Effects of voluntary and forced physical exercise on the retinal health of aging Wistar rats

Aging is accompanied by an increased prevalence of degenerative conditions, including those affecting ocular health, which significantly impact quality of life and increase the burden on healthcare systems. Among these, retinal aging is of particular concern due to its direct link to vision impairment, a leading cause of disability in the elderly. Vision loss in the aging population is associated with heightened risks of cognitive decline, social isolation, and morbidity. This study addresses the critical gap in our understanding of modifiable lifestyle factors, such as physical exercise, that may mitigate retinal aging and its related pathologies. We investigated the effects of different exercise regimens-voluntary (recreational-type) and forced (high-intensity)-on the retinal health of aging Wistar rats (18-month-old), serving as a model for studying the translational potential of exercise interventions in humans. Male Wistar rats were divided into four groups: a young control (3-month-old) for baseline comparison, an aged sedentary control, an aged group engaging in voluntary exercise via a running wheel in their cage, and an aged group subjected to forced exercise on a treadmill for six sessions of 20 min each per week. After a 6-month experimental period, we assessed retinal function via electroretinography (ERG), measured retinal thickness histologically, and analyzed protein expression changes relevant to oxidative stress, inflammation, and anti-aging mechanisms. Our findings reveal that voluntary exercise positively impacts retinal function and morphology, reducing oxidative stress and inflammation markers while enhancing anti-aging protein expression. In contrast, forced exercise showed diminished benefits. These insights underscore the importance of exercise intensity and preference in preserving retinal health during aging. The study highlights the potential of recreational physical activity as a non-invasive strategy to counteract retinal aging, advocating for further research into exercise regimens as preventative therapies for age-related ocular degenerations.

Moderate intensity aerobic exercise alleviates motor deficits in 6-OHDA lesioned rats and reduces serum levels of biomarkers of Parkinson's disease severity without recovery of striatal dopamine or tyrosine hydroxylase

Alleviation of motor impairment by aerobic exercise (AE) in Parkinson's disease (PD) patients points to activation of neurobiological mechanisms that may be targetable by therapeutic approaches. However, evidence for AE-related recovery of striatal dopamine (DA) signaling or tyrosine hydroxylase (TH) loss has been inconsistent in rodent studies. This ambiguity may be related to the timing of AE intervention in relation to the status of nigrostriatal neuron loss. Here, we replicated human PD at diagnosis by establishing motor impairment with >80% striatal DA and TH loss prior to initiating AE, and assessed its potential to alleviate motor decline and restore DA and TH loss. We also evaluated if serum levels of neurofilament light (NfL) and glial fibrillary acidic protein (GFAP), biomarkers of human PD severity, changed in response to AE. 6-hydroxydopamine (6-OHDA) was infused unilaterally into rat medial forebrain bundle to induce progressive nigrostriatal neuron loss over 28 days. Moderate intensity AE (3× per week, 40 min/session), began 8-10 days post-lesion following establishment of impaired forelimb use. Striatal tissue DA, TH protein and mRNA, and serum levels of NfL/GFAP were determined 3-wks after AE began. Despite severe striatal DA depletion at AE initiation, forelimb use deficits and hypokinesia onset were alleviated by AE, without recovery of striatal DA or TH protein loss, but reduced NfL and GFAP serum levels. This proof-of-concept study shows AE alleviates motor impairment when initiated with >80% striatal DA loss without obligate recovery of striatal DA or TH protein. Moreover, the AE-related reduction of NfL and GFAP serum levels may serve as objective blood-based biomarkers of AE efficacy.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSIONS

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

Intensive Aerobic Cycling Is Feasible and Elicits Improvements in Gait Velocity in Individuals With Multiple Sclerosis: A Preliminary Study

BACKGROUND

Aerobic exercise (AEx) has many potential benefits; however, it is unknown whether individuals with multiple sclerosis (MS) can attain the optimal intensity and duration to harness its effects. Forced-rate exercise (FE) is a novel paradigm in which the voluntary pedaling rate during cycling is supplemented to achieve a higher exercise intensity. The aim of this pilot trial was to investigate the feasibility and initial efficacy of a 12-week FE or voluntary exercise (VE) cycling intervention for individuals with MS.

METHODS

Twenty-two participants with MS (Expanded Disability Severity Scale [EDSS] 2.0-6.5) were randomly assigned to FE (n = 12) or VE (n = 10), each with twice weekly 45-minute sessions at a prescribed intensity of 60% to 80% of maximum heart rate (HR).

RESULTS

Eighteen individuals (FE = 11; VE = 7) completed the intervention, however, adaptations were required in both groups to overcome barriers to cycling. Overall, participants exercised for an average of 42.2 ± 2.3 minutes at an aerobic intensity of 65% ± 7% of maximum HR and a pedaling cadence of 67.3 ± 13.3 RPM. Cycling led to improved treadmill walking speed (0.61 to 0.68 m/sec, P = .010), with somewhat greater improvement with FE compared to VE (increase of 0.09 vs 0.03 m/s, respectively, P = .17) post intervention. Notably, the participant with the highest disability level (EDSS 6.5) tolerated FE but not VE.

CONCLUSIONS

Aerobic exercise is feasible for individuals with MS, although those with increased disability may require novel paradigms such as FE to achieve targeted intensity. Further trials are warranted to investigate the effects of FE across the MS disability spectrum.

Effects of Group Exercise on Motor Function and Mobility for Parkinson Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

Parkinson disease (PD) is associated with a predictable decline in motor function and mobility that is commonly managed with exercise. There is a limited understanding of the effects of group exercise compared to individual exercise (IE) and usual care (UC) on motor function and mobility. Our purpose was to investigate the effects of group exercise compared to IE and UC on motor function and mobility for people with PD.

METHODS

A systematic review and meta-analysis was performed with randomized control trials that investigated the effects of group compared with IE and UC on motor function and mobility for people with PD. A systematic search was performed in PubMed, EBSCO, and Science Direct databases. Methodological quality was assessed using the Cochrane Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

Twenty-three studies assessed at least 1 mobility-related outcome measure, met our inclusion criteria, and were included in quantitative analysis. There was no significant difference on motor function and mobility between group exercise and IE for all standardized outcome assessment meta-analyses. Motor function and mobility were significantly improved with group exercise compared to UC in 9 of 11 standardized outcome assessment meta-analyses. Results were based upon low to moderate quality of evidence.

CONCLUSION

Based upon low to moderate quality of evidence, group exercise has a similar to larger effect as IE and UC on improving motor function and mobility for people with PD. When used in combination with skilled physical therapy, group exercise may be an appropriate adjunct to individualized physical therapy to maximize mobility and function.

IMPACT

Long-term adherence to exercise is essential to maintain mobility and motor function for people with PD. Our study suggests group exercise is as effective as IE and may be an appropriate option to encourage long-term adherence related to increased access, socialization, and accountability.

