Effects of 2 Years of Exercise on Gait Impairment in People With Parkinson Disease: The PRET-PD Randomized Trial. J Neurol Phys Ther. 2017;41:21-30. [PMID: 27977518 DOI: 10.1097/npt.0000000000000163]

Effectiveness and Safety of Meridian Activation Remedy System for Alleviating Motor Symptoms in Parkinson's Disease: an Observational Study

Background

Parkinson's disease (PD) lacks disease-modifying drugs or sustainable interventions, creating an unmet treatment need. Investigating complementary and alternative medicines aims to improve PD patients' quality of life by alleviating symptoms and delaying the course of the disease.

Objectives

In this single-center, prospective, observational, single-arm study, we aimed to assess the effectiveness and safety of acupuncture combined with exercise therapy and the Meridian Activation Remedy System (MARS).

Methods

From March to October 2021, 13 PD patients with Hoehn and Yahr stages 1 to 3 were recruited. For 8 weeks, MARS intervention was carried out twice a week. T-statistics were used to evaluate functional near-infrared spectroscopy (fNIRS) and GAITRite outcomes. All of the remaining outcome variables were evaluated using the Wilcoxon signed-rank test.

Results

The MARS intervention significantly reduced PD patients' Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDSUPDRS) Part III score (from 20.0 ± 11.8 to 8.8 ± 5.5, p = 0.003), 10-meter walk test speed (from 9.5 ± 1.8 to 8.7 ± 1.3 seconds, p = 0.040), and timed up and go time (from 9.8 ± 1.8 to 8.9 ± 1.4 seconds, p = 0.040). Moreover, the MDS-UPDRS Part II, fNIRS hemodynamics, 360-degree turn test, fall efficacy scale, and Parkinson's Disease Questionnaire 39 scores improved but not significantly. All participants completed the 8-week intervention without any adverse reactions.

Conclusion

An 8-week MARS intervention improved motor symptoms in PD patients. In particular, improvements in UPDRS Part III scores exhibited large clinically important differences. The findings are encouraging, and a randomized controlled trial will be conducted to determine the efficacy and cost-effectiveness of MARS intervention.

Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis

BACKGROUND

Physical exercise is effective in managing Parkinson's disease (PD), but the relative benefit of different exercise types remains unclear.

OBJECTIVES

To compare the effects of different types of physical exercise in adults with PD on the severity of motor signs, quality of life (QoL), and the occurrence of adverse events, and to generate a clinically meaningful treatment ranking using network meta-analyses (NMAs).

SEARCH METHODS

An experienced information specialist performed a systematic search for relevant articles in CENTRAL, MEDLINE, Embase, and five other databases to 17 May 2021. We also searched trial registries, conference proceedings, and reference lists of identified studies up to this date.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing one type of physical exercise for adults with PD to another type of exercise, a control group, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. A third author was involved in case of disagreements. We categorized the interventions and analyzed their effects on the severity of motor signs, QoL, freezing of gait, and functional mobility and balance up to six weeks after the intervention using NMAs. Two review authors independently assessed the risk of bias using the risk of bias 2 (RoB 2) tool and rated the confidence in the evidence using the CINeMA approach for results on the severity of motor signs and QoL. We consulted a third review author to resolve any disagreements. Due to heterogeneous reporting of adverse events, we summarized safety data narratively and rated our confidence in the evidence using the GRADE approach.

MAIN RESULTS

We included 154 RCTs with a total of 7837 participants with mostly mild to moderate disease and no major cognitive impairment. The number of participants per study was small (mean 51, range from 10 to 474). The NMAs on the severity of motor signs and QoL included data from 60 (2721 participants), and 48 (3029 participants) trials, respectively. Eighty-five studies (5192 participants) provided safety data. Here, we present the main results. We observed evidence of beneficial effects for most types of physical exercise included in our review compared to a passive control group. The effects on the severity of motor signs and QoL are expressed as scores on the motor scale of the Unified Parkinson's Disease Rating Scale (UPDRS-M) and the Parkinson's Disease Questionnaire 39 (PDQ-39), respectively. For both scales, higher scores denote higher symptom burden. Therefore, negative estimates reflect improvement (minimum clinically important difference: -2.5 for UPDRS-M and -4.72 for PDQ-39). Severity of motor signs The evidence from the NMA (60 studies; 2721 participants) suggests that dance and gait/balance/functional training probably have a moderate beneficial effect on the severity of motor signs (dance: mean difference (MD) -10.18, 95% confidence interval (CI) -14.87 to -5.36; gait/balance/functional training: MD -7.50, 95% CI -11.39 to -3.48; moderate confidence), and multi-domain training probably has a small beneficial effect on the severity of motor signs (MD -5.90, 95% CI -9.11 to -2.68; moderate confidence). The evidence also suggests that endurance, aqua-based, strength/resistance, and mind-body training might have a small beneficial effect on the severity of motor signs (endurance training: MD -5.76, 95% CI -9.78 to -1.74; aqua-based training: MD -5.09, 95% CI -10.45 to 0.40; strength/resistance training: MD -4.96, 95% CI -9.51 to -0.40; mind-body training: MD -3.62, 95% CI -7.24 to 0.00; low confidence). The evidence is very uncertain about the effects of "Lee Silverman Voice training BIG" (LSVT BIG) and flexibility training on the severity of motor signs (LSVT BIG: MD -6.70, 95% CI -16.48 to 3.08; flexibility training: MD 4.20, 95% CI -1.61 to 9.92; very low confidence). Quality of life The evidence from the NMA (48 studies; 3029 participants) suggests that aqua-based training probably has a large beneficial effect on QoL (MD -15.15, 95% CI -23.43 to -6.87; moderate confidence). The evidence also suggests that mind-body, gait/balance/functional, and multi-domain training and dance might have a small beneficial effect on QoL (mind-body training: MD -7.22, 95% CI -13.57 to -0.70; gait/balance/functional training: MD -6.17, 95% CI -10.75 to -1.59; multi-domain training: MD -5.29, 95% CI -9.51 to -1.06; dance: MD -3.88, 95% CI -10.92 to 3.00; low confidence). The evidence is very uncertain about the effects of gaming, strength/resistance, endurance, and flexibility training on QoL (gaming: MD -8.99, 95% CI -23.43 to 5.46; strength/resistance training: MD -6.70, 95% CI -12.86 to -0.35; endurance training: MD -6.52, 95% CI -13.74 to 0.88; flexibility training: MD 1.94, 95% CI -10.40 to 14.27; very low confidence). Adverse events Only 85 studies (5192 participants) provided some kind of safety data, mostly only for the intervention groups. No adverse events (AEs) occurred in 40 studies and no serious AEs occurred in four studies. AEs occurred in 28 studies. The most frequently reported events were falls (18 studies) and pain (10 studies). The evidence is very uncertain about the effect of physical exercise on the risk of adverse events (very low confidence). Across outcomes, we observed little evidence of differences between exercise types.

