Systematic review on strength training in Parkinson's disease: an unsolved question

Short-term effects of Pilates-based exercise on upper limb strength and function in people with Parkinson's disease

BACKGROUND

People with Parkinson's disease (PD) have impaired upper limb motor coordination, limiting the execution of activities of daily living. This study investigated the feasibility and safety of a short-term Pilates-based exercise program in the treatment of upper limb motor coordination for people with PD.

METHODS

Fifteen patients - n (%) 4 women/11 men (27/73), median [interquartile range] age 66 [9] years - participated in this quasi-experimental (before-and-after) clinical trial. Patients underwent a 6-week (30 min/day, 3 days/week) Pilates exercise program using Reformer, Cadillac, Chair, and Barrel equipment. Feasibility was evaluated by adherence to the program and the ability to perform the exercises including progressions on difficulty. Safety was evaluated based on self-reported adverse events. Clinical and functional trends before and after the intervention were also computed regarding handgrip strength (HGS), fine motor coordination (9 Hole Peg Test; 9HPT), bradykinesia (Movement Disorder Society - Unified Parkinson's disease Rating Scale; MDS-UPDRS), and upper limb functionality (Test D'évaluation des Membres Supérieurs des Personnes Âgées, TEMPA).

RESULTS

Of the 18 Pilates sessions, exercise adherence was 100%. The only adverse event observed was mild muscle pain. Pre-post differences were observed only for body bradykinesia and hypokinesia (1.0 [0.0] vs. 0.0 [1.0] s, adjusted p = 0.048).

CONCLUSIONS

A short-term Pilates-based exercise program in the treatment of upper limb muscle strength, manual dexterity, bradykinesia, and functionality is feasible and safe for people with PD. Changes in upper limb bradykinesia encourage randomized clinical trials.

General Treatments Promoting Independent Living in Parkinson's Patients and Physical Therapy Approaches for Improving Gait-A Comprehensive Review

This study delves into the multifaceted approaches to treating Parkinson's disease (PD), a neurodegenerative disorder primarily affecting motor function but also manifesting in a variety of symptoms that vary greatly among individuals. The complexity of PD symptoms necessitates a comprehensive treatment strategy that integrates surgical interventions, pharmacotherapy, and physical therapy to tailor to the unique needs of each patient. Surgical options, such as deep brain stimulation (DBS), have been pivotal for patients not responding adequately to medication, offering significant symptom relief. Pharmacotherapy remains a cornerstone of PD management, utilizing drugs like levodopa, dopamine agonists, and others to manage symptoms and, in some cases, slow down disease progression. However, these treatments often lead to complications over time, such as motor fluctuations and dyskinesias, highlighting the need for precise dosage adjustments and sometimes combination therapies to optimize patient outcomes. Physical therapy plays a critical role in addressing the motor symptoms of PD, including bradykinesia, muscle rigidity, tremors, postural instability, and akinesia. PT techniques are tailored to improve mobility, balance, strength, and overall quality of life. Strategies such as gait and balance training, strengthening exercises, stretching, and functional training are employed to mitigate symptoms and enhance functional independence. Specialized approaches like proprioceptive neuromuscular facilitation (PNF), the Bobath concept, and the use of assistive devices are also integral to the rehabilitation process, aimed at improving patients' ability to perform daily activities and reducing the risk of falls. Innovations in technology have introduced robotic-assisted gait training (RAGT) and other assistive devices, offering new possibilities for patient care. These tools provide targeted support and feedback, allowing for more intensive and personalized rehabilitation sessions. Despite these advancements, high costs and accessibility issues remain challenges that need addressing. The inclusion of exercise and activity beyond structured PT sessions is encouraged, with evidence suggesting that regular physical activity can have neuroprotective effects, potentially slowing disease progression. Activities such as treadmill walking, cycling, and aquatic exercises not only improve physical symptoms but also contribute to emotional well-being and social interactions. In conclusion, treating PD requires a holistic approach that combines medical, surgical, and therapeutic strategies. While there is no cure, the goal is to maximize patients' functional abilities and quality of life through personalized treatment plans. This integrated approach, along with ongoing research and development of new therapies, offers hope for improving the management of PD and the lives of those affected by this challenging disease.

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

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

Visual feedback improves propulsive force generation during treadmill walking in people with Parkinson disease

Persons with Parkinson's disease experience gait alterations, such as reduced step length. Gait dysfunction is a significant research priority as the current treatments targeting gait impairment are limited. This study aimed to investigate the effects of visual biofeedback on propulsive force during treadmill walking in persons with Parkinson's. Sixteen ambulatory persons with Parkinson's participated in the study. They received real-time biofeedback of anterior ground reaction force during treadmill walking at a constant speed. Peak propulsive force values were measured and normalized to body weight. Spatiotemporal parameters were also assessed, including stride length and double support percent. Persons with Parkinson's significantly increased peak propulsive force during biofeedback compared to baseline (p <.0001, Cohen's dz = 1.69). Variability in peak anterior ground reaction force decreased across repeated trials (p <.0001, dz = 1.51). While spatiotemporal parameters did not show significant changes individually, stride length and double support percent improved marginally during biofeedback trials. Persons with Parkinson's can increase propulsive force with visual biofeedback, suggesting the presence of a propulsive reserve. Though stride length did not significantly change, clinically meaningful improvements were observed. Targeting push-off force through visual biofeedback may offer a potential rehabilitation technique to enhance gait performance in Persons with Parkinson's. Future studies could explore the long-term efficacy of this intervention and investigate additional strategies to improve gait in Parkinson's disease.

