A Tandem Cycling Program: Feasibility and Physical Performance Outcomes in People With Parkinson Disease

The impact of cycling on the physical and mental health, and quality of life of people with disabilities: a scoping review

Adaptive cycling holds potential for promoting physical and mental health among individuals with disabilities, who often face barriers to traditional cycling and other forms of exercise. This scoping review systematically examines existing scientific literature to assess the effects of adaptive cycling on the physical and mental health of individuals with disabilities. Following a widely recognized methodological scoping review framework, 35 qualitative and quantitative studies were identified through comprehensive database searches and manual screenings. The review highlights the positive impacts of adaptive cycling on cardiovascular fitness, muscle strength, and overall physical well-being, as well as improvements in mental health and quality of life. Despite these benefits, significant research gaps remain, particularly concerning adaptive cycling modalities, such as sociable cycles, chair transporters, and power-assisted bikes, which were underrepresented in the existing literature. This review underscores the need for further studies to provide a comprehensive understanding on the effects of different adaptive cycling modalities. Such studies are essential to improve accessibility and ultimately support the health and social inclusion of individuals with disabilities.

Treadmill intervention attenuates motor deficit with 6-OHDA-induced Parkinson's disease rat via changes in lipid profiles in brain and muscle

One of the key hallmarks of Parkinson's disease is the disruption of lipid homeostasis in the brain, which plays a critical role in neuronal membrane integrity and function. Understanding how treadmill training impacts lipid restructuring and its subsequent influence on motor function could provide a basis for developing targeted non-pharmacological interventions for individuals living with early stage of PD. This study aims to investigate the effects of a treadmill training intervention on motor deficits induced by 6-OHDA in rats model of PD. PD was induced by injecting 6-hydroxy dopamine (6-OHDA) into the medial forebrain bundle (MFB). For 10 weeks, rats underwent treadmill training on a four-lane motorized treadmill. Motor function deficits were evaluated through behavioral tests. Lipidomic analysis was performed through ultrahigh-performance liquid chromatography-tandem mass spectrometry (UPLC MS/MS). Treadmill intervention significantly improved motor function and restored altered brain and muscle lipid profiles in PD rats. Among the lipid species identified in PD rats, brain abundance was highest for phosphatidylethanolamine (PE), correlating positively with the beam-walking scores; muscle abundance peaked with lysophosphatidylethanolamine (LysoPE), correlating positively with grip strength scores. In the brain, the levels of diacylglycerol (DG), triacylglycerol (TG), and lysophosphatidylcholine (PC) correlated positively with grip strength and rotarod scores, while only phosphatidylethanolamine (PE) linked to beam-walking scores. In the muscle, the levels of phosphatidylinositol (PI), lysophosphatidylethanolamine (PE), lysophosphatidic acid (PA), ceramide (Cer), and ganglioside were positively correlated with grip strength and rotarod scores. In conclusion, treadmill may protect the cortex, mitigating motor deficits via change lipid profiles in the brain and muscle.

The Feasibility and Efficacy of a Virtual Reality Tandem Cycling Program for Persons with Parkinson's Disease and Their Care Partners

INTRODUCTION

Persons with Parkinson's disease (PwPD) suffer from motor and non-motor symptoms which significantly affect their quality of life (QoL), and the QoL of their care partners (CP). Tandem cycling reduces PwPD motor symptoms; however, no studies have examined other benefits or included PwPD CP. We conducted an 8-week community virtual reality (VR) tandem cycling intervention to assess the feasibility and efficacy for PwPD and their CP (i.e., PD dyads). We hypothesized that dyadic tandem cycling would improve (1) PwPD motor and non-motor symptoms and (2) dimensions of PD dyads' QoL and physiologic health.

METHODS

Ten PD dyads were recruited to complete 8 weeks of progressive intensity, bi-weekly tandem cycling. At pre- and post-testing, PwPD were assessed using the Movement Disorder Society-Unified Parkinson's Disease Rating Scale-III (MDS-UPDRS-III), functional gait assessment (FGA), and 10-m gait speed test. PD dyads also completed emotional and cognitive status questionnaires [e.g., Geriatric Depression Scale-Short Form (GDS-SF)], and wore BodyGuard 2 heart rate (HR) monitors for 48 h to assess surrogate measures of heart rate variability. Statistical analyses were conducted using Student's t tests with significance set at p ≤ 0.05.

