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

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

PURPOSE

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

MATERIALS/METHODS

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

RESULTS

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

CONCLUSION

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

Utilizing Entropy of Cadence to Optimize Cycling Rehabilitation in Individuals With Parkinson's Disease

BACKGROUND

Previous studies have established that increased Sample Entropy (SampEn) of cadence, a measure of non-linear variability, during dynamic cycling leads to greater improvements in motor function for individuals with Parkinson's disease (PD). However, there is significant variability in responses among individuals with PD due to symptoms and disease progression.

OBJECTIVES

The aim of this study was to develop and test a paradigm for adapting a cycling exercise intervention using SampEn of cadence and rider effort to improve motor function.

METHODS

Twenty-two participants were randomized into either patient-specific adaptive dynamic cycling (PSADC) or non-adaptive (NA) group. SampEn of cadence was calculated after each of the 12 sessions, and motor function was evaluated using the Kinesia test. Pearson's correlation coefficient was used to analyze the relationship between SampEn of cadence and motor function improvement. Multiple linear regression (MLR) was used to identify the strongest predictors of motor function improvement.

RESULTS

Pearson's correlation coefficient revealed a significant correlation between SampEn of cadence and motor function improvements (R2 = -.545, P = .009), suggesting that higher SampEn of cadence led to greater motor function improvement. MLR demonstrated that SampEn of cadence was the strongest predictor of motor function improvement (β = -8.923, t = -2.632, P = .018) over the BMI, Levodopa equivalent daily dose, and effort.

CONCLUSIONS

The findings show that PSADC paradigm promoted a greater improvement in motor function than NA dynamic cycling. These data will be used to develop a predictive model to optimize motor function improvement after cycling in individuals with PD.

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).

High cadence cycling not high work rate, increases gait velocity post-exercise

Gait velocity, or walking speed, has been referred to as the sixth vital sign, and research suggests that it is highly sensitive to change. Previous research has demonstrated the utility of cycling to improve gait parameters and in particular gait velocity in a variety of populations. However, it is unclear if the benefits from cycling to gait velocity stem from increased cadence, increased work rate, or the interaction between them. Therefore, the objective of the current research was to explicitly test the relationship between cycling work rate, cycling cadence, and gait velocity. 45 recreationally active young adults were randomly assigned to cycle at a normalised cadence and work rate, a higher cadence, or a higher work rate (CONTROL, FAST, HARD). All participants completed two ten-metre walk tests (10 MWT) pre- and post-cycling intervention. There was a significant interaction between group and time and post hoc comparisons showed that the FAST group walked significantly faster than the HARD group post-cycling. These results support the hypothesis that cycling at a cadence greater than the comfortable walking cadence, and not cycling at an increased work rate, increased gait velocity post-exercise for all members of our sample of healthy young adults.

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.

Brain Dynamics Underlying Preserved Cycling Ability in Patients With Parkinson's Disease and Freezing of Gait

Parkinson's disease (PD) is generally associated with abnormally increased beta band oscillations in the cortico-basal ganglia loop during walking. PD patients with freezing of gait (FOG) exhibit a more distinct, prolonged narrow band of beta oscillations that are locked to the initiation of movement at ∼18 Hz. Upon initiation of cycling movements, this oscillation has been reported to be weaker and rather brief in duration. Due to the suppression of the overall beta band power during cycling and its continuous nature of the movement, cycling is considered to be less demanding for cortical networks compared to walking, including reduced need for sensorimotor processing, and thus unimpaired continuous cycling motion. Furthermore, cycling has been considered one of the most efficient non-pharmacological therapies with an influence on the subthalamic nucleus (STN) beta rhythms implicative of the deep brain stimulation effects. In the current review, we provide an overview of the currently available studies and discuss the underlying mechanism of preserved cycling ability in relation to the FOG in PD patients. The mechanisms are presented in detail using a graphical scheme comparing cortical oscillations during walking and cycling in PD.