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

DESIGN

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

DATA SOURCES

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

RESULTS

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

CONCLUSION

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

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.

Samba, deep water, and poles: a framework for exercise prescription in Parkinson's disease

Parkinson's disease is a brain disorder that leads to tremor, slowness, muscle stiffness, and other movement disorders. The benefits of exercise for reducing disability in individuals with Parkinson’s disease are numerous. However, not much is known about the designing and prescription of exercise in neurodegenerative diseases. A brief review and indications for exercise prescription and evaluation are discussed throughout. In this scoping review, we specifically aimed to describe the applicability of walking tests (6-min/10-m) for the prescription of exercise in individuals with Parkinson’s disease and to propose training (undulating periodized) designs in three exercise modalities, Brazilian dance rhythms (Samba and Forró), deep-water exercises, and Nordic walking. These training models and evaluation methods may assist coaches and therapists in organizing exercise programs adequate to people with Parkinson’s disease, and are essential steps toward a comprehensive and more detailed understanding of the training loads in motor disorders and disease states.

Parkinson's disease: Alterations of motor plasticity and motor learning

This chapter reviews the alterations in motor learning and motor cortical plasticity in Parkinson's disease (PD), the most common movement disorder. Impairments in motor learning, which is a hallmark of basal ganglia disorders, influence the performance of motor learning-related behavioral tasks and have clinical implications for the management of disturbance in gait and posture, and for rehabilitative management of PD. Although plasticity is classically induced and assessed in sliced preparation in animal models, in this review we have concentrated on the results from non-invasive brain stimulation techniques such as transcranial magnetic stimulation (TMS), transcranial alternating current stimulation (tACS) and transcranial direct current stimulation (tDCS) in patients with PD, in addition to a few animal electrophysiologic studies. The chapter summarizes the results from different cortical and subcortical plasticity investigations. Plasticity induction protocols reveal deficient plasticity in PD and these plasticity measures are modulated by medications and deep brain stimulation. There is considerable variability in these measures that are related to inter-individual variations, different disease characteristics and methodological considerations. Nevertheless, these pathophysiologic studies expand our knowledge of cortical excitability, plasticity and the effects of different treatments in PD. These tools of modulating plasticity and motor learning improve our understanding of PD pathophysiology and help to develop new treatments for this disabling condition.

Dynamics of balance indicators, activities of daily living, and quality of life of elderly suffering from Parkinson's disease and frailty after proximal humerus fracture following physiotherapeutic functional training

Balance dysfunction in elderly patients with Parkinson's disease (PD) is a high-risk fall precaution, along with sarcopenia and senile asthenia, which leads to traumas, including fractures of the proximal humerus fractures (PHF). The objective of the study was to determine the effectiveness of a functional training as part of a physical therapy program on balance, upper limb (UL) function, daily living activities, and quality of life in elderly patients with PD and frailty, following proximal humerus fractures. We examined 33 elderly patients with PD and frailty in the recovery period after PHF. The control group included individuals who underwent rehabilitation according to the general principles of kinesitherapy. The treatment group consisted of patients engaged in a program of physical therapy directed at improving balance, function of the upper UL, motor stereotype, and activities of daily living. The effectiveness of the program was evaluated using the Short Physical Performance Battery (SPPB), Berg Balance Scale (BBS), Disability of the Arm, Shoulder and Hand Outcome Measure (DASH), Wrist Dynamometry, Falls efficacy Scale International (FES-I), Barthel Activities of daily living (ADL) Index, Lawton Instrumental activities of daily living (IADL) Scale, PD Questionnaire-39 (PDQ-39). According to all studied indicators, the patients of both groups showed a statistically and significantly better result compared to the initial data (p<0.05), but the treatment group showed better outcomes compared with the control group (p<0.05).

Breathing disorders in neurodegenerative diseases

Neurodegenerative disorders are a diverse group of conditions caused by progressive degeneration of neurons resulting in cognitive, motor, sensory, and autonomic dysfunction, leading to severe disability and death. Pulmonary dysfunction is relatively common in these conditions, may be present early in the disease, and is less well recognized and treated than other symptoms. There are variable disorders of upper and lower airways, central control of ventilation, strength of respiratory muscles, and breathing during sleep which further impact daily activities and quality of life and have the potential to injure vulnerable neurons. Laryngopharyngeal dysfunction affects speech, swallowing, and clearance of secretions, increases the risk of aspiration pneumonia, and can cause stridor and sudden death. In Parkinson's disease, L-Dopa benefits some pulmonary symptoms but there are limited pharmacological treatment options for pulmonary dysfunction. Targeted treatments include strengthening of respiratory muscles, positive airway pressure in sleep and techniques to improve cough efficacy. Well-designed clinical trials are needed to evaluate the long-term benefits of these interventions. Challenges for the future include earlier identification of pulmonary dysfunction in the clinic, institution of the most effective treatments (based on clinical trials that measure long-term meaningful outcomes) and the development of neuroprotective treatment.

