Study protocol for a single-blind randomised controlled trial to evaluate the clinical effects of an Integrated Qigong exercise intervention on freezing of gait in Parkinson's disease

Effects of Baduanjin exercise on motor function, balance and gait in Parkinson's disease: a systematic review and meta-analysis

OBJECTIVE

This study aims to systematically evaluate the effects of Baduanjin on motor function, balance and gait in patients with Parkinson's disease (PD).

DESIGN

Systematic review and meta-analysis.

STUDY SELECTION

All eligible randomised controlled trials (RCTs) published in the English and Chinese language were included.

DATA SOURCES

Ten electronic databases were systematically searched, from inception to 17 March 2022: PubMed, Web of Science, Cochrane Library, Embase, EBSCOhost, OVID, SinoMed, China National Knowledge Infrastructure, Wanfang Data and China Science Journal Database (VIP).

REVIEW METHODS

Methodological quality assessment and meta-analysis were performed for the included studies using the Cochrane Review Manager V.5.4 software.

RESULTS

Ten RCTs with 804 participants were included. The results revealed the following: (1) Baduanjin significantly improved the motor function of patients with PD, based on the Unified Parkinson's Disease Rating Scale Part III (mean difference, MD -5.37, 95% CI -8.96 to -1.78, p=0.003) and Fugl-Meyer Assessment of Lower Extremity (MD 5.39, 95% CI 2.71 to 8.07, p<0.0001); (2) Baduanjin significantly improved the ability of balance of patients with PD, based on the Berg Balance Scale (MD 4.40, 95% CI 3.08 to 5.73, p<0.00001); (3) Baduanjin significantly improved the gait of patients with PD, based on the 6 min walk distance (MD 21.62, 95% CI 11.14 to 32.10, p<0.0001). After the further subgroup and sensitivity analyses, the heterogeneity was identified to be potentially due to the different degrees of disease severity in patients with PD and the difference in Baduanjin intervention durations.

CONCLUSIONS

The analysis of this systematic evaluation indicates that Baduanjin might have a positive effect in improving the motor function, balance and gait of patients with PD. However, due to the quantity and clinical heterogeneity limitations of the included studies, this conclusion still warrants more high-quality and multicentre RCTs for further verification.

Interventions for preventing falls in Parkinson's disease

BACKGROUND

Most people with Parkinson's disease (PD) experience at least one fall during the course of their disease. Several interventions designed to reduce falls have been studied. An up-to-date synthesis of evidence for interventions to reduce falls in people with PD will assist with informed decisions regarding fall-prevention interventions for people with PD.

OBJECTIVES

To assess the effects of interventions designed to reduce falls in people with PD.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, four other databases and two trials registers were searched on 16 July 2020, together with reference checking, citation searching and contact with study authors to identify additional studies. We also conducted a top-up search on 13 October 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of interventions that aimed to reduce falls in people with PD and reported the effect on falls. We excluded interventions that aimed to reduce falls due to syncope.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane Review procedures. Primary outcomes were rate of falls and number of people who fell at least once. Secondary outcomes were the number of people sustaining one or more fall-related fractures, quality of life, adverse events and economic outcomes. The certainty of the evidence was assessed using GRADE.

