Parkinson's disease and intensive exercise therapy - An updated systematic review and meta-analysis

Breaking barriers in Parkinson's care: the multidisciplinary team approach

Parkinson's disease is a complex neurodegenerative disorder presenting a range of motor and non-motor symptoms that greatly impact both patients and caregivers. The diverse needs arising from these symptoms make a multidisciplinary team (MDT) approach crucial for effective management. This article explores the role and benefits of MDTs in Parkinson's care, highlighting how collaborative models improve clinical outcomes and quality of life. MDTs integrate neurologists, nurse specialists, therapists, and other professionals to deliver comprehensive, patient-centered care. The inclusion of patients and caregivers fosters shared decision-making, enhancing health outcomes. However, challenges like limited controlled trials, lack of comprehensive guidelines, and under-referral remain. Innovative models, such as telehealth and community-based care, offer promising solutions, especially in underserved regions. The article advocates for further research and standardized guidelines to optimize the MDT approach for Parkinson's disease.

"There is only one motive … fun." Perspectives of participants and providers of physical exercise for people with Parkinson's disease

PURPOSE

To explore the perspectives of people with Parkinson's disease (PD) and exercise providers regarding facilitating factors, barriers, needs, and demands relating to physical exercise for people with PD.

MATERIALS AND METHODS

Focus group discussions or telephone interviews of 30 people with PD (with or without an active sports history) and 13 providers were conducted and analyzed using structuring content analysis.

RESULTS

Factors facilitating participation in physical exercise included motivation-enhancing elements (enjoyment, group training environment) and providers with sufficient qualifications in PD-specific training demands. Identified barriers were lack of motivation, physical limitations, poor service accessibility, and inadequate matching of intervention groups based on capability or age. Providers found it difficult to design and conduct group trainings for people with PD with varying physical limitations. Having an active sports history before PD-onset was described as generally beneficial, though a competitive mindset could lead to frustration. People with PD reported needing their physicians to provide better education regarding physical exercise.

CONCLUSION

Enjoyment of physical exercise is a key aspect of maintaining physical activity engagement, which should be considered more in research and clinical practice. Developing qualifications for providers could help to broaden and enhance the dissemination of PD-specific exercise approaches. Physicians should be trained to encourage physical exercise.Implications for rehabilitationPhysicians should highlight the benefits and be knowledgeable regarding the availability of physical exercise interventions for people with PD.Additional physical exercise providers should become qualified to work with people with PD.The joyfulness of physical exercise interventions is a key aspect of maintaining physical activity engagement for 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.

Influence of Aerobic Exercise on Functional Capacity and Maximal Oxygen Uptake in Patients With Parkinson Disease: A Systematic Review and Meta-analysis

OBJECTIVE

To determine the effects of aerobic training in randomized controlled clinical trials on functional capacity, motor symptoms, and oxygen consumption in individuals with Parkinson disease (PD) through a systematic literature review and meta-analysis.

DATA SOURCES

PUBMED, Web of Science, CINAHL, SciELO, and Medline databases were searched to identify published studies until September 2023.

STUDY SELECTION

Randomized controlled clinical trials that evaluated the long-term effect of aerobic exercise in individuals with PD were included.

DATA EXTRACTION

Two independent reviewers extracted the data and assessed the risk of bias and the Grading of Recommendation Assessment, Development, and Evaluation. In case of disagreement, a third reviewer was consulted.

DATA SYNTHESIS

Thirteen studies were included in the systematic review, and the number of participants was 588 with an average age of 66.2 years (57-73y). The study's exercise intervention lasted between 6 and 70 weeks, with most studies lasting 10-12 weeks, with 3 sessions per week and an average duration of 47 minutes per session. The meta-analysis revealed that aerobic exercise is effective in enhancing maximal oxygen uptake (standardized mean difference, SMD 0.42 [95% CI, 0.18, 0.66; P=.0007]) and functional capacity (SMD 0.48 [95% CI, 0.24-0.71; P<.0001]). In addition, aerobic exercise can reduce the motor-unified Parkinson disease rating scale (mean difference-2.48 [95% CI, -3.16 to -1.81; P<.00001]) score in individuals with PD.

CONCLUSIONS

Aerobic exercise training conducted 2-3 times a week, with different intensities (low to high), can be an effective intervention for enhancing functional capacity, maximizing oxygen uptake, and reducing the UPDRS scores in individuals with PD.

Exercise, Neuroprotective Exerkines, and Parkinson's Disease: A Narrative Review

Parkinson's disease (PD) is a prevalent neurodegenerative disease in which treatment often includes an exercise regimen. Exercise is neuroprotective in animal models of PD, and, more recently, human clinical studies have verified exercise's disease-modifying effect. Aerobic exercise and resistance training improve many of PD's motor and non-motor symptoms, while neuromotor therapy and stretching/flexibility exercises positively contribute to the quality of life in people with PD. Therefore, understanding the role of exercise in managing this complex disorder is crucial. Exerkines are bioactive substances that are synthesized and released during exercise and have been implicated in several positive health outcomes, including neuroprotection. Exerkines protect neuronal cells in vitro and rodent PD models in vivo. Aerobic exercise and resistance training both increase exerkine levels in the blood, suggesting a role for exerkines in the neuroprotective theory. Many exerkines demonstrate the potential for protecting the brain against pathological missteps caused by PD. Every person (people) with Parkinson's (PwP) needs a comprehensive exercise plan tailored to their unique needs and abilities. Here, we provide an exercise template to help PwP understand the importance of exercise for treating PD, describe barriers confronting many PwP in their attempt to exercise, provide suggestions for overcoming these barriers, and explore the role of exerkines in managing PD. In conclusion, exercise and exerkines together create a powerful neuroprotective system that should contribute to slowing the chronic progression of PD.

Current interventional model for movement in Parkinson's disease: network meta-analysis based on the improvement of motor ability

Aim

To identify optimally therapeutic exercise interventions for improving motor ability among patients with Parkinson's disease (PD), we conducted a network meta-analysis (NMA) of randomized controlled trials comparing different exercise regimens.

Methods

Relevant RCTs were retrieved by searching PubMed, Embase, Cochrane, Web of Science, CINAHL, CBM, China National Knowledge Infrastructure (CNKI), Wan fang, VIP, and other databases from inception to July 9, 2023 is available in English as the primary language. Exercise outcomes as measured by Movement Disorder Society- Unified Parkinson's Disease Rating Scale Part III (MDS-UPDRS-III) score change were evaluated and ranked using STATA software version 18.0. All included studies were assessed for methodological quality using the Cochrane Risk of Bias tool.

Results

The final NMA included 71 studies involving 3,732 participants, 87 intervention experiments, and 27distinct interventions. Although most exercise interventions showed some efficacy (reducing MDS-UPDRS-III score), cumulative ranking probability surface (SUCRA) values indicated that the best exercise interventions for motor function improvement were archery (95.6%), riding a bicycle (80.9%), and binary rhythm dance (80.8%).