AUTHORS' CONCLUSIONS

We found evidence of beneficial effects on the severity of motor signs and QoL for most types of physical exercise for people with PD included in this review, but little evidence of differences between these interventions. Thus, our review highlights the importance of physical exercise regarding our primary outcomes severity of motor signs and QoL, while the exact exercise type might be secondary. Notably, this conclusion is consistent with the possibility that specific motor symptoms may be treated most effectively by PD-specific programs. Although the evidence is very uncertain about the effect of exercise on the risk of adverse events, the interventions included in our review were described as relatively safe. Larger, well-conducted studies are needed to increase confidence in the evidence. Additional studies recruiting people with advanced disease severity and cognitive impairment might help extend the generalizability of our findings to a broader range of people with PD.

Exercise as medicine in Parkinson's disease

Parkinson's disease (PD) is an incurable and progressive neurological disorder leading to deleterious motor and non-motor consequences. Presently, no pharmacological agents can prevent PD evolution or progression, while pharmacological symptomatic treatments have limited effects in certain domains and cause side effects. Identification of interventions that prevent, slow, halt or mitigate the disease is therefore pivotal. Exercise is safe and represents a cornerstone in PD rehabilitation, but exercise may have even more fundamental benefits that could change clinical practice. In PD, the existing knowledge base supports exercise as (1) a protective lifestyle factor preventing the disease (ie, primary prevention), (2) a potential disease-modifying therapy (ie, secondary prevention) and (3) an effective symptomatic treatment (ie, tertiary prevention). Based on current evidence, a paradigm shift is proposed, stating that exercise should be individually prescribed as medicine to persons with PD at an early disease stage, alongside conventional medical treatment.

Exercise-Induced Functional Changes in People with Parkinson's Disease following External Cueing and Task-Based Intervention

Introduction

The purpose of this study was to evaluate change in motor function, gait speed, dynamic balance, balance confidence, and quality of life (QoL) in nine participants with Parkinson's disease (PwPD) completing Lee Silverman Voice Treatment BIG (LSVT-BIG), an external cueing and task-based intervention. Although supported as an efficacious treatment in PwPD, there is limited research examining clinically meaningful change in outcome measures related to external cueing and task-based interventions.

Materials and Methods

This was a case series of nine PwPD (age range 64-76 years, 55% male) who completed the LSVT-BIG protocol. Disease duration ranged from 1 to 17 years and was classified as moderate in all participants (Hoehn and Yahr = 2 or 3). Outcome measures included motor function (MDS-UPDRS Part III Motor), gait speed, dynamic balance (MiniBEST), Activities-specific Balance Confidence (ABC), and Summary Index for PD Quality of Life 39 (PDQ-SI). Assessments were completed at baseline (BASE), end of treatment (EOT), and 4 weeks after EOT (EOT+4).

Results

Minimal detectable change (MDC) or minimal clinical important difference (MCID) was observed in one or more outcome measures in 8 of 9 participants at EOT and EOT+4 across domains of motor function (67%, 78%), gait speed (78%, 67%), balance confidence (44%, 33%), quality of life (44%, 78%), and dynamic balance (22%, 22%). Discussion. In this case series, 8 of 9 participants showed MDC or MCID changes across multiple functional domains. Improvements were observed immediately post (EOT) and 4-week post-treatment (EOT+4) suggesting a temporal component of the LSVT-BIG impact on functional change. Future research should include clinical trials to examine additional external cueing and task-based intervention efficacy with consideration of intensity, frequency, and mode of delivery across disease severity.

Telerehabilitation-based trunk exercise training for motor symptoms of individuals with Parkinson's disease: A randomized controlled clinical trial

BACKGROUND

Poor gait and static balance performance may be associated with trunk muscles in individuals with Parkinson's disease.

AIM

The study aims at evaluating the effects of a home-based trunk exercise program on gait and balance performance in Parkinson's disease.

METHODS

A randomized controlled trial was conducted with 28 individuals with Parkinson's disease with Hoehn & Yahr stage II-IV. The control group (n = 14) performed upper and lower limb exercises, while the experimental group (n = 14) engaged in a trunk exercise program. Both groups performed home-based exercises three times daily for 3 weeks. At the end of interventions (post-training) and 4 weeks after post-training (follow-up), static balance (force plate) and gait (motion capture system) were evaluated. Mixed analysis of variance compared time × group interaction (α = 5%).

RESULTS

No time × group interaction was observed in the center of pressure displacement, center of pressure mean velocity, and anteroposterior and mediolateral center of pressure range during bipedal support with eyes opened and closed; and gait speed, hip, knee, and ankle range of motion during gait analysis. No intragroup differences were found.

CONCLUSION

Trunk strengthening exercises did not improve gait and balance compared with upper and lower limb exercises. The non-adherence rate (33%) to the remote intervention may have also hindered our results.

Results of the MOVE MS Program: A Feasibility Study on Group Exercise for Individuals with Multiple Sclerosis

Exercise improves a wide range of symptoms experienced by those living with multiple sclerosis (MS) and may foster community and a positive sense of disability identity. However, exercise rates remain low. Sustained exercise participation has the greatest likelihood of improving symptoms and requires a theory-based approach accounting for the barriers faced by people with MS that impede exercise participation long-term. MOVE MS is a once weekly group exercise program based on Social Cognitive Theory supporting long-term exercise participation through peer instruction, behavior change education, multiple exercise modalities, and seated instruction. This feasibility study evaluated MOVE MS with a 7-month trial. The primary scientific outcome was exercise participation and the secondary outcomes were MS symptoms/impact, self-efficacy, depression, anxiety, disability identity, and quality of life, among others. We further conducted semi-structured formative interviews post-intervention. Thirty-three participants began the program. The onset of COVID-19 necessitated a shift toward online delivery. Seventeen participants completed the program. There were non-significant improvements in exercise participation (Godin Leisure-Time Exercise Questionnaire, baseline mean = 14.2 (SD = 11.8), post-intervention mean = 16.6 (SD = 11.2), F-value = 0.53 (Partial Eta2 = 0.08), and several secondary outcomes (including the MS Impact Scale, MS Walking Scale, and the Leeds MS Quality of Life Scale). Sixteen participants were interviewed, and analysis yielded five themes on program components and feedback. MOVE MS-delivered in-person or online-may be a feasible option for long-term exercise programming for people with MS.