Use of a Home-Based, Commercial Exercise Platform to Remotely Monitor Aerobic Exercise Adherence and Intensity in People With Parkinson Disease

OBJECTIVE

Physical therapists are well-positioned to prescribe exercise outside of a clinical setting to promote positive health behaviors in people with Parkinson disease (PD). Traditionally, a barrier to precise exercise prescription has been reliance on participant self-reported exercise adherence and intensity. Home-based, commercially available exercise platforms offer an opportunity to remotely monitor exercise behavior and facilitate adherence based on objective performance metrics. The primary aim of this project was to characterize the feasibility and processes of remote aerobic exercise data monitoring from a home-based, commercially available platform in individuals participating in the 12-month Cyclical Lower Extremity Exercise for PD II (CYCLE-II) randomized clinical trial. Secondary aims focused on using exercise behavior to classify the cohort into exercise archetypes and describing a shared decision-making process to facilitate exercise adherence.

METHODS

Data from each exercise session were extracted, visualized, and filtered to ensure ride integrity. Weekly exercise frequency was used to determine exercise archetypes: Adherent (2-4 exercise sessions per week), Over-adherent (>4 exercise sessions per week), and Under-adherent (<2 exercise sessions per week).

RESULTS

A total of 123 people with PD completed 22,000+ exercise sessions. Analysis of exercise frequency indicated that 79% of participants were adherent; 8% were over-adherent; and 13% were under-adherent. Three case reports illustrate how shared decision-making with the use of exercise performance data points guided exercise prescription.

CONCLUSIONS

The number of exercise sessions and completeness of the data indicate that people with PD were able to utilize a commercial, home-based exercise platform to successfully engage in long-term aerobic exercise. Physical therapists can use objective data as a part of a shared decision-making process to facilitate exercise adherence.

IMPACT

Commercially available exercise platforms offer a unique approach for physical therapists to monitor exercise behavior outside of a clinical setting. The methods used in this project can serve as a roadmap to utilizing data from consumer-based platforms.

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

Introduction

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

Materials and Methods

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

Results

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

Explainable machine learning for predicting conversion to neurological disease: Results from 52,939 medical records

Objective

This study assesses the application of interpretable machine learning modeling using electronic medical record data for the prediction of conversion to neurological disease.

Methods

A retrospective dataset of Cleveland Clinic patients diagnosed with Alzheimer's disease, amyotrophic lateral sclerosis, multiple sclerosis, or Parkinson's disease, and matched controls based on age, sex, race, and ethnicity was compiled. Individualized risk prediction models were created using eXtreme Gradient Boosting for each neurological disease at four timepoints in patient history. The prediction models were assessed for transparency and fairness.

Results

At timepoints 0-months, 12-months, 24-months, and 60-months prior to diagnosis, Alzheimer's disease models achieved the area under the receiver operating characteristic curve on a holdout test dataset of 0.794, 0.742, 0.709, and 0.645; amyotrophic lateral sclerosis of 0.883, 0.710, 0.658, and 0.620; multiple sclerosis of 0.922, 0.877, 0.849, and 0.781; and Parkinson's disease of 0.809, 0.738, 0.700, and 0.651, respectively.

Conclusions

The results demonstrate that electronic medical records contain latent information that can be used for risk stratification for neurological disorders. In particular, patient-reported outcomes, sleep assessments, falls data, additional disease diagnoses, and longitudinal changes in patient health, such as weight change, are important predictors.

Unveiling the Impact of Outpatient Physiotherapy on Specific Motor Symptoms in Parkinson's Disease: A Prospective Cohort Study

Understanding how outpatient physiotherapy impacts on specific motor symptoms in Parkinson's disease (PD) is important for multidisciplinary care, but these points have not been clarified. We investigated the impact of outpatient physiotherapy on individual motor symptoms in PD patients. Fifty-five PD patients participated in the prospective cohort study, which examined the changes in motor symptoms after 90 min of outpatient physiotherapy program (1×/week for 10 weeks) and at 3 months follow-up. Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor score and tremor, rigidity, bradykinesia, and axial scores were assessed and compared pre-intervention, post-intervention, and at follow-up. Significant level was set at 0.05. Their MDS-UPDRS motor score and axial score significantly decreased post-intervention and at the follow-up. In the analysis differentiating effects based on the severity of motor symptoms according to the MDS-UPDRS motor score, only the moderate-severe group showed significant decreases in their MDS-UPDRS motor score, bradykinesia, and axial scores post-intervention, as well as in their MDS-UPDRS motor score, rigidity, bradykinesia, and axial scores at the follow-up. These findings suggest the outpatient physiotherapy might provide benefits, particularly in managing axial symptoms and bradykinesia, for community dwelling PD patients with moderate-severe motor symptoms within a multidisciplinary care framework.

Moderate intensity aerobic exercise in 6-OHDA-lesioned rats alleviates established motor deficits and reduces neurofilament light and glial fibrillary acidic protein serum levels without increased striatal dopamine or tyrosine hydroxylase protein

Background

Alleviation of motor impairment by aerobic exercise (AE) in Parkinson's disease (PD) points to a CNS response that could be targeted by therapeutic approaches, but recovery of striatal dopamine (DA) or tyrosine hydroxylase (TH) has been inconsistent in rodent studies.

Objective

To increase translation of AE, 3 components were implemented into AE design to determine if recovery of established motor impairment, concomitant with >80% striatal DA and TH loss, was possible. We also evaluated if serum levels of neurofilament light (NfL) and glial fibrillary acidic protein (GFAP), blood-based biomarkers of disease severity in human PD, were affected.

Methods

We used a 6-OHDA hemiparkinson rat model featuring progressive nigrostriatal neuron loss over 28 days, with impaired forelimb use 7 days post-lesion, and hypokinesia onset 21 days post-lesion. After establishing forelimb use deficits, moderate intensity AE began 1-3 days later, 3x per week, for 40 min/session. Motor assessments were conducted weekly for 3 wks, followed by determination of striatal DA, TH protein and mRNA, and NfL and GFAP serum levels.

Results

Seven days after 6-OHDA lesion, recovery of depolarization-stimulated extracellular DA and DA tissue content was <10%, representing severity of DA loss in human PD, concomitant with 50% reduction in forelimb use. Despite severe DA loss, recovery of forelimb use deficits and alleviation of hypokinesia progression began after 2 weeks of AE and was maintained. Increased NfLand GFAP levels from lesion were reduced by AE. Despite these AE-driven changes, striatal DA tissue and TH protein levels were unaffected.

Conclusions

This proof-of-concept study shows AE, using exercise parameters within the capabilities most PD patients, promotes recovery of established motor deficits in a rodent PD model, concomitant with reduced levels of blood-based biomarkers associated with PD severity, without commensurate increase in striatal DA or TH protein.

The Rehabilitative Effect of Archery Exercise Intervention in Patients with Parkinson's Disease

Background

Archery exercise exerts a rehabilitative effect on patients with paraplegia and might potentially serve as complementary physiotherapy for patients with Parkinson's disease.

Objective

This study aimed to examine the rehabilitative effects of an archery intervention.