Conclusion

An exercise intervention comprising archery, cycling, and(or) binary rhythm dance may yield superior improvements in motor function among patients with Parkinson's disease.

Neurodegenerative disorders, metabolic icebergs, and mitohormesis

Neurodegenerative disorders are typically "split" based on their hallmark clinical, anatomical, and pathological features, but they can also be "lumped" by a shared feature of impaired mitochondrial biology. This leads us to present a scientific framework that conceptualizes Alzheimer's disease (AD), Parkinson's disease (PD), amyotrophic lateral sclerosis (ALS), and Huntington's disease (HD) as "metabolic icebergs" comprised of a tip, a bulk, and a base. The visible tip conveys the hallmark neurological symptoms, neurodegenerative regions, and neuronal protein aggregates for each disorder. The hidden bulk depicts impaired mitochondrial biology throughout the body, which is multifaceted and may be subdivided into impaired cellular metabolism, cell-specific mitotypes, and mitochondrial behaviours, functions, activities, and features. The underlying base encompasses environmental factors, especially modern industrial toxins, dietary lifestyles, and cognitive, physical, and psychosocial behaviours, but also accommodates genetic factors specific to familial forms of AD, PD, and ALS, as well as HD. Over years or decades, chronic exposure to a particular suite of environmental and genetic factors at the base elicits a trajectory of impaired mitochondrial biology that maximally impacts particular subsets of mitotypes in the bulk, which eventually surfaces as the hallmark features of a particular neurodegenerative disorder at the tip. We propose that impaired mitochondrial biology can be repaired and recalibrated by activating "mitohormesis", which is optimally achieved using strategies that facilitate a balanced oscillation between mitochondrial stressor and recovery phases. Sustainably harnessing mitohormesis may constitute a potent preventative and therapeutic measure for people at risk of, or suffering with, neurodegenerative disorders.

Parkinson's disease motor intervention patterns: a network meta-analysis based on patient motor function

Background

Parkinson's disease is characterized by symptoms such as bradykinesia and rigidity, which worsen as the disease progresses, significantly impacting patients' independence and quality of life. This study utilizes a network meta-analysis approach to quantify information gathered from randomized controlled trials (RCTs) regarding motor interventions that effectively improve the motor function of Parkinson's disease patients, aiming to provide evidence for selecting appropriate exercise intervention strategies for patients.

Methods

A systematic search strategy for randomized controlled trials (RCTs) restricted to English was constructed based on multiple biomedical databases. Databases searched included PubMed, Embase, Cochrane, Web of Science, CINAHL, CBM, China National Knowledge Infrastructure (CNKI), Wan fang, VIP, etc., with searches conducted from inception to July 9, 2023. Two authors screened all studies, extracted data, and used frequency domain analysis methods. Network meta-analysis was performed using STATA software version 18.0 to compare and rank exercises that could effectively improve the motor function of Parkinson's disease patients (measured by indicators such as MDS-UPDRS-III, TUG, BBS, Mini-BES Test, 6MWT scores). Additionally, a series of analyses and evaluations were conducted, such as assessing the methodological quality of included studies using the Cochrane risk of bias tool.

Results

The network meta-analysis included a total of 111 studies involving 5,358 participants, 133 intervention experiments, and 31 intervention measures. Although most exercise interventions showed effectiveness, cumulative ranking curves under the surface (SUCRA) values showed that archery exercise significantly improved patients' MDS-UPDRS-III scores (SUCRA = 95.6%), significantly superior to routine care [standardized mean difference (SMD = 16.92, 95%CI = -28.97, -4.87)]. High-intensity and agility exercise (High strength and agility) referred to as high-intensity exercise or agility training or a combination of both, collectively termed as high-intensity agility training, significantly improved patients' completion time for the time-up-and-go test (SUCRA = 99.7%), (SMD = -7.88, 95%CI = -9.47, -6.28). Dance and Tai Chi exercises significantly improved patients' balance abilities: Mini-Balance Evaluation Systems Test (SUCRA = 77.9%), (SMD = 5.25, 95%CI = -0.42, 10.92) for dance intervention and Berg Balance Scale (SUCRA = 94.7%), (SMD = 11.22, 95%CI = 3.26, 19.18) for Tai Chi intervention. Dance also significantly improved patients' walking ability in the 6-min walk test (SUCRA = 80.5%), (SMD = 71.31, 95%CI = 13.77, 128.84).

Conclusion

Compared to other exercises, archery, dance, Tai Chi, and high-intensity agility exercises demonstrate superior efficacy in improving the motor function of Parkinson's disease patients.

The IntegraPark Study: An Opportunity to Facilitate High-Intensity Exercise with Immersive Virtual Reality in Parkinson's Disease Patients

BACKGROUND

high-intensity exercise is a feasible and effective modality in the early stages of Parkinson's disease (PD). However, there are only a few studies that have carried out this type of intervention in customizable immersive virtual reality (IVR) environments. We explore the feasibility and effects of IVR-based high-intensity training through rowing and cycling exercises on the functional capacity, quality of life, and progression of PD.

METHODS

a total of 12 participants (61.50 ± 10.49 years old; 41.7% female, 58.3% male; stages I-III) were part of the study, which consisted of interventions of rowing and cycling in an IVR commercial exergame (25 min; twice per week for 14 weeks). The main variables measured were functional capacity, handgrip strength, functional mobility (TUG), functional lower-limb strength (FTSST), aerobic capacity (2-min step test), quality of life (PDQ-39), and Parkinson's disease progression (MDS-UPDRS).

RESULTS

the results showed a general improvement in handgrip strength in both hands (p = 0.008; d = 0.28), FTSST (p = 0.029; d = 0.96), and TUG times (p = 0.152; d = 0.22). Aerobic capacity, assessed by a 2-min step test, showed enhanced scores (p = 0.031; d = 0.78). Related to the PDQ-39, all dimensions of the scale were enhanced, highlighting activities of daily living (p = 0.047; d = 0.29) and bodily discomfort (p = 0.041; d = 0.37). Finally, the main symptoms of the disease were reduced, with an improvement in the parameters that show a better incidence of disease progression, such as Part IA and IB (p = 0.013; d = 0.29 and p = 0.021; d = 0.25, respectively), Part II (p = 0.021; d = 0.23), Part III (p = 0.040; d = 0.39), and Part IV (p = 0.013; d = 0.39).

CONCLUSIONS

the therapeutic exercise (rowing and cycling), when carried out at a high intensity and in a personalized IVR scenario, appear to be a feasible and safe modality for patients with stages I-III of PD, improving their functional capacity, quality of life, and disease progression.

The effect of chronotropic incompetence on physiologic responses during progressive exercise in people with Parkinson's disease

PURPOSE

Heart rate (HR) response is likely to vary in people with Parkinson's disease (PD), particularly for those with chronotropic incompetence (CI). This study explores the impact of CI on HR and metabolic responses during cardiopulmonary exercise test (CPET) in people with PD, and its implications for exercise intensity prescription.

