Blunted Maximal and Submaximal Responses to Cardiopulmonary Exercise Tests in Patients With Parkinson Disease

Vagus nerve stimulation in Parkinson's disease: a scoping review of animal studies and human subjects research

Parkinson's Disease (PD) is a prevalent, progressive neurodegenerative disease with motor and non-motor symptoms. Vagus Nerve Stimulation (VNS) has emerged as a potential therapeutic approach for PD, but published research on this topic varies widely. This scoping review maps existing literature on VNS for PD, highlighting stimulation methods, operational parameters, safety profiles, neurophysiological mechanisms, and clinical outcomes in human and animal models. Online databases were used to identify 788 papers published between 2013 and 2023, from which 17 publications on invasive and non-invasive VNS in PD were selected. Studies showed high variability in VNS parameters and study design. Evidence in animal models and human subjects suggests potential neurophysiological effects on PD-related pathology and motor function improvements. However, significant gaps in the literature remain. Future research should include rigorous reporting of study design, standardization of stimulation parameters, and larger sample sizes to ultimately facilitate translation of VNS into clinical practice.

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.

Pushing the limit to reach meaningful change: the impact of intensity-driven exercise on clinical outcomes for individuals with Parkinson's disease. A single-subject design

PURPOSE

Parkinson's disease creates an inability to perform previous learned autonomic tasks, such as walking, which worsens with disease progression. Recommendations to incorporate exercise at moderate to high intensities for this population has been established but there is limited knowledge about its impact on clinical based outcomes. The purpose of this research is to investigate the effectiveness of a 6-week intensity-driven walking program on clinical-based outcomes in individuals with PD.

MATERIALS/METHODS

Five individuals with PD were recruited for this single-subject withdrawal design (A-B-A-B) study. 6-minute walk performance and other core neurological measures of gait were collected. Intervention phases incorporated a 30-minute individualized intensity-driven treadmill walking program practiced at 65% or more of ones maximum heart rate. Increased treadmill speed, incline, and resistance were manipulated to reach the target heart rate zone.

RESULTS

6-minute walk test within condition visual analysis demonstrated a therapeutic change during intervention phases and a countertherapeutic change during withdraw periods for all 5 individuals. An abrupt therapeutic effect was demonstrated for all individuals between conditions with the percent of nonoverlapping data ranging from 70-90%. Band method analysis revealed a range of 9-19 sessions two standard deviations above baseline mean performances for all individuals.

CONCLUSION

To achieve sufficient walking performance, gait practiced at higher intensity levels may provide the optimal solution as an adjunct to standard care for individuals with PD who want to improve their walking.

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.

Association between autonomic dysfunction with motor and non-motor symptoms in patients with Parkinson's disease

To investigate the association between autonomic dysfunction (AutD) and motor as well as non-motor symptoms (NMS) in patients with Parkinson's disease (PD). Fifty-three PD patients were divided into two groups based on the number of domains affected by AutD: a multi-domain AutD group (AutD-M) and a single-domain AutD group (AutD-S), as evaluated using the Scale for Outcomes in Parkinson's disease-Autonomic (SCOPA-AUT), which assesses autonomic symptoms, one of the NMS. A comprehensive comparison was conducted between the two groups, including clinical measures such as clinical scales, quantitative evaluations of motor function and exercise capacity. Spearman correlation analysis was employed to investigate the relationship between AutD severity and PD symptoms. Additionally, we performed multiple linear regression model analysis to determine whether associations between SCOPA-AUT scores and clinical assessments remained significant after adjusting for Hoehn and Yahr stage, sex, and age. PD patients in the AutD-M group exhibited significantly more severe NMS and motor symptoms compared to those in the AutD-S group. In correlation analysis, SCOPA-AUT scores showed significant correlations with multiple clinical symptoms, such as most of the NMS, 10-MWT and CPET parameters. Furthermore, regression analysis also revealed that more pronounced fatigue, anxiety, depressive symptoms, worse walking speed and impaired exercise capacity were associated with higher SCOPA-AUT scores. The presence of AutD is correlated with emotional disturbances, decreased exercise endurance, and impaired gait function in patients with PD. Early management of AutD may prove beneficial in alleviating some NMS and motor symptoms in PD.

Use of a Home-Based, Commercial Exercise Platform to Remotely Monitor Aerobic Exercise Adherence and Intensity in People With Parkinson Disease

OBJECTIVE

Physical therapists are well-positioned to prescribe exercise outside of a clinical setting to promote positive health behaviors in people with Parkinson disease (PD). Traditionally, a barrier to precise exercise prescription has been reliance on participant self-reported exercise adherence and intensity. Home-based, commercially available exercise platforms offer an opportunity to remotely monitor exercise behavior and facilitate adherence based on objective performance metrics. The primary aim of this project was to characterize the feasibility and processes of remote aerobic exercise data monitoring from a home-based, commercially available platform in individuals participating in the 12-month Cyclical Lower Extremity Exercise for PD II (CYCLE-II) randomized clinical trial. Secondary aims focused on using exercise behavior to classify the cohort into exercise archetypes and describing a shared decision-making process to facilitate exercise adherence.