Methods

A randomized controlled trial of a 12-week intervention was performed in patients with idiopathic Parkinson's disease. Thirty-one of the 39 eligible patients recruited from a medical center in Taiwan participated in the trial, of whom 16 were in the experimental group practicing archery exercises and 15 were in the control group at the beginning; twenty-nine completed the whole process. The Purdue pegboard test (PPT), the Unified Parkinson's Disease Rating Scale I to III (UPDRS I to III), physical fitness test, and timed up and go test (TUG) were used to assess the intervention effects of archery exercise.

Results

Compared to the control group, the outcome differences between the posthoc and baseline tests in PPT, UPDRS I to III, lower extremity muscular strength, and TUG in the experimental group (between-group difference in difference's mean: 2.07, 1.59, 1.36, -2.25, -3.81, -9.10, 3.57, and -1.51, respectively) did show positive changes and their effect sizes examined from Mann-Whitney U tests (η: 0.631, 0.544, 0.555, 0.372, 0.411, 0.470, 0.601, and 0.381, respectively; Ps < 0.05) were medium to large, indicating that the archery intervention exerted promising effects on improving hand flexibility and finger dexterity, activity functions in motor movement, lower extremity muscular strength, and gait and balance ability.

Conclusions

Traditional archery exercise was suggested to have a rehabilitative effect for mild to moderate Parkinson's disease and could be a form of physiotherapy. Nevertheless, studies with larger sample sizes and extended intervention periods are needed to ascertain the long-term effects of archery exercise.

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.

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

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

Study in Parkinson's disease of exercise phase 3 (SPARX3): study protocol for a randomized controlled trial

BACKGROUND

To date, no medication has slowed the progression of Parkinson's disease (PD). Preclinical, epidemiological, and experimental data on humans all support many benefits of endurance exercise among persons with PD. The key question is whether there is a definitive additional benefit of exercising at high intensity, in terms of slowing disease progression, beyond the well-documented benefit of endurance training on a treadmill for fitness, gait, and functional mobility. This study will determine the efficacy of high-intensity endurance exercise as first-line therapy for persons diagnosed with PD within 3 years, and untreated with symptomatic therapy at baseline.

METHODS

This is a multicenter, randomized, evaluator-blinded study of endurance exercise training. The exercise intervention will be delivered by treadmill at 2 doses over 18 months: moderate intensity (4 days/week for 30 min per session at 60-65% maximum heart rate) and high intensity (4 days/week for 30 min per session at 80-85% maximum heart rate). We will randomize 370 participants and follow them at multiple time points for 24 months. The primary outcome is the Movement Disorders Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor score (Part III) with the primary analysis assessing the change in MDS-UPDRS motor score (Part III) over 12 months, or until initiation of symptomatic antiparkinsonian treatment if before 12 months. Secondary outcomes are striatal dopamine transporter binding, 6-min walk distance, number of daily steps, cognitive function, physical fitness, quality of life, time to initiate dopaminergic medication, circulating levels of C-reactive protein (CRP), and brain-derived neurotrophic factor (BDNF). Tertiary outcomes are walking stride length and turning velocity.

DISCUSSION

SPARX3 is a Phase 3 clinical trial designed to determine the efficacy of high-intensity, endurance treadmill exercise to slow the progression of PD as measured by the MDS-UPDRS motor score. Establishing whether high-intensity endurance treadmill exercise can slow the progression of PD would mark a significant breakthrough in treating PD. It would have a meaningful impact on the quality of life of people with PD, their caregivers and public health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04284436 . Registered on February 25, 2020.

Perception of Physical Demand, Mental Demand, and Performance: A Comparison of Two Voice Interventions for Parkinson's Disease

PURPOSE

The purpose of the study was to examine the effect of two voice intervention approaches for hypophonia secondary to Parkinson's disease (PD) on self-reported measures of physical demand, mental demand, and vocal performance.

METHOD

Thirty-four persons with hypophonia secondary to PD were assigned to one of three groups: Lee Silverman Voice Treatment (LSVT) LOUD (n = 12), SpeechVive (n = 12), and nontreatment clinical control (n = 10). The LSVT LOUD and the SpeechVive participants received 8 weeks of voice intervention following the standardized protocol previously described for each approach. To confirm the effectiveness of each voice intervention, sound pressure level (dB SPL) data were analyzed for the experimental and control participants for a monologue sample obtained pretreatment, midtreatment, and posttreatment. During the voice intervention period, the LSVT LOUD and the SpeechVive participants were instructed to complete a modified version of the National Aeronautics and Space Administration Task Load Index rating scale to indicate the mental and physical demand required to complete the intervention activities, and to indicate how well they performed in completing the assigned vocal tasks.

RESULTS

The LSVT LOUD and the SpeechVive participants demonstrated a significant posttreatment increase in SPL (dB), in comparison to the clinical controls, thus confirming a positive intervention effect. The LSVT LOUD participants reported significantly higher ratings of physical and mental demand over the course of treatment, in comparison to the SpeechVive participants.

CONCLUSION

Consideration of the mental and physical demand associated with two voice intervention approaches, commonly used for PD, may help to foster improved therapeutic compliance and treatment outcomes.

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

In 2015, Uhrbrand et al. published the first review on Parkinson´s disease (PD) and exercise entirely based on randomized controlled trials (RCT) applying strict exercise definitions. The present review aimed to update the PD literature by assessing the effects of different intensive exercise modalities: resistance training (RT), endurance training (ET), and other intensive exercise modalities (OITM). An updated systematic literature search identified 33 new RCTs. Qualitative and quantitative analyses were performed. A total of 18 RT, 14 ET, and 1 OITM studies were identified (adding to the 8 RT, 6 ET, and 4 OITM studies identified by Uhrbrand et al. in 2015). RT, ET, and OITM were feasible, safe, and did not worsen PD symptoms. Furthermore, RT, ET, and OITM may positively affect functional outcomes (e.g., balance) and depressive symptoms in PD but inconsistencies across these findings warrant cautious conclusions. Meta-analyses showed that RT had a positive impact on muscle strength (standardized mean difference (SMD) = 0.83 [95% CI;0.54, 1.12]), functional capacity (Timed Up and Go Test (TUG): SMD = -0.62 [-1.01, -0.24]), and quality of life (SMD = -0.41 [-0.72, -0.09]), while ET had a positive impact on cardiorespiratory fitness (SMD = 0.27 [0.07, 0.47]) and functional capacity (TUG: SMD = -0.21 [-0.46, 0.04], 6-Min Walk Test: SMD = 0.89 [0.17, 1.62]), and a potentially positive impact on "on-medication" UPDRS-III (SMD = -0.15 [-0.38, 0.09]) and "off-medication" UPDRS-III (SMD = -0.19 [-0.41, 0.04]). In conclusion, RT, ET, and OITM all represent safe, feasible, and beneficial adjunct rehabilitation strategies in PD, with particularly RT and ET showing solid effects.