Co-designing a remote rehabilitation tool for Parkinson's disease: exploratory values and challenges

BACKGROUND

Impaired motor function is one of the early symptoms shown in patients with Parkinson Disease (PD). For this reason, rehabilitative interventions have been used for many years to improve motor and non-motor symptoms. Among them, the use of music therapy has shown benefits in helping to overcome some of the most common motor dysfunction. Addressing the challenge of providing access to this type of therapy, this document presents the collaborative design process to develop a remote training support tool for PD based on music therapy.

METHODS

A qualitative study with creative co-design methods was used in which different groups of healthcare professionals, patients, and relatives participated in six iterative sessions. Workshops were designed and structured to incrementally discover requirements and needs and validate the proposed prototype ideas.

RESULTS

The study provided key aspects that were used for the development and validation of the proposed prototypes for the remote music-based training support tool for PD. Up to 20 factors that had a positive and/or negative influence on patient access to training were detected. These factors were classified into three common themes: daily activities and independence, participation in treatment and barriers to daily treatment, and self-management and personalization of information and telecommunication technologies (ICT).

CONCLUSIONS

This paper shows the results of a collaborative design process aimed at identifying the different factors, relevant to patients with PD, to improve their access to remote ICT-based training therapy and their expectations regarding alternative therapies, such as music. The participatory design methods and the iterative model used helped overcome many of the traditionally barriers that this type of technological support solutions usually have, facilitating the future participation.

Effectiveness of interventions to prevent falls for people with multiple sclerosis, Parkinson's disease and stroke: an umbrella review

Background

The implementation of condition-specific falls prevention interventions is proving challenging due to lack of critical mass and resources. Given the similarities in falls risk factors across stroke, Parkinson’s Disease (PD) and Multiple Sclerosis (MS), the development of an intervention designed for groups comprising of people with these three neurological conditions may provide a pragmatic solution to these challenges. The aims of this umbrella review were to investigate the effectiveness of falls prevention interventions in MS, PD and stroke, and to identify the commonalities and differences between effective interventions for each condition to inform the development of an intervention for mixed neurological groups.

Methods

A systematic literature search was conducted using 15 electronic databases, grey literature searches and hand-screening of reference lists. Systematic reviews of studies investigating the effects of falls prevention interventions in MS, PD and stroke were included. Methodological quality of reviews was assessed using the A MeaSurement Tool to Assess Systematic Reviews 2. A matrix of evidence table was used to assess the degree of overlap. The Grading of Recommendations Assessments, Development and Evaluation framework was used to rate the quality of evidence. Findings were presented through narrative synthesis and a summary of evidence table.

Results

Eighteen reviews were included; three investigating effectiveness of falls prevention interventions in MS, 11 in PD, three in stroke, and one in both PD and stroke. Exercise-based interventions were the most commonly investigated for all three conditions, but differences were identified in the content and delivery of these interventions. Low to moderate quality evidence was found for the effectiveness of exercise-based interventions at reducing falls in PD. Best available evidence suggests that exercise is effective at reducing falls in stroke but no evidence of effect was identified in MS.

Conclusions

The findings suggest that exercise-based interventions are effective at reducing falls in PD, however, the evidence for MS and stroke is less conclusive. A strong theoretical rationale remains for the use of exercise-based interventions to address modifiable physiological falls risk factors for people with MS, PD and stroke, supporting the feasibility of a mixed-diagnosis intervention. Given the high overlap and low methodological quality of primary studies, the focus should be on the development of high-quality trials investigating the effectiveness of falls prevention interventions, rather than the publication of further systematic reviews.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02402-6.

Effects of resistance training on postural control in Parkinson's disease: a randomized controlled trial

BACKGROUND

Postural instability affects Parkinson's disease (PD) patients' postural control right from the early stages of the disease. The benefits of resistance training (RT) for balance and functional capacity have been described in the literature, but few studies have been conducted showing its effects on PD patients' postural control.

OBJECTIVE

To investigate the effects of a three-month RT intervention on static posturography (SP) measurements and clinical functional balance assessment among PD patients.

METHODS

Seventy-four patients were randomly assigned to a three-month RT intervention consisting of using weightlifting machines at a gym (gym group) or RT consisting of using free weights and elastic bands (freew group), or to a control group. The participants were evaluated at baseline, three months and six months. We evaluated changes of SP measurements under eyes-open, eyes-closed and dual-task conditions (primary endpoint), along with motor performance and balance effects by means of clinical scales, dynamic posturography and perceptions of quality of life (secondary endpoints).

RESULTS

There were no significant interactions in SP measurements among the groups. Unified Parkinson Disease Rating Scale (UPDRS-III) motor scores decreased in both RT groups (p<0.05). Better perceived quality of life for the mobility domain was reported in the gym group while functional balance scores improved in the freew group, which were maintained at the six-month follow-up (p<0.05).

CONCLUSIONS

This study was not able to detect changes in SP measurements following a three-month RT intervention. Both RT groups of PD patients showed improved motor performance, with positive balance effects in the freew group and better perceived quality of life in the gym group.