Effects of Ten Different Exercise Interventions on Motor Function in Parkinson’s Disease Patients—A Network Meta-Analysis of Randomized Controlled Trials

Objective: The aim of this study was to evaluate ten exercise interventions (YOGA: yoga training, RT: resistance training, AQU: aquatic training, TAI: Taiji Qigong training, TRD: treadmill training, VR: virtual reality training, DANCE: musical dance training, WKT: walking training, CYC: cycling training, BDJ: Baduanjin Qigong training) on motor function in Parkinson’s disease (PD) patients. Design: Through searching PubMed, Embase, Cochrane Library, Web of Science, and CNKI, only randomized controlled trials (RCTs) were collected to study the effects of the ten exercise interventions on motor function in patients with Parkinson’s disease. The included studies were evaluated for methodological quality by the Cochrane bias risk assessment tool. Results: The RCTs were collected between the earliest available date and April 2022. Sixty RCTs were included and the total sample size used in the study was 2859. The results of the network meta-analysis showed that DANCE can significantly improve patients’ Berg Balance Scale (BBS) (SUCRA = 78.4%); DANCE can significantly decline patients’ Unified Parkinson’s Disease Rating Scale score (UPDRS) (SUCRA = 72.3%) and YOGA can significantly decline patients’ Timed-Up-and-Go score (TUGT) (SUCRA = 78.0%). Conclusion: Based on the network meta-analysis and SUCRA ranking, we can state that dance, yoga, virtual reality training and resistance training offers better advantages than other exercise interventions for patients’ motor function.

Analysis of Movement Entropy during Community Dance Programs for People with Parkinson's Disease and Older Adults: A Cohort Study

Dance therapy can improve motor skills, balance, posture, and gait in people diagnosed with Parkinson’s disease (PD) and healthy older adults (OA). It is not clear how specific movement patterns during dance promote these benefits. The purpose of this cohort study was to identify differences and complexity in dance movement patterns among different dance styles for PD and OA participants in community dance programs using approximate entropy (ApEn) analysis. The hypothesis was that PD participants will show greater ApEn during dance than OA participants and that the unique dance style of tango with more pronounced foot technique and sharp direction changes will show greater ApEn than smoother dance types such as foxtrot and waltz characterized by gradual changes in direction and gliding movement with rise and fall. Individuals participated in one-hour community dance classes. Movement data were captured using porTable 3D motion capture sensors attached to the arms, torso and legs. Classes were also video recorded to assist in analyzing the dance steps. Movement patterns were captured and ApEn was calculated to quantify the complexity of movements. Participants with PD had greater ApEn in right knee flexion during dance movements than left knee flexion (p = 0.02), greater ApEn of right than left hip flexion (p = 0.05), and greater left hip rotation than right (p = 0.03). There was no significant difference in ApEn of body movements (p > 0.4) or mean body movements (p > 0.3) at any body-segment in OA. ApEn analysis is valuable for quantifying the degree of control and predictability of dance movements and could be used as another tool to assess the movement control of dancers and aid in the development of dance therapies.

Perceived exercise habits of individuals with Parkinson’s disease living in the community

Context

Exercise has been shown to improve gait in individuals with Parkinson’s disease (PD). Stepping practice at higher intensity levels has been suggested as a beneficial treatment option to improve gait in the neurological population. Unfortunately, this mode is poorly understood and underutilized within the PD population. Information on what individuals with PD are doing for exercise would be beneficial to help tailor exercise programs to improve gait and provide exercise options in the community for intensity-based exercise.

Objective

To investigate the current exercise habits of individuals living with PD in the community aimed at improving walking and to understand the impact of perceived intensity on daily exercise practices.

Design, setting, participants

One hundred thirty-eight individuals with PD living in the community were surveyed online regarding their current exercise habits.

Main outcome measure

A total of 22 questions aimed to understand exercise selection, focus, and perceived intensity. Questions asked basic demographic, symptom presentation and management of disease related symptoms that were present while living with PD. Exercise questions focused understanding participants current function level, practice exercise habits and perceived levels of exercise intensity during daily routines.

Results

Of the 138 individuals surveyed for this preliminary study, eighty-seven percent of individuals with PD participated in exercise with seventy-five percent choosing walking as a mode for exercise. Sixty-five percent of the respondents noted that despite exercise, their walking speed and endurance has worsened since diagnosis. Eighty-one percent perceived exercising at moderate intensity levels, however little provocation of intensity symptoms was noted.

Conclusion

Our preliminary study survey results suggest that individuals with PD are exercising but not at high enough intensity levels to promote improvements in gait performance. Individuals with PD may need to be pushed at higher intensity levels, beyond their voluntary limits, to induce gait performance changes. These findings can provide a foundation for future fitness interventions within this population to target improving gait.