METHODS

Twenty-eight participants with mild PD and seventeen healthy controls underwent CPET to identify the presence or absence of CI. HR and metabolic responses were measured at submaximal (first (VT1) and second (VT2) ventilatory thresholds), and at peak exercise. Main outcome measures were HR, oxygen consumption (VO2), and changes in HR responses (HR/WR slope) to an increase in exercise demand.

RESULTS

CI was present in 13 (46%) PD participants (PDCI), who during CPET, exhibited blunted HR responses compared to controls and PD non-CI beyond 60% of maximal workload (p ≤ 0.05). PDCI presented a significantly lower HR at VT2, and peak exercise compared to PD non-CI and controls (p ≤ 0.001). VO2 was significantly lower in PDCI than PD non-CI and controls at VT2 (p = 0.003 and p = 0.036, respectively) and at peak exercise (p = 0.001 and p = 0.023, respectively).

CONCLUSION

Although poorly understood, the presence of CI in PD and its effect on HR and metabolic responses during incremental exercise is significant and important to consider when programming aerobic exercises.

Enhanced Parkinson's gait, reduced fall risk, and improved cognitive function through multimodal rehabilitation combined with rivastigmine treatment

OBJECTIVE

This study aimed to examine the effects of combined rehabilitation and rivastigmine treatment on patients with Parkinson's disease (PD).

METHODS

Gait parameters were assessed using the Gibbon Gait Analyzer in fifteen patients. Baseline gait data and cognitive assessments were collected. Each patient underwent external counterpulsation therapy, transcranial magnetic stimulation therapy, and exercise therapy for one hour per day, five days a week for three weeks. Post-intervention, gait and cognitive data were re-evaluated. Alongside their standard PD medications, all participants were administered rivastigmine throughout the study period.

RESULTS

The intervention significantly enhanced motor function in the single-task test, evidenced by marked improvements in gait metrics such as stride width and walking speed, and a substantial reduction in fall risk. Cognitive function, assessed by mini-mental state examination and Montreal cognitive assessment, showed an improvement trend after the three-week intervention. Improvements in dual-task walking function were observed, although these changes did not reach statistical significance.

CONCLUSION

Multimodal exercise training combined with rivastigmine treatment significantly improves certain gait parameters in the single-task test, enhances balance, and reduces the risk of falling in patients with PD. Cognitive function also demonstrated improvement.

Exploring the experiences, priorities and preferences of people living with Parkinson's on exercise and physical activity promotion in the UK

BACKGROUND

People with Parkinson's (PwP) want access to timely, relevant, and specific exercise and physical activity (PA) information to enable them to manage their symptoms and maintain wellbeing and quality of life. Research that promotes exercise in this population group is limited. Little is also known about the clinical practice around PA promotion in this population, especially around the time of diagnosis.

OBJECTIVE

To explore the experiences, preferences, and priorities of PwP around exercise and PA promotion and assess their knowledge on these topics.

METHODS

A cross-sectional online survey for PwP in the United Kingdom was conducted from July to December 2021.

RESULTS

430 participants started the survey and 405 completed it. Participants had a mean age of 65.1 (±9.2) and had been living with Parkinson's for a varying time (up to 2 years = 38%, up to 6 years = 39% and for 7 or more years = 23%). Most participants reported they had not received an education (68%; n = 276) or exercise intervention (54%; n = 217) as part of their routine management by the National Health Service (NHS) since diagnosis and had sought services privately. Knowledge of the overall benefits of exercise was good, however participants lacked specific knowledge on the impact of Parkinson's Disease (PD) on posture, falls and muscle strength. 90% of participants reported they would participate in an exercise and PA education interventions.

CONCLUSIONS

PwP want exercise and PA education interventions that provide knowledge, skills and access to opportunities that enable participation. For the majority, these interventions have not been provided as part of their routine care pathway. To align with the priorities and preferences of PwP, interventions should be offered around the time of diagnosis, include content that is relevant and specific to how exercise and PA can mitigate symptoms of PD and should be delivered in person or online in a group setting.

Evidence for exercise-based interventions across 45 different long-term conditions: an overview of systematic reviews

Background

Almost half of the global population face significant challenges from long-term conditions (LTCs) resulting in substantive health and socioeconomic burden. Exercise is a potentially key intervention in effective LTC management.

Methods

In this overview of systematic reviews (SRs), we searched six electronic databases from January 2000 to October 2023 for SRs assessing health outcomes (mortality, hospitalisation, exercise capacity, disability, frailty, health-related quality of life (HRQoL), and physical activity) related to exercise-based interventions in adults (aged >18 years) diagnosed with one of 45 LTCs. Methodological quality was assessed using AMSTAR-2. International Prospective Resister of Systematic Reviews (PROSPERO) ID: CRD42022319214.

Findings

Forty-two SRs plus three supplementary RCTs were included, providing 990 RCTs in 936,825 people across 39 LTCs. No evidence was identified for six LTCs. Predominant outcome domains were HRQoL (82% of SRs/RCTs) and exercise capacity (66%); whereas disability, mortality, physical activity, and hospitalisation were less frequently reported (≤25%). Evidence supporting exercise-based interventions was identified in 25 LTCs, was unclear for 13 LTCs, and for one LTC suggested no effect. No SRs considered multimorbidity in the delivery of exercise. Methodological quality varied: critically-low (33%), low (26%), moderate (26%), and high (12%).

Interpretation

Exercise-based interventions improve HRQoL and exercise capacity across numerous LTCs. Key evidence gaps included limited mortality and hospitalisation data and consideration of multimorbidity impact on exercise-based interventions.

Funding

This study was funded by the National Institute for Health and Care Research (NIHR; Personalised Exercise-Rehabilitation FOR people with Multiple long-term conditions (multimorbidity)-NIHR202020).

Are physical activity levels, cardiorespiratory fitness and peak power associated with Parkinson's disease severity?

INTRODUCTION

Increased physical activity (PA) may slow Parkinson's disease (PD) progression. Associations between markers of PA and PD severity could justify further studies evaluating interventions increasing PA levels in PD. The objectives of the present study were to assess associations between PA, cardiorespiratory fitness (VO2-max), and muscle peak power and measures of the Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS), the Parkinson's disease questionnaire-39 (PDQ-39), and the four PD hallmark motor symptoms (rigidity, bradykinesia, postural instability, and tremor).

METHODS

Data from 105 people with PD were used. PA was measured for seven consecutive days using accelerometers. Peak power was measured with a linear encoder during a chair rise test, while VO2-max was directly assessed during a graded bicycle test. Analyses included simple and multiple linear regression and hurdle exponential regression.