Efficacy of Specific Trunk Exercises in the Balance Dysfunction of Patients with Parkinson's Disease: A Systematic Review and Meta-Analysis

Parkinson's disease (PD) is a neurodegenerative pathology classified as a movement disorder. Physical exercise within a physiotherapy program is an important element to improve postural stability, balance and mobility in order to reduce falls in people with PD. The aim of this work was to determine the efficacy of specific balance and trunk mobility exercises, as well as their benefits for and effects on patients with idiopathic PD. A systematic review and meta-analysis was conducted according to PRISMA standards. The search was performed in five databases: Cochrane Library, SciELO, PEDro, Scopus and PubMed, in February 2022 with the following descriptors: Parkinson's disease, trunk, exercise, therapy and physical therapy. The inclusion criteria were randomized controlled trials (RCTs) over the last ten years. A meta-analysis on static and dynamic balance was conducted with the software Review Manager. Nine articles met the objectives and inclusion criteria, with a total of 240 participants. The trials had moderate methodological quality according to the PEDro scale. The studies included differed with regard to intervention protocol and outcome measures. Finally, eight studies were included in a quantitative analysis in which it was shown that trunk-specific exercises interventions did not significantly improve static balance (SMD = -0.10, 95% CI = -0.29, 0.08; p = 0.28) or dynamic balance (SMD = 0.64 95% CI = -0.24, 1.52; p = 0.15). However, significant differences were found in static balance measured subjectively using the Berg Balance Scale (SMD = -0.52, 95% CI = -1.01, -0.02; p = 0.04). Although some differences were not significant, the studies included in this systematic review consider that specific trunk exercises or balance training combined with muscle strengthening in patients with idiopathic PD should be a complement to pharmacological treatment for improving balance dysfunction and postural instability, preventing falls and promoting wellness.

Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis

BACKGROUND

Physical exercise is effective in managing Parkinson's disease (PD), but the relative benefit of different exercise types remains unclear.

OBJECTIVES

To compare the effects of different types of physical exercise in adults with PD on the severity of motor signs, quality of life (QoL), and the occurrence of adverse events, and to generate a clinically meaningful treatment ranking using network meta-analyses (NMAs).

SEARCH METHODS

An experienced information specialist performed a systematic search for relevant articles in CENTRAL, MEDLINE, Embase, and five other databases to 17 May 2021. We also searched trial registries, conference proceedings, and reference lists of identified studies up to this date.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing one type of physical exercise for adults with PD to another type of exercise, a control group, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. A third author was involved in case of disagreements.  We categorized the interventions and analyzed their effects on the severity of motor signs, QoL, freezing of gait, and functional mobility and balance up to six weeks after the intervention using NMAs. Two review authors independently assessed the risk of bias using the risk of bias 2 (RoB 2) tool and rated the confidence in the evidence using the CINeMA approach for results on the severity of motor signs and QoL. We consulted a third review author to resolve any disagreements. Due to heterogeneous reporting of adverse events, we summarized safety data narratively and rated our confidence in the evidence using the GRADE approach.

MAIN RESULTS

We included 156 RCTs with a total of 7939 participants with mostly mild to moderate disease and no major cognitive impairment. The number of participants per study was small (mean 51, range from 10 to 474). The NMAs on the severity of motor signs and QoL included data from 71 (3196 participants), and 55 (3283 participants) trials, respectively. Eighty-five studies (5192 participants) provided safety data. Here, we present the main results. We observed evidence of beneficial effects for most types of physical exercise included in our review compared to a passive control group. The effects on the severity of motor signs and QoL are expressed as scores on the motor scale of the Unified Parkinson Disease Rating Scale (UPDRS-M) and the Parkinson's Disease Questionnaire 39 (PDQ-39), respectively. For both scales, higher scores denote higher symptom burden. Therefore, negative estimates reflect improvement (minimum clinically important difference: -2.5 for UPDRS-M and -4.72 for PDQ-39). Severity of motor signs The evidence from the NMA (71 studies; 3196 participants) suggests that dance has a moderate beneficial effect on the severity of motor signs (mean difference (MD) -10.32, 95% confidence interval (CI) -15.54 to -4.96; high confidence), and aqua-based, gait/balance/functional, and multi-domain training might have a moderate beneficial effect on the severity of motor signs (aqua-based: MD -7.77, 95% CI -13.27 to -2.28; gait/balance/functional: MD -7.37, 95% CI -11.39 to -3.35; multi-domain: MD -6.97, 95% CI -10.32 to -3.62; low confidence). The evidence also suggests that mind-body training and endurance training might have a small beneficial effect on the severity of motor signs (mind-body: MD -6.57, 95% CI -10.18 to -2.81; endurance: MD -6.43, 95% CI -10.72 to -2.28; low confidence). Flexibility training might have a trivial or no effect on the severity of motor signs (MD 2.01, 95% CI -4.82 to 8.98; low confidence). The evidence is very uncertain about the effects of strength/resistance training and "Lee Silverman Voice training BIG" (LSVT BIG) on the severity of motor signs (strength/resistance: MD -6.97, 95% CI -11.93 to -2.01; LSVT BIG: MD -5.49, 95% CI -14.74 to 3.62; very low confidence). Quality of life The evidence from the NMA (55 studies; 3283 participants) suggests that aqua-based training probably has a large beneficial effect on QoL (MD -14.98, 95% CI -23.26 to -6.52; moderate confidence). The evidence also suggests that endurance training might have a moderate beneficial effect, and that gait/balance/functional and multi-domain training might have a small beneficial effect on QoL (endurance: MD -9.16, 95% CI -15.68 to -2.82; gait/balance/functional: MD -5.64, 95% CI -10.04 to -1.23; multi-domain: MD -5.29, 95% CI -9.34 to -1.06; low confidence). The evidence is very uncertain about the effects of mind-body training, gaming, strength/resistance training, dance, LSVT BIG, and flexibility training on QoL (mind-body: MD -8.81, 95% CI -14.62 to -3.00; gaming: MD -7.05, 95% CI -18.50 to 4.41; strength/resistance: MD -6.34, 95% CI -12.33 to -0.35; dance: MD -4.05, 95% CI -11.28 to 3.00; LSVT BIG: MD 2.29, 95% CI -16.03 to 20.44; flexibility: MD 1.23, 95% CI -11.45 to 13.92; very low confidence). Adverse events Only 85 studies (5192 participants) provided some kind of safety data, mostly only for the intervention groups. No adverse events (AEs) occurred in 40 studies and no serious AEs occurred in four studies. AEs occurred in 28 studies. The most frequently reported events were falls (18 studies) and pain (10 studies). The evidence is very uncertain about the effect of physical exercise on the risk of adverse events (very low confidence). Across outcomes, we observed little evidence of differences between exercise types.

AUTHORS' CONCLUSIONS

We found evidence of beneficial effects on the severity of motor signs and QoL for most types of physical exercise for people with PD included in this review, but little evidence of differences between these interventions. Thus, our review highlights the importance of physical exercise regarding our primary outcomes severity of motor signs and QoL, while the exact exercise type might be secondary. Notably, this conclusion is consistent with the possibility that specific motor symptoms may be treated most effectively by PD-specific programs. Although the evidence is very uncertain about the effect of exercise on the risk of adverse events, the interventions included in our review were described as relatively safe. Larger, well-conducted studies are needed to increase confidence in the evidence. Additional studies recruiting people with advanced disease severity and cognitive impairment might help extend the generalizability of our findings to a broader range of people with PD.