Mobility Improvements After a High-cadence Dynamic Cycling Intervention in an Individual with Motor Neuron Disease: A Case Study

Previous exercise studies in individuals with motor neuron disease have shown some positive benefits but the stress of regular exercise could result in overuse weakness in this population. The purpose of this case study is to determine the efficacy, and tolerability of a high-cadence dynamic cycling intervention in an individual with motor neuron disease. A 67-year-old male with significant lower extremity weakness and a diagnosis of idiopathic motor neuron disease completed six 30-minute sessions of high cadence dynamic cycling over a two-week period using a custom-built motorized ergometer with the motor speed set at 80 revolutions per minute. This intervention resulted in an 80.4 m increase in walking distance during the six-minute walk test (21% increase), with a lower rating of perceived exertion than at baseline. Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised scores improved slightly (2.4%) suggesting that the intervention was tolerated, and it did not compromise the participant's physical function. These data show that this intervention can improve mobility, is well-tolerated and minimizes the risk of overuse weakness in an individual with motor neuron disease.

A randomised controlled trial on effectiveness and feasibility of sport climbing in Parkinson's disease

Physical activity is of prime importance in non-pharmacological Parkinson's disease (PD) treatment. The current study examines the effectiveness and feasibility of sport climbing in PD patients in a single-centre, randomised controlled, semi-blind trial. A total of 48 PD patients without experience in climbing (average age 64 ± 8 years, Hoehn & Yahr stage 2-3) were assigned either to participate in a 12-week sport climbing course (SC) or to attend an unsupervised physical training group (UT). The primary outcome was the improvement of symptoms on the Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS-III). Sport climbing was associated with a significant reduction of the MDS-UPDRS-III (-12.9 points; 95% CI -15.9 to -9.8), while no significant improvement was to be found in the UT (-3.0 points; 95% CI -6.0 to 0.1). Bradykinesia, rigidity and tremor subscales significantly improved in SC, but not in the unsupervised control group. In terms of feasibility, the study showed a 99% adherence of participants to climbing sessions and a drop-out rate of only 8%. No adverse events occurred. This trial provides class III evidence that sport climbing is highly effective and feasible in mildly to moderately affected PD patients.

Sensory Attenuation in Sport and Rehabilitation: Perspective from Research in Parkinson's Disease

People with Parkinson's disease (PD) experience motor symptoms that are affected by sensory information in the environment. Sensory attenuation describes the modulation of sensory input caused by motor intent. This appears to be altered in PD and may index important sensorimotor processes underpinning PD symptoms. We review recent findings investigating sensory attenuation and reconcile seemingly disparate results with an emphasis on task-relevance in the modulation of sensory input. Sensory attenuation paradigms, across different sensory modalities, capture how two identical stimuli can elicit markedly different perceptual experiences depending on our predictions of the event, but also the context in which the event occurs. In particular, it appears as though contextual information may be used to suppress or facilitate a response to a stimulus on the basis of task-relevance. We support this viewpoint by considering the role of the basal ganglia in task-relevant sensory filtering and the use of contextual signals in complex environments to shape action and perception. This perspective highlights the dual effect of basal ganglia dysfunction in PD, whereby a reduced capacity to filter task-relevant signals harms the ability to integrate contextual cues, just when such cues are required to effectively navigate and interact with our environment. Finally, we suggest how this framework might be used to establish principles for effective rehabilitation in the treatment of PD.

Neural Correlates of Freezing of Gait in Parkinson's Disease: An Electrophysiology Mini-Review

Freezing of gait (FoG) is a disabling symptom characterized as a brief inability to step or by short steps, which occurs when initiating gait or while turning, affecting over half the population with advanced Parkinson's disease (PD). Several non-competing hypotheses have been proposed to explain the pathophysiology and mechanism behind FoG. Yet, due to the complexity of FoG and the lack of a complete understanding of its mechanism, no clear consensus has been reached on the best treatment options. Moreover, most studies that aim to explore neural biomarkers of FoG have been limited to semi-static or imagined paradigms. One of the biggest unmet needs in the field is the identification of reliable biomarkers that can be construed from real walking scenarios to guide better treatments and validate medical and therapeutic interventions. Advances in neural electrophysiology exploration, including EEG and DBS, will allow for pathophysiology research on more real-to-life scenarios for better FoG biomarker identification and validation. The major aim of this review is to highlight the most up-to-date studies that explain the mechanisms underlying FoG through electrophysiology explorations. The latest methodological approaches used in the neurophysiological study of FoG are summarized, and potential future research directions are discussed.