RESULTS

Eight PD dyads and one PwPD completed the intervention. Retention of PwPD (90%) and CP (80%) was adequate, and PD dyad adherence ranged from 91.67 to 97.91%. PwPD demonstrated significant clinical improvements in MDS-UPDRS-III scores (- 7.38, p < 0.01), FGA scores (+ 3.50, p < 0.01), and 10-m gait speed times (+ 0.27 m/s, p < 0.01), in addition to significant self-reported improvements in mobility (- 13.61, p = 0.02), fatigue (- 5.99, p = 0.02), and social participation (+ 4.69, p < 0.01). CP depressive symptoms significantly decreased (- 0.88, p = 0.02), and PD dyads shared a significant increase in root mean square of the successive differences (RMSSD; p = 0.04).

CONCLUSION

Our pilot study demonstrated feasibility and multiple areas of efficacy supporting further investigation of community VR tandem cycling as a therapeutic intervention for PD dyads.

Bicycling for Rehabilitation of Persons With Parkinson Disease: A Scoping Review

BACKGROUND AND PURPOSE

Exercise is beneficial for persons with Parkinson disease (PwPD). The overarching purpose of this scoping review was to provide guidance to clinicians and scientists regarding current evidence for bicycling exercise for PwPD. A scoping review was conducted to examine the heterogeneous literature on stationary bicycling for PwPD to reduce motor symptoms and body function structure impairments, improve activities and motor performance, and reduce disease severity.

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines were followed. PubMed, CINAHL, and PEDro were searched from inception to January 23, 2023. Articles reporting original data on relevant outcome measures were included. Search results were screened and articles were extracted. Data were analyzed quantitatively with percentages of significant and clinically meaningful findings and qualitatively to extract themes.

RESULTS

Bicycling was categorized using bicycle types (assisted, nonassisted) and training modes (speed, aerobic, force). A high percentage of the 34 studies showed statistical significance for reducing motor symptoms (83%), body function structure impairments (78%), disease severity (82%), and improving activities (gait 72%, balance 60%). Clinically meaningful findings were achieved in 71% of the studies for reduction in disease severity and in 50% for improving gait.

DISCUSSION AND CONCLUSIONS

The literature on bicycling for PwPD has evolved from speed to aerobic studies. The terminology describing types of bicycling was simplified. Of all the outcomes reported, reduction of disease severity achieved the highest frequency of clinical meaningful improvements. Bicycling was comparable with other forms of aerobic training for walking speed and endurance. Opportunities for translation to practice and research are presented.

A backward cycling programme for people with Parkinson's disease: a feasibility and preliminary results study

OBJECTIVE

To assess the feasibility of backward cycling for people with Parkinson's disease. Secondary objectives were to assess changes in gait and balance following a 6-week program.

DESIGN

A single-group prospective pre-test, post-test study with 1-month follow-up.

SUBJECTS/PATIENTS

Twenty-six people with Parkinson's disease (mean age: 69 (7.74) years, gender: 83% males, time since diagnosis: 6 (4.44) years).

METHODS

Participants pedaled backward on a stationary bicycle for 30 minutes at moderate intensity twice a week for 6 weeks. Feasibility was assessed by acceptability, suitability, and burden. Data collected at pre- and post-intervention with 1-month follow-up included backward stepping response variables, forward/backward gait variables, Mini-Balance Evaluation Systems Test (MBT), and 6 Minute Walk Test.

RESULTS

There was a high retention rate (95.8%) and adherence rate (100%) with one adverse event and minimal burden. Significant improvements were seen in step count and excursion distance during backward stepping responses, forward and backward gait velocity, forward step length, and the Mini-BESTest.

CONCLUSION

Backward cycling was a feasible intervention for people with Parkinson's disease, demonstrating low burden with high retention and adherence rates, and it is a safe exercise with the potential for benefits in gait and balance variables.

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.

Development and Evaluation of Wireless Interfaces to Monitor and Control Cycling Exercise During Home Telerehabilitation

Purpose

This paper focuses on developing and testing three versions of interactive bike (iBikE) interfaces for remote monitoring and control of cycling exercise sessions to promote upper and lower limb rehabilitation.

Methods

Two versions of the system, which consisted of a portable bike and a tablet PC, were designed to communicate through either Bluetooth low energy (BLE) or Wi-Fi interfaces for real-time monitoring of exercise progress by both the users and their clinical team. The third version of the iBikE system consisted of a motorized bike and a tablet PC. It utilized conventional Bluetooth to implement remote control of the motorized bike's speed during an exercise session as well as to provide real-time visualization of the exercise progress. We developed three customized tablet PC apps with similar user interfaces but different communication protocols for all the platforms to provide a graphical representation of exercise progress. The same microcontroller unit (MCU), ESP-32, was used in all the systems.