Phase-Dependent Effects of Closed-Loop Tactile Feedback on Gait Stability in Parkinson's Disease

Gait disturbances in people with Parkinson's disease (PD) are a major cause for functional dependence and have recently been shown to be the largest risk factor for falls, institutionalization and death in PD. The use of external cues has been successful at improving gait in people with PD, but the effect of external cues on gait stability is unclear. We examined whether different forms of cueing, open-loop and closed-loop, influenced the local dynamic stability of three critical phases of gait. Forty-three adults with PD completed six, two-minute long walking trials in the following cued conditions: no cue (B), open-loop cueing, fixed auditory cue (OL), closed-loop cueing, tactile feedback delivered to wrist when the ipsilateral foot contacted with the ground (CL). Conditions were performed with and without a cognitive task. Kinematic data were recorded with inertial sensors. Only CL cueing was associated with changes in trunk stability, and these changes were only evident during the weight transfer phase of gait. Both OL and CL caused reductions in overall gait speed, stride length, and an increase in stride time. While CL cueing significantly influenced local dynamic stability during weight transfer, it remains unknown whether these changes are associated with more or less global stability. Future research will explore the clinical implications.

A Single Session of Whole-Body Electromyostimulation Increases Muscle Strength, Endurance and proNGF in Early Parkinson Patients

Parkinson's disease (PD) patients lead a sedentary lifestyle, being unable or unwilling to exercise conventionally, due to physical and mental limitations. The aim of this study was to assess the acute effects of a single session of whole-body electromyostimulation (WB-EMS) on the physical performances and serum levels of the neurotrophic factors in PD patients. Ten subjects (aged 72.60 ± 6.82) underwent 20 min of physical activity with superimposed WB-EMS and, after four weeks, the same protocol with no WB-EMS. WB-EMS was conducted with intermittent stimulation, with 4 s WB-EMS/4 s rest, at 85 Hz, 350 μs. A physical fitness assessment and blood samples collection, to evaluate neurotrophic factors' levels (BDNF, FGF21, proNGF, mNGF), were collected before and after the intervention. The RM-ANOVA showed significant improvements in sit-to-stand (p < 0.01), arm curl (p < 0.01), handgrip (p < 0.01) and soda pop test (p < 0.01) after the WB-EMS intervention. Higher proNFG serum levels were observed in the WB-EMS condition compared to the no WB-EMS after 60 min post-intervention (p = 0.0163). The effect of WB-EMS confirmed the electrostimulation ability to modulate the proNGF quantity. The positive impact of the WB-EMS protocol on physical functioning, and eye-hand coordination, makes this intervention a promising strategy to improve motor and non-motor symptoms in PD patients.

Strengthening the Case for Cluster Set Resistance Training in Aged and Clinical Settings: Emerging Evidence, Proposed Benefits and Suggestions

Resistance training (RT) is a fundamental component of exercise prescription aimed at improving overall health and function. RT techniques such as cluster set (CS) configurations, characterized by additional short intra-set or inter-repetition rest intervals, have been shown to maintain acute muscular force, velocity, and 'power' outputs across a RT session, and facilitate positive longer-term neuromuscular adaptations. However, to date CS have mainly been explored from a human performance perspective despite potential for application in health and clinical exercise settings. Therefore, this current opinion piece aims to highlight emerging evidence and provide a rationale for why CS may be an advantageous RT technique for older adults, and across several neurological, neuromuscular, cardiovascular and pulmonary settings. Specifically, CS may minimize acute fatigue and adverse physiologic responses, improve patient tolerance of RT and promote functional adaptations (i.e., force, velocity, and power). Moreover, we propose that CS may be a particularly useful exercise rehabilitation technique where injury or illness, persistent fatigue, weakness and dysfunction exist. We further suggest that CS offer an alternative RT strategy that can be easily implemented alongside existing exercise/rehabilitation programs requiring no extra cost, minimal upskilling and/or time commitment for the patient and professional. In light of the emerging evidence and likely efficacy in clinical exercise practice, future research should move toward further direct investigation of CS-based RT in a variety of adverse health conditions and across the lifespan given the already demonstrated benefits in healthy populations.

Is fatigue a muscular phenomenon in Parkinson's disease? Implications for rehabilitation

BACKGROUND

Fatigue in Parkinson's Disease (PD) compromises patients' physical activity and poses questions on how to plan correct rehabilitation training. In addition, the relationship between subjective perceived fatigue and fatigue in motor performance is not yet entirely understood. As a consequence, a conclusive interpretation of muscular mechanisms of fatigue in PD has not yet been achieved. Among the various instrumental evaluations for fatigue, multichannel surface electromyography (sEMG) is a recognized tool that permits the study of myoelectric manifestations of fatigue.

AIM

To assess if muscles in PD show a different myoelectric fatigue pattern compared to the muscles of healthy age-matched subjects.

DESIGN

Observational controlled study.

POPULATION

Idiopathic Parkinson's Disease, Hohen &Yahr II and III stage, Parkinsonian Fatigue Scale average score ≥ 2.95, no therapy modification in the 4 weeks preceding the study; exclusion criteria: Mini Mental State Examination ≤ 24, upper limb disease/symptoms that might interfere with sEMG analysis, presence of other fatiguerelated conditions. Twenty patients were selected according to these criteria. Twenty untrained healthy subjects were matched.

METHODS

All subjects underwent a muscle fatigue protocol and a sEMG analysis of the right biceps brachii muscle during electrically stimulated and voluntary contractions in order to obtain a myoelectric fatigue muscular pattern. The myoelectric pattern is characterized by the modifications of the following sEMG variables: reduction of mean frequency and muscle fibre conduction velocity, increase of average rectified value.