RESULTS

PA was weakly to moderately associated with MDS-UPDRS II + III, rigidity, bradykinesia, and postural instability, as well as PDQ-39 mobility and activities of daily living sub-scores. VO2-max and peak power were weakly to moderately associated with MDS-UPDRS III, bradykinesia, and postural instability, while peak power was further weakly associated with the MDS-UPDRS II. Lastly, VO2-max was associated with PDQ-39 mobility and activities of daily living sub-scores.

CONCLUSION

PA, VO2-max, and peak power were associated with PD severity, thus highlighting the potential benefits of a physically active lifestyle. Furthermore, PA and VO2-max were associated with PDQ-39 sub-scores. This calls for confirmation of the potential effect of PA on quality of life in PD.

Validity and reliability of linear encoder muscle power testing in persons with Parkinson's disease

OBJECTIVE

To investigate the construct validity ON medication and the reliability both ON and OFF medication of linear encoder muscle power testing in persons with Parkinson's disease (pwPD).

DESIGN

A study using baseline data from one randomized controlled trial (study 1) and one cohort study (study 2).

SETTING

University exercise lab.

PARTICIPANTS

Study 1: 35 healthy controls and 70 pwPD. Study 2: 20 pwPD.

INTERVENTION

Study 1: baseline data. Study 2: 4 chair rise tests (2 ON and 2 OFF medication), in a randomized order, separated by 4 to 16 days.

MAIN MEASURES

Linear encoder data were collected from a chair rise test. Known groups validity and convergent validity (i.e., construct validity) were assessed by comparing peak power between pwPD and healthy controls and associations between peak power and functional performance (i.e., 6-Min Walk Test, Timed Up and Go Test, Six-Spot Step Test), respectively. Reliability was assessed as day-to-day variation and by intraclass correlation coefficients.

RESULTS

Peak power was comparable between pwPD and healthy controls (-7.2%, p = 0.17), but lower in moderately impaired pwPD compared to mildly impaired pwPD (-27%, p < 0.01) and healthy controls (-23%, p < 0.01). Moderate to strong associations were observed between peak power and functional performance (r2 = 0.44-0.51). Day-to-day variation ON and OFF medication were 1.0 and 1.3 W/kg, respectively, while intraclass correlation coefficients were 0.95 (0.87;0.98) and 0.93 (0.82;0.97), respectively.

CONCLUSION

Linear encoder muscle power testing shows inconsistent known groups validity, acceptable convergent validity ON medication, and excellent day-to-day reliability ON and OFF medication in pwPD.

Vertical locomotion improves horizontal locomotion: effects of climbing on gait and other mobility aspects in Parkinson's disease. A secondary analysis from a randomized controlled trial

BACKGROUND

In the Climb Up! Head Up! trial, we showed that sport climbing reduces bradykinesia, tremor, and rigidity in mildly to moderately affected participants with Parkinson's disease. This secondary analysis aimed to evaluate the effects of sport climbing on gait and functional mobility in this cohort.

METHODS

Climb Up! Head Up! was a 1:1 randomized controlled trial. Forty-eight PD participants (Hoehn and Yahr stage 2-3) either participated in a 12-week, 90-min-per-week sport climbing course (intervention group) or were engaged in regular unsupervised physical activity (control group). Relevant outcome measures for this analysis were extracted from six inertial measurement units placed on the extremities, chest, and lower back, that were worn during supervised gait and functional mobility assessments before and after the intervention. Assessments included normal and fast walking, dual-tasking walking, Timed Up and Go test, Instrumented Stand and Walk test, and Five Times Sit to Stand test.

RESULTS

Compared to baseline, climbing improved gait speed during normal walking by 0.09 m/s (p = 0.005) and during fast walking by 0.1 m/s. Climbing also reduced the time spent in the stance phase during fast walking by 0.03 s. Climbing improved the walking speed in the 7-m- Timed Up and Go test by 0.1 m/s (p < 0.001) and the turning speed by 0.39 s (p = 0.052), the speed in the Instrumented Stand and Walk test by 0.1 m/s (p < 0.001), and the speed in the Five Times Sit to Stand test by 2.5 s (p = 0.014). There was no effect of sport climbing on gait speed or gait variables during dual-task walking.

CONCLUSIONS

Sport climbing improves gait speed during normal and fast walking, as well as functional mobility in people with Parkinson's disease. Trial registration This study was registered within the U.S. National Library of Medicine (No: NCT04569981, date of registration September 30th, 2020).

An Exploration of People Living with Parkinson's Experience of Cardio-Drumming; Parkinson's Beats: A Qualitative Phenomenological Study

Research has shown that physical activity has a range of benefits for people living with Parkinson's (PLwP), improving muscle strength, balance, flexibility, and walking, as well as non-motor symptoms such as mood. Parkinson's Beats is a form of cardio-drumming, specifically adapted for PLwP, and requires no previous experience nor skills. Nineteen PLwP (aged between 55 and 80) took part in the regular Parkinson's Beats sessions in-person or online. Focus group discussions took place after twelve weeks to understand the impacts of Parkinson's Beats. Through the framework analysis, six themes and fifteen subthemes were generated. Participants reported a range of benefits of cardio-drumming, including improved fitness and movement, positive mood, the flow experience, and enhanced social wellbeing. A few barriers to participation were also reported. Future research is justified, and best practice guidelines are needed to inform healthcare professionals, PLwP and their care givers.

Feasibility of a novel eHealth intervention for Parkinson's disease targeting motor-cognitive function in the home

BACKGROUND

Parkinson's disease (PD) drastically affects motor and cognitive function, but evidence shows that motor-cognitive training improves disease symptoms. Motor-cognitive training in the home is scarcely investigated and eHealth methods can provide continual support for PD self-management. Feasibility testing is however required.

OBJECTIVE

To assess the feasibility (i) Recruitment capability (ii) Acceptability and Suitability (iii) Demand and Safety of a home-based motor-cognitive eHealth exercise intervention in PD.

METHODS

The 10-week intervention was delivered using the ExorLive® application and exercises were individually adapted and systematically progressed and targeted functional strength, cardiovascular fitness, flexibility, and motor-cognitive function. People with mild-to moderate PD were assessed before and after the intervention regarding; gait performance in single and dual-task conditions; functional mobility; dual-task performance; balance performance; physical activity level; health related quality of life and perceived balance confidence and walking ability; global cognition and executive function. Feasibility outcomes were continuously measured using a home-exercise diary and contact with a physiotherapist. Changes from pre- and post-intervention are reported descriptively.

RESULTS

Fifteen participants (mean age 68.5 years) commenced and 14 completed the 10-week intervention. In relation to intervention Acceptability, 64% of the motor sessions and 52% of motor-cognitive sessions were rated as "enjoyable". Concerning Suitability, the average level of exertion (Borg RPE scale) was light (11-12). Adherence was high, with 86% of all (420) sessions reported as completed. No falls or other adverse events occurred in conjunction with the intervention.

CONCLUSIONS

This motor-cognitive eHealth home exercise intervention for PD was safe and feasible in terms of Recruitment capability, Acceptability, Safety and Demand. The intensity of physical challenge needs to be increased before testing in an efficacy trial.