Results

Each system was tested in 1-minute exercise sessions at various speeds. To evaluate the accuracy of the measured data, in addition to reading speed values from the iBikE app, the cycling speed of the bikes was measured continuously using a tachometer. The mean differences of averaged RPMs for both data sets were calculated. The calculated values were 0.38 ± 0.03, 0.25 ± 0.27, and 6.7 ± 3.3 for the BLE system, the Wi-Fi system, and the conventional Bluetooth system, respectively.

Conclusion

All interfaces provided sufficient accuracy for use in telerehabilitation.

Community-based high-intensity cycling improves disease symptoms in individuals with Parkinson's disease: A six-month pragmatic observational study

Participation in supervised, laboratory-based aerobic exercise protocols holds promise in slowing the progression of Parkinson's disease (PD). Gaps remain regarding exercise adherence and effectiveness of laboratory protocols translated to community-based programs. The aim of the project was to monitor exercise behaviour and evaluate its effect on disease progression over a 6 month period in people with PD participating in a community-based Pedalling for Parkinson's (PFP) cycling program. A pragmatic, observational study design was utilised to monitor exercise behaviour at five community sites. The Movement Disorders Society-Unified Parkinson's disease Rating Scale Motor III (MDS-UPDRS-III) and other motor and non-motor outcomes were gathered at enrollment and following 6 months of exercise. Attendance, heart rate, and cadence data were collected for each exercise session. On average, people with PD (N = 41) attended nearly 65% of the offered PFP classes. Average percent of age-estimated maximum heart rate was 69.3 ± 11.9%; average cadence was 74.9 ± 9.0 rpms. The MDS-UPDRS III significantly decreased over the 6-month exercise period (37.2 ± 11.7 to 33.8 ± 11.7, p = 0.001) and immediate recall significantly improved (42.3 ± 12.4 to 47.1 ± 12.7, p = 0.02). Other motor and non-motor metrics did not exhibit significant improvement. Participants who attended ~74% or more of available PFP classes experienced the greatest improvement in MDS-UPDRS III scores; of those who attended less than 74% of classes, cycling greater than or equal to 76 rpms lead to  improvement. Attendance and exercise intensity data indicated that a laboratory-based exercise protocol can be successfully translated to a community setting. Consistent attendance and pedalling at a relatively high cadence may be key variables to PD symptom mitigation. Improvement in clinical ratings coupled with lack of motor and non-motor symptom progression over 6 months provides rationale for further investigation of the real-world, disease-modifying potential of aerobic exercise for people with PD.

Split-Belt Adaptation and Savings in People With Parkinson Disease

BACKGROUND AND PURPOSE

Upper extremity studies suggest that implicit adaptation is less impaired than explicit learning in persons with Parkinson disease (PD). Little work has explored implicit locomotor adaptation and savings in this population, yet implicit locomotor learning is critical for everyday function. This cross-sectional study examined adaptation and savings in individuals with PD during split-belt treadmill walking.

METHODS

Fourteen participants completed the following treadmill protocol: Baseline (6 minutes belts tied), Adaptation (10 minutes split), Washout (10 minutes tied), and Readaptation (10 minutes split). Step length and step symmetry index (SSI) were calculated to determine magnitude and rate of adaptation and savings. Rate was calculated as strides to reach SSI plateau during Adaptation and Readaptation.

RESULTS

During Early Adaptation and Early Readaptation, SSI was perturbed from Baseline ( P < 0.001 and P = 0.002, respectively). Less perturbation in Early Readaptation ( P < 0.001) demonstrated savings. In Late Adaptation and Late Readaptation, participants returned to Baseline symmetry ( P = 0.026 and P = 0.022, respectively, with adjusted level of significance = 0.007). Adaptation was also seen in reverse asymmetry observed in Early Washout ( P = 0.003 vs Baseline). Readaptation rate was faster than in Adaptation ( P = 0.015), demonstrating savings.

DISCUSSION AND CONCLUSIONS

Individuals with PD showed locomotor adaptation in an implicit sensorimotor adaptation task. They also demonstrated savings, with less perturbation and faster adaptation during the second split-belt exposure. However, performance was variable; some individuals showed minimal adaptation. Variations in learning, savings, and clinical presentation highlight the need to further explore characteristics of individuals with PD most likely to benefit from adaptation-based locomotor training.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A395 ).