RESULTS

No statistical differences where observed between groups for sEMG variables and muscular electric behaviour in all contraction conditions (all p> .05).

CONCLUSIONS

Our results show that parkinsonian muscles does not differ from the muscles of healthy age-matched subjects in developing peripheral myoelectric fatigue. Nevertheless, the role of fatigue perception at rest and particularly during physical activity must be clearly understood in order to further target the rehabilitative approach for fatigued parkinsonian patients and to reduce hypomobility.

CLINICAL REHABILITATION IMPACT

In rehabilitative terms, these findings allow us to highlight the possibility of performing sustained training with isometric contractions in PD subjects; therefore, fatigue "per se" does not constitute a barrier for the execution of muscular exercises, likewise intensive.

Predictors of physical activity levels in individuals with Parkinson's disease: a cross-sectional study

BACKGROUND

To investigate whether modifiable predictors (depressive symptoms, impairment in behavior and mood, balance impairments, and knee extensor muscle strength) are determinants of the physical activity level in Parkinson's disease.

MATERIALS AND METHODS

A cross-sectional study with individuals diagnosed with idiopathic Parkinson's disease. Regression analysis of the data was used to investigate whether depressive symptoms, impairments in behavior and mood, balance impairments, or dominant knee extensor muscle strength are predictors of physical activity levels in Parkinson's disease.

RESULTS

A total of 50 individuals with mild to moderate Parkinson's disease participated in this study, with a mean age of 67 ± 8 years and 68% male. Balance impairments explained 29% of the variation in the physical activity levels. The explained variance increased to 34% when depressive symptoms were included in the model.

CONCLUSION

Among the predictor variables investigated in our study, only balance impairments and depressive symptoms explained the variance in physical activity levels in individuals with Parkinson's disease.

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

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

The Mechanism of Physical Activity-induced Amelioration of Parkinson's Disease: A Narrative Review

Physical activity, together with its ameliorative effects on Parkinson's disease (PD) symptoms, remains a relatively unappreciated factor which may be beneficial for the treatment outcome. Contemporary evidence supports the positive effects of non-pharmacological approaches to PD symptom management, in particular the effects of the exercise on both, motor and non-motor symptoms. The aim of the study was to review the mechanisms of exercise-induced amelioration of PD symptoms. Methods: Electronic databases (PubMed, Web of Science and Google Scholar) were searched using the following key words: "Parkinson and physical activity" OR "Parkinson disease and exercise" OR "Parkinson disease and lifestyle factors" OR "Parkinson disease and longevity". A total of 97 studies which investigated PD genetics and various forms of exercise and their etiologic impact on PD were reviewed. The studies were subdivided into four topic groups: 1) genetics of PD, 2) exercise and the brain, 3) physical activity and PD, 4) mind-body interventions, and discussed accordingly. Adequate levels of physical activity are associated with higher quality of life in PD patients. Physical activity may have protective and stimulatory effects for better functional efficiency in higher-level cognitive networks. It can also improve balance and motor functions by improving muscle strength. Given the etiologic evidence of the beneficial effects of physical activity on PD, albeit tentative, a concerted effort to elucidate the processes and outcomes of physical activity on ameliorating symptoms of PD must be undertaken.

Factors associated with bite force in people with Parkinson's disease

ABSTRACT Purpose: to assess the bite force in people with Parkinson’s disease and correlate it with age, sex, stage and time of the disease, dentures use, presence of temporomandibular disorder, side of symptom onset, and masticatory preference. Methods: the Research Diagnostic Criteria for Temporomandibular Disorders and the Hoehn & Yahr Parkinson’s disease scale were used, and the participants’ oral cavity was clinically examined. Then, the bite force was measured with an analog dynamometer, whose bar was adapted for mouth grip. The bite force results and their correlation with the variables were analyzed with the independent t-test (p<0.05). Results: the sample comprised 42 parkinsonians at a mean age of 64 years, 67% of whom were males. No difference was observed in the correlation with age, temporomandibular disorder, stage and time of Parkinson's disease; or between the sides, symptom onset and masticatory preference. However, there was a significant association between the sexes (males and females) for both sides (right - p=0.002; left - p=0.04) and denture use for bite force on the right side (p=0.03). Conclusion: being a female and using dentures are factors associated with decreased bite force in people with Parkinson’s disease.

Functional relevance of resistance training-induced neuroplasticity in health and disease

Repetitive, monotonic, and effortful voluntary muscle contractions performed for just a few weeks, i.e., resistance training, can substantially increase maximal voluntary force in the practiced task and can also increase gross motor performance. The increase in motor performance is often accompanied by neuroplastic adaptations in the central nervous system. While historical data assigned functional relevance to such adaptations induced by resistance training, this claim has not yet been systematically and critically examined in the context of motor performance across the lifespan in health and disease. A review of muscle activation, brain and peripheral nerve stimulation, and imaging data revealed that increases in motor performance and neuroplasticity tend to be uncoupled, making a mechanistic link between neuroplasticity and motor performance inconclusive. We recommend new approaches, including causal mediation analytical and hypothesis-driven models to substantiate the functional relevance of resistance training-induced neuroplasticity in the improvements of gross motor function across the lifespan in health and disease.