TRIAL REGISTRATION

This trial is registered at Clinicaltrials.gov (NCT05027620).

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

INTRODUCTION

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

OBJECTIVES

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

DESIGN

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Identification of serum microRNA alterations associated with long-term exercise-induced motor improvements in patients with Parkinson disease

BACKGROUND

Long-term physical exercise has been shown to benefit patients with Parkinson disease (PD), but there is a lack of evidence regarding the underlying mechanism. A better understanding of how such benefits are induced by exercise might contribute to the development of therapeutic targets for improving the motor function in individuals with PD. The purpose of this study was therefore to investigate the possible association between exercise-induced motor improvements and the changes in serum microRNA (miRNA) levels of PD patients through small RNA sequencing for the first time.

METHODS

Thirteen PD patients completed our 3-month home-and-community-based exercise program, while 6 patients were assigned to the control group. Motor functions were measured, and small RNA sequencing with data analysis was performed on serum miRNAs both before and after the program. The results were further validated by quantitative real-time polymerase chain reaction. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes enrichment analyses were then conducted to determine the role of differentially expressed miRNAs.

RESULTS

The 3-month home-and-community-based exercise program induced significant motor improvements in PD patients in terms of Unified Parkinson's Disease Rating Scale activities of daily living and Motor Subscale (P < .05), comfortable walking speed (P = .003), fast walking speed (P = .028), Six-Minute Walk Test (P = .004), Berg Balance Scale (P = .039), and Timed Up and Go (P = .002). A total of 11 miRNAs (10 upregulated and one downregulated) were identified to be remarkably differentially expressed after intervention in the exercise group, but not in the control group. The results of miRNA sequencing were further validated by quantitative real-time polymerase chain reaction. It was found that the targets of altered miRNAs were mostly enriched in the mitogen-activated protein kinase, Wnt, and Hippo signaling pathways and the GO annotations mainly included binding, catalytic activity, and transcription regulator activity.

CONCLUSION

The exercise-induced motor improvements were possibly associated with changes in circulating miRNA levels in PD patients. These miRNAs, as well as the most enriched pathways and GO terms, may play a critical role in the mechanism of exercise-induced benefits in PD and serve as novel treatment targets for the disease, although further investigations are needed.

Effects of physical exercise interventions on balance, postural stability and general mobility in Parkinson's disease: a network meta-analysis

OBJECTIVE

To assess which type of physical exercise intervention has the most beneficial effects on balance, postural stability and general mobility in patients with Parkinson's disease. These parameters were assessed using the Activities-specific Balance Confidence (ABC) scale, Berg Balance Scale (BBS), Mini-Balance Evaluation Systems Test (MiniBESTest) and Timed Up and Go Test (TUG).

DESIGN

Network meta-analysis.

METHODS

The PubMed, Cochrane Central Register of Controlled Trials, and Web of Science databases were searched up to August 2022 to identify randomized controlled trials on the effects of physical exercise interventions on balance, postural stability, and general mobility. The network meta-analysis included pairwise and indirect comparisons of results on the ABC scale, BBS, MiniBESTest, and TUG across 8 categories of physical exercise.

RESULTS

Eighty-six studies with a total of 4,693 patients were included. For the ABC scale, the indirect comparison showed that the highest effect size was observed for balance vs sensorimotor training without including endurance interventions (0.62; 95% confidence interval (95% CI) 0.06, 1.17). The highest effect sizes for BBS were observed for alternative exercises (1.21; 95% CI 0.62, 1.81), body-weight supported (BWS) interventions (1.31; 95% CI 0.57, 2.05), dance (1.18; 95% CI 0.33, 2.03) and sensorimotor training, including endurance interventions (1.10; 95% CI 0.46, 1.75) vs control groups. Indirect comparisons showed that the highest effect size for the MiniBESTest were observed for balance (0.75; 95% CI 0.46, 1.04) and resistance (0.58; 95% CI 0.10, 1.07) vs control groups. For the TUG, comparisons showed a significant effect size for alternative exercises (-0.54; 95% CI -0.82, -0.26), balance (-0.42; 95% CI -0.75, -0.08), resistance (-0.60; 95% CI -0.89, -0.31), and sensorimotor training including endurance interventions (-0.61; 95% CI -0.95, -0.27) vs control comparisons.

CONCLUSION

Balance interventions improve balance, postural stability, and general mobility in people with Parkinson's disease. Moreover, alternative exercises, dance, BWS interventions, resistance, and sensorimotor training, including and not including endurance interventions, are also effective.

Dietary Interventions in Parkinson's Disease

Several dietary patterns and nutritional supplements have been linked to the development, progression, and symptomatic treatment of Parkinson's disease (PD). Most of the evidence, at this point, is preliminary and based largely on observational studies. Interventional studies are scarce, so the evidence on effectiveness remains inconclusive. Dietary interventions could, analogous to exercise, potentially have a beneficial effect on disease symptoms as well as on the progression of the disease and should therefore be researched in high quality studies. Further work is also needed to study whether dietary interventions, when applied to an at-risk population, have any potential to postpone the onset of manifest PD. In this paper, we summarize all ongoing clinical trials on dietary interventions in PD. We found 10 ongoing studies, all aimed at a different intervention. These studies are mostly exploratory in nature or represent phase I or phase II trials focusing on safety, biological responses, and symptomatic effects. Taken together, we conclude that research on dietary interventions in persons with PD is still in its early days. The results of the various ongoing trials are expected to generate new hypotheses and will help to shape the agenda for future research on this important topic.

Physical exercise and its effects on people with Parkinson's disease: Umbrella review

INTRODUCTION

Parkinson's disease is neurodegenerative, complex and progressive, manifesting in a slow and irreversible way. Physical exercise has been proposed as therapeutic alternative to people with Parkinson´s disease.

OBJECTIVE

To synthesize knowledge about the effects of physical exercise on people with Parkinson´s Disease as presented by published systematic reviews.

METHODS

Nine electronic databases and two grey literature databases were searched for systematic reviews reporting the effects of physical exercises on people with Parkinson´s Disease. Searches involved a two-phase process, by, at least, two independent reviewers. Methodological quality of the included systematic reviews was assessed using AMSTAR-2.

RESULTS

From 2,122 systematic reviews, 139 were included. Motor outcomes were assessed in 91% of the studies, with balance being the most studied. Non-motor outcomes were assessed in 68% of the studies, with emphasis on quality of life. Physical exercises were classified into five categories: aerobic exercises, strength, combined, sensorimotor activities and other activity protocols. Findings of the systematic reviews suggest that all exercise categories can be prescribed to improve balance and mobility, while combined exercises, strength, and specific activities improve both motor and non-motor outcomes, and aerobic exercise and sensorimotor activities improve motor outcomes.