Parkinson's disease patients benefit from bicycling - a systematic review and meta-analysis

Many Parkinson's disease (PD) patients are able to ride a bicycle despite being severely compromised by gait disturbances up to freezing of gait. This review [PROSPERO CRD 42019137386] aimed to find out, which PD-related symptoms improve from bicycling, and which type of bicycling exercise would be most beneficial. Following a systematic database literature search, peer-reviewed studies with randomized control trials (RCT) and with non-randomized trials (NRCT) investigating the interventional effects of bicycling on PD patients were included. A quality analysis addressing reporting, design and possible bias of the studies, as well as a publication bias test was done. Out of 202 references, 22 eligible studies with 505 patients were analysed. An inverse variance-based analysis revealed that primary measures, defined as motor outcomes, benefitted from bicycling significantly more than cognitive measures. Additionally, secondary measures of balance, walking speed and capacity, and the PDQ-39 ratings improved with bicycling. The interventions varied in durations, intensities and target cadences. Conclusively, bicycling is particularly beneficial for the motor performance of PD patients, improving crucial features of gait. Furthermore, our findings suggest that bicycling improves the overall quality-of-life of PD 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.

Implementation of high-cadence cycling for Parkinson's disease in the community setting: A pragmatic feasibility study

BACKGROUND

Efficacy of exercise to improve motor symptoms in Parkinson's Disease (PD) has been established in multiple clinical trials. The Pedaling for Parkinson's ™ (PFP) program is an existing community-based cycling intervention for individuals with PD. Although PFP program design was informed by in-laboratory efficacy studies, the implementation and effectiveness of the program in the community have not been studied. This feasibility study explores implementation and effectiveness of PFP utilizing the RE-AIM implementation evaluation framework.

METHODS

This was a pragmatic open-label multi-site study. First, community-based gyms were recruited to implement the PFP protocol with enhanced multi-modal training and support. Second individuals with Hoehn and Yahr stage I-III idiopathic PD were recruited to participate. Reach, effectiveness (both clinical scores and participant enjoyment), adoption, implementation (gym and participant fidelity, cost), and maintenance (sustainability) were assessed. Tracking of adverse events was used to monitor safety of the intervention.

RESULTS

Reach was moderate: 59% of participants who expressed interest opted to participate. No effectiveness outcomes demonstrated a significant change from pre to post; however, the program was highly enjoyable (96% of participants who started classes enjoyed the program and 87% wished to continue). Adoption was poor with only four out of 34 gyms participating. The program had poor gym and moderate participant fidelity. The program was maintained for at least 4 months across all sites. The program was implemented safely.

CONCLUSION

Barriers to implementation of nonpharmacologic interventions such as exercise protocols limit reach and availability of these interventions to patients. Pilot studies are needed to inform and direct further implementation efforts. Our pilot study suggests the PFP cycling intervention should be modified prior to attempts at widespread implementation. Modifications made by gyms in this study suggest adaptations to the protocol that may increase fidelity and effectiveness.

The efficacy of cognitive-cycling dual-task training in patients with early-stage Parkinson's disease: A pilot study

BACKGROUND

Recent studies have suggested that cognitive-motor dual-task (DT) training might improve gait performance, locomotion automaticity, balance, and cognition in patients with Parkinson's disease (PD).

OBJECTIVE

We aimed to investigate the efficacy of cognitive-cycling DT training in patients with early-stage PD.

METHODS

Participants were scheduled to perform cognitive tasks simultaneously with the cycling training twice per week for eight weeks for a total of 16 sessions during their on-states. Clinical assessments were conducted using the unified Parkinson's disease rating scale (UPDRS), modified Hoehn and Yahr stage, Timed Up and Go (TUG) test, gait and cognitive performances under dual-task paradigm, the new freezing of gait questionnaire, Schwab and England Activities of Daily Living scale, 39-item Parkinson's disease questionnaire, and cognitive performance.

RESULTS

Thirteen eligible patients were enrolled in the study. The mean age was 60.64±5.32 years, and the mean disease duration was 7.02±3.23 years. Twelve PD patients completed 16 serial cognitive-cycling sessions for two months. After 16 sessions of training (T2), the UPDRS III scores improved significantly in both the off- and on-states, and TUG were significantly less than those at pretraining (T0). During both the single-task and the DT situations, gait performance and spatial memory cognitive performance significantly improved from T0 to T2.

CONCLUSION

The present study demonstrated that cognitive-cycling DT training improves the motor functions, gait and cognitive performances of PD patients.