Body Mass Index and Exercise Effort Influences Changes in Motor Symptoms After High-Cadence Dynamic Cycling in Parkinson's Disease

High-cadence dynamic cycling improves motor symptoms of Parkinson's disease (PD), such as tremor and bradykinesia. However, some participants experience greater benefits than others. To gain insight into how individual characteristics and cycling performance affects functional changes, data from two previous studies were used to build several preliminary predictive models. The purpose was to examine which variables contribute to greater improvement in symptoms after high-cadence dynamic cycling. We hypothesized that individuals with higher body mass index (BMI), increased age, more severe symptoms, and higher PD medication dosages were less likely to contribute effort during cycling. UPDRS-III was assessed before and after each session, and cadence and power were recorded every second. Entropy of cadence was calculated, and data were analyzed using analysis of variance and multiple linear regression. The multiple linear regression model of post UPDRS significantly (R2 = 0.81, p &lt; 0.001) explained its variance, with pre UPDRS as the main predictor (p &lt; 0.0001). The binomial logistic model of mean effort did not significantly (R2 = 0.36, p = 0.14) explain the variance. Post-hoc analysis found a significant (β = 0.28, p = 0.03) moderating effect of different levels of BMI on the association between mean effort and post UPDRS. These results suggest that BMI, effort, and baseline UPDRS levels can potentially predict individual responses to high-cadence dynamic cycling.

Effects of Endurance Training on Motor Signs of Parkinson's Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Evidence has demonstrated that endurance training (ET) reduces the motor signs of Parkinson's disease (PD). However, there has not been a comprehensive meta-analysis of studies to date.

OBJECTIVE

The aim of this study was to compare the effect of ET versus nonactive and active control conditions on motor signs as assessed by either the Unified Parkinson's Disease Rating Scale part III (UPDRS-III) or Movement Disorder Society-UPDRS-III (MDS-UPDRS-III).

METHODS

A random-effect meta-analysis model using standardized mean differences (Hedges' g) determined treatment effects. Moderators (e.g., combined endurance and physical therapy training [CEPTT]) and meta-regressors (e.g., number of sessions) were used for sub-analyses. Methodological quality was assessed by the Physiotherapy Evidence Database.

RESULTS

Twenty-seven randomized controlled trials (RCTs) met inclusion criteria (1152 participants). ET is effective in decreasing UPDRS-III scores when compared with nonactive and active control conditions (g =  - 0.68 and g =  - 0.33, respectively). This decrease was greater (within- and between-groups average of - 8.0 and - 6.8 point reduction on UPDRS-III scores, respectively) than the moderate range of clinically important changes to UPDRS-III scores (- 4.5 to - 6.7 points) suggested for PD. Although considerable heterogeneity was observed between RCTs (I² = 74%), some moderators that increased the effect of ET on motor signs decreased the heterogeneity of the analyses, such as CEPTT (I² = 21%), intensity based on treadmill speed (I² = 0%), self-perceived exertion rate (I² = 33%), and studies composed of individuals with PD and freezing of gait (I² = 0%). Meta-regression did not produce significant relationships between ET dosage and UPDRS-III scores.

CONCLUSIONS

ET is effective in decreasing UPDRS-III scores. Questions remain about the dose-response relationship between ET and reduction in motor signs.

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.

Establishing Equivalent Aerobic Exercise Parameters Between Early-Stage Parkinson's Disease and Pink1 Knockout Rats

BACKGROUND

Rodent Parkinson's disease (PD) models are valuable to interrogate neurobiological mechanisms of exercise that mitigate motor impairment. Translating these mechanisms to human PD must account for physical capabilities of the patient.

OBJECTIVE

To establish cardiovascular parameters as a common metric for cross-species translation of aerobic exercise impact.

METHOD

We evaluated aerobic exercise impact on heart rate (HR) in 21 early-stage PD subjects (Hoehn Yahr ≤1.5) exercising in non-contact boxing training for ≥3 months, ≥3x/week. In 4-month-old Pink1 knockout (KO) rats exercising in a progressively-increased treadmill speed regimen, we determined a specific treadmill speed that increased HR to an extent similar in human subjects.

RESULTS

After completing aerobic exercise for ∼30 min, PD subjects had increased HR∼35% above baseline (∼63% maximum HR). Motor and cognitive test results indicated the exercising subjects completed the timed up and go (TUG) and trail-making test (TMT-A) in significantly less time versus exercise-naïve PD subjects. In KO and age-matched wild-type (WT) rats, treadmill speeds of 8-10 m/min increased HR up to 25% above baseline (∼67% maximum HR), with no further increases up to 16 m/min. Exercised KO, but not WT, rats showed increased locomotor activity compared to an age-matched exercise-naïve cohort at 5 months old.

CONCLUSION

These proof-of-concept results indicate HR is a cross-species translation parameter to evaluate aerobic exercise impact on specific motor or cognitive functions in human subjects and rat PD models. Moreover, a moderate intensity exercise regimen is within the physical abilities of early-stage PD patients and is therefore applicable for interrogating neurobiological mechanisms in rat PD models.

An equation to calculate UPDRS motor severity for online and rural assessments of Parkinson's

OBJECTIVE

Management of PD has largely been affected by COVID-19. Due to the restrictions posed by COVID-19, there has been a shift from in-person to online forms of assessment. This presents a challenge as not all motor symptoms can be assessed virtually. Two of the four cardinal symptoms of PD (rigidity and postural instability) cannot be assessed virtually using the gold-standard Unified Parkinson's Disease Rating Scale (UPDRS-III). As a result, an accurate total motor severity score can not be computed from the remaining subsections. Recently, one study stated that in order for accurate scores to be calculated, only three sections could be absent. Virtually, six sections are unable to be evaluated with online assessments. This inability to compute a total motor severity score may result in poor disease management. Thus, in this study a regression equation was developed to predict total motor severity scores from partial scores.

METHODS

Total motor severity scores (UPDRS-III) from N = 234 individuals with idiopathic Parkinson's were retrospectively analyzed. In order to conduct a linear regression analysis predictor and outcome variables were created. The variables were then used for the linear regression. The equation was then tested on an independent data set N = 1168.

RESULTS

The regression analysis resulted in the equation to predict total motor symptom severity of PD.

CONCLUSIONS

In conclusion, the developed equation will be very useful for outreach in rural communities, as well as the continued remote management of PD during COVID-19 and beyond.

Effectiveness of a Long-Term, Home-Based Aerobic Exercise Intervention on Slowing the Progression of Parkinson Disease: Design of the Cyclical Lower Extremity Exercise for Parkinson Disease II (CYCLE-II) Study

OBJECTIVE

Previous short duration studies have demonstrated that high-intensity aerobic exercise improves aspects of motor and non-motor function in people with Parkinson disease (PwPD); however, the effectiveness of a long-term exercise intervention on slowing disease progression is unknown. The primary aim of this study is to determine the disease-altering effects of high-intensity aerobic exercise, administered on an upright stationary cycle, on the progression of PD. A secondary aim is to develop a prognostic model for 12-month changes in the Movement Disorder Society Unified Parkinson's Disease Rating Scale III (MDS-UPDRS III) of PwPD undergoing an aerobic exercise intervention.