METHODS

Data from each exercise session were extracted, visualized, and filtered to ensure ride integrity. Weekly exercise frequency was used to determine exercise archetypes: Adherent (2-4 exercise sessions per week), Over-adherent (>4 exercise sessions per week), and Under-adherent (<2 exercise sessions per week).

RESULTS

A total of 123 people with PD completed 22,000+ exercise sessions. Analysis of exercise frequency indicated that 79% of participants were adherent; 8% were over-adherent; and 13% were under-adherent. Three case reports illustrate how shared decision-making with the use of exercise performance data points guided exercise prescription.

CONCLUSIONS

The number of exercise sessions and completeness of the data indicate that people with PD were able to utilize a commercial, home-based exercise platform to successfully engage in long-term aerobic exercise. Physical therapists can use objective data as a part of a shared decision-making process to facilitate exercise adherence.

IMPACT

Commercially available exercise platforms offer a unique approach for physical therapists to monitor exercise behavior outside of a clinical setting. The methods used in this project can serve as a roadmap to utilizing data from consumer-based platforms.

Chronotropic Incompetence During Exercise Testing as a Marker of Autonomic Dysfunction in Individuals with Early Parkinson's Disease

BACKGROUND

An attenuated heart rate response to exercise, termed chronotropic incompetence, has been reported in Parkinson's disease (PD). Chronotropic incompetence may be a marker of autonomic dysfunction and a cause of exercise intolerance in early stages of PD.

OBJECTIVE

To investigate the relationship between chronotropic incompetence, orthostatic blood pressure change (supine - standing), and exercise performance (maximal oxygen consumption, VO2peak) in individuals with early PD within 5 years of diagnosis not on dopaminergic medications.

METHODS

We performed secondary analyses of heart rate and blood pressure data from the Study in Parkinson's Disease of Exercise (SPARX).

RESULTS

128 individuals were enrolled into SPARX (63.7±9.3 years; 57.0% male, 0.4 years since diagnosis [median]). 103 individuals were not taking chronotropic medications, of which 90 had a normal maximal heart rate response to exercise testing (155.3±14.0 bpm; PDnon-chrono) and 13 showed evidence of chronotropic incompetence (121.3±11.3 bpm; PDchrono, p < 0.05). PDchrono had decreased VO2peak compared to PDnon-chrono (19.7±4.5 mL/kg/min and 24.3±5.8 mL/kg/min, respectively, p = 0.027). There was a positive correlation between peak heart rate during exercise and the change in systolic blood pressure from supine to standing (r = 0.365, p < 0.001).

CONCLUSIONS

A subgroup of individuals with early PD not on dopaminergic medication had chronotropic incompetence and decreased VO2peak, which may be related to autonomic dysfunction. Evaluation of both heart rate responses to incremental exercise and orthostatic vital signs may serve as biomarkers of early autonomic impairment and guide treatment. Further studies should investigate whether cardiovascular autonomic dysfunction affects the ability to exercise and whether exercise training improves autonomic dysfunction.

Advice to People with Parkinson's in My Clinic: Exercise

There is compelling evidence that exercise must be part of main line therapy for people with Parkinson's disease. In this viewpoint, we outline the four key components of exercise: aerobic exercise, resistance exercise, flexibility exercise, and neuromotor exercises (posture, gait, balance, and agility) that can improve both motor and non-motor symptoms of the disease and, in the case of aerobic exercise, may delay the disease. We outline guidelines on how to change and optimize the exercise prescription at different stages of the disease.

Feasibility and effect of high-intensity training on the progression of motor symptoms in adult individuals with Parkinson's disease: A systematic review and meta-analysis

BACKGROUND

To determine the feasibility and effect of high-intensity interval training (HIIT) in individuals with Parkinson's and their effect on symptom modification and progression.

METHODS

We conducted this systematic review following the Preferred Reporting Items for systematic review and meta-analysis (PRISMA). All studies were searched in seven databases: MEDLINE (PubMed), Cochrane Central Register of Controlled Trials, Web of Science, EMBASE, SPORTDiscus, Virtual Health Library (VHL) and SCOPUS in September 2020 and updated in June 2023. The risk of bias was assessed by the Cochrane Collaboration tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. We used standardized mean difference (SMD) with a 95% confidence interval (CI) and random effects models, as well as the non-parametric Cochran's Q test and I2 inconsistency test to assess heterogeneity.