Physiotherapy in Parkinson's Disease: A Meta-Analysis of Present Treatment Modalities

BACKGROUND

Physiotherapy is a commonly prescribed intervention for people with Parkinson's disease (PD). Conventional types of physiotherapy have been studied extensively, while novel modalities are being developed and evaluated.

OBJECTIVE

To evaluate the effectiveness of conventional and more recent physiotherapy interventions for people with PD. The meta-analysis performed as part of the 2014 European Physiotherapy Guideline for PD was used as the starting point and updated with the latest evidence.

METHODS

We performed a systematic search in PubMed, CINAHL, Embase, and Web of Science. Randomized controlled trials comparing any physiotherapy intervention with no intervention or sham treatment were included. Trials were classified into 12 categories: conventional physiotherapy, resistance training, treadmill training, strategy training, dance, martial arts, aerobic exercises, hydrotherapy, balance and gait training, dual tasking, exergaming, and Nordic walking. Outcomes included motor symptoms, balance, gait, and quality of life, and are presented as standardized mean differences. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to systematically appraise methodological quality.

RESULTS

A total of 191 trials with 7998 participants were included. Conventional physiotherapy significantly improved motor symptoms, gait, and quality of life. Resistance training improved gait. Treadmill training improved gait. Strategy training improved balance and gait. Dance, Nordic walking, balance and gait training, and martial arts improved motor symptoms, balance, and gait. Exergaming improved balance and quality of life. Hydrotherapy improved balance. Finally, dual task training did not significantly improve any of the outcomes studied.

CONCLUSIONS

This meta-analysis provides a comprehensive overview of the evidence for the effectiveness of different physiotherapy interventions in the management of PD, allowing clinicians and patients to make an evidence-based decision for specific treatment modalities. Further work is needed to directly compare the relative efficacy of the various treatments.

The safety and feasibility of a Halliwick style of aquatic physiotherapy for falls and balance dysfunction in people with Parkinson's Disease: A single blind pilot trial

BACKGROUND

There is growing evidence that aquatic physiotherapy may be effective for people with Parkinson's Disease (PD) but most studies have investigated land based type exercises in the aquatic environment. Few studies have examined customised aquatic therapies such as the Halliwick concept which focuses on trunk rotation and core stabilisation.

OBJECTIVE

The primary aim was to determine the feasibility of a Halliwick style aquatic physiotherapy intervention for people with PD. The secondary aim was to compare the Halliwick intervention with traditional aquatic and land based physiotherapy in terms of disease severity, balance and fear of falling.

METHODS

Halliwick style aquatic, traditional aquatic and land based physiotherapy were trialled in a single blind pilot study. All interventions ran for 60 minutes per week over 12 weeks. Feasibility outcomes were safety, adherence and attrition. Secondary outcomes included the Unified Parkinson's Disease Rating Scale motor subsection (UPDRS-III), Berg Balance Scale (BBS), Mini BESTest and modified Falls Efficacy Scale (mFES).

RESULTS

30 participants with moderate PD were recruited. Participant mean age was 72 years (SD 8.4; range 51-86) with moderate disease severity (median Hoehn & Yahr score 3; IQR 1).No falls occurred during intervention sessions, however ten participants reported falls during the study period. No other adverse consequences were reported. All groups had adherence over 85%. No within group significant differences were found in UPDRS-III, BBS or mFES scores post-intervention for all groups, but the Halliwick aquatic group improved significantly in the Mini BESTest post-intervention (p = 0.011, 95% CI -7.36,-1.31, t (10) = -2.98).

CONCLUSIONS

Despite people with PD being a vulnerable population, aquatic physiotherapy, including the Halliwick style is a safe treatment option. Promising results for balance in the Halliwick aquatic group were observed, but further studies with larger sample sizes is required to increase confidence in the results.

Dyspnea in Parkinson's disease: an approach to diagnosis and management

INTRODUCTION

Dyspnea is a complex and debilitating non-motor symptom experienced by a significant proportion of PD patients which results in limitations to physical ability and a reduction in quality of life.

AREAS COVERED

The authors highlight the underlying pathophysiological mechanisms that can contribute to dyspnea in PD patients, and provide the clinician with a practical working algorithm for the management of such patients. The authors further highlight important clinical red flags that should be heeded in dyspneic PD patients and discuss therapeutic strategies for managing dyspnea.

EXPERT OPINION

Although awareness of dyspnea in PD is increasing, further studies of its prevalence and natural history at different stages of the disease are needed. In particular, it is important to determine whether dyspnea could be an early or prodromal disease manifestation. Although peripheral mechanisms are likely to play a major role in the pathophysiology of dyspnea, the possibility that central changes in brainstem ventilatory control may also play a part warrants further investigation.

Can Resistance Training Improve Upper Limb Postural Tremor, Force Steadiness and Dexterity in Older Adults? A Systematic Review

BACKGROUND

The ageing process and several health conditions may increase tremor and reduce force steadiness and dexterity, which can severely impact on function and quality of life. Resistance training can evoke a range of neuromuscular adaptions that may significantly reduce tremor and/or increase force steadiness and/or dexterity in older adults, irrespective of their health condition.

OBJECTIVES

The objective of this study was to systematically review the literature to determine if a minimum of 4 weeks' resistance training can reduce postural tremor and improve force steadiness and/or dexterity in older adults, defined as aged 65 years and over.