CONCLUSION

Current evidence from systematic reviews suggests that physical exercises impacts both motor and non-motor outcomes in people with Parkinson´s Disease. Limits in evidence provided by the systematic reviews were related to methodological issues and to the description of the interventions and must be considered to improve decision-making and clinical application.

Exercise Made Accessible: the Merits of Community-Based Programs for Persons with Parkinson's Disease

PURPOSE OF REVIEW

Many studies have identified positive effects of physiotherapy and exercise for persons with Parkinson's disease (PD). Most work has thus far focused on the therapeutic modality of exercise as used within physiotherapy programs. Stimulated by these positive findings, there is now a strong move to take exercise out of the clinical setting and to deliver the interventions in the community. Although the goals and effects of many such community-based exercise programs overlap with those of physiotherapy, it has also become more clear that both exercise modalities also differ in various ways. Here, we aim to comprehensively review the evidence for community-based exercise in PD.

RECENT FINDINGS

Many different types of community-based exercise for people with PD are emerging and they are increasingly being studied. There is a great heterogeneity considering the types of exercise, study designs, and outcome measures used in research on this subject. While this review is positive regarding the feasibility and potential effects of community-based exercise, it is also evident that the general quality of these studies needs improvement. By focusing on community-based exercise, we hope to generate more knowledge on the effects of a wide range of different exercise modalities that can be beneficial for people with PD. This knowledge may help people with PD to select the type and setting of exercise activity that matches best with their personal abilities and preferences. As such, these insights will contribute to an improved self-management of PD.

C-reactive protein as the biomarker of choice to monitor the effects of exercise on inflammation in Parkinson's disease

Parkinson's disease (PD), a heterogeneous disease with no disease-modifying treatments available, is the fastest growing neurological disease worldwide. Currently, physical exercise is the most promising treatment to slow disease progression, with evidence suggesting it is neuroprotective in animal models. The onset, progression, and symptom severity of PD are associated with low grade, chronic inflammation which can be quantified by measuring inflammatory biomarkers. In this perspective, we argue that C-reactive protein (CRP) should be used as the primary biomarker for monitoring inflammation and therefore disease progression and severity, particularly in studies examining the impact of an intervention on the signs and symptoms of PD. CRP is the most studied biomarker of inflammation, and it can be detected using relatively well-standardized assays with a wide range of detection, allowing for comparability across studies while generating robust data. An additional advantage of CRP is its ability to detect inflammation irrespective of its origin and specific pathways, an advantageous characteristic when the cause of inflammation remains unknown, such as PD and other chronic, heterogeneous diseases.

Efficacy of non-pharmacological interventions on depressive symptoms in patients with Parkinson's disease: a study protocol for a systematic review and network meta-analysis

INTRODUCTION

Depression is the most dominant non-motor symptom of Parkinson's disease (PD), with a prevalence of up to 50%, and can lead to a range of psychiatric and psychological problems that can affect quality of life and overall functioning. While several randomised controlled trials (RCTs) have tested the effect of certain non-pharmacological interventions on the outcome of PD depression symptoms, the comparative benefits and harms of these remain unclear. We will conduct a systematic review and network meta-analysis to compare the efficacy and safety of different non-pharmacological interventions for patients with PD depression.

METHODS AND ANALYSIS

We will search PubMed, Web of Science, Cochrane, Embase, Google Scholar, the Chinese National Knowledge Infrastructure, the Chinese Biomedical Literature Database, WanFang Data and the Chongqing VIP Database from their inception date to June 2022. The studies will be limited to results published in English or Chinese. The primary outcomes will be the changes in the depressive symptoms, while secondary outcomes will include adverse effects and the quality of life. Two researchers will screen those documents that meet the inclusion criteria, extracting data according to the preset table and evaluating the methodological quality of the included studies using the Cochrane Risk of Bias 2.0 Tool. The STATA and ADDIS statistical software will be used to conduct a systematic review and network meta-analysis. A traditional pairwise meta-analysis and a network meta-analysis will be performed to compare the efficacy and safety of different non-pharmacological interventions, ensuring the robustness of the findings. The Grading of Recommendations Assessment, Development and Evaluation system will be used to assess the overall quality of the body of evidence associated with the main results. The publication bias assessment will be conducted using comparison-adjusted funnel plots.

ETHICS AND DISSEMINATION

All the data for this study will be extracted from published RCTs. As a literature-based systematic review, this study does not require ethical approval. The results will be disseminated through peer-reviewed journals and national/international conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42022347772.

The feasibility, safety, physiological and clinical effects of high-intensity interval training for people with Parkinson's: a systematic review and meta-analysis

BACKGROUND

Exercise is important for people with Parkinson's (PwP), with high-intensity interval training (HIIT) proposed as a feasible and effective exercise modality. However, no literature synthesis for PwP has been undertaken.

OBJECTIVES

To evaluate the feasibility, safety, physiological and clinical effects of HIIT for PwP.

METHODS

Systematic searches of Medline, Embase, CINAHL, Web of Science, and Google Scholar were undertaken. Studies that included ≥ 2 weeks of HIIT for PwP and reported sufficient detail for full quality assessment were eligible. Quality was assessed with the TESTEX scale or the Downs and Black tool according to study design. Feasibility and safety data, physiological and clinical outcomes were extracted. Meta-analyses explored the pooled effects of HIIT on VO_2peak/max compared to moderate-intensity continuous exercise (MICE) and usual care.

RESULTS

Eleven articles were identified (seven controlled/comparator studies and four single group) including 117 HIIT participants predominantly of mild-to-moderate disease severity. HIIT programmes were professionally supervised and between 6 weeks and 24 months. Overall, study quality was deemed to be moderate to good. Following screening, nine studies reported 90-100% programme completion; however, only one was > 12 weeks in duration. Adverse events were uncommon. HIIT improved VO_2peak/max compared to usual care, but not to MICE. Increased brain-derived neurotrophic factor (BDNF) and improved motor symptoms were also reported.

CONCLUSION

Up to 12 weeks of supervised HIIT appears to be feasible and safe for some people with mild-to-moderate disease severity. HIIT improves cardiorespiratory fitness and may increase BDNF and improve motor symptoms in PwP. Future studies should explore safe ways to facilitate access and long-term adherence.

Validity and reliability of VO2-max testing in persons with Parkinson's disease

INTRODUCTION

Direct whole body assessment of maximal oxygen consumption (VO₂-max test) is considered the gold standard when assessing cardiorespiratory fitness (VO₂-max) in healthy people. VO₂-max is also an important health and performance indicator for persons with Parkinson's disease (pwPD) and is often used when prescribing exercise and evaluating aerobic exercise interventions. However, no study has examined the content validity of the VO₂-max test in pwPD as well as the test-retest reliability (i.e., day-to-day variation) in both the ON and OFF medication state. Therefore, the present study investigated the content validity and test-retest reliability of the VO₂-max test in pwPD both ON and OFF medication.