RESULTS

A total of 15 randomized clinical trials with 654 participants (mean age, 65.4 years). The majority of studies included high intensity training interventions versus moderate intensity, usual care, or control group. The meta-analysis comparing high-intensity exercise versus control group showed an improvement in the disease severity (MD = -4.80 [95%CI, -6.38; -3.21 high evidence certainty); maximum oxygen consumption (MD = 1.81 [95%CI, 0.36; 3.27] very low evidence certainty) and quality of life (MD = -0.54 [95%CI, -0.94; -0.13] moderate evidence certainty). The results showed that high-intensity exercise compared with moderate intensity exercise group showed a improve motor function and functional mobility measured by the TUG test (MD = -0.38 [95%CI, -0.91; 0.16] moderate evidence certainty) with moderate heterogeneity between studies.

CONCLUSION

High-intensity exercise performed in both continuous and interval modes when compared with control groups may provide motor function benefits for individuals with Parkinson's disease. HIIT may be feasible, but the intensity of the exercise may influence individuals with Parkinson's disease. However, there was a lack of evidence comparing high intensity and moderate intensity for this population, as the results showed heterogeneity.

Predictive Value of Exercise Blood Pressure Changes for Orthostatic Hypotension in Patients With Parkinson's Disease

BACKGROUND AND PURPOSE

Orthostatic hypotension (OH) is common in patients with Parkinson's disease (PD). Early recognition OH is required with sensitive assessments. The purpose of this study was to determine whether blood pressure (BP) changes during exercise can predict the occurrence of OH in PD.

METHODS

This prospective cohort study included 80 consecutive patients with PD. All patients agreed to participate in a baseline evaluation and cardiopulmonary exercise test (CPET). According to the initial active standing test (AST), those without OH (PD-nonOH) at baseline had their AST results followed up for 6 months. The main outcome was defined as whether patients without OH at baseline would develop OH after 6 months. Logistic regression analysis was applied to identify the relevant variables. A nomogram was constructed based on clinical features and identified variables. The concordance index (C-index) and area under the receiver operating characteristic curve (AUC) were used to evaluate the accuracy and predictive ability of the nomogram, respectively.

RESULTS

CPET results indicated that peak load, peak heart rate, heart rate recovery at 1 min, and systolic BP change (ΔSBP) were lower in those with OH than in the PD-nonOH group (p<0.05) at baseline. Logistic regression analysis indicated that peak load and ΔSBP during CPET had significant effects on OH (p<0.05). Age, sex, peak load, and ΔSBP were used to construct the nomogram model (C-index=0.761). The prediction model had an AUC of 0.782 (95% confidence interval=0.649-0.889) and a specificity and sensitivity of 70.0% and 81.8%, respectively.

CONCLUSIONS

This study has identified predictive factors for OH development in patients with PD. CPET could be used as a complementary examination to identify patients at a high risk of OH.

Study in Parkinson's disease of exercise phase 3 (SPARX3): study protocol for a randomized controlled trial

BACKGROUND

To date, no medication has slowed the progression of Parkinson's disease (PD). Preclinical, epidemiological, and experimental data on humans all support many benefits of endurance exercise among persons with PD. The key question is whether there is a definitive additional benefit of exercising at high intensity, in terms of slowing disease progression, beyond the well-documented benefit of endurance training on a treadmill for fitness, gait, and functional mobility. This study will determine the efficacy of high-intensity endurance exercise as first-line therapy for persons diagnosed with PD within 3 years, and untreated with symptomatic therapy at baseline.

METHODS

This is a multicenter, randomized, evaluator-blinded study of endurance exercise training. The exercise intervention will be delivered by treadmill at 2 doses over 18 months: moderate intensity (4 days/week for 30 min per session at 60-65% maximum heart rate) and high intensity (4 days/week for 30 min per session at 80-85% maximum heart rate). We will randomize 370 participants and follow them at multiple time points for 24 months. The primary outcome is the Movement Disorders Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor score (Part III) with the primary analysis assessing the change in MDS-UPDRS motor score (Part III) over 12 months, or until initiation of symptomatic antiparkinsonian treatment if before 12 months. Secondary outcomes are striatal dopamine transporter binding, 6-min walk distance, number of daily steps, cognitive function, physical fitness, quality of life, time to initiate dopaminergic medication, circulating levels of C-reactive protein (CRP), and brain-derived neurotrophic factor (BDNF). Tertiary outcomes are walking stride length and turning velocity.

DISCUSSION

SPARX3 is a Phase 3 clinical trial designed to determine the efficacy of high-intensity, endurance treadmill exercise to slow the progression of PD as measured by the MDS-UPDRS motor score. Establishing whether high-intensity endurance treadmill exercise can slow the progression of PD would mark a significant breakthrough in treating PD. It would have a meaningful impact on the quality of life of people with PD, their caregivers and public health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04284436 . Registered on February 25, 2020.

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.

Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association

A clinical practice guideline on Parkinson disease was developed by an American Physical Therapy Association volunteer guideline development group that consisted of physical therapists and a neurologist. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for management of Parkinson disease. The Spanish version of this clinical practice guideline is available as a supplement (Suppl. Appendix 1).

Effectiveness of a Long-Term, Home-Based Aerobic Exercise Intervention on Slowing the Progression of Parkinson Disease: Design of the Cyclical Lower Extremity Exercise for Parkinson Disease II (CYCLE-II) Study

OBJECTIVE

Previous short duration studies have demonstrated that high-intensity aerobic exercise improves aspects of motor and non-motor function in people with Parkinson disease (PwPD); however, the effectiveness of a long-term exercise intervention on slowing disease progression is unknown. The primary aim of this study is to determine the disease-altering effects of high-intensity aerobic exercise, administered on an upright stationary cycle, on the progression of PD. A secondary aim is to develop a prognostic model for 12-month changes in the Movement Disorder Society Unified Parkinson's Disease Rating Scale III (MDS-UPDRS III) of PwPD undergoing an aerobic exercise intervention.

METHODS

This pragmatic, multisite, single-rater blinded, randomized controlled trial will recruit PwPD from 2 large, urban, academic medical centers. Participants (N = 250 PwPD) will be randomized to (1) home-based aerobic exercise or (2) usual and customary care. Those in the aerobic exercise arm will be asked to complete in-home aerobic exercise sessions at 60% to 80% of heart rate reserve 3 times per week for 12 months utilizing a commercially available upright exercise cycle. The usual and customary care group will continue normal activity levels. Daily activity will be monitored for both groups throughout the 12-month study period. The primary outcome, both to assess disease-modifying response to aerobic exercise and for prognostic modeling in the aerobic exercise arm, is 12-month rate of change in the MDS-UPDRS III. Clinical and biomechanical measures will also be used to assess upper and lower extremity motor function as well as non-motor functions.

IMPACT

Should long-term aerobic exercise demonstrate disease-modifying capability, this study will provide evidence that "Exercise is Medicine" for PwPD. Further, the derived prognostic model will inform a patient-specific exercise prescription for PwPD and expected effects on PD progression.

Acute Cardiovascular Responses to Self-selected Intensity Exercise in Parkinson's Disease

Parkinson's disease patients frequently present cardiovascular dysfunction. Exercise with a self-selected intensity has emerged as a new strategy for exercise prescription aiming to increase exercise adherence. Thus, the current study evaluated the acute cardiovascular responses after a session of aerobic exercise at a traditional intensity and at a self-selected intensity in Parkinson's disease patients. Twenty patients (≥ 50 years old, Hoehn & Yahr 1-3 stages) performed 3 experimental sessions in random order: Traditional session (cycle ergometer, 25 min, 50 rpm, 60-80% maximum heart rate); Self-selected intensity: (cycle ergometer, 25 min, 50 rpm with self-selected intensity); and Control session (resting for 25 min). Before and after 30 min of intervention, brachial and central blood pressure (auscultatory method and pulse wave analysis, respectively), cardiac autonomic modulation (heart rate variability), and arterial stiffness (pulse wave analysis) were evaluated. Brachial and central systolic and diastolic blood pressure, heart rate, and the augmentation index increased after the control session, whereas no changes were observed after the exercise sessions (P<0.01). Pulse wave velocity and cardiac autonomic modulation parameters did not change after the three interventions. In conclusion, a single session of traditional intensity or self-selected intensity exercises similarly blunted the increase in brachial and central blood pressure and the augmentation index compared to a non-exercise control session in Parkinson's disease patients.

Individuals With Parkinson Disease Are Adherent to a High-Intensity Community-Based Cycling Exercise Program

BACKGROUND AND PURPOSE

Parkinson disease is a progressive neurological disorder with no known cure or proven method of slowing progression. High-intensity, laboratory-based aerobic exercise interventions are currently being pursued as candidates for altering disease progression. The aim of this project was to evaluate the translation of a laboratory-based intervention to the community by monitoring exercise adherence (eg, attendance) and intensity (eg, heart rate [HR] and cadence) in 5 established Pedaling for Parkinson's exercise classes. A secondary aim was to determine the impact of disease severity and demographics variables on exercise adherence.

METHODS

A 12-month pragmatic design was utilized to monitor attendance, HR, and cadence during each Pedaling for Parkinson's class session. Over the course of 1 year, approximately 130 sessions were offered. Forty-nine (n = 30 males) persons with mild to moderate Parkinson disease from 5 community fitness facilities participated.

RESULTS

Out of the approximately 130 cycling sessions offered at each site over 12 months, 37% of the participants attended greater than 2 classes per week (80-130 total sessions), 47% attended 1 to 1.9 classes per week (40-79 total sessions), and less than 17% attended less than 1 class per week (<40 total sessions). Average pedaling cadence was 74.1 ± 9.6 rpms while average percentage of HR maximum was 68.9 ± 12.0%. There were no significant differences between cycling adherence and intensity variables based on disease severity, age, or sex.