Effect of a High-Intensity Tandem Bicycle Exercise Program on Clinical Severity, Functional Magnetic Resonance Imaging, and Plasma Biomarkers in Parkinson's Disease

Rationale: The optimal modality, intensity, duration, frequency, and dose-response of exercise as a therapy for Parkinson's Disease (PD) are insufficiently understood. Objective: To assess the impact of a high-intensity tandem bicycle program on clinical severity, biomarkers, and functional MRI (fMRI) in PD. Methods: A single-center, parallel-group clinical trial was conducted. Thirteen PD patients aged 65 or younger were divided in two groups: a control group and an intervention group that incorporated a cycling program at 80% of each individual's maximum heart rate (HR) (≥80 rpm), three times a week, for 16 weeks. Both groups continued their conventional medications for PD. At baseline and at the end of follow-up, we determined in all participants the Unified Parkinson's Disease Rating Scale, anthropometry, VO₂max, PD biomarkers, and fMRI. Results: VO₂max improved in the intervention group (IG) (+5.7 ml/kg/min), while it slightly deteriorated in the control group (CG) (-1.6 ml/kg/min) (p = 0.041). Mean Unified Parkinson's Disease Rating Scale (UPDRS) went down by 5.7 points in the IG and showed a small 0.9-point increase in the CG (p = 0.11). fMRI showed activation of the right fusiform gyrus during the motor task and functional connectivity between the cingulum and areas of the frontal cortex, and between the cerebellar vermis and the thalamus and posterior temporal gyrus. Plasma brain-derived neurotrophic factor (BDNF) levels increased more than 10-fold in the IG and decreased in the CG (p = 0.028). Larger increases in plasma BDNF correlated with greater decreases in UPDRS (r = -0.58, p = 0.04). Conclusions: Our findings suggest that high-intensity tandem bicycle improves motor function and biochemical and functional neuroimaging variables in PD patients. Trial registration number: ISRCTN 13047118, Registered on February 8, 2018.

The benefits and mechanisms of exercise training for Parkinson's disease

Parkinson's disease (PD) is a significantly progressive neurodegenerative disease characterised by both motor and nonmotor disorders. The main pathological characteristics of PD consist of the loss of dopaminergic neurons and the formation of alpha-synuclein-containing Lewy bodies in the substantia nigra. Currently, the main therapeutic method for PD is anti-Parkinson medications, including levodopa, madopar, sirelin, and so on. However, the effect of pharmacological treatment has its own limitations, the most significant of which is that the therapeutic effect of dopaminergic treatments gradually diminishes with time. Exercise training, as an adjunctive treatment and complementary therapy, can improve the plasticity of cortical striatum and increase the release of dopamine. Exercise training has been proven to effectively improve motor disorders (including balance, gait, risk of falls and physical function) and nonmotor disorders (such as sleep impairments, cognitive function and quality of life) in PD patients. In recent years, various types of exercise training have been used to treat PD. In this review, we summarise the exercise therapy mechanisms and the protective effects of different types of exercise training on PD patients.

Therapeutic effects of forced exercise cycling in individuals with Parkinson's disease

Currently there is no cure for the progressive movement disorders associated with Parkinson's Disease (PD). Pharmacological management of movement disorders in PD are associated with significant negative side effects. Exercise improves the efficacy of anti-parkinsonian medication, but does not ameliorate the side effects. Consensus on the optimal mode of exercise training or dosing to improve motor function for individuals with PD is lacking. The new concept of forced exercise is gaining traction in the literature as a mode of exercise which has the potential to improve motor function in individuals with PD. The purpose of this article is to review the effects of forced exercise on specific components of motor function that would help guide clinical decision making and exercise prescription for the PD patient population. Collectively, the evidence provided in this review suggests that forced exercise may be safely added as an ancillary therapy to the medical management of PD.

Exercise and Parkinson's Disease

Parkinson's disease (PD) is an aging-related neurodegenerative disorder characterized by progressive motor impairment.The etiology of PD is poorly understood but likely involves both genetic and environmental factors; the management of the disease is still with symptomatic therapy without any interference on the progression of neurodegeneration. In the past two decades, the results of a series of prospective cohort studies suggested that lifestyle factors likely modify the risk of developing PD. Among these, physical activity is known to reduce the risk of a wide range of diseases and conditions, including cardiovascular disease, stroke, and diabetes.Recently, a growing body of evidence has suggested that increased physical activity may also reduce the risk of PD and partly improve motor and non-motor symptoms during the disease course.Here we report the main findings on the effect of physical activity on both mobility and cognition either in animal models of PD or in people with PD. We also highlighted the structural and functional links between gait and cognition by reporting evidence from neuroimaging studies.