The role of exercise in Parkinson's Disease

Parkinson's disease (PD) is a progressive widespread neurodegenerative disorder affecting the brain. It is characterized by dopaminergic neuron degeneration in the substantia nigra pars compacta (SNpc). Current therapeutic options ease the symptoms of PD; however, they have multiple undesirable effects and do not slow the disease progression. Exercise by itself has many positive impacts on general health. In this review, the positive impact of different forms of exercise were found to improve motor and non-motor symptoms in PD. Exercise effects is mediate by multiple mechanisms, including the upregulation of brain-derived neurotrophic factor, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor, and autophagy regulating proteins; and downregulates proinflammatory cytokines. In this review, the significance of exercise in PD, as well as in the prevention and maintenance of the disease was discussed. Many questions are left unanswered in this manuscript, including potential genetic factors underlying response to exercise. Therefore, further high-quality studies on humans are needed.

The effect of limb selection methods on gait analysis in Parkinson's disease

INTRODUCTION

Asymmetry of motor symptoms is a common characteristic of Parkinson's disease (PD), yet gait outcomes are often reported as limb averages or authors fail to report which limb is being analyzed. This study aimed to investigate how varying limb selection methods may impact statistical comparisons of common gait measures amongst fallers and non-fallers with PD.

METHODS

Overground walking data was collected on 53 fallers and 117 non-fallers during routine clinical visits. The relationship between limb selection method (left, right, most-affected, least-affected, and limbs averaged) and faller status (faller vs non-faller) on spatiotemporal gait parameters was analyzed using a mixed linear model.

RESULTS

Significant interactions between limb selection method and faller status were found for step time variability and swing time variability. Regardless of selection method, it was possible to discern significant differences between fallers and non-fallers. Yet, if researchers only analyze the least-affected limb during gait analysis, the differences between fallers and non-fallers are less apparent.

CONCLUSION

In individuals experiencing uneven laterality of symptoms that affect gait, limb averaging may alter interpretation of statistical findings and mask compensation patterns. This study promotes a refined gait analysis process, particularly in individuals that present with possible asymmetric walking. Including limb selection methods in future studies encourages holistic and transparent analyses within the literature.

Harmonic ratio is the most responsive trunk-acceleration derived gait index to rehabilitation in people with Parkinson's disease at moderate disease stages

BACKGROUND

Harmonic ratios (HRs), recurrence quantification analysis in the antero-posterior direction (RQA_detAP), and stride length coefficient of variation (CV) have recently been shown to characterize gait abnormalities and fall risk in people with Parkinson's disease (pwPD) at moderate disease stages.

RESEARCH QUESTION

This study aimed to i) assess the internal and external responsiveness to rehabilitation of HR, RQA_detAP, and CV, ii) identify the baseline predictors of normalization of the gait stability indexes, and iii) investigate the correlations between the gait indexes modifications (∆) and clinical and kinematic ∆s in pwPD at Hoehn and Yahr disease staging classification 3.

METHODS

The trunk acceleration patterns of 21 pwPD and 21 age- and speed-matched healthy subjects (HSmatched) were acquired during gait using an inertial measurement unit at baseline (T0). pwPD were also assessed after a 4-week rehabilitation period (T1). Each participant's HR in the antero-posterior (HR_AP), medio-lateral (HR_ML), and vertical directions, RQA_detAP, CV, spatio-temporal, and kinematic variables were calculated.

RESULTS

At T1, HR_AP and HR_ML improved to normative values and showed high internal and external responsiveness. Lower HRs and higher pelvic rotation values at baseline were predictors of ∆HRs. A minimal clinically important difference (MCID) ≥ 21.5 % is required to normalize HR_AP with 95 % probability. MCID ≥ 36.9 % is required to normalize HR_ML with 92 % probability. ∆HR_AP correlated with ∆HR_ML and both correlated with ∆stride length and ∆pelvic rotation, regardless of ∆gait speed. RQAdetAP and step length CV were not responsive to rehabilitation.

SIGNIFICANCE

When using inertial measurement units, HR_AP and HR_ML can be considered as responsive outcome measures for assessing the effectiveness of rehabilitation on trunk smoothness during walking in pwPD at moderate disease stages.

Smartphone-Based Body Location-Independent Functional Mobility Analysis in Patients with Parkinson’s Disease: A Step towards Precise Medicine

Ecological evaluation of gait using mobile technologies provides crucial information regarding the evolution of symptoms in Parkinson’s disease (PD). However, the reliability and validity of such information may be influenced by the smartphone’s location on the body. This study analyzed how the smartphone location affects the assessment of PD patients’ gait in a free-living environment. Twenty PD patients (mean ± SD age, 64.3 ± 10.6 years; 9 women (45%) performed 3 trials of a 250 m outdoor walk using smartphones in 5 different body locations (pants pocket, belt, hand, shirt pocket, and a shoulder bag). A method to derive gait-related metrics from smartphone sensors is presented, and its reliability is evaluated between different trials as well as its concurrent validity against optoelectronic and smartphone criteria. Excellent relative reliability was found with all intraclass correlation coefficient values above or equal to 0.85. High absolute reliability was observed in 21 out of 30 comparisons. Bland-Altman analysis revealed a high level of agreement (LoA between 4.4 and 17.5%), supporting the use of the presented method. This study advances the use of mobile technology to accurately and reliably quantify gait-related metrics from PD patients in free-living walking regardless of the smartphone’s location on the body.

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).

Validation of quantitative gait analysis systems for Parkinson's disease for use in supervised and unsupervised environments

BACKGROUND

Gait impairments are among the most common and impactful symptoms of Parkinson's disease (PD). Recent technological advances aim to quantify these impairments using low-cost wearable systems for use in either supervised clinical consultations or long-term unsupervised monitoring of gait in ecological environments. However, very few of these wearable systems have been validated comparatively to a criterion of established validity.

OBJECTIVE

We developed two movement analysis solutions (3D full-body kinematics based on inertial sensors, and a smartphone application) in which validity was assessed versus the optoelectronic criterion in a population of PD patients.

METHODS

Nineteen subjects with PD (7 female) participated in the study (age: 62 ± 12.27 years; disease duration: 6.39 ± 3.70 years; HY: 2 ± 0.23). Each participant underwent a gait analysis whilst barefoot, at a self-selected speed, for a distance of 3 times 10 m in a straight line, assessed simultaneously with all three systems.

RESULTS

Our results show excellent agreement between either solution and the optoelectronic criterion. Both systems differentiate between PD patients and healthy controls, and between PD patients in ON or OFF medication states (normal difference distributions pooled from published research in PD patients in ON and OFF states that included an age-matched healthy control group). Fair to high waveform similarity and mean absolute errors below the mean relative orientation accuracy of the equipment were found when comparing the angular kinematics between the full-body inertial sensor-based system and the optoelectronic criterion.

CONCLUSIONS

We conclude that the presented solutions produce accurate results and can capture clinically relevant parameters using commodity wearable sensors or a simple smartphone. This validation will hopefully enable the adoption of these systems for supervised and unsupervised gait analysis in clinical practice and clinical trials.