DISCUSSION AND CONCLUSIONS

Consistent attendance and exercise performance at moderate to high intensities are feasible in the context of a community-based Pedaling for Parkinson's class. Consistency and intensity of aerobic exercise have been proposed as critical features to elicit potential disease modification benefits associated with exercise. Community-based fitness programs that bring laboratory protocols to the "real world" are a feasible intervention to augment current Parkinson disease treatment approaches. See the Supplementary Video, available at: http://links.lww.com/JNPT/A357.

Hemodynamic response to exercise is impaired in individuals with Parkinson's disease

PURPOSE

To assess hemodynamic and cardiac autonomic response to high-intensity interval exercise (HIIE) versus moderate-intensity continuous exercise (MICE) in individuals with Parkinson's disease (PD).

METHODS

12 individuals (six men) with PD were randomly assigned to perform HIIE (4 min of warm-up followed by 21 min alternating 1 min at levels 15-17 with 2 min at levels 9-11 of rating of perceived exertion [RPE] in a cycle ergometer), MICE (4 min of warm-up followed by 26 min at levels 11-14 of RPE in a cycle ergometer) and control (CON; 30 min of sitting rest) interventions in separate days. Heart rate (HR), blood pressure (BP), endothelial reactivity and heart rate variability (HRV) were assessed before, immediately after and 45 min after each intervention. HR and exercise workload were measured during each intervention.

RESULTS

Despite the within (high- vs. low-intensity intervals of HIIE) and between (HIIE vs. MICE) differences in workload during exercise sessions, HR was not different between high- (average HR = 98±18 bpm) and low-intensity (average HR 97±19 bpm) intervals of HIIE, as well as between HIIE (average HR = 97±18 bpm) and MICE (average HR = 93±19 bpm) throughout the exercise. There were significant, but small, increases (P < 0.01) in HR and systolic BP at post HIIE and MICE, which returned to levels similar to pre-intervention during recovery. There were no within- and betweenintervention differences in diastolic BP, endothelial reactivity and HRV.

CONCLUSIONS

The present results suggest that hemodynamic response to exercise is impaired in individuals with PD.

Cardiovascular, perceived exertion and affective responses during aerobic exercise performed with imposed and a self-selected intensity in patients with Parkinson's disease

BACKGROUND

Exercise with self-selected intensity (SSI) has emerged as a new strategy for exercise prescription aiming to increase exercise adherence in Parkinson's disease (PD).

OBJECTIVE

We compared the cardiovascular, perceived exertion and affective responses during traditional aerobic exercise and with SSI in PD.

METHODS

Twenty patients with PD performed two aerobic exercise sessions in random order with an interval of at least 72 h between them: Traditional session (cycle ergometer, 25 min, 50 rpm) with imposed intensity (II) (60-80% maximum heart rate [HR]) and SSI: (cycle ergometer, 25 min, 50 rpm) with SSI. The HR (Polar V800 monitor), systolic blood pressure (auscultatory method), rating of perceived exertion (Borg scale 6-20) and affective responses (feeling scale) were assessed during the exercise at 8th and 18th minute. The Generalized Estimating Equation Model was used for comparison between both sessions (P < 0.05).

RESULTS

The exercise intensity was not significantly different between both exercise sessions (8th minute: II -76.3±1.0 vs. SSI -76.5±1.3 % of maximal HR; 18th minute: II -78.9±0.9 vs. SSI -79.1±1.3 % of maximal HR, p = 0.93). Blood pressure, perceived exertion and affective responses were also not significantly different between both sessions (P > 0.05).

CONCLUSIONS

Cardiovascular and psychophysiological responses were not different during aerobic exercise performed with II and with SSI in patients with PD.

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.

Effects of resistance training on metabolic and cardiovascular responses to a maximal cardiopulmonary exercise test in Parkinson`s disease

Objective:

To evaluate the effects of resistance training on metabolic and cardiovascular responses during maximal cardiopulmonary exercise testing in patients with Parkinson’s disease.

Methods:

Twenty-four patients with Parkinson’s disease (modified Hoehn and Yahr stages 2 to 3) were randomly assigned to one of two groups: Control or Resistance Training. Patients in the Resistance Training Group completed an exercise program consisting of five resistance exercises (two to four sets of six to 12 repetitions maximum per set) twice a week. Patients in the Control Group maintained their usual lifestyle. Oxygen uptake, systolic blood pressure and heart rate were assessed at rest and during cycle ergometer-based maximal cardiopulmonary exercise testing at baseline and at 12 weeks. Assessments during exercise were conducted at absolute submaximal intensity (slope of the linear regression line between physiological variables and absolute workloads), at relative submaximal intensity (anaerobic threshold and respiratory compensation point) and at maximal intensity (maximal exercise). Muscle strength was also evaluated.