METHODS

An electronic search using Ovid, CINAHL, SPORTDiscus and EMBASE was performed. Risk of bias was assessed using the Cochrane Risk of Bias Tool.

RESULTS

Fourteen studies met the eligibility criteria, including six randomised controlled trials and two quasi-randomised controlled trials. All eight studies that recruited healthy older adults reported significant reductions in postural tremor and/or improvements in force steadiness and dexterity. Five out of seven studies that examined older adults with a particular health condition reported some improvements in force steadiness and/or dexterity. Specifically, significant benefits were observed for older adults with chronic obstructive pulmonary disease and essential tremor; however, small or no changes were observed for individuals with osteoarthritis or stroke.

CONCLUSIONS

Resistance training is a non-pharmacological treatment that can reduce tremor and improve force steadiness and dexterity in a variety of older adult populations. Future research should employ randomised controlled trials with larger sample sizes, better describe training programme methods, and align exercise prescription to current recommendations for older adults.

Taking Time: A Mixed Methods Study of Parkinson's Disease Caregiver Participation in Activities in Relation to Their Wellbeing

OBJECTIVES

Although many studies have shown that psychosocial interventions, such as dance classes, can improve quality of life for people with Parkinson's disease (PD): few have addressed the role of, and potential benefits to, the caregivers in such activities. This mixed methods study explored the reasons for caregiver participation in a variety of activities and considered whether participation in, or abstention from these, affected the wellbeing of the caregivers.

METHOD

Transcriptions of a focus group (two people with PD, two caregivers) and eight semistructured interviews (caregivers) were analysed using Grounded Theory (GT). To test the hypotheses derived from the GT, caregivers (n = 75) completed an online survey about activities they and the person they care for participated in, alongside the PDQ-Carer questionnaire, to establish the caregiver's levels of wellbeing.

RESULTS

Qualitative findings suggested that caregivers tried to find a balance between caring for the person with PD and participating in activities to attend to their own needs. Reasons for participating in activities for people with PD included being able to socialise in an empathetic safe space, alongside engaging in physical activity that provided some respite distraction, such as dancing with others to music. Reasons for not participating included generating time for oneself and increasing the independence of the person with PD. Quantitative results suggested that most of the participants' wellbeing was not compromised, although this was gendered: female caregivers reported lower wellbeing scores than male caregivers. Overall, 62% of caregivers participated in joint activities. Linear regression revealed a significant relationship between nonparticipation in daily activities and stress levels for female caregivers only, whereby the more independent the person with PD was, the lower the stress of the caregiver.

CONCLUSION

This study suggests that caregivers of people with PD can find a healthy balance in terms of their own wellbeing by jointly participating in two-thirds of activities while ensuring the remaining third is time reserved for themselves.

Treating Patients Like Athletes: Sports Science Applied to Parkinson's Disease

The evidence demonstrating the benefits of exercise is indisputable for healthy subjects, and more recently, it is growing for Parkinson's disease (PD) patients. Due to its easy access, low cost, social facilitation and, above all, the symptomatic effect, clinical exercise may have a profound impact on PD management. Especially considering that in recent decades there have been no major advances from the pharmacological point of view. Despite this, clinical exercise use it stills limited by the existent flaws in the available evidence supporting its use and guiding its prescription as a PD therapeutic intervention. We believe that a approach from the most relevant scientific and clinical fields is crucial to establish the use of clinical exercise in PD patients' routine care. Therefore, in this viewpoint, we aim to highlight the importance of clinical exercise as a therapeutic intervention in PD, and particularly of the benefits of applying sports science principles to potentiate the use of clinical exercise as a therapeutic intervention in PD management.

Progressive Resistance Training Improves Bradykinesia, Motor Symptoms and Functional Performance in Patients with Parkinson's Disease

Purpose

Bradykinesia and muscle weaknesses are common symptoms of Parkinson’s Disease (PD) and are associated with impaired functional performance, increased risk of falls, and reduced quality of life. Recent studies have pointed to progressive resistance training (PRT) as an effective method to control and reduce these symptoms, increasing possibilities to treat the disease. However, few studies have focused on assessing the PRT effects in the short-term. Therefore, the present study aimed to assess the short-term PRT effects on people with PD, in order to offer new parameters for a better understanding of its effects, so as an adequation and PRT use as a complementary therapy.

Patients and Methods

Forty individuals diagnosed with PD from stage 1 to 3 on the Hoehn and Yahr scale took part on the study and were allocated into 2 groups; Training Group (TG) performed a 9-week RT program twice a week, and the Control Group (CG) attended disease lectures. Bradykinesia UPDRS subscale (BSS), knee extensors isokinetic strength, Ten Meters Walk Test (TMW), Timed Up&Go Test (TUG) and 30-Second Chair Stand (T30) were measured before and after the intervention period. Statistical significance was set at p ≤ 0.05.

Results

Significant time was noted by the group interaction for all functional tests (TUG, T30, and TWM; all p < 0.01) and BSS (p < 0.01). Post hoc analyses revealed that these differences were driven by significant improvements in these dependent variables (all p < 0.01) while the CG remained unchanged (all p > 0.05). Moreover, TUG, T30, TWM, and BSS were significantly different between TG and CG in the post-training assessments (all p < 0.01). Isokinetic muscle strength was slightly increased in the TG (2.4%) and decreased in the CG (−2.2%), but statistical analyses did not reach significance for interaction but only a trend (p = 0.12).