Treatment Options for Motor and Non-Motor Symptoms of Parkinson's Disease

Parkinson’s disease (PD) usually presents in older adults and typically has both motor and non-motor dysfunctions. PD is a progressive neurodegenerative disorder resulting from dopaminergic neuronal cell loss in the mid-brain substantia nigra pars compacta region. Outlined here is an integrative medicine and health strategy that highlights five treatment options for people with Parkinson’s (PwP): rehabilitate, therapy, restorative, maintenance, and surgery. Rehabilitating begins following the diagnosis and throughout any additional treatment processes, especially vis-à-vis consulting with physical, occupational, and/or speech pathology therapist(s). Therapy uses daily administration of either the dopamine precursor levodopa (with carbidopa) or a dopamine agonist, compounds that preserve residual dopamine, and other specific motor/non-motor-related compounds. Restorative uses strenuous aerobic exercise programs that can be neuroprotective. Maintenance uses complementary and alternative medicine substances that potentially support and protect the brain microenvironment. Finally, surgery, including deep brain stimulation, is pursued when PwP fail to respond positively to other treatment options. There is currently no cure for PD. In conclusion, the best strategy for treating PD is to hope to slow disorder progression and strive to achieve stability with neuroprotection. The ultimate goal of any management program is to improve the quality-of-life for a person with Parkinson’s disease.

Evidence for Early and Regular Physical Therapy and Exercise in Parkinson's Disease

Advances in medical management of Parkinson's disease (PD) have resulted in living longer with disability. Although disability worsens over the course of the disease, there are signs of disability even in the early stages. Several studies reveal an early decline in gait and balance and a high prevalence of nonmotor signs in the prodromal period that contribute to early disability. There is a growing body of evidence revealing the benefits of physical therapy and exercise to mitigate motor and nonmotor signs while improving physical function and reducing disability. The presence of early disability coupled with the benefits of exercise suggests that physical therapy should be initiated earlier in the disease. In this review, we present the evidence revealing early disability in PD and the effectiveness of physical therapy and exercise, followed by a discussion of a secondary prevention model of rehabilitation to reduce early disability and optimize long-term outcomes.

Gait parameters of Parkinson's disease compared with healthy controls: a systematic review and meta-analysis

We systematically reviewed observational and clinical trials (baseline) studies examining differences in gait parameters between Parkinson’s disease (PD) in on-medication state and healthy control. Four electronic databases were searched (November-2018 and updated in October-2020). Independent researchers identified studies that evaluated gait parameters measured quantitatively during self-selected walking speed. Risk of bias was assessed using an instrument proposed by Downs and Black (1998). Pooled effects were reported as standardized mean differences and 95% confidence intervals using a random-effects model. A total of 72 studies involving 3027 participants (1510 with PD and 1517 health control) met the inclusion criteria. The self-selected walking speed, stride length, swing time and hip excursion were reduced in people with PD compared with healthy control. Additionally, PD subjects presented higher cadence and double support time. Although with a smaller difference for treadmill, walking speed is reduced both on treadmill (.13 m s⁻¹) and on overground (.17 m s⁻¹) in PD. The self-select walking speed, stride length, cadence, double support, swing time and sagittal hip angle were altered in people with PD compared with healthy control. The precise determination of these modifications will be beneficial in determining which intervention elements are most critical in bringing about positive, clinically meaningful changes in individuals with PD (PROSPERO protocol CRD42018113042).

Lower Limb Resistance Training in Individuals With Parkinson's Disease: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective: Initial randomized controlled trials (RCTs) and recently released systematic reviews have identified resistance training (RT) as a modality to manage motor symptoms and improve physical functioning in individuals with Parkinson's disease (PD), although the effects are inconsistent. Therefore, we conducted an updated meta-analysis to reassess the evidence of the relationship.

Methods: We performed a systematic search of studies reporting the effects of RT in PD available through major electronic databases (PubMed, Medline, Embase, Ovid, Cochrane Library, CNKI, Wanfang) through 20 July 2020. Eligible RCTs were screened based on established inclusion criteria. We extracted data on the indicators of leg strength, balance, gait capacity, and quality of life (QoL) of lower limbs. Random and fixed effects models were used for the analysis of standard mean differences (SMD) or mean differences (MD) with their 95% confidence intervals (CI).

Results: Thirty-one papers from 25 independent trials compromising 1,239 subjects were selected for eligibility in this systematic review and meta-analysis. Summarized data indicated that the leg strength increased statistically significant in PD patients (SMD = 0.79, 95% CI 0.3, 1.27, P = 0.001), the balance capability was improved statistically significant in PD patients (SMD = 0.34, 95% CI 0.01, 0.66, P = 0.04), and QoL statistically significantly improved (MD = −7.22, 95% CI −12.05, −2.39, P = 0.003). For gait performance, four indicators were measured, the results as follows: fast gait velocity (MD = 0.14, 95% CI 0.06, 0.23, P = 0.001), Timed-up-and-go-test (TUG, MD = −1.17, 95% CI −2.27, −0.08, P = 0.04) and Freezing of Gait Questionnaire (FOG-Q, MD = −1.74, 95% CI −3.18, −0.3, P = 0.02) were improved statistically significant across trials, while there were no statistically significant improvement in stride length (MD = −0.05, 95% CI −0.12, 0.02, P = 0.15) in PD patients.

Conclusions: Lower limb RT has positive effects during rehabilitation in individuals with PD in leg strength, QoL, and improve gait performance to a certain extent. RT also could improve balance capacity of patients, although a wide variety of tools were used, and further study is needed to confirm these findings.

The Adapted Resistance Training with Instability Randomized Controlled Trial for Gait Automaticity

BACKGROUND

Deficits in the cerebellar locomotor region (CLR) have been associated with loss of gait automaticity in individuals with freezing of gait in Parkinson's disease (freezers); however, exercise interventions that restore gait automaticity in freezers are lacking. We evaluated the effects of the adapted resistance training with instability ([ARTI] complex exercises) compared with traditional motor rehabilitation (without complex exercises) on gait automaticity and attentional set-shifting. We also verified associations between gait automaticity change and CLR activation change previously published.

METHODS

Freezers were randomized either to the experimental group (ARTI, n = 17) or to the active control group (traditional motor rehabilitation, n = 15). Both training groups performed exercises 3 times a week for 12 weeks. Gait automaticity (dual-task and dual-task cost [DTC] on gait speed and stride length), single-task gait speed and stride length, attentional set-shifting (time between Trail Making Test parts B and A), and CLR activation during a functional magnetic resonance imaging protocol of simulated step initiation task were evaluated before and after interventions.

RESULTS

Both training groups improved gait parameters in single task (P < 0.05), but ARTI was more effective than traditional motor rehabilitation in improving DTC on gait speed, DTC on stride length, dual-task stride length, and CLR activation (P < 0.05). Changes in CLR activation were associated with changes in DTC on stride length (r = 0.68, P = 0.002) following ARTI. Only ARTI improved attentional set-shifting at posttraining (P < 0.05).

CONCLUSIONS

ARTI restores gait automaticity and improves attentional set-shifting in freezers attributed to the usage of exercises with high motor complexity. © 2020 International Parkinson and Movement Disorder Society.