Results:

Both groups had similar increase in peak oxygen uptake after 12 weeks of training. Heart rate and systolic blood pressure measured at absolute and relative submaximal intensities and at maximal exercise intensity did not change in any of the groups. Muscle strength increased in the Resistance Training but not in the Control Group after 12 weeks.

Conclusion:

Resistance training increases muscle strength but does not change metabolic and cardiovascular responses during maximal cardiopulmonary exercise testing in patients with Parkinson’s disease without cardiovascular comorbidities.

Autonomic Function in Patients With Parkinson's Disease: From Rest to Exercise

Parkinson’s disease (PD) is a common neurodegenerative disorder classically characterized by symptoms of motor impairment (e.g., tremor and rigidity), but also presenting with important non-motor impairments. There is evidence for the reduced activity of both the parasympathetic and sympathetic limbs of the autonomic nervous system at rest in PD. Moreover, inappropriate autonomic adjustments accompany exercise, which can lead to inadequate hemodynamic responses, the failure to match the metabolic demands of working skeletal muscle and exercise intolerance. The underlying mechanisms remain unclear, but relevant alterations in several discrete central regions (e.g., dorsal motor nucleus of the vagus nerve, intermediolateral cell column) have been identified. Herein, we critically evaluate the clinically significant and complex associations between the autonomic dysfunction, fatigue and exercise capacity in PD.

Effect of Aerobic Exercise on Cardiopulmonary Responses and Predictors of Change in Individuals With Parkinson's Disease

OBJECTIVE

To determine the effect of aerobic exercise on maximal and submaximal cardiopulmonary responses and predictors of change in individuals with Parkinson's disease (PD).

DESIGN

Single-center, parallel-group, rater-blind study.

SETTING

Research laboratory.

PARTICIPANTS

Individuals with mild to moderate PD (N=100).

INTERVENTION

Participants were enrolled in a trial evaluating the effect of cycling on PD and randomized to either voluntary exercise (VE), forced exercise (FE), or a no exercise control group. The exercise groups were time and intensity matched and exercised 3×/wk for 8 weeks on a stationary cycle.

MAIN OUTCOME MEASURES

Cardiopulmonary responses were collected via gas analysis during a maximal graded exercise test at baseline and post intervention.

RESULTS

Exercise attendance was 97% and 93% for the FE and VE group, respectively. Average exercise heart rate reserve was 67%±11% for FE and 70%±10% for VE. No significant difference was present for change in peak oxygen consumption (VO₂peak) post intervention, even though the FE group had a 5% increase in VO₂peak. Both the FE and VE groups had significantly higher percentage oxygen consumption per unit time (V˙o₂) at ventilator threshold (VT) than the control group compared with baseline values (P=.04). Mean V˙O₂ at VT was 5% (95% CI, 0.1%-11%) higher in the FE group (P=.04) and 7% (2%, 12%) higher in VE group compared with controls. A stepwise linear regression model revealed that lower age, higher exercise cadence, and lower baseline VO₂peak were most predictive of improved VO₂peak. The overall model was found to be significant (P<.01).

CONCLUSIONS

Peak and submaximal cardiopulmonary function may improve after aerobic exercise in individuals with PD. Lower age, higher exercise cadence, and lower baseline VO₂peak were most predictive of improved VO₂peak in this exercise cohort. The improvements observed in aerobic capacity were gained after a relatively short aerobic cycling intervention.

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.

Altered cardiorespiratory regulation during exercise in patients with Parkinson's disease: A challenging non-motor feature

The incidence of Parkinson’s disease is increasing worldwide. The motor dysfunctions are the hallmark of the disease, but patients also experience non-motor impairments, and over 40% of the patients experience coexistent abnormalities, such as orthostatic hypotension. Exercise training has been suggested as a coping resource to alleviate Parkinson’s disease symptoms and delay disease progression. However, the body of knowledge is showing that the cardiovascular response to exercise in patients with Parkinson’s disease is altered. Adequate cardiovascular and hemodynamic adjustments to exercise are necessary to meet the metabolic demands of working skeletal muscle properly. Therefore, since Parkinson’s disease affects parasympathetic and sympathetic branches of the autonomic nervous system and the latter are crucial in ensuring these adjustments are adequately made, the understanding of these responses during exercise in this population is necessary. Several neural control mechanisms are responsible for the autonomic changes in the cardiovascular and hemodynamic systems seen during exercise. In this sense, the purpose of the present work is to review the current knowledge regarding the cardiovascular responses to dynamic and isometric/resistance exercise as well as the mechanisms by which the body maintains appropriate perfusion pressure to all organs during exercise in patients with Parkinson’s disease. Results from patients with Parkinson’s disease and animal models of Parkinson’s disease provide the reader with a well-rounded knowledge base. Through this, we will highlight what is known and not known about how the neural control of circulation is responding during exercise and the adaptations that occur when individuals exercise regularly.