Effects of Simulated Horseback Riding on Balance, Postural Sway, and Quality of Life in Older Adults With Parkinson's Disease

The purpose of this study was to determine changes in balance, postural sway, and quality of life after 6 wk of simulated horseback riding in adults diagnosed with Parkinson's disease. Eight older adults completed two 60-min riding sessions weekly for 6 wk. Variables of balance, postural sway, and quality of life were measured 6 wks before and within 1 wk before and after the intervention. Berg Balance Scale scores decreased from baseline to preintervention (48.36 ± 5.97 vs. 45.86 ± 6.42, p = .050) and increased from preintervention to postintervention (45.86 ± 6.42 vs. 50.00 ± 4.38, p = .002). Cognitive impairment, a dimension of quality of life, improved from baseline to postintervention (37.5 ± 20.5 vs. 21.5 ± 14.4, p = .007). Six weeks of simulated horseback riding may improve balance and cognitive impairment in older adults with Parkinson's disease.

Effects of handwriting exercise on functional outcome in Parkinson disease: A randomized controlled trial

Parkinson disease (PD) patients frequently experience micrographia and difficulty writing, which could potentially impact their quality of life. This study aimed to determine whether handwriting exercise could improve fine manual motor function in PD. The study was a randomized controlled trial assessing the efficacy of a 4-week handwriting exercise using a newly developed handwriting practice book. The primary endpoint was an improvement in the time used to complete the handwriting test. Secondary endpoints were accuracy of the writing performance, patient's subjective rating scale of their handwriting and a UPDRS part III motor examination. Of a total of 46 subjects, 23 were randomly assigned to the handwriting exercise group. After 4 weeks, the mean time used to complete the test was significantly lower in the exercise group, compared to the control group (143.43 ± 34.02 vs. 175 ± 48.88 s, p = 0.015). Mean time used to complete the handwriting test decreased from the baseline by 16.16% in the exercise group, but increased by 3.63% in the control group (p < 0.001). Significant improvements were also observed by assessing the subjective rating scale and the UPDRS part III scores. The 4-week handwriting exercise using the studied handwriting practice book appears to promote an improvement in writing speed and motor function of hands. The optimal duration and frequency of the exercise, the quantity and characteristic of the letters in the handwriting practice book, and the benefits of the exercise in other languages merit further studies.

High-Cadence Cycling Promotes Sustained Improvement in Bradykinesia, Rigidity, and Mobility in Individuals with Mild-Moderate Parkinson's Disease

Introduction

Exercise has been shown to be an important adjunct therapy to medication in Parkinson's disease (PD). However, the optimal type, frequency, and intensity of exercise or physiotherapy are still being debated. An important part of understanding the optimal frequency is to examine how acute bouts of exercise affect motor function and mobility in this population. The purpose of this study is to assess if six bouts of high-cadence cycling improves motor function and mobility in individuals with PD.

Methods

Sixteen subjects with mild-moderate idiopathic PD were randomized into either a high-cadence cycling or a control (stretching) group. High-cadence cycling was completed on a custom motorized recumbent bicycle at a high cadence between 75 and 85 rpm. Cycling and stretching sessions were separated by 1 day of rest and took place over a 15-day period. Motor function and mobility were assessed after every cycling/stretching bout using the UPDRS Motor III scale, Kinesia ONE, and Timed up and Go (TUG).

Results

Six bouts of high-cadence cycling improved UPDRS scores (2.5 pts, P=0.002), hand movement amplitude (P=0.013), rapid alternating hand movement speed (P=0.003), gait (P=0.012), and TUG time (1.17 s, P=0.002) from baseline testing to end of treatment. The control group showed no improvements.

Conclusions

These findings suggest that they are both acute and sustained improvements in motor function and mobility after high-cadence cycling. Future research should examine how exercise type, frequency, and intensity can be optimized for each individual.

Mobility improves after high intensity aerobic exercise in individuals with Parkinson's disease

Emerging literature indicates aerobic exercise improves the motor symptoms associated with Parkinson's disease (PD). However, the impact of aerobic exercise on functional locomotor performance has not been evaluated systematically. The aim of this project was to determine the impact of an 8-week high intensity aerobic exercise intervention on Timed Up and Go (TUG) performance in PD. Fifty-nine participants with idiopathic PD completed 24 aerobic exercise sessions over 8 weeks. Two modes of exercise were utilized: forced (FE) and voluntary (VE). A mobile application was used to gather biomechanical data for the characterization of the TUG subtasks: Sit-Stand, Gait, Turning, and Stand-Sit. Participants were assessed in an off medication state at: 1) baseline, prior to any exercise intervention, and 2) after completion of exercise treatment. At baseline, the VE group completed the TUG in 9.41 s, while the FE group completed the TUG significantly faster in 8.0 s. Following the exercise intervention, the VE group decreased TUG time to 8.9 s (p < .01). Both exercise groups demonstrated significant improvements in Turning Velocity, time of Gait phase and Stand-Sit duration. Overall mobility in participants with PD was significantly improved after high intensity aerobic exercise training. Improvements in turning and gait speed, and in Stand-Sit times indicate exercise is effective in improving functional aspects of mobility that are often associated with falls and quality of life measures. These results support the use of high intensity aerobic exercise for improvements in functional lower extremity performance in a PD population.