METHODS

Twenty pwPD completed four VO₂-max tests (two tests ON and two tests OFF medication), in a randomized order, separated by four to sixteen days. The first tests ON and OFF medication were used to assess content validity based on attainment of five pre-defined end-criteria (one primary and four secondary). Reliability was examined by intraclass correlation coefficients (ICC) and the day-to-day variation of the two ON and OFF medication tests.

RESULTS

In pwPD, 50% and 60% attained the primary end-criterion ON and OFF medication, respectively. A higher proportion (i.e., 70-90%) attained the secondary end-criteria both ON and OFF medication with no difference between medication states. Day-to-day variations were 1.2 and 1.8 ml O₂/kg/min, while ICC_2.1 were 0.97 (95%-CI: 0.92; 0.99) and 0.96 (95%-CI: 0.90; 0.98) ON and OFF medication, respectively.

CONCLUSION

The VO₂-max test has an acceptable content validity and excellent day-to-day reliability ON and OFF medication in pwPD.

Muscle Strength and Power in People With Parkinson Disease: A Systematic Review and Meta-analysis

BACKGROUND AND PURPOSE

No studies have synthesized the literature regarding mechanical muscle function (ie, strength, power, rate of force development [RFD]) in people with Parkinson disease (PD). Here, we aimed to expand our understanding of mechanical muscle function in people with PD (PwPD) by systematically reviewing (1) the psychometric properties of isokinetic/isometric dynamometry in PD, (2) the literature comparing mechanical muscle function in PwPD with healthy controls (HC), and (3) reported associations between muscle mechanical muscle function and functional capacity and/or disease severity.

METHODS

Systematic literature search in 6 databases. Included studies had to (1) enroll and report data on PwPD, (2) include assessment(s) of psychometric properties (ie, validity, reliability, responsiveness) of isokinetic/isometric dynamometry in PD, and/or (3) assess mechanical muscle function in both PwPD and HC using isokinetic/isometric dynamometry.

RESULTS

A total of 40 studies were included. Aim 1 studies (n = 2) showed high reliability for isometric dynamometry (hip-abductor/dorsiflexor/trunk flexor-extensor/handgrip: intraclass correlations coefficients range = 0.92-0.98). Aim 2 studies (n = 40) showed impaired mechanical muscle function (ie, strength, power, RFD) in PwPD compared with HC (effect sizes range = 0.52-1.89). Aim 3 studies (n = 11) showed weak-to-strong associations between overall and lower extremities muscle strength and functional capacity and/or disease severity outcomes (ie, Unified Parkinson Disease Rating Scale).

DISCUSSION AND CONCLUSIONS

Sparse methodological evidence suggests high reliability when using dynamometry in PwPD. Muscle strength, power, and RFD are impaired in PwPD compared with HC. Muscle strength is associated with functional capacity and disease severity.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A403 ).

Effects and parameters of community-based exercise on motor symptoms in Parkinson's disease: a meta-analysis

BACKGROUND

Community-based exercise is a continuation and complement to inpatient rehabilitation for Parkinson's disease and does not require a professional physical therapist or equipment. The effects, parameters, and forms of each exercise are diverse, and the effect is affected by many factors. A meta-analysis was conducted to determine the effect and the best parameters for improving motor symptoms and to explore the possible factors affecting the effect of community-based exercise.  METHODS: We conducted a comprehensive search of six databases: PEDro, PubMed/Medline, CENTRAL, Scopus, Embase, and WOS. Studies that compared community-based exercise with usual care were included. The intervention mainly included dance, Chinese martial arts, Nordic walking, and home-based exercise. The primary outcome measure was the Unified Parkinson's Disease Rating Scale part III (UPDRS-III) score. The mean difference (95% CI) was used to calculate the treatment outcomes of continuous outcome variables, and the I² statistic was used to estimate the heterogeneity of the statistical analysis. We conducted subgroup analysis and meta-regression analysis to determine the optimal parameters and the most important influencing factors of the exercise effect.  RESULTS: Twenty-two studies that enrolled a total of 809 subjects were included in the analysis. Exercise had a positive effect on the UPDRS-III (MD = -5.83; 95% CI, -8.29 to -3.37), Timed Up and Go test (MD = -2.22; 95% CI -3.02 to -1.42), UPDRS ((MD = -7.80; 95% CI -10.98 to -6.42), 6-Minute Walk Test (MD = 68.81; 95% CI, 32.14 to 105.48), and Berg Balance Scale (MD = 4.52; 95% CI, 2.72 to 5.78) scores. However, the heterogeneity of each included study was obvious. Weekly frequency, age, and duration of treatment were all factors that potentially influenced the effect.

CONCLUSIONS

This meta-analysis suggests that community-based exercise may benefit motor function in patients with PD. The most commonly used modalities of exercise were tango and tai chi, and the most common prescription was 60 min twice a week. Future studies should consider the influence of age, duration of treatment, and weekly frequency on the effect of exercise.

PROSPERO TRIAL REGISTRATION NUMBER

CRD42022327162.

Clinical Trial Highlights - Aerobic Exercise for Parkinson's Disease

Converging lines of evidence suggest that aerobic exercise impacts Parkinson's disease (PD) motor symptoms and might slow it's progression. We provide an overview of the ongoing randomized clinical trials (RCTs) on aerobic exercise in PD. We found six RCTs with sample sizes between 28 and 370 and a follow-up between 8 weeks and 18 months. PD motor symptoms is mostly used as primary outcome while various secondary outcomes are reported. We need more trials that use both clinical endpoints and markers of neuroplasticity, and provide insight into the optimal exercise mode, duration and intensity.

[New approaches in exercise therapy for Parkinson's disease]

BACKGROUND

Exercise therapy is an important component in the treatment of motor symptoms in people with Parkinson's disease (PD). In this context, goal-based task-specific training has shown to be particularly effective compared to nonspecific approaches.

OBJECTIVE

In this article two novel exercise interventions for targeted improvement of motor function in PD are presented: 1) task-specific training with perturbations and 2) combined task-specific and cardiovascular training.

MATERIAL AND METHODS

Summary and discussion of the current evidence for both therapeutic approaches.

RESULTS

First randomized controlled trials show that perturbation training is an effective task-specific training to improve gait and balance function and potentially reduce falls. Experimental findings on combined cardiovascular exercise and task-specific training suggest that processes of neuroplasticity are enhanced, thereby improving therapy outcomes. However, the quality of evidence for both therapeutic approaches is currently low.

CONCLUSION

The presented exercise approaches show promising results in first randomized controlled studies and have the potential to improve treatment outcomes in PD. Further high-quality clinical studies are needed to ensure an effective transfer into practice.