Conclusion

The results indicate that 9 weeks of PRT reduces bradykinesia and improves functional performance in patients with mild to moderate PD. These findings reinforce this mode of exercise as an important component of public health promotion programs for PD.

Physical Activity, Exercise, and Physiotherapy in Parkinson's Disease: Defining the Concepts

Background

Exercise is gaining extreme relevancy as a new therapeutic intervention for Parkinson's disease (PD). However, the frequent misuse of the concepts exercise, physiotherapy, and physical activity limits the possibility of summarizing research findings. This review aims to clarify these concepts and summarize the evidence on exercise in PD.

Methods

We critically appraised physical activity-related concepts and conducted a systematic review of clinical trials evaluating exercise interventions in PD. Additionally, we discussed the implications for PD clinical practice and research.

Results

Exercise is a subset of physical activity, and a major component of physiotherapy for PD management, having as the main goal to improve physical fitness. The appraisal of the 83 identified clinical trials found high variability in exercise interventions. Multimodal exercise was the most studied, and 60 minutes, two times/week for 12 weeks, the most reported prescription parameters.

Conclusion

The best available evidence recommends increasing physical activity levels in PD. Exercise and physiotherapy programs seem the most efficacious strategies to achieve this goal. As a result of the heterogeneity in the type and manner exercise is prescribed, it is not possible to propose strong recommendations for exercise in PD. We believe that, in addition to the clarification of concepts here presented, a collaborative and rigorous work of different areas of knowledge is needed.

A Narrative Review of Lifestyle Factors Associated with Parkinson's Disease Risk and Progression

Parkinson's disease is a complex slowly progressive neurodegenerative disorder with motor and non-motor symptoms affecting daily living. Despite effective symptomatic treatments, with various degrees of side effects, no disease-modifying therapeutic options presently exist. Symptoms progress, with an accumulating burden, reducing the quality of life and forming the impression that medications are no longer effective. Adopting positive lifestyle behaviours can empower patients, improve the quality of life, alleviate symptoms, and potentially slow disease progression. Lifestyle behaviours including nutrition, cognitive enrichment, physical activity, and stress management have beneficial effects on brain health and quality of life. While some evidence of an association of lifestyle with Parkinson's disease risk and progression exists, the sparse and often conflicting data make it difficult to provide clinical recommendations. Herein, we highlight studies showing promising associations between lifestyle and Parkinson's disease. Given the increasing aging of populations worldwide and the prevalence of neurological disorders, further research into self-management through adoption of positive lifestyle behaviours is clearly warranted to better enable individualized care.

Kettlebell training in clinical practice: a scoping review

BACKGROUND

A scoping review of scientific literature on the effects of kettlebell training. There are no authoritative guidelines or recommendations for using kettlebells within a primary care setting. Our review objectives were to identify the extent, range and nature of the available evidence, to report on the types of evidence currently available to inform clinical practice, to synthesise key concepts, and identify gaps in the research knowledge base.

METHODS

Following the PRISMA-ScR Checklist, we conducted a search of 10 electronic databases from inception to 1 February 2019. There were no exclusions in searching for publications. A single reviewer screened the literature and abstracted data from relevant publications. Articles were grouped and charted by concepts and themes relevant to primary care, and narratively synthesised. Effect sizes from longitudinal studies were identified or calculated, and randomised controlled trials assessed for methodological quality.

RESULTS

Eight hundred and twenty-nine records were identified to 1 February 2019. Four hundred and ninety-six were screened and 170 assessed for eligibility. Ninety-nine publications met the inclusion criteria. Effect sizes were typically trivial to small. One trial used a pragmatic hardstyle training program among healthy college-age participants. Two trials reported the effects of kettlebell training in clinical conditions. Thirty-three studies explicitly used 'hardstyle' techniques and 4 investigated kettlebell sport. Also included were 6 reviews, 22 clinical/expert opinions and 3 case reports of injury. Two reviewers independently evaluated studies using a modified Downs & Black checklist.

CONCLUSIONS

A small number of longitudinal studies, which are largely underpowered and of low methodological quality, provide the evidence-informed therapist with little guidance to inform the therapeutic prescription of kettlebells within primary care. Confidence in reported effects is low to very low. The strength of recommendation for kettlebell training improving measures of physical function is weak, based on the current body of literature. Further research on reported effects is warranted, with inclusion of clinical populations and investigations of musculoskeletal conditions common to primary care. There is a need for an externally valid, standardised approach to the training and testing of kettlebell interventions, which better informs the therapeutic use of kettlebells in primary care.

Resistance training reduces depressive symptoms in elderly people with Parkinson disease: A controlled randomized study

BACKGROUND

Depression affects up to 40% of individuals with Parkinson's disease (PD).

PURPOSE

To assess resistance training effects on the depressive symptoms of elderly PD patients.

STUDY DESIGN

A randomized control study.

METHODS

Thirty-three patients (aged ≥ 60 years) were randomly divided into two groups: (a) control group: n = 16 and (b) resistance training group (RTG): n = 17. All patients with Parkinson's disease (stage 1-3 on the Hoehn and Yahr scale). The RTG, in addition to maintaining their pharmacological