METHODS

This pragmatic, multisite, single-rater blinded, randomized controlled trial will recruit PwPD from 2 large, urban, academic medical centers. Participants (N = 250 PwPD) will be randomized to (1) home-based aerobic exercise or (2) usual and customary care. Those in the aerobic exercise arm will be asked to complete in-home aerobic exercise sessions at 60% to 80% of heart rate reserve 3 times per week for 12 months utilizing a commercially available upright exercise cycle. The usual and customary care group will continue normal activity levels. Daily activity will be monitored for both groups throughout the 12-month study period. The primary outcome, both to assess disease-modifying response to aerobic exercise and for prognostic modeling in the aerobic exercise arm, is 12-month rate of change in the MDS-UPDRS III. Clinical and biomechanical measures will also be used to assess upper and lower extremity motor function as well as non-motor functions.

IMPACT

Should long-term aerobic exercise demonstrate disease-modifying capability, this study will provide evidence that "Exercise is Medicine" for PwPD. Further, the derived prognostic model will inform a patient-specific exercise prescription for PwPD and expected effects on PD progression.

The effects of arm crank training on aerobic capacity, physical performance, quality of life, and health-related disability in patients with Parkinson's disease

BACKGROUND

Aerobic exercise training contributes to improvement of cardiopulmonary capacity, mobility, neurological function, and quality of life.

AIMS

To investigate the effects of arm crank ergometer training on aerobic capacity, quality of life, and Parkinson's disease (PD)-related disability METHODS: Seventeen patients with PD were recruited to study. Assessments were performed at baseline and at the end of an 8-week arm crank ergometer (ACE) training program (3 days/week; 1 h per session, 50-70% VO_2peak) with patients acting as their own control. Outcome measures included aerobic capacity assessment, 6-min walk test (6MWT), timed up and go test (TUG), Unified Parkinson's Disease Rating Scale (UPDRS), Parkinson's Disease Questionnaire-39 (PDQ-39), Beck Depression Index (BDI), the Falls Efficacy Scale (FES), and Montreal Cognitive Assessment (MoCA).

RESULTS

At the end of the study, an increase of 30.49% in aerobic capacity was observed. Statistically significant improvements were found for the 6MWT (p = 0.001), TUG test (p = 0.001), UPDRS total score (p = 0.002), quality of life assessed with PDQ-39 (p = 0.006), BDI (p = 0.001), and FES scores (p = 0.002) after an 8-week ACE training. No significant effect on MoCA was found (p = 0.264).

CONCLUSION

An 8-week ACE training led to significant improvement in aerobic capacity, physical performance, and PD-related disabilities.

Individuals With Parkinson Disease Are Adherent to a High-Intensity Community-Based Cycling Exercise Program

BACKGROUND AND PURPOSE

Parkinson disease is a progressive neurological disorder with no known cure or proven method of slowing progression. High-intensity, laboratory-based aerobic exercise interventions are currently being pursued as candidates for altering disease progression. The aim of this project was to evaluate the translation of a laboratory-based intervention to the community by monitoring exercise adherence (eg, attendance) and intensity (eg, heart rate [HR] and cadence) in 5 established Pedaling for Parkinson's exercise classes. A secondary aim was to determine the impact of disease severity and demographics variables on exercise adherence.

METHODS

A 12-month pragmatic design was utilized to monitor attendance, HR, and cadence during each Pedaling for Parkinson's class session. Over the course of 1 year, approximately 130 sessions were offered. Forty-nine (n = 30 males) persons with mild to moderate Parkinson disease from 5 community fitness facilities participated.

RESULTS

Out of the approximately 130 cycling sessions offered at each site over 12 months, 37% of the participants attended greater than 2 classes per week (80-130 total sessions), 47% attended 1 to 1.9 classes per week (40-79 total sessions), and less than 17% attended less than 1 class per week (<40 total sessions). Average pedaling cadence was 74.1 ± 9.6 rpms while average percentage of HR maximum was 68.9 ± 12.0%. There were no significant differences between cycling adherence and intensity variables based on disease severity, age, or sex.

DISCUSSION AND CONCLUSIONS

Consistent attendance and exercise performance at moderate to high intensities are feasible in the context of a community-based Pedaling for Parkinson's class. Consistency and intensity of aerobic exercise have been proposed as critical features to elicit potential disease modification benefits associated with exercise. Community-based fitness programs that bring laboratory protocols to the "real world" are a feasible intervention to augment current Parkinson disease treatment approaches. See the Supplementary Video, available at: http://links.lww.com/JNPT/A357.

Current Status of Pain Management in Parkinson's Disease

BACKGROUND

Pain is a non-motor symptom in Parkinson's disease (PD) which commonly goes underreported. Adequate treatment for pain in PD remains challenging, and to date, no clear guidelines for management are available.

METHODS

With the goal of understanding and organizing the current status of pain management in PD, we conducted a review of pharmacological and non-pharmacological treatments for pain in patients with PD. Suitable studies cataloged in PubMed and the Cochrane database up to October 31, 2019, were included prioritizing randomized controlled trials. Post-hoc analyses and open-label studies were also included.

RESULTS

Treatment with levodopa increases pain thresholds in patients with PD. Apomorphine did not have similar efficacy. Duloxetine provided benefit in an open-label trial. Oxycodone-naloxone PR did not have a significant improvement in pain, but per-protocol analysis showed a reduction in pain when adherence was strong. Rotigotine patch had numerical improvement on pain scales with no statistical significance. Safinamide significantly improved the "bodily discomfort" domain in the PDQ-39 questionnaire. Botulinum toxin A had a non-significant signal toward improving dystonic limb pain in PD. DBS to the subthalamic nucleus may modulate central pain thresholds, and a pilot study of cranioelectric therapy warrants future research in the area.

CONCLUSION

After optimizing dopaminergic therapy, understanding the type of pain a patient is experiencing is essential to optimizing pain control in PD. While recommendations can be made regarding the treatment options in each domain, evidence remains weak and future randomized controlled studies are needed.

Current Methodological Pitfalls and Caveats in the Assessment of Exercise-Induced Changes in Peripheral Brain-Derived Neurotrophic Factor: How Result Reproducibility Can Be Improved

Neural mechanisms, such as enhanced neuroplasticity within the motor system, underpin exercise-induced motor improvements. Being a key mediator of motor plasticity, brain-derived neurotrophic factor (BDNF) is likely to play an important role in mediating exercise positive effects on motor function. Difficulties in assessing brain BDNF levels in humans have drawn attention to quantification of blood BDNF and raise the question of whether peripheral BDNF contributes to exercise-related motor improvements. Methodological and non-methodological factors influence measurements of blood BDNF introducing a substantial variability that complicates result interpretation and leads to inconsistencies among studies. Here, we discuss methodology-related issues and approaches emerging from current findings to reduce variability and increase result reproducibility.