EMPOWER-PD - A physical therapy intervention to empower the individuals with Parkinson's disease: a study protocol for a feasibility randomized controlled trial

Background

One of the greatest barriers found by physical therapy treating individuals with Parkinson’s disease (PD) is the adherence to treatment, associated with the lack of motivation to remain active. Therefore, there is a need to change the look given to physical therapy and for the individual, seeking the centralization of the therapy in their preferences. This study aims to present the EMPOWER-PD, a protocol based on individual preferences and its design for feasibility.

Method

A 12-week pilot for a randomized clinical trial will assess the feasibility and preliminary effectiveness of the EMPOWER-PD and make comparisons with conventional physical therapy (CPh). Both protocols consist of mobility and locomotion training, and aim at improving motor and non-motor symptoms through different approaches. The EMPOWER-PD aims to provide a source of motivation and empowerment of health through the self-knowledge of the individual’s abilities and limitations, in a protocol that addresses individual preferences. The CPh is based only on physiotherapist decisions, not addressing the individual’s preferences or motivation/empowerment. The target recruitment will be 24 PD individuals, between stages I and III of Hoehn and Yahr (HY), who will be recruited from Brazilian Parkinson’s disease Rehabilitation Initiative (BPaRkI) with allocation ratio 1:1. A computerized block randomization procedure will be implemented by a blinded researcher with the participants blinded to group assignment. The sessions will be conducted in a group setting, twice a week, during 60 min for 8 weeks, followed by 4 weeks of follow-up. The primary outcomes will be the feasibility data (adherence, recruitment rate, and safety). The secondary outcomes will assess the preliminary efficacy on qualitative assessment about individual’s motivation/empowerment and quantitative motor outcomes (Timed Up and Go and Dynamic Gait Index) and non-motor symptoms (6-min walk test and Fatigue Severity Scale). The recommendation to have 6–12 participants per group will be adopted based on the qualitative analysis to the sample size.

Discussion

This study will provide important insights about the physical therapy approach in PD individuals. The EMPOWER-PD is innovative because (1) it proposes an intervention that includes an individual-centered approach with motor control principles; (2) it aims to provide a source of motivation and empowerment of health; (3) assesses the individual in a global view considering motor and non-motor symptoms, using both, qualitative and quantitative metrics.

Trial registration

RBR-7ZBXQ5

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0394-9) contains supplementary material, which is available to authorized users.

The effects of exercise on cognition and gait in Parkinson's disease: A scoping review

Cognitive and gait deficits are two debilitating symptoms that occur in Parkinson's disease (PD). Importantly, a relationship between cognitive and gait deficits exists in PD, suggesting reliance on cognition is increased to compensate for gait deficits and/or deterioration of cognition and gait may share common mechanisms. Rehabilitation strategies targeting one factor could lead to the improvement of the other, presenting a unique opportunity to treat both simultaneously. Gold-standard pharmaceuticals partially alleviate these deficits with significant side effects, highlighting the importance of investigating adjunct therapies like exercise. We critically reviewed the influence of three exercise modalities (aerobic, resistance, and goal-based) on cognition and/or gait in PD. Most studies showed improvements in cognition or gait, yet, a limited number investigated them concurrently. This is the first review examining exercise for cognition and gait in PD. Key gaps in the literature are identified; potential exercise-driven mechanisms for enhancements in cognition and gait proposed, and suggestions for the design of future studies investigating the effects of exercise on cognition and gait in PD.

Integrating Health Promotion Into Physical Therapy Practice to Improve Brain Health and Prevent Alzheimer Disease

BACKGROUND AND PURPOSE

Alzheimer disease is the most common cause of dementia, and brain pathology appears years before symptoms are evident. Primary prevention through health promotion can incorporate lifestyle improvement across the lifespan. Risk factor assessment and identifying markers of disease might also trigger preventive measures needed for high-risk individuals and groups.