Exercise for Older Adults Improves the Quality of Life in Parkinson's Disease and Potentially Enhances the Immune Response to COVID-19

Parkinson’s disease (PD) is a progressive neurodegenerative disorder brought about due to dopaminergic neuronal cell loss in the midbrain substantia nigra pars compacta region. PD presents most commonly in older adults and is a disorder of both motor and nonmotor dysfunction. The novel SARS-CoV-2 virus is responsible for the recent COVID-19 pandemic, and older individuals, those with preexisting medical conditions, or both have an increased risk of developing COVID-19 with more severe outcomes. People-with-Parkinson’s (PwP) of advanced age can have both immune and autonomic nervous problems that potentially lead to pre-existing pulmonary dysfunction and higher infection risk, increasing the probability of contracting COVID-19. A lifestyle change involving moderate-intensity exercise has the potential to protect against SARS-CoV-2 through strengthening the immune system. In addition to a potential protective measure against SARS-CoV-2, exercise has been shown to improve quality-of-life (QoL) in PD patients. Recent studies provide evidence of exercise as both neuroprotective and neuroplastic. This article is a literature review investigating the role exercise plays in modifying the immune system, improving health outcomes in PwP, and potentially acting as a protective measure against SARS-Cov-2 infection. We conclude that exercise, when correctly performed, improves QoL and outcomes in PwP, and that the enhanced immune response from moderate-intensity exercise could potentially offer additional protection against COVID-19.

The Effect of Conduction Exercise and Self-Acupressure in Treatment of Parkinson's Disease: A Pilot Study

Introduction

Parkinson's disease cannot be well treated by conventional medication. Acupuncture and Tai Chi are proven to be effective in relieving symptoms of Parkinson's disease. Traditional Chinese medicine exercises may prove to be an effective complementary therapy.

Objective

To evaluate the efficacy and safety of conduction exercise and self-acupressure in treating Parkinson's disease.

Method

This study is an accessor- and data analyzer-blind, add-on, randomized, controlled, pilot clinical study. In the treatment group, they were taught to practice conduction exercise and self-acupressure for 8 weeks. No additional treatment was given in the control group. Assessments were done at week 4 and week 8 of the treatment period. The primary outcomes are the total score and domain scores of the Chinese version of 39-item Parkinson's Disease Questionnaire. The secondary outcomes are the total score and domain scores of a custom-designed questionnaire, which is a short form of Nonmotor Symptom Scale.

Results

22 patients in the treatment group and 14 in the control group continued to the treatment phase. Patients in the treatment group displayed improvement trends in primary and secondary outcomes. Improvements were significant in two areas of a custom-designed questionnaire: total score (p=0.014) and domain score of gastrointestinal tract (p=0.004). No severe adverse events were reported.

Conclusion

Conduction exercise and self-acupressure were well accepted by and feasible for Parkinson's disease patients. The data generated can be used for the planning of future studies. The exercise regime can be promoted as a home-based, self-practice therapy for Parkinson's disease patients, due to its safety, low cost, and convenience in implementation. This study is registered with the Chinese Clinical Trial Registry (ChiCTR-IPR-17011987, on 14 July 2017).

Nutrition and Lifestyle Interventions for Managing Parkinson's Disease: A Narrative Review

The etiology of Parkinson's disease (PD) is not fully understood, but environmental toxin overexposure, increased intestinal permeability, and dysbiosis related to nutrition and lifestyle habits are thought to be contributors. Considering these nutrition and lifestyle implications, there is a lack of practice-based programs utilizing interventions for managing symptoms or slowing the progression of the disease. The purpose of this narrative review was to identify relevant research related to nutrition and lifestyle interventions for PD, evaluate the research utilizing the evidence analysis process of the Academy of Nutrition and Dietetics to assess the quality of each research article, and group the research into categories. A grading of recommendations assessment, development and evaluation (GRADE) of either good, fair, limited, or not assignable was allocated to each category of research, including diet patterns, vitamin D, B-complex, omega-3 fatty acids, coenzyme Q10, probiotics, physical activity, stress, and sleep. An intervention based on the research presented in the review may be utilized for coaching people with PD on symptom management.

Wearable Sensors Measure Ankle Joint Changes of Patients with Parkinson's Disease before and after Acute Levodopa Challenge

Background

Previous studies found levodopa could improve the activity of the ankle joints of patients with Parkinson's disease (PD). But ankle joint movement is composed of four motion ranges. The specific changes of four motion ranges in PD remain unknown.

Objective

The purpose of this study was to decompose the complex ankle joint movement, measure ankle joint changes before and after the acute levodopa challenge test (ALCT), and investigate the effects of these parameters on gait performance.

Methods

29 PD patients and 30 healthy control subjects (HC) completed the Instrumented Stand and Walk (ISAW) test and gait parameters were collected by the JiBuEn gait analysis system. The percentage of improvement of gait data and the UPDRS III in the on-drug condition (ON) were determined with respect to the off-drug condition (OFF).

Results

We observed a reduction in the heel strike angle (HS), 3-plantarflexion (3-PF) angle, and 4-dorsiflexion (4-DF) angle of ankle joints. We did not find significant difference in the toe-off angle (TO), 1-plantarflexion (1-PF) angle, and 2-dorsiflexion (2-DF) angle among three groups. Stride length improvement rate was significantly correlated with HS (r _s = 0.616, P < 0.001) and 3-PF (r _s = 0.639, P < 0.001) improvement rates. The improvement in the sum of rigidity items (UPDRS motor subsection item 22) was also correlated with HS (r _s = 0.389, P=0.037) and 3-PF (r _s = 0.373, P=0.046) improvement rates.

Conclusions

Exogenous levodopa supplementation can significantly reduce the rigidity of patients with PD, improve their 3-PF and 4-DF of ankle joint kinematic parameters, and ultimately enhance their gait.

Factors Associated With Responsiveness to Gait and Balance Training in People With Parkinson Disease

BACKGROUND AND PURPOSE

Although increasing evidence supports the benefit- of exercise among people with Parkinson disease (PwPD), it is unclear whether a given exercise modality suits all PwPD, given the heterogeneity of the disease. The purpose of this study was to explore factors associated with responsiveness to a highly challenging training intervention that incorporated dual-task exercises.

METHODS

Forty-seven PwPD (mean age: 73 years; 19 females, Hoehn and Yahr stages 2-3) who had participated in 10 weeks of highly challenging gait and balance training were included. Baseline demographics, disease-related factors, physical and cognitive ability, and perceived health were used for the prediction of percent change in balance performance (the Mini-BESTest) and comfortable gait speed between the pre- and postassessments, using multiple linear regression analyses.

RESULTS

Thirty-five percent of the variance of change in balance performance was explained by General Health Perceptions (β = -0.36), the Timed Up and Go test (β = -0.33), and the single-task performance of a cognitive task (β = -0.24). Forty-nine percent of change in gait speed was explained by gait speed while performing a dual task (β = -0.46), dual-task interference while walking (β = 0.43), time to complete the Timed Up and Go test (β = -0.29), and percent error on a cognitive task (β = -0.25).