MAIN RESULTS

This review includes 32 studies with 3370 participants randomised. We included 25 studies of exercise interventions (2700 participants), three studies of medication interventions (242 participants), one study of fall-prevention education (53 participants) and three studies of exercise plus education (375 participants). Overall, participants in the exercise trials and the exercise plus education trials had mild to moderate PD, while participants in the medication trials included those with more advanced disease. All studies had a high or unclear risk of bias in one or more items. Illustrative risks demonstrating the absolute impact of each intervention are presented in the summary of findings tables. Twelve studies compared exercise (all types) with a control intervention (an intervention not thought to reduce falls, such as usual care or sham exercise) in people with mild to moderate PD. Exercise probably reduces the rate of falls by 26% (rate ratio (RaR) 0.74, 95% confidence interval (CI) 0.63 to 0.87; 1456 participants, 12 studies; moderate-certainty evidence). Exercise probably slightly reduces the number of people experiencing one or more falls by 10% (risk ratio (RR) 0.90, 95% CI 0.80 to 1.00; 932 participants, 9 studies; moderate-certainty evidence).  We are uncertain whether exercise makes little or no difference to the number of people experiencing one or more fall-related fractures (RR 0.57, 95% CI 0.28 to 1.17; 989 participants, 5 studies; very low-certainty evidence). Exercise may slightly improve health-related quality of life immediately following the intervention (standardised mean difference (SMD) -0.17, 95% CI -0.36 to 0.01; 951 participants, 5 studies; low-certainty evidence). We are uncertain whether exercise has an effect on adverse events or whether exercise is a cost-effective intervention for fall prevention. Three studies trialled a cholinesterase inhibitor (rivastigmine or donepezil). Cholinesterase inhibitors may reduce the rate of falls by 50% (RaR 0.50, 95% CI 0.44 to 0.58; 229 participants, 3 studies; low-certainty evidence). However, we are uncertain if this medication makes little or no difference to the number of people experiencing one or more falls (RR 1.01, 95% CI 0.90 to 1.14230 participants, 3 studies) and to health-related quality of life (EQ5D Thermometer mean difference (MD) 3.00, 95% CI -3.06 to 9.06; very low-certainty evidence). Cholinesterase inhibitors may increase the rate of non fall-related adverse events by 60% (RaR 1.60, 95% CI 1.28 to 2.01; 175 participants, 2 studies; low-certainty evidence). Most adverse events were mild and transient in nature.  No data was available regarding the cost-effectiveness of medication for fall prevention. We are uncertain of the effect of education compared to a control intervention on the number of people who fell at least once (RR 10.89, 95% CI 1.26 to 94.03; 53 participants, 1 study; very low-certainty evidence), and no data were available for the other outcomes of interest for this comparisonWe are also uncertain (very low-certainty evidence) whether exercise combined with education makes little or no difference to the number of falls (RaR 0.46, 95% CI 0.12 to 1.85; 320 participants, 2 studies), the number of people sustaining fall-related fractures (RR 1.45, 95% CI 0.40 to 5.32,320 participants, 2 studies), or health-related quality of life (PDQ39 MD 0.05, 95% CI -3.12 to 3.23, 305 participants, 2 studies). Exercise plus education may make little or no difference to the number of people experiencing one or more falls (RR 0.89, 95% CI 0.75 to 1.07; 352 participants, 3 studies; low-certainty evidence). We are uncertain whether exercise combined with education has an effect on adverse events or is a cost-effective intervention for fall prevention.  AUTHORS' CONCLUSIONS: Exercise interventions probably reduce the rate of falls, and probably slightly reduce the number of people falling in people with mild to moderate PD.  Cholinesterase inhibitors may reduce the rate of falls, but we are uncertain if they have an effect on the number of people falling. The decision to use these medications needs to be balanced against the risk of non fall-related adverse events, though these adverse events were predominantly mild or transient in nature. Further research in the form of large, high-quality RCTs are required to determine the relative impact of different types of exercise and different levels of supervision on falls, and how this could be influenced by disease severity. Further work is also needed to increase the certainty of the effects of medication and further explore falls prevention education interventions both delivered alone and in combination with exercise.

Cognitive and Physical Intervention in Metals’ Dysfunction and Neurodegeneration

Metals—especially iron, copper and manganese—are important elements of brain functions and development. Metal-dysregulation homeostasis is associated with brain-structure damage to the motor, cognitive and emotional systems, and leads to neurodegenerative processes. There is more and more evidence that specialized cognitive and motor exercises can enhance brain function and attenuate neurodegeneration in mechanisms, such as improving neuroplasticity by altering the synaptic structure and function in many brain regions. Psychological and physical methods of rehabilitation are now becoming increasingly important, as pharmacological treatments for movement, cognitive and emotional symptoms are limited. The present study describes physical and cognitive rehabilitation methods of patients associated with metal-induced neurotoxicity such as Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis, Huntington’s disease and Wilson’s disease. In our review, we describe physical (e.g., virtual-reality environments, robotic-assists training) and psychological (cognitive training, cognitive stimulation, neuropsychological rehabilitation and cognitive-behavioral and mindfulness-based therapies) methods, significantly improving the quality of life and independence of patients associated with storage diseases. Storage diseases are a diverse group of hereditary metabolic defects characterized by the abnormal cumulation of storage material in cells. This topic is being addressed due to the fact that rehabilitation plays a vital role in the treatment of neurodegenerative diseases. Unfortunately so far there are no specific guidelines concerning physiotherapy in neurodegenerative disorders, especially in regards to duration of exercise, type of exercise and intensity, as well as frequency of exercise. This is in part due to the variety of symptoms of these diseases and the various levels of disease progression. This further proves the need for more research to be carried out on the role of exercise in neurodegenerative disorder treatment.

A Longitudinal Randomized Controlled Trial Protocol to Evaluate the Effects of Wuqinxi on Dynamic Functional Connectivity in Parkinson's Disease Patients

Background: Parkinson’s disease (PD) is a neurodegenerative movement disease that includes non-motor symptoms such as cognitive impairment. Long-term mind-body exercise has been shown to improve cognitive ability in PD patients, but the methods of assessment and intervention were inconsistent across studies. Wuqinxi is a mind-body exercise that is easy to learn, has few physical and cognitive demands, and is recommended for PD patients. Dynamic functional connectivity (DFC) has been associated with cognitive alterations in PD patients, but no studies have yet explored the effects of Wuqinxi on this association. The current protocol is designed to measure the effects of long-term Wuqinxi intervention on cognition in PD patients, and explore the underlying neural mechanisms through DFC.

