CM, Goh L, Fung VS. Home-based treadmill training for individuals with Parkinson's disease: a randomized controlled pilot trial. Clin Rehabil. 2012 Jan 18. [Epub ahead of print]
Abstract: Objective: To investigate the feasibility and effectiveness of six weeks of home-based treadmill training in people with mild Parkinson's disease. Design: Pilot randomized controlled trial of a six-week intervention followed by a further six weeks follow-up. Setting: Home-based treadmill training with outcome measures taken at a hospital clinic. Participants: Twenty cognitively intact participants with mild Parkinson's disease and gait disturbance. Two participants from the treadmill training group and one from the control group dropped out. Interventions: The treadmill training group undertook a semi-supervised home-based programme of treadmill walking for 20-40 minutes, four times a week for six weeks. The control group received usual care. Main outcome measures: The feasibility of the intervention was assessed by recording exercise adherence and acceptability, exercise intensity, fatigue, muscle soreness and adverse events. The primary outcome measure of efficacy was walking capacity (6-minute walk test distance).Results: Home-based treadmill training was feasible, acceptable and safe with participants completing 78% (SD 36) of the prescribed training sessions. The treadmill training group did not improve their walking capacity compared to the control group. The treadmill training group showed a greater improvement than the control group in fatigue at post test (P = 0.04) and in quality of life at six weeks follow-up testing (P = 0.02). Conclusions: Semi-supervised home-based treadmill training is a feasible and safe form of exercise for cognitively intact people with mild Parkinson's disease. Further investigation regarding the effectiveness of home-based treadmill training is warranted.

Physical therapy for Parkinson's disease:
[Article in French]
Hubert M. Service de Kinésithérapie neurologique, Hôpital Erasme, Bruxelles. marcelle.hubert@ulb.ac.be
Parkinson's disease is a complex neurologic and progressive incapacitating disease. Parkinson's disease severely threatens the quality of live and the number of patients worldwide is expected to rise considerably in the coming decade due to aging of the population. Even with optimal medical management using drugs or neurosurgery, patients are faced with progressively increasing impairments (e.g. in speech, mental and movement related functions), and restrictions in participation (e.g. domestic life and social activities). Physical therapy is often prescribed next to medical treatment but there is a lack of uniform treatment. A systematic literature search for guidelines, systematic reviews, trials, and expert opinions lead to a better understanding. The key question: Is physiotherapy able to optimally treat the Parkinson's disease symptoms? In which way, how and on which scientific bases can the physiotherapist participate to improve autonomy and to help them living independently and avoid, as long as possible, institutionalization? This article has integrated clinical research findings to provide clinicians with an overview to physical therapist management of disorders in people with Parkinson's disease. An Evidence-Based Physical Therapy Guideline providing practice recommendations was developed by the Royal Dutch Society for Physical Therapy (KNGF). Evidence from research was supplemented with clinical expertise and patients values. Randomized clinical trials reflect specific core areas of physical therapy, that is, transfer, posture, balance, reaching and grasping, gait and physical condition. Another aspect is that of educating patients (as well as their partners and family) about the disease process and the benefits of exercise therapy. Alternative therapies can be helpful like Tai Chi, virtual games, dancing, yoga, ball games for example.

Wii Fit:
Esculier JF, Vaudrin J, Bériault P, Gagnon K, Tremblay LE. Faculty of Health Sciences, School of Rehabilitation, University of Ottawa, Québec, Canada. Home-based balance training programme using Wii Fit with balance board for Parkinsons's disease: A pilot study. J Rehabil Med. 2012 Feb;44(2):144-50.
OBJECTIVES: To evaluate the effects of a home-based balance training programme using visual feedback (Nintendo Wii Fit game with balance board) on balance and functional abilities in subjects with Parkinson's disease, and to compare the effects with a group of paired healthy subjects. SUBJECTS: Ten subjects with moderate Parkinson's disease and 8 healthy elderly subjects. METHODS: Subjects participated in a 6-week home-based balance training programme using Nintendo Wii Fit and balance board. Baseline measures were taken before training for the Sit-to-Stand test (STST), Timed-Up-and-Go (TUG), Tinetti Performance Oriented Mobility Assessment (POMA), 10-m walk test, Community Balance and Mobility assessment (CBM), Activities-specific Balance and Confidence scale (ABC), unipodal stance duration, and a force platform. All measurements were taken again after 3 and 6 weeks of training. RESULTS: The Parkinson's disease group significantly improved their results in TUG, STST, unipodal stance, 10-m walk test, CBM, POMA and force platform at the end of the 6-week training programme. The healthy subjects group significantly improved in TUG, STST, unipodal stance and CBM. CONCLUSION: This pilot study suggests that a home-based balance programme using Wii Fit with balance board could improve static and dynamic balance, mobility and functional abilities of people affected by Parkinson's disease.