Golf as a Physical Activity to Potentially Reduce the Risk of Falls in Older Adults with Parkinson's Disease

Advanced age is associated with an increased risk for falls in aging adults. Older adults are also more likely to be diagnosed with Parkinson’s disease (PD), with advanced age as the most significant risk factor. PD is a neurodegenerative disorder with four Cardinal motor symptoms: rigidity, bradykinesia, postural instability, and tremor. Thus, people (person)-with-Parkinson’s disease (PwP) have an even greater risk of falling than non-disorder age-matched peers. Exercise is an activity requiring physical effort, typically carried out to sustain or improve overall health and fitness, and it lowers the risk of falls in the general population. The sport of golf provides a low-impact all-around workout promoting a range of motion, activation of muscles in the upper and lower body, flexibility, and balance. Swinging a golf club offers a unique combination of high amplitude axial rotation, strengthening postural musculature, coordination, and stabilization, demonstrating the potential to impact PD symptoms positively. Golf may be a novel exercise treatment regimen for PD to use in conjunction with traditional medical therapy. We completed a literature review to determine the relationship between the game of golf, PD, and the risk of falls. We concluded that regularly playing golf can lower the risk for falls in community ambulating older adults with PD and demonstrates the potential to improve quality of life for PwP.

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.

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

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

High intensity aerobic exercise improves bimanual coordination of grasping forces in Parkinson's disease

INTRODUCTION

Parkinson's disease (PD) disrupts the control and coordination of grasping forces, likely due to a disruption in basal ganglia circuitry and diminished activity within the supplementary motor area (SMA). High intensity aerobic exercise has been shown to enhance connectivity between basal ganglia nuclei and cortical areas, including the SMA. The aim of this project was to determine the effects of high intensity lower extremity exercise on motor control patterns underlying a manual dexterity task.

METHODS

PD participants completed eight weeks of high intensity aerobic exercise under forced or voluntary exercise (FE or VE) modalities. Grasping forces for each limb were quantified during a functional bimanual dexterity task. Data were collected while OFF antiparkinsonian medication at baseline, end of treatment (EOT), and eight weeks after exercise cessation (EOT+8).

RESULTS

Eight weeks of high intensity exercise improved MDS-UPDRS Motor III clinical ratings by more than 4 points (~15%) for the FE and VE groups. Time to complete the task decreased nearly 30% across both groups as well. The control and coordination of grasping forces, simultaneity of force initiation, and rate of grip and load force exhibited significant improvements following exercise. In general, improvements in biomechanical outcomes were sustained following exercise cessation.

CONCLUSION

High intensity aerobic exercise, achieved via a forced or voluntary mode, improved PD symptoms and bimanual dexterity. Sustained improvement of upper extremity motor control following exercise cessation indicates high intensity exercise enhances CNS functioning and suggests exercise may be a candidate for altering PD progression.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Triggers and alleviating factors for fatigue in Parkinson's disease

BACKGROUND

Fatigue is common in Parkinson's Disease, but few effective treatments are available for it. Exploring triggers and alleviating factors, including effects of exercise, could inform development of management strategies for Parkinson's Disease fatigue.

OBJECTIVES

To examine triggers and alleviating factors for fatigue reported by individuals with Parkinson's Disease, including perceived effect of exercise.

METHODS

A sample of individuals with self-reported Parkinson's Disease participating in the study Fox Insight were administered an online survey. The survey included the Parkinson's Fatigue Scale, the Physical Activity Scale for the Elderly, and multiple-choice questions about triggers and alleviating factors for fatigue.

RESULTS

Among the sample of 1,029 individuals with Parkinson's disease, mean (standard deviation (SD)) age was 67.4 (9.3) years, 44.0% were female. Parkinson's Fatigue Scale score ranged from 16-80, mean (SD) 48.8 (16.2). Poor sleep (62.1%) and physical exertion (45.1%) were frequently reported triggers for fatigue. Coping strategies including sitting quietly (58.1%), laying down with or without napping, and exercise (20%). Physical Activity Scale for the Elderly scores were higher in those who reported that exercise alleviated their fatigue (49.7%) compared to those who reported it worsened their fatigue (18.9%) (mean (SD) score 158.5 (88.8) vs 119.8 (66.6) respectively; p<0.001).

CONCLUSIONS

Several behavioral and environmental triggers and alleviating strategies for fatigue are reported by individuals with Parkinson's disease. Many feel that exercise alleviates fatigue, though the relationship between exercise and fatigue in Parkinson's Disease appears complex. This exploratory study may inform future development of treatments or coping strategies for Parkinson's disease fatigue.

Effect of Aerobic Exercise on Cardiopulmonary Responses and Predictors of Change in Individuals With Parkinson's Disease

OBJECTIVE

To determine the effect of aerobic exercise on maximal and submaximal cardiopulmonary responses and predictors of change in individuals with Parkinson's disease (PD).

DESIGN

Single-center, parallel-group, rater-blind study.

SETTING

Research laboratory.

PARTICIPANTS

Individuals with mild to moderate PD (N=100).

INTERVENTION

Participants were enrolled in a trial evaluating the effect of cycling on PD and randomized to either voluntary exercise (VE), forced exercise (FE), or a no exercise control group. The exercise groups were time and intensity matched and exercised 3×/wk for 8 weeks on a stationary cycle.

MAIN OUTCOME MEASURES

Cardiopulmonary responses were collected via gas analysis during a maximal graded exercise test at baseline and post intervention.

RESULTS

Exercise attendance was 97% and 93% for the FE and VE group, respectively. Average exercise heart rate reserve was 67%±11% for FE and 70%±10% for VE. No significant difference was present for change in peak oxygen consumption (VO₂peak) post intervention, even though the FE group had a 5% increase in VO₂peak. Both the FE and VE groups had significantly higher percentage oxygen consumption per unit time (V˙o₂) at ventilator threshold (VT) than the control group compared with baseline values (P=.04). Mean V˙O₂ at VT was 5% (95% CI, 0.1%-11%) higher in the FE group (P=.04) and 7% (2%, 12%) higher in VE group compared with controls. A stepwise linear regression model revealed that lower age, higher exercise cadence, and lower baseline VO₂peak were most predictive of improved VO₂peak. The overall model was found to be significant (P<.01).

CONCLUSIONS

Peak and submaximal cardiopulmonary function may improve after aerobic exercise in individuals with PD. Lower age, higher exercise cadence, and lower baseline VO₂peak were most predictive of improved VO₂peak in this exercise cohort. The improvements observed in aerobic capacity were gained after a relatively short aerobic cycling intervention.

High intensity aerobic exercise improves information processing and motor performance in individuals with Parkinson's disease

Parkinson's disease (PD) adversely affects information processing and motor performance. The impact of aerobic exercise on modifying the deleterious effects of PD underlying information and motor control processes is not well established. The primary aim of this project was to determine the effects of an 8-week high intensity exercise intervention on information processing and movement execution in individuals with PD. A secondary aim sought to understand the effects of antiparkinsonian medication relative to exercise on motor control processes. Data were collected at baseline (on- and off-medication) and upon completion of the exercise intervention (off-medication). Information processing and motor execution were evaluated via simple and choice reaction time paradigms (SRT and CRT) performed on a mobile device. Neither exercise nor medication impacted information processing or movement execution under the SRT paradigm. However, under CRT, exercise improved movement execution and information processing: total time was significantly reduced from 814 to 747 ms (p < 0.001), reaction time improved from 543 to 502 ms (p < 0.001), movement time improved from 270 to 246 ms (p = 0.01), and movement velocity improved from 28 cm/sec to 30 cm/sec (p = 0.01). Improvements in total time and reaction time in the CRT paradigm persisted 4 and 8 weeks following exercise cessation. Antiparkinsonian medication improved motor execution, but not information processing. The improvement in information processing following aerobic exercise, but not levodopa administration, suggests high intensity exercise may be enhancing neural processing and non-motor pathways outside those impacted by medication. The persistence of symptom improvement despite exercise intervention cessation indicates exercise is a candidate for disease modification. Trial registration: The trial was first registered at ClinicalTrials.gov on 7/10/2012 under registration number NCT01636297.