Hemodynamic responses to an exercise stress test in Parkinson's disease patients without orthostatic hypotension

The presence of postganglionic sympathetic denervation is well established in Parkinson's disease (PD). Denervation at cardiac and blood vessel sites may lead to abnormal cardiovascular and hemodynamic responses to exercise. The aim of the present investigation was to examine how heart rate (HR) and hemodynamics are affected by an exercise test in PD patients without orthostatic hypotension. Thirty individuals without orthostatic hypotension, 14 individuals with PD, and 16 age-matched healthy controls performed an exercise test on a cycle ergometer. Heart rate, blood pressure, and other hemodynamic variables were measured in a fasted state during supine rest, active standing, exercise, and supine recovery. Peak HR and percent of age-predicted maximum HR (HR_max) achieved were significantly blunted in PD (p < 0.05, p < 0.01). HR remained significantly elevated in PD during recovery compared with controls (p = 0.03, p < 0.05). Systolic, diastolic, and mean arterial pressures were significantly lower at multiple time-points during active standing in PD compared with controls. Systemic vascular resistance index (SVRI) decreased significantly at the onset of exercise in PD, and remained significantly lower during exercise and the first minute of supine recovery. End diastolic volume index (EDVI) was significantly lower in PD during supine rest and recovery. Our results indicate for the first time that normal hemodynamics are disrupted during orthostatic stress and exercise in PD. Despite significant differences in EDVI at rest and during recovery, and SVRI during exercise, cardiac index was unaffected. Our finding of significantly blunted HR_max and HR recovery in PD patients has substantial implications for exercise prescription and recovery guidelines.

High-intensity interval training in people with Parkinson's disease: a randomized, controlled feasibility trial

OBJECTIVES:

To investigate whether people with Parkinson's disease can exercise at a high-intensity across a 12-week intervention and to assess the impact of the intervention on cardiorespiratory fitness.

DESIGN:

This is a randomized, controlled, feasibility study with waiting list control. Assessors were blinded to group allocation.

SETTING:

The intervention took place at an exercise centre and assessments at a district general hospital.

SUBJECTS:

This study included 20 people with idiopathic Parkinson's disease.

INTERVENTION:

A total of 36 exercise sessions over 12 weeks, with each session lasting ~45 minutes, were conducted.

MAIN MEASURES:

The main measures were maximal heart rates achieved during exercise, recruitment rate, attendance, drop-out, change in peak oxygen consumption, cardiac output, cognitive function and quality of life. The study was considered technically feasible if participants achieved ⩾85% of maximal heart rate during exercise.

RESULTS:

There were 12 male and 8 female participants; they had a mean age of 68.5 years (standard deviation 6.825). Two participants were of Hoehn and Yahr stage I, 11 stage II and 7 stage III. In all, 17 participants completed the intervention. The median (interquartile range) proportion of repetitions delivered across the intervention which met our high-intensity criterion was 80% (67% to 84%). Mean peak heart rate was 88.8% of maximal. Peak oxygen consumption increased by 2.8 mL kg^-1 min^-1 in the intervention group and 1.5 mL kg^-1 min^-1 in the control group after 12 weeks of exercise. We estimate that a fully powered randomized controlled trial would require 30 participants per group.

CONCLUSION:

High-intensity interval exercise is feasible in people with Parkinson's disease. Improvements in cardiorespiratory function are promising.

A Single Bout of Aerobic Exercise Improves Motor Skill Consolidation in Parkinson's Disease

Background: Motor learning is impaired in Parkinson’s disease (PD), with patients demonstrating deficits in skill acquisition (online learning) and consolidation (offline learning) compared to healthy adults of similar age. Recent studies in young adults suggest that single bouts of aerobic exercise (AEX), performed in close temporal proximity to practicing a new motor task, may facilitate motor skill learning. Thus, we aimed at investigating the effects of a single bout of aerobic cycling on online and offline learning in PD patients.

Methods: 17 PD patients (Hoehn and Yahr 1 – 2.5, age: 64.4 ± 6.2) participated in this crossover study. Immediately prior to practicing a novel balance task, patients either performed 30 min of (i) moderate intensity (60–70% VO_2max) aerobic cycling, or (ii) seated rest (order counterbalanced). The task required patients to stabilize a balance platform (stabilometer) in a horizontal position for 30 s. For each experimental condition, patients performed 15 acquisition trials, followed by a retention test 24 h later. We calculated time in balance (platform within ± 5° from horizontal) for each trial, and analyzed within- and between-subjects differences in skill acquisition (online learning) and skill retention (offline learning) using mixed repeated-measures ANOVA.