Wii-Home Based Activity: Synnott J, Chen L, Nugent CD, Moore G. WiiPD--an approach for the objective home assessment of Parkinson's disease. Conf Proc IEEE Eng Med Biol Soc. 2011;2011:2388-91.Source: Computer Science Research Institute and the School of Computing and Mathematics, University of Ulster. Abstract: This paper introduces WiiPD, an approach to home-based objective assessment of Parkinson's disease. WiiPD aims to make use of the many capabilities of the Nintendo Wii Remote in combination with a number of bespoke data gathering methods to provide a rich and engaging user experience that can capture a wide range of motor and non-motor metrics. In this paper we discuss the architecture of the approach, and provide details of the implementation and testing of the motor-assessment component of the system. Initial results of testing on 6 users indicate that the system is able to differentiate between normal and abnormal motor performance, suggesting that the system has the potential to monitor the motor fluctuations associated with Parkinson's disease.

Walking: BIG and LSVT
Ebersbach G, et al Comparing exercise in Parkinson's disease--the Berlin LSVT®BIG study. Movement Disorders Clinic, Beelitz-Heilstätten, Germany. ebersbach@parkinson-beelitz.de Erratum in Mov Disord. 2010 Oct 30;25(14):2478. Abstract: Physiotherapy is widely used in Parkinson's disease (PD), but there are few controlled studies comparing active interventions. Recently, a technique named "LSVT®BIG" has been introduced. LSVT®BIG is derived from the Lee Silverman Voice Treatment and focuses on intensive exercising of high-amplitude movements. In the present comparative study, 60 patients with mild to moderate PD were randomly assigned to receive either one-to-one training (BIG), group training of Nordic Walking (WALK), or domestic nonsupervised exercises (HOME). Patients in training (BIG) and WALK received 16 hours of supervised training within 4 (BIG) or 8 (WALK) weeks. The primary efficacy measure was difference in change in Unified Parkinson's Disease Rating Scale (UPDRS) motor score from baseline to follow-up at 16 weeks between groups. UPDRS scores were obtained by blinded video rating. ANCOVA showed significant group differences for UPDRS-motor score at final assessment (P < 0.001). Mean improvement of UPDRS in BIG was -5.05 (SD 3.91) whereas there was a mild deterioration of 0.58 (SD 3.17) in WALK and of 1.68 (SD 5.95) in HOME. LSVT®BIG was also superior to WALK and HOME in timed-up-and-go and timed 10 m walking. There were no significant group differences for quality of life (PDQ39). These results provide evidence that LSVT®BIG is an effective technique to improve motor performance in patients with PD.

Walking: Nordic pole walking
van Eijkeren FJ, Reijmers RS, Kleinveld MJ, Minten A, Bruggen JP, Bloem BR. Nordic walking improves mobility in Parkinson’s disease. Department of Neurology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.; Mov Disord. 2008 Nov 15;23(15):2239-43. Abstract: Nordic walking may improve mobility in Parkinson's disease (PD). Here, we examined whether the beneficial effects persist after the training period. We included 19 PD patients [14 men; mean age 67.0 years (range 58-76); Hoehn and Yahr stage range 1-3] who received a 6-week Nordic walking exercise program. Outcome was assessed prior to training (T1), immediately after the training period (T2) and-in a subgroup of 9 patients--5 months after training (T3). At T2, we observed a significant improvement in timed 10-m walking, the timed get-up-and-go-test (TUG), the 6-min walking test and quality of life (PDQ-39). All treatment effects persisted at T3. Compliance was excellent, and there were no adverse effects. These preliminary findings suggest that Nordic walking could provide a safe, effective, and enjoyable way to reduce physical inactivity in PD and to improve the quality of life. A large randomized clinical trial now appears justified.

Fuzhong Li et al, Tai Chi and Postural Stability in Patients with Parkinson’s Disease, N Engl J Med 2012;366:511-9
Abstract: Patients with Parkinson’s disease have substantially impaired balance, leading to diminished functional ability and an increased risk of falling. Although exercise is routinely encouraged by health care providers, few programs have been proven effective. We conducted a randomized, controlled trial to determine whether a tailored tai chi program could improve postural control in patients with idiopathic Parkinson’s disease. We randomly assigned 195 patients with stage 1 to 4 disease on the Hoehn and Yahr staging scale (which ranges from 1 to 5, with higher stages indicating more severe disease) to one of three groups: tai chi, resistance training, or stretching. The patients participated in 60-minute exercise sessions twice weekly for 24 weeks. The primary outcomes were changes from baseline in the limits-of-stability test (maximum excursion and directional control; range, 0 to 100%). Secondary outcomes included measures of gait and strength, scores on functional-reach and timed up-andgo tests, motor scores on the Unified Parkinson’s Disease Rating Scale, and number of falls. The tai chi group performed consistently better than the resistance-training and stretching groups in maximum excursion (between-group difference in the change from baseline, 5.55 percentage points; 95% confidence interval [CI], 1.12 to 9.97; and 11.98 percentage points; 95% CI, 7.21 to 16.74, respectively) and in directional control (10.45 percentage points; 95% CI, 3.89 to 17.00; and 11.38 percentage points; 95% CI, 5.50 to 17.27, respectively). The tai chi group also performed better than the stretching group in all secondary outcomes and outperformed the resistance training group in stride length and functional reach. Tai chi lowered the incidence of falls as compared with stretching but not as compared with resistance training. The effects of tai chi training were maintained at 3 months after the intervention. No serious adverse events were observed. CONCLUSIONS: Tai chi training appears to reduce balance impairments in patients with mild-to moderate Parkinson’s disease, with additional benefits of improved functional capacity and reduced falls.