DISCUSSION AND CONCLUSIONS

The results may suggest that the PwPD with overall lower perceived health, functional mobility, and cognitive functions are the ones most likely to benefit from highly challenging and attention-demanding gait and balance training.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A240).

Physical exercise protects against mitochondria alterations in the 6-hidroxydopamine rat model of Parkinson's disease

Parkinson's disease (PD) is typicaly caractherized by loss of dopaminergic neurons, as well as the presence of mitochondrial impairments. Although physical exercise is known to promote many beneficial effects in healthy subjects, such as enhancing mitocondrial biogenesis and function, it is not clear if these effects are evident after exercise in individuals with PD. The aim of this study was to investigate the effects of two different protocol durations on motor behavior (aphomorphine and gait tests), mitochondrial biogenesis signaling (PGC-1α, NRF-1 and TFAM), structure (oxidative phosphorylation system protein levels) and respiratory chain activity (complex I) in a unilateral PD rat model. For this, male Wistar rats were injected with 6-hydroxydopamine unilaterally into the striatum and submitted to an intermitent moderate treadmill exercise for one or four weeks. In the gait test, only stride width data revealed an improvement after one week of exercise. On the other hand, after 4 weeks of the exercise protocol all gait parameters analyzed and the aphomorphine test demonstrated a recovery. Analysis of protein revealed that one week of exercise was able to prevent PGC-1α and NRF-1 expression decrease in PD animals. In addition, after four weeks of physical exercise, besides PGC-1α and NRF-1, reduction in TFAM and complex I protein levels and increased complex I activity were also prevented in PD animals. Thus, our results suggest a neuroprotective and progressive effect of intermittent treadmill exercise, which could be related to its benefits on mitochondrial biogenesis signaling and respiratory chain modulation of the dopaminergic system in PD.

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 as a prescription for patients with various diseases

A growing understanding of the benefits of exercise over the past few decades has prompted researchers to take an interest in the possibilities of exercise therapy. Because each sport has its own set of characteristics and physiological complications that tend to occur during exercise training, the effects and underlying mechanisms of exercise remain unclear. Thus, the first step in probing the effects of exercise on different diseases is the selection of an optimal exercise protocol. This review summarizes the latest exercise prescription treatments for 26 different diseases: musculoskeletal system diseases (low back pain, tendon injury, osteoporosis, osteoarthritis, and hip fracture), metabolic system diseases (obesity, type 2 diabetes, type 1 diabetes, and nonalcoholic fatty liver disease), cardio-cerebral vascular system diseases (coronary artery disease, stroke, and chronic heart failure), nervous system diseases (Parkinson's disease, Huntington's disease, Alzheimer's disease, depression, and anxiety disorders), respiratory system diseases (chronic obstructive pulmonary disease, interstitial lung disease, and after lung transplantation), urinary system diseases (chronic kidney disease and after kidney transplantation), and cancers (breast cancer, colon cancer, prostate cancer, and lung cancer). Each exercise prescription is displayed in a corresponding table. The recommended type, intensity, and frequency of exercise prescriptions are summarized, and the effects of exercise therapy on the prevention and rehabilitation of different diseases are discussed.

Treatment options for postural instability and gait difficulties in Parkinson's disease

Introduction: Gait and balance disorders in Parkinson's disease (PD) represent a major therapeutic challenge as frequent falls and freezing of gait impair quality of life and predict mortality. Limited dopaminergic therapy responses implicate non-dopaminergic mechanisms calling for alternative therapies.Areas covered: The authors provide a review that encompasses pathophysiological changes involved in axial motor impairments in PD, pharmacological approaches, exercise, and physical therapy, improving physical activity levels, invasive and non-invasive neurostimulation, cueing interventions and wearable technology, and cognitive interventions.Expert opinion: There are many promising therapies available that, to a variable degree, affect gait and balance disorders in PD. However, not one therapy is the 'silver bullet' that provides full relief and ultimately meaningfully improves the patient's quality of life. Sedentariness, apathy, and emergence of frailty in advancing PD, especially in the setting of medical comorbidities, are perhaps the biggest threats to experience sustained benefits with any of the available therapeutic options and therefore need to be aggressively treated as early as possible. Multimodal or combination therapies may provide complementary benefits to manage axial motor features in PD, but selection of treatment modalities should be tailored to the individual patient's needs.

Prediction of Responsiveness of Gait Variables to Rehabilitation Training in Parkinson's Disease

Background: Gait disorders represent one of the most disabling features of Parkinson's disease, which may benefit from rehabilitation. No consistent evidence exists about which gait biomechanical factors can be modified by rehabilitation and which clinical characteristic can predict rehabilitation-induced improvements.

Objectives: The aims of the study were as follows: (i) to recognize the gait parameters modifiable by a short-term rehabilitation program; (ii) to evaluate the gait parameters that can normalize after rehabilitation; and (iii) to identify clinical variables predicting improvements in gait function after rehabilitation.

Methods: Thirty-six patients affected by idiopathic Parkinson's disease in Hoehn-Yahr stage 1–3 and 22 healthy controls were included in the study. Both clinical and instrumental (gait analysis) evaluations were performed before and after a 10-weeks rehabilitation treatment. Time-distance parameters, lower limb joint, and trunk kinematics were measured.

Results: At baseline evaluation with matched speed, almost all gait parameters were significantly different between patients and healthy controls. After the 10-weeks rehabilitation, most gait parameters improved, and spatial asymmetry and trunk rotation normalized. Multiple linear regression of gender combined with Unified Parkinson's Disease Rating Scale-III predicted both ΔSpeed and ΔStep length of both sides; gender combined with Unified Parkinson's Disease Rating Scale-II predicted ΔCadence; age combined with Hoehn-Yahr score and disease duration predicted Δtrunk rotation range of motion.

Conclusions: Impaired gait parameters are susceptible to improvement by rehabilitation, and younger men with Parkinson's disease who are less severely affected and at early disease stage are more susceptible to improvements in gait function after a 10-weeks rehabilitation program.

Exercise as medicine to be prescribed in osteoarthritis

Inactivity contributes to chronic diseases, including diabetes, hypertension, cardiovascular disorders, and obesity. Sedentary habits can shorten life expectancy. Exercise has been widely proposed as a valuable approach to prevention. Regular physical activity, as part of one's daily routine, may help to manage pathological conditions. This editorial especially addresses osteoarthritis (OA), a degenerative disease of the articular cartilage, which is one of the most common causes of disability worldwide. Standard treatments for this illness include surgical procedures and pharmacological management; behavioural approaches are also strongly recommended. Physical exercise represents a practical strategy to preserve function, decrease pain and fatigue, and increase muscle strength and flexibility. We suggest that physical activity be considered as an established form of treatment, which means including exercise in standard therapeutic guidelines. A growing number of patients suffer from preventable chronic conditions that impose a heavy social and economic burden on the healthcare system. Preventive exercise training should be prescribed in the same way as pharmaceuticals.