Effect Modification between Genes and Environment and Parkinson's Disease Risk

Parkinson's disease (PD) is a complex neurodegenerative condition in which genetic and environmental factors interact to contribute to its etiology. Remarkable progress has been made in deciphering disease etiology through genetic approaches, but there is limited data about how environmental and genetic factors interact to modify penetrance, risk, and disease severity. Here, we provide insights into environmental modifiers of PD, discussing precedents from other neurological and non-neurological conditions. Based on these examples, we outline genetic and environmental factors contributing to PD and review potential environmental modifiers of penetrance and clinical variability in monogenic and idiopathic PD. We also highlight the potential challenges and propose how future studies might tackle these important questions. ANN NEUROL 2022;92:715-724.

Management of psychiatric and cognitive complications in Parkinson's disease

Neuropsychiatric symptoms (NPSs) such as affective disorders, psychosis, behavioral changes, and cognitive impairment are common in Parkinson's disease (PD). However, NPSs remain under-recognized and under-treated, often leading to adverse outcomes. Their epidemiology, presentation, risk factors, neural substrate, and management strategies are incompletely understood. While psychological and psychosocial factors may contribute, hallmark PD neuropathophysiological changes, plus the associations between exposure to dopaminergic medications and occurrence of some symptoms, suggest a neurobiological basis for many NPSs. A range of psychotropic medications, psychotherapeutic techniques, stimulation therapies, and other non-pharmacological treatments have been studied, are used clinically, and are beneficial for managing NPSs in PD. Appropriate management of NPSs is critical for comprehensive PD care, from recognizing their presentations and timing throughout the disease course, to the incorporation of different therapeutic strategies (ie, pharmacological and non-pharmacological) that utilize a multidisciplinary approach.

Efficacy and evaluation of therapeutic exercises on adults with Parkinson's disease: a systematic review and network meta-analysis

Background

Exercises are an effective treatment in Parkinson’s disease (PD), but there is still controversy over which types should be used. We aimed to compare and rank the types of exercise that improve PD symptoms by quantifying information from randomised controlled trials.

Methods

We performed a systematic review and network meta-analysis and searched PubMed, MEDLINE, Embase, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and China National Knowledge Infrastructure (CNKI) from their inception date to June 30, 2022. We included randomized controlled trials of 24 types of exercise for the interventional treatment of adults (≥ 50 years old) with PD. Effect size measures were standardized mean differences (SMDs) with 95% credible intervals (CrIs). The confidence of evidence was examined using Confidence in Network Meta-Analysis (CINeMA).

Results

We identified 10 474 citations and included 250 studies involving 13 011 participants. Results of NMA showed that power training (PT) had the best benefits for motor symptoms compared with the control group (CON), with SMDs (95% CrI) (-1.46, [-2.18 to -0.74]). Body weight support treadmill training (BWS_TT) showed the best improvement in balance (1.55, [0.72 to 2.37]), gait velocity (1.15 [0.57 to 1.31]) and walking distance (1.96, [1.18 to 2.73]), and robotic assisted gait training (RA_GT) had the most benefits for freezing of gait (-1.09, [-1.80 to -0.38]). For non-motor symptoms, Dance showed the best benefits for depression (-1.71, [-2.79 to -0.73]). Only Yoga significantly reduced anxiety symptom compared with CON (-0.53, [0.96 to -0.11]). Only resistance training (RT) significantly enhanced sleep quality and cognition (-1.42, [-2.60 to -0.23]; 0.51, [0.09 to 0.94]). For muscle strength, PT showed the best advance (1.04, [0.64 to 1.44]). For concern of falling, five types of exercise were more effective than CON.

Conclusions

There is low quality evidence that PT, Yoga, BWS_TT, Dance, and RT are the most effective treatments, pending outcome of interest, for adults with PD.

Trial registration

PROSPERO (CRD42021220052).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03510-9.

Effectiveness of aerobic and resistance training on the motor symptoms in Parkinson's disease: Systematic review and network meta-analysis

Background/objectives

Aerobic and resistance training are common complementary therapies to improve motor symptoms in people with Parkinson's disease (PD), and there is still a lack of advice on which intensity and period of aerobic or resistance training is more appropriate for people with PD. Therefore, a network meta-analysis was conducted to assess the comparative efficacy of aerobic and resistance training of different intensities and cycles on motor symptoms in patients with Parkinson's disease.

Methods

Based on several biomedical databases, a search strategy system was conducted to retrieve randomized controlled trials (RCTs) without language restrictions. A network meta-analysis with a frequentist approach was conducted to estimate the efficacy and probability rankings of aerobic and resistance training on Parkinson's patients. What's more, a range of analyses and assessments, such as routine meta-analyses and risk of bias, were performed as well.

Results

Twenty trials with 719 patients evaluating 18 different therapies were identified. Through the Unified Parkinson's Disease Motor Rating Scale, (UPDRS III); 6-minute walk test, (6MWT); 10-meter walk test, (TWM); and time up and go (TUG) and Quality of Life Scale-39 (PDQ-39), to explore the effects of different intensity resistance and aerobic exercise on PD. As a result, short period high intensity resistance movement (standard mean difference (SMD) = -0.95, 95% confidence interval (CI) -1.68 to -0.22) had significantly decreased the Unified Parkinson's Disease Motor Rating Scale (UPDRS III). Short period high intensity resistance exercise showed similar superiority in other indices; also, aerobic and resistance training of different cycle intensities produced some efficacy in PD patients, both in direct and indirect comparisons.

Conclusion

For patients with moderate to mild Parkinson's symptoms, short periods high intensity resistance training may provide complementary therapy for PD, and aerobic or resistance training of varying intensity and periodicity may be recommended as exercise prescription for PD patients. However, more large scale and high quality clinical trials are needed to confirm the effectiveness of this exercise therapy in the future.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022324824.

The impact of aerobic and resistance training intensity on markers of neuroplasticity in health and disease

OBJECTIVE

To determine the effects of low- vs. high-intensity aerobic and resistance training on motor and cognitive function, brain activation, brain structure, and neurochemical markers of neuroplasticity and the association thereof in healthy young and older adults and in patients with multiple sclerosis, Parkinson's disease, and stroke.

DESIGN

Systematic review and robust variance estimation meta-analysis with meta-regression.

DATA SOURCES

Systematic search of MEDLINE, Web of Science, and CINAHL databases.

RESULTS

Fifty studies with 60 intervention arms and 2283 in-analyses participants were included. Due to the low number of studies, the three patient groups were combined and analyzed as a single group. Overall, low- (g=0.19, p = 0.024) and high-intensity exercise (g=0.40, p = 0.001) improved neuroplasticity. Exercise intensity scaled with neuroplasticity only in healthy young adults but not in healthy older adults or patient groups. Exercise-induced improvements in neuroplasticity were associated with changes in motor but not cognitive outcomes.

CONCLUSION

Exercise intensity is an important variable to dose and individualize the exercise stimulus for healthy young individuals but not necessarily for healthy older adults and neurological patients. This conclusion warrants caution because studies are needed that directly compare the effects of low- vs. high-intensity exercise on neuroplasticity to determine if such changes are mechanistically and incrementally linked to improved cognition and motor function.