Madeleine E. Hackney, PhD1 and Gammon M. Earhart, PhD, PT. Effects of dance on balance and gait in severe Parkinson disease: A case study. Disabil Rehabil. 2010; 32(8): 679–684
Abstract: Purpose: Dance may improve functional mobility in individuals with mild - moderate Parkinson disease (PD), yet dance effects in severe PD remain unexamined. This study's purpose was to evaluate the feasibility and effects of partnered tango classes on balance, endurance and quality of life in an individual with severe PD. Design: Over 10 weeks, the participant attended 20, 1-hour tango classes for individuals with PD. Balance, walking, and quality of life were evaluated before and after the intervention and at a one month follow-up in this single case design. Caregiver burden was also assessed at all time points. Results: The participant improved on the Berg balance scale, 6 minute walk test, and functional reach. He reported increased balance confidence and improved quality of life as measured by the Parkinson Disease Questionnaire-39 summary index. Gains were maintained at the one-month follow-up. Caregiver burden increased from baseline immediately post-intervention and at follow up. Conclusion: Twenty partnered tango lessons improved balance, endurance, balance confidence, and quality of life in a participant with severe PD. This is the first report of the use of dance as rehabilitation for an individual with advanced disease who primarily used a wheelchair for transportation.

The following two references are noted in in Physical Activity and Parkinson’s disease resource, Parkinson Society Canada, Canadian Physiotherapy Association, 2012.

Goodwin, VA, et al. The Effectiveness of Exercise Interventions for People with Parkinson’s disease: a systematic review and meta-analysis. Movement Disorders, 2008; 23(5); 631-640. Abstract: Parkinson's disease (PD) is a neurodegenerative disorder affecting the physical, psychological, social, and functional status of individuals. Exercise programs may be an effective strategy to delay or reverse functional decline for people with PD and a large body of empirical evidence has emerged in recent years. The objective is to systematically review randomized controlled trials (RCTs) reporting on the effectiveness of exercise interventions on outcomes (physical, psychological or social functioning, or quality of life) for people with PD. RCTs meeting the inclusion criteria were identified by systematic searching of electronic databases. Key data were extracted by two independent researchers. A mixed methods approach was undertaken using narrative, vote counting, and random effects meta-analysis methods. Fourteen RCTs were included and the methodological quality of most studies was moderate. Evidence supported exercise as being beneficial with regards to physical functioning, health-related quality of life, strength, balance and gait speed for people with PD. There was insufficient evidence support or refute the value of exercise in reducing falls or depression. This review found evidence of the potential benefits of exercise for people with PD, although further good quality research is needed. Questions remain around the optimal content of exercise interventions (dosing, component exercises) at different stages of the disease.

Goodwin, VA, et al. An exercise intervention to prevent falls in people with Parkinson’s disease: a pragmatic randomized controlled trial. Journal of Neurology, Neurosurgery and Psychiatry with practical neurology. 2011;82: 1232-8. Abstract: Objective: To compare the effectiveness of an exercise programme with usual care in people with Parkinson's disease (PD) who have a history of falls. Design: Pragmatic randomised controlled trial. Setting: Recruitment was from three primary and four secondary care organisations, and PD support groups in South West England. The intervention was delivered in community settings. Participants: People with PD, with a history of two or more falls in the previous year, who were able to mobilise independently. Intervention: 10 week, physiotherapy led, group delivered strength and balance training programme with supplementary home exercises (intervention) or usual care (control). Main Outcome Measure: Number of falls during the (a) 10 week intervention period and (b) the 10 week follow-up period. Results: 130 people were recruited and randomised (64 to the intervention; 66 to usual care). Seven participants (5.4%) did not complete the study. The incidence rate ratio for falls was 0.68 (95% CI 0.43 to 1.07, p=0.10) during the intervention period and 0.74 (95% CI 0.41 to 1.33, p=0.31) during the follow-up period. Statistically significant between group differences were observed in Berg balance, Falls Efficacy Scale-International scores and recreational physical activity levels. Conclusions: The study did not demonstrate a statistically significant between group difference in falls although the difference could be considered clinically significant. However, a type 2 error cannot be ruled out. The findings from this trial add to the evidence base for physiotherapy and exercise in the management of people with PD.