Results: We found that the exercise bout had no effect on performance level or online gains during acquisition, despite affecting the time course of skill improvements (larger initial and reduced late skill gains). Aerobic cycling significantly improved offline learning, as reflected by larger 24-h skill retention compared to the rest condition.

Conclusion: Our results suggest that a single bout of moderate-intensity AEX is effective in improving motor skill consolidation in PD patients. Thus, acute exercise may represent an effective strategy to enhance motor memory formation in this population. More work is necessary to understand the underlying mechanisms, the optimal scheduling of exercise, and the applicability to other motor tasks. Further, the potential for patients in later disease stages need to be investigated. The study was a priori registered at ClinicalTrials.gov (NCT03245216).

Blunted cardiovascular responses to exercise in Parkinson’s disease patients: role of the muscle metaboreflex

Patients with Parkinson’s disease (PD) exhibit attenuated cardiovascular responses to exercise. The underlying mechanisms that are potentially contributing to these impairments are not fully understood. Therefore, we sought to test the hypothesis that patients with PD exhibit blunted cardiovascular responses to isolated muscle metaboreflex activation following exercise. For this, mean blood pressure, cardiac output, and total peripheral resistance were measured using finger photoplethysmography and the Modelflow method in 11 patients with PD [66 ± 2 yr; Hoehn and Yahr score: 2 ± 1 a.u.; time since diagnosis: 7 ± 1 yr; means ± SD) and 9 age-matched controls (66 ± 3 yr). Measurements were obtained at rest, during isometric handgrip exercise performed at 40% maximal voluntary contraction, and during postexercise ischemia. Also, a cold pressor test was assessed to confirm that blunted cardiovascular responses were specific to exercise and not representative of generalized sympathetic responsiveness. Changes in mean blood pressure were attenuated in patients with PD during handgrip (PD: ∆25 ± 2 mmHg vs. controls: ∆31 ± 3 mmHg; P < 0.05), and these group differences remained during postexercise ischemia (∆17 ± 1 mmHg vs. ∆26 ± 1 mmHg, respectively; P < 0.01). Additionally, changes in total peripheral resistance were attenuated during exercise and postexercise ischemia, indicating blunted reflex vasoconstriction in patients with PD. Responses to cold pressor test did not differ between groups, suggesting no group differences in generalized sympathetic responsiveness. Our results support the concept that attenuated cardiovascular responses to exercise observed in patients with PD are, at least in part, explained by an altered skeletal muscle metaboreflex.

NEW & NOTEWORTHY Patients with Parkinson’s disease (PD) presented blunted cardiovascular responses to exercise. We showed that cardiovascular response evoked by the metabolic component of the exercise pressor reflex is blunted in patients with PD. Furthermore, patients with PD presented similar pressor response during the cold pressor test compared with age-matched controls. Altogether, our results support the hypothesis that attenuated cardiovascular responses to exercise observed in patients with PD are mediate by an altered skeletal muscle metaboreflex.

Exercise response in Parkinson's disease: insights from a cross-sectional comparison with sedentary controls and a per-protocol analysis of a randomised controlled trial

OBJECTIVES

To investigate the acute and adaptation cardiovascular and metabolic training responses in people with Parkinson's disease (pwP).

DESIGN

(1) A cross-sectional study of exercise response of pwP compared with sedentary controls and (2) an interventional study of exercise training in pwP.

SETTING

Community leisure facilities.

PARTICIPANTS

pwP (n=83) and sedentary controls (n=55).

INTERVENTIONS

Study 1 included participants from a two-arm-parallel single-blind phase II randomised controlled trial (RCT), that undertook a baseline maximal incremental exercise test and study 2 included those randomised to the exercise group in the RCT, who completed a 6-month weekly exercise programme (n=37). The intervention study 2 was a prescribed exercise program consisting of sessions lasting 60 min, two times a week over a 6-month period. The control group followed the same protocol which derived the same cardiorespiratory parameters, except that they were instructed to aim for a cadence of ~60 revolutions per minute and the unloaded phase lasted 3 min with an initial step of 25 W.

PRIMARY AND SECONDARY OUTCOME MEASURES

Stepwise incremental exercise test to volitional exhaustion was the primary outcome measure.

RESULTS

Study 1 showed higher maximum values for heart rate (HR), VO₂ L/min, VCO₂ L/min and ventilation L/min for the control group; respiratory exchange ratio (RER), perceived exertion and O₂ pulse (VO₂ L/min/HR) did not differ between groups. In study 2, for pwP who adhered to training (n=37), RER increased significantly and although there was no significant change in aerobic capacity or HR response, reduced blood pressure was found.

CONCLUSIONS

An abnormal cardiovascular response to exercise was observed in pwP compared to controls. After the exercise programme, metabolic deficiencies remained for pwP. These observations add to the pathogenic understanding of PD, acknowledge an underling metabolic contribution and support that certain cardiovascular symptoms may improve as a result of this type of exercise.