Exercise for Parkinson's disease

Parkinson's disease is the second most common neurodegenerative disease with a prevalence rate of 1-2 per 1000 of the population worldwide. Pharmacological management is the mainstay of treatment. Despite optimal medication, motor impairment particularly balance and gait impairment persist leading to various degree of disability and reduced quality-of-life. The present review describes motor impairment including postural impairment, gait dysfunction, reduced muscle strength and aerobic capacity and falls. Physical therapy and complementary exercises have been proven to improve motor performance and functional mobility. Evidence on the efficacy of physical therapy and complementary exercises is presented in this review. These exercises include gait training with cues, gait training with treadmill, Nordic walking, brisk walking, balance training, virtual reality interventions, Tai Chi and dance. All these treatment interventions produce short-term beneficial effects and some interventions demonstrate long-term benefit. Gait training with treadmill enhance walking performance and the effects sustain for 3-6 months. Balance training improves balance, function and reduces fall rate, and these effects carry over to at least 12 months after training ended. Sustained Tai Chi for 6 months, dance therapy for 12 months, progressive resistive training for 24 months alleviates the PD motor symptoms, suggesting that they could slow down PD progression. Based on this evidence, individuals with PD are encouraged to sustain their training in order to improve/maintain their physical ability and to combat the progression of PD.

Motor Learning Deficits in Parkinson's Disease (PD) and Their Effect on Training Response in Gait and Balance: A Narrative Review

Parkinson's disease (PD) is a neurological disorder traditionally associated with degeneration of the dopaminergic neurons within the substantia nigra, which results in bradykinesia, rigidity, tremor, and postural instability and gait disability (PIGD). The disorder has also been implicated in degradation of motor learning. While individuals with PD are able to learn, certain aspects of learning, especially automatic responses to feedback, are faulty, resulting in a reliance on feedforward systems of movement learning and control. Because of this, patients with PD may require more training to achieve and retain motor learning and may require additional sensory information or motor guidance in order to facilitate this learning. Furthermore, they may be unable to maintain these gains in environments and situations in which conscious effort is divided (such as dual-tasking). These shortcomings in motor learning could play a large part in degenerative gait and balance symptoms often seen in the disease, as patients are unable to adapt to gradual sensory and motor degradation. Research has shown that physical and exercise therapy can help patients with PD to adapt new feedforward strategies to partially counteract these symptoms. In particular, balance, treadmill, resistance, and repeated perturbation training therapies have been shown to improve motor patterns in PD. However, much research is still needed to determine which of these therapies best alleviates which symptoms of PIGD, the needed dose and intensity of these therapies, and long-term retention effects. The benefits of such technologies as augmented feedback, motorized perturbations, virtual reality, and weight-bearing assistance are also of interest. This narrative review will evaluate the effect of PD on motor learning and the effect of motor learning deficits on response to physical therapy and training programs, focusing specifically on features related to PIGD. Potential methods to strengthen therapeutic effects will be discussed.

Exercise as a therapeutic intervention for motor and non-motor symptoms in Parkinson's disease: Evidence from rodent models

Parkinson's disease (PD) is characterised by degeneration of dopaminergic neurons of the nigrostriatal pathway, which leads to the cardinal motor symptoms of the disease - tremor, rigidity and postural instability. A number of non-motor symptoms are also associated with PD, including cognitive impairment, mood disturbances and dysfunction of gastrointestinal and autonomic systems. Current therapies provide symptomatic relief but do not halt the disease process, so there is an urgent need for preventative strategies. Lifestyle interventions such as aerobic exercise have shown potential to lower the risk of developing PD and to alleviate both motor and non-motor symptoms. However, there is a lack of large-scale randomised clinical trials that have employed exercise in PD patients. This review will focus on the evidence from studies on rodent models of PD, for employing exercise as an intervention for both motor and non-motor symptoms.

Exercise Guidelines for Gait Function in Parkinson’s Disease: A Systematic Review and Meta-analysis

This systematic review and meta-analysis is to provide comprehensive evidence-based exercise recommendations targeting walking function for adults with Parkinson’s disease. Methods. Fixed- or random-effect meta-analyses estimated standardized effect sizes (Hedge’s g), comparing treatment effects from exercise with nonexercise and another form of exercise (non-EXE control and EXE control). Cuing and exercise duration were used as moderators for subanalyses. Results. The 40 included randomized controlled trials comprised 1656 patients. The exercise group showed significantly superior performance in timed up-and-go ( g = −0.458; g = −0.390) compared with non-EXE control and EXE control; significantly greater improvement in comfortable walking speed ( g = 0.449), fast walking speed ( g = 0.430), and stride or step length ( g = 0.379) compared with non-EXE control; and significantly greater cadence ( g = 0.282) compared with EXE controls. No significant differences between intervention and control groups were observed for double-leg support time (DLST), dynamic gait index (DGI), 6-minute walk test, or freezing of gait questionnaire (FOG-Q). Notably, treatment effect from the exercise of interest compared with a standard exercise was greater than for nonexercise for cadence and FOG-Q. Moreover, EXE control was favored for DLST and DGI. Cuing had a significantly positive effect on stride length alone. Exercise duration significantly, but negatively, influenced the treatment effect on comfortable walking speed. Conclusion. Gait-specific training, rather than a general exercise program, should be emphasized if gait is the outcome of interest. Further investigation is needed on exercise dosage and its selective effect on more challenging walking tasks, endurance, and freezing of gait.

Treadmill exercise produces neuroprotective effects in a murine model of Parkinson's disease by regulating the TLR2/MyD88/NF-κB signaling pathway

Parkinson's disease (PD) is characterized by progressive dopamine depletion and a loss of dopaminergic neurons in the substantia nigra pars compacta (SNpc). Treadmill exercise is a promising non-pharmacological approach for reducing the risk of PD and other neuroinflammatory disorders, such as Alzheimer's disease. The goal of this study was to investigate the effects of treadmill exercise on α-synuclein-induced neuroinflammation and neuronal cell death in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced mouse model of PD. Eight weeks of treadmill exercise improved motor deficits and reduced α-synuclein expression, a major causative factor of PD-like symptoms, in MPTP mice. Treadmill exercise also down-regulated the expression of toll-like receptor 2 and its associated downstream signaling molecules, including myeloid differentiation factor-88, tumor necrosis factor receptor-associated factor 6, and transforming growth factor-β-activated protein kinase 1. These effects were associated with reduced ionized calcium-binding adapter molecule 1 expression, decreased IκBα and nuclear transcription factor-κB phosphorylation, decreased tumor necrosis factor α and interleukin-1β expression, and decreased NADPH oxidase subunit expression in the SNpc and striatum. Additionally, it promoted the expression of tyrosine hydroxylase and the dopamine transporter, as well as plasma dopamine levels, in MPTP mice; these effects were associated with decreased caspase-3 expression and cleavage, as well as increased Bcl-2 expression in the SNpc. Taken together, our data suggest that treadmill exercise improves MPTP-associated motor deficits by exerting neuroprotective effects in the SNpc and striatum, supporting the notion that treadmill exercise is useful as a non-pharmacological tool for the management of PD.