Current Perspectives on Aerobic Exercise in People with Parkinson's Disease

Parkinson's disease (PD) is a progressive neurological disorder characterized by motor and non-motor symptoms for which only symptomatic treatments exist. Exercise is a widely studied complementary treatment option. Aerobic exercise, defined as continuous movement of the body's large muscles in a rhythmic manner for a sustained period that increases caloric requirements and aims at maintaining or improving physical fitness, appears promising. We performed both a scoping review and a systematic review on the generic and disease-specific health benefits of aerobic exercise for people with PD. We support this by a meta-analysis on the effects on physical fitness (VO2max), motor symptoms (Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor section), and health-related quality of life (39-item Parkinson's disease Questionnaire (PDQ-39)). Aerobic exercise has generic health benefits for people with PD, including a reduced incidence of cardiovascular disease, a lower mortality, and an improved bone health. Additionally, there is level 1 evidence that aerobic exercise improves physical fitness (VO2max) and attenuates motor symptoms (MDS-UPDRS motor section) in the off-medication state, although the long-term effects (beyond 6 months) remain unclear. Dosing the exercise matters: improvements appear to be greater after training at higher intensities compared with moderate intensities. We found insufficient evidence for a beneficial effect of aerobic exercise on health-related quality of life (PDQ-39) and conflicting results regarding non-motor symptoms. Compliance to exercise regimes is challenging for PD patients but may be improved by adding exergaming elements to the training program. Aerobic exercise seems a safe intervention for people with PD, although care must be taken to avoid falls in at-risk individuals. Further studies are needed to establish the long term of aerobic exercise, including a focus on non-motor symptoms and health-related quality of life.

A Ketone Ester Drink Enhances Endurance Exercise Performance in Parkinson's Disease

Objectives

Routine exercise is thought to be among the only disease-modifying treatments for Parkinson's disease; however, patients' progressive loss of physical ability limits its application. Therefore, we sought to investigate whether a ketone ester drink, which has previously been shown to enhance endurance exercise performance in elite athletes, could also improve performance in persons with Parkinson's disease.

Participants

14 patients, aged 40-80 years, with Hoehn and Yahr stage 1-2 Parkinson's disease.

Intervention

A randomized, placebo-controlled, crossover study in which each participant was administered a ketone ester drink or an isocaloric carbohydrate-based control drink on separate occasions prior to engaging in a steady state cycling test at 80 rpm to assess endurance exercise performance.

Outcomes Measures

The primary outcome variable was length of time participants could sustain a therapeutic 80 rpm cadence. Secondary, metabolic outcomes measures included cardiorespiratory parameters as well as serum β-hydroxybutyrate, glucose, and lactate.

Results

The ketone ester increased the time that participants were able to sustain an 80 rpm cycling cadence by 24 ± 9% (p = 0.027). Correspondingly, the ketone ester increased β-hydroxybutyrate levels to >3 mmol/L and decreased respiratory exchange ratio, consistent with a shift away from carbohydrate-dependent metabolism.

Conclusion

Ketone ester supplementation improved endurance exercise performance in persons with Parkinson's disease and may, therefore, be useful as an adjunctive therapy to enhance the effectiveness of exercise treatment for Parkinson's disease.

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

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

The Universal Prescription for Parkinson's Disease: Exercise

Over the past two decades, aerobic exercise has emerged as a mainstream recommendation to aid in treating Parkinson's disease (PD). Despite the acknowledgement of the benefits of exercise for people with PD (PwPD), frequently, exercise recommendations lack specificity in terms of frequency, intensity and duration. Additionally, conflating physical activity with exercise has contributed to providing vague exercise recommendations to PwPD. Therefore, the beneficial effects of exercise may not be fully realized in PwPD. Data provided by animal studies and select human trials indicate aerobic exercise may facilitate structural and functional changes in the brain. Recently, several large human clinical trials have been completed and collectively support the use of aerobic exercise, specifically high-intensity aerobic exercise, in improving PD motor symptoms. Data from these and other studies provide the basis to include aerobic exercise as an integral component in treating PD. Based on positive clinical findings and trials, it is advised that PwPD perform aerobic exercise in the following dose: 3x/week, 30-40-minute main exercise set, 60-80% of heart rate reserve or 70-85% of heart rate max. In lieu of heart rate, individuals can achieve an intensity of 14-17 on a 20-point RPE scale. Ongoing clinical trials, SPARX3 and CYCLE-II, have potential to further develop patient-specific exercise recommendations through prognostic modeling.

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

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

The effects of concentric and eccentric training in murine models of dysferlin-associated muscular dystrophy

INTRODUCTION

Dysferlin-deficient murine muscle sustains severe damage after repeated eccentric contractions.

METHODS

With a robotic dynamometer, we studied the response of dysferlin-sufficient and dysferlin-deficient mice to 12 weeks of concentrically or eccentrically biased contractions. We also studied whether concentric contractions before or after eccentric contractions reduced muscle damage in dysferlin-deficient mice.

RESULTS

After 12 weeks of concentric training, there was no net gain in contractile force in dysferlin-sufficient or dysferlin-deficient mice, whereas eccentric training produced a net gain in force in both mouse strains. However, eccentric training induced more muscle damage in dysferlin-deficient vs dysferlin-sufficient mice. Although concentric training produced minimal muscle damage in dysferlin-deficient mice, it still led to a prominent increase in centrally nucleated fibers. Previous exposure to concentric contractions conferred slight protection on dysferlin-deficient muscle against damage from subsequent injurious eccentric contractions.

DISCUSSION

Concentric contractions may help dysferlin-deficient muscle derive the benefits of exercise without inducing damage.