Methods: A long-term single-blind, randomized trial will be conducted. PD patients and age- and gender-matched HC will be recruited; PD patients will be randomly assigned to either Wuqinxi or balance groups, and HC will all receive health education. The Wuqinxi group will receive a 90-min session of Wuqinxi intervention three times a week for 24 weeks, while the balance group will receive balance exercise instruction on the same schedule. Primary outcomes will include assessment of cognitive domains and dynamic temporal characteristics of functional connectivity. Secondary outcomes will include severity of motor symptoms, mobility, balance, and emotional state. Assessments will be conducted at baseline, at the end of 24 weeks of intervention, and 12 weeks after interventions have ended.

Discussion: This study will provide evidence to the effects of Wuqinxi exercise on cognitive improvements in PD patients from the perspective of DFC, and will contribute to the understanding of neural mechanisms underlying cognitive enhancement through Wuqinxi practice.

Clinical Trial Registration:www.chictr.org.cn, identifier ChiCTR2000038517.

Long-Term Wu Qin Xi Exercise on Response Inhibition and Cortical Connectivity in Parkinson's Disease: Design and Implementation of a Randomized Controlled Clinical Trial

Background: Motor symptom disorders in patients with Parkinson disease (PD) are closely related to reduced inhibitory ability. Although exercise has been shown to improve this ability in patients with PD, its effects on proactive and reactive inhibition have not been determined. Most previous studies of inhibitory control disorder in people with PD have been behavioral, and little attention has been paid to functional cortical connectivity. Wu Qin Xi, a low–medium-intensity qigong exercise that is safe and easy to do for elderly individuals, can support physical well-being and help prevent and alleviate disease. In this study, our aims were to explore the effects of a long-term Wu Qin Xi intervention on response inhibition and to examine how improved inhibition control relates to cortical connectivity using dual-site paired-pulse transcranial magnetic stimulation (ppTMS), in patients with mild–moderate PD.

Methods: A single-blind randomized controlled trial will be conducted. A total of 90 elderly subjects will be recruited and allocated randomly to Wu Qin Xi, balance exercise, and healthy control groups. The exercise interventions will be implemented in three 90-min sessions per week for 24 weeks; the healthy control group will receive no intervention. The primary assessments will be response inhibition metrics and task-based ppTMS. The secondary outcomes will include motor symptom severity, mobility, balance, emotional state, and quality of life. Assessments will be conducted at baseline, at the conclusion of the intervention period (week 24), and a few months after the intervention (week 36 follow-up).

Discussion: This study is designed to provide insights into the effects of practicing Wu Qin Xi on response inhibition function in people with PD. The results will provide evidence on the value of traditional Chinese exercise as a therapeutic rehabilitation option for these patients. They will also provide data addressing how brain function–related cortical connectivity is related to reactive vs. proactive inhibition in people with PD participating in an exercise intervention.

Clinical Trial Registration: This study has been registered prospectively in the Chinese Clinical Trial Registry (ChiCTR2000038517, 18 January 2021).

Effects of Health Qigong Exercises on Physical Function on Patients with Parkinson's Disease

Purpose

To measure motor function improvements in patients with Parkinson's disease (PD) using Health Qigong exercises.

Patients and Methods

Fifty-two PD patients (Hoehn and Yahr stages I to IV) were randomly divided into experimental and control groups. Twenty-six PD patients in the experimental group were intervened with routine medicine and fitness Qigong exercise. The other 26 PD patients as the control group were treated only with regular medication. Twelve-week intervention had been conducted for the study, and participants completed the scheduled exercises 4 times per week for 60 minutes each time. Data which included the one-legged blind balance, physical coordination, and gait was collected before, during, and after the intervention. Comparisons were made between the experimental and control groups through the repeated measures analysis of variance.

Results

A total of 40 participants (77% response rate) completed the study. There was no significant difference in baseline data. After 12 weeks of Health Qigong therapy, the length of time the one-legged blind balance test had increased (P < 0.01), and the time it took to TUG test was reduced (P < 0.01). Joint range of motion and gait significantly improved. The control group's there were no significant differences in the above variables, except for joint range of motion, which decreased.

Conclusion

Health Qigong exercises can significantly improve physical functions in patients with PD, especially for the balance ability, gait, joint range of motion in patients with PD. It can reduce their activity risk factor and improve their quality of life.

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

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