SUMMARY OF KEY POINTS

Many potential risk factors are modifiable through exercise, and may be responsive to early intervention strategies to reduce the downward slope toward disability. Through the use of common clinical tests to identify cognitive and noncognitive functional markers of disease, detection and intervention can occur at earlier stages, including preclinical stages of disease. Physical activity and exercise interventions to address modifiable risk factors and impairments can play a pivotal role in the prevention and delay of functional decline, ultimately reducing the incidence of dementia. This article discusses prevention, prediction, plasticity, and participation in the context of preserving brain health and preventing Alzheimer disease and related dementias in aging adults.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Rehabilitation professionals have opportunities to slow disease progression through research, practice, and education initiatives. From a clinical perspective, interventions that target brain health through lifestyle changes and exercise interventions show promise for preventing stroke and associated neurovascular diseases in addition to dementia. Physical therapists are well positioned to integrate primary health promotion into practice for the prevention of dementia and other neurological conditions in older adults.

An 8-Week Low-Intensity Progressive Cycling Training Improves Motor Functions in Patients with Early-Stage Parkinson's Disease

BACKGROUND AND PURPOSE

The effects of high-intensity cycling as an adjuvant therapy for early-stage Parkinson's disease (PD) were highlighted recently. However, patients experience difficulties in maintaining these cycling training programs. The present study investigated the efficacy of cycling at a mild-to-moderate intensity in early-stage PD.

METHODS

Thirteen PD patients were enrolled for 16 serial cycling sessions over a 2-month period. Motor function was assessed using the Unified Parkinson's Disease Rating Scale part III (UPDRS III) and Timed Up and Go (TUG) test as primary outcomes. The Montreal Cognitive Assessment (MoCA), modified Hoehn and Yahr Stage (mHYS), total UPDRS, Falls Efficacy Scale, New Freezing of Gait Questionnaire, Schwab and England Activities of Daily Living, 39-item Parkinson's Disease Questionnaire, Patient Global Impression of Change, and gait performance were assessed as secondary outcomes.

RESULTS

The age and the age at onset were 59.67±7.24 and 53.23±10.26 years (mean±SD), respectively. The cycling cadence was 53.27±8.92 revolutions per minute. The UPDRS III score improved significantly after 8 training sessions (p=0.011) and 16 training sessions (T2) (p=0.001) in the off-state, and at T2 (p=0.004) in the on-state compared to pretraining (T0). The TUG duration was significantly shorter at T2 than at T0 (p<0.05). The findings of MoCA, total UPDRS, double limb support time, and mHYS (in both the off- and on-states) also improved significantly at T2.

CONCLUSIONS

Our pioneer study has demonstrated that a low-intensity progressive cycling exercise can improve motor function in PD, especially akinesia. The beneficial effects were similar to those of high-intensity rehabilitation programs.

Lee Silverman Voice Treatment (LSVT)-BIG to improve motor function in people with Parkinson's disease: a systematic review and meta-analysis

OBJECTIVE

The technique called Lee Silverman Voice Treatment (LSVT)-LOUD has previously been used to improve voice quality in people with Parkinson's disease. The objective of this study was to assess the effectiveness of an alternate intervention, LSVT-BIG (signifying big movements), to improve functional mobility.

DESIGN

Systematic review with meta-analysis of randomized trials.

DATA SOURCES

Medline, Embase, CINAHL, AgeLine, Scopus and Cochrane Library were searched from inception to September 2017 using multiple search terms related to Parkinson's disease and LSVT-BIG.

REVIEW METHOD

Two researchers searched the literature for studies of the LSVT-BIG intervention of 16 sessions, delivered by a certified instructor over four weeks, to any other intervention. Outcomes related to functional ability were included. Study quality was appraised using the Cochrane Risk of Bias tool.

RESULTS

Four studies were included, reporting on three randomized trials of 84 participants with mild Parkinson's disease. Compared to physiotherapy exercises, or a shorter training protocol, there was a significant improvement in motor function assessed with the Unified Parkinson's Disease Rating Scale part III (mean difference = -3.20, 95% confidence interval = -5.18 to -1.23) and a trend towards faster Timed Up and Go performance (mean difference = -0.47, 95% confidence interval = -0.99 to 0.06) and 10-metre walk test (mean difference = -0.53, 95% confidence interval = -1.07 to 0.01).

CONCLUSION

Compared to shorter format LSVT-BIG or general exercise, LSVT-BIG was more effective at improving motor function. This provides preliminary, moderate quality evidence that amplitude-oriented training is effective in reducing motor impairments for people with mild Parkinson's disease.