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

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

Functional and Brain Activation Changes Following Specialized Upper-Limb Exercise in Parkinson's Disease

For the management of Parkinson's disease (PD), the concept of forced exercise (FE) has drawn interest. In PD subjects, the FE executed with lower limbs has been shown to lessen symptoms and to promote brain adaptive changes. Our study is aimed to investigate the effect of an upper-limb exercise, conceptually comparable with the FE, in PD. Upper-limb exercise was achieved in a sitting position by using a specially designed device (Angel's Wings^®). Clinical data, computerized dynamic posturography, magnetic resonance imaging (MRI) (resting-state MRI and arterial spin labeling), and neuropsychological tests were used before and after 2 months' exercise training. We found a significant long-lasting improvement in Unified Parkinson Disease Rating Scale (UPDRS)-III and cognitive scales, along with improvement in balance and postural control (better alignment of the gravity center and improvement in weight symmetry and in anticipatory motor strategies). Computerized dynamic posturography pointed out an enhanced central ability to integrate the vestibular signals with afferents from other sensory systems. Neuroimaging analyses after 2 months' exercise training showed, with respect to pretraining condition, many changes. An increase of the cerebral blood flow was evident in the left primary motor cortex (M1), left supplementary motor cortical area, and left cerebellar cortex. The bilateral globus pallidus showed an increased functional connectivity to the right central operculum, right posterior cingulate gyrus, and left sensorimotor cortex. Seed-to-voxel analysis demonstrated a functional connectivity between M1 and the left superior frontal gyrus. Left crus II showed strengthened connections with the left pre-rolandic area, left post-rolandic area, and left supramarginal area. These findings likely reflect compensatory mechanisms to the neuropathological hallmark of PD. Overall, our results show that this upper-limb exercise model, conceptually comparable with the FE already tested in the lower limbs, leads to a global improvement (involving non-exercised limbs) likely consistent with the functional changes observed in the central nervous system.

Determinants of fine manual dexterity in adolescents and young adults with Down's syndrome

BACKGROUND

To date, numbers of studies have indicated the important role of fine manual dexterity in typical and special populations. However, the relevant studies in Down's syndrome (DS) population is still limited. The purpose of this study was to investigate the determinants of manual dexterity in adolescents and young adults with DS.

METHODS

Thirty participants with DS (22 males, 8 females, aged 13-31) were screened by anthropometric variables (i.e. sex, chronological age, verbal intelligence, body mass index), levels of physical activity, and sleep disorders, and were administered the Purdue Pegboard Test and the Choice Reaction Time Test. Measures of correlation, t-test and multiple regression model were used for data analysis.

RESULTS

It was indicated that sex and sleep-related disorders during the day explained 37.2% of the variance in the performance of the Purdue Pegboard Test. The additional of 9.7% can be explained the variance by adding reaction time test performance. Verbal intelligence had the negatively relation with the performance of non-Dominant Hand and Bimanual subtests of the Purdue Pegboard Test.

CONCLUSION

This study suggested that sex, sleep disorder, and neuromotor function may be the important determinants of fine manual dexterity performance in adolescents and young adults with DS. In addition, the level of intelligence might also exert the effect on fine motor development in this population. In order to design effective interventions and optimize manual performance in individuals with DS, these possible determinants should be considered. Future research should be replicated with large sample size, different age groups, and validated measures of finger size, physical activity and sleep behaviors.

Effect of High-Intensity Treadmill Exercise on Motor Symptoms in Patients With De Novo Parkinson Disease: A Phase 2 Randomized Clinical Trial

Importance

Parkinson disease is a progressive neurologic disorder. Limited evidence suggests endurance exercise modifies disease severity, particularly high-intensity exercise.

Objectives

To examine the feasibility and safety of high-intensity treadmill exercise in patients with de novo Parkinson disease who are not taking medication and whether the effect on motor symptoms warrants a phase 3 trial.

Design, Setting, and Participants

The Study in Parkinson Disease of Exercise (SPARX) was a phase 2, multicenter randomized clinical trial with 3 groups and masked assessors. Individuals from outpatient and community-based clinics were enrolled from May 1, 2012, through November 30, 2015, with the primary end point at 6 months. Individuals with idiopathic Parkinson disease (Hoehn and Yahr stages 1 or 2) aged 40 to 80 years within 5 years of diagnosis who were not exercising at moderate intensity greater than 3 times per week and not expected to need dopaminergic medication within 6 months participated in this study. A total of 384 volunteers were screened by telephone; 128 were randomly assigned to 1 of 3 groups (high-intensity exercise, moderate-intensity exercise, or control).

Interventions

High-intensity treadmill exercise (4 days per week, 80%-85% maximum heart rate [n = 43]), moderate-intensity treadmill exercise (4 days per week, 60%-65% maximum heart rate [n = 45]), or wait-list control (n = 40) for 6 months.

Main Outcomes and Measures

Feasibility measures were adherence to prescribed heart rate and exercise frequency of 3 days per week and safety. The clinical outcome was 6-month change in Unified Parkinson's Disease Rating Scale motor score.

Results

A total of 128 patients were included in the study (mean [SD] age, 64 [9] years; age range, 40-80 years; 73 [57.0%] male; and 108 [84.4%] non-Hispanic white). Exercise rates were 2.8 (95% CI, 2.4-3.2) days per week at 80.2% (95% CI, 78.8%-81.7%) maximum heart rate in the high-intensity group and 3.2 (95% CI, 2.8-3.6; P = .13) days per week at 65.9% (95% CI, 64.2%-67.7%) maximum heart rate in the moderate-intensity group (P < .001). The mean change in Unified Parkinson's Disease Rating Scale motor score in the high-intensity group was 0.3 (95% CI, -1.7 to 2.3) compared with 3.2 (95% CI, 1.4 to 5.1) in the usual care group (P = .03). The high-intensity group, but not the moderate-intensity group, reached the predefined nonfutility threshold compared with the control group. Anticipated adverse musculoskeletal events were not severe.

Conclusions and Relevance

High-intensity treadmill exercise may be feasible and prescribed safely for patients with Parkinson disease. An efficacy trial is warranted to determine whether high-intensity treadmill exercise produces meaningful clinical benefits in de novo Parkinson disease.

Trial Registration

clinicaltrials.gov Identifier: NCT01506479.

Forced, Not Voluntary, Aerobic Exercise Enhances Motor Recovery in Persons With Chronic Stroke

Background. The recovery of motor function following stroke is largely dependent on motor learning-related neuroplasticity. It has been hypothesized that intensive aerobic exercise (AE) training as an antecedent to motor task practice may prime the central nervous system to optimize motor recovery poststroke. Objective. The objective of this study was to determine the differential effects of forced or voluntary AE combined with upper-extremity repetitive task practice (RTP) on the recovery of motor function in adults with stroke. Methods. A combined analysis of 2 preliminary randomized clinical trials was conducted in which participants (n = 40) were randomized into 1 of 3 groups: (1) forced exercise and RTP (FE+RTP), (2) voluntary exercise and RTP (VE+RTP), or (3) time-matched stroke-related education and RTP (Edu+RTP). Participants completed 24 training sessions over 8 weeks. Results. A significant interaction effect was found indicating that improvements in the Fugl-Meyer Assessment (FMA) were greatest for the FE+RTP group (P = .001). All 3 groups improved significantly on the FMA by a mean of 11, 6, and 9 points for the FE+RTP, VE+RTP, and Edu+RTP groups, respectively. No evidence of a treatment-by-time interaction was observed for Wolf Motor Function Test outcomes; however, those in the FE+RTP group did exhibit significant improvement on the total, gross motor, and fine-motor performance times (P ≤ .01 for all observations). Conclusions. Results indicate that FE administered prior to RTP enhanced motor skill acquisition greater than VE or stroke-related education. AE, FE in particular, should be considered as an effective antecedent to enhance motor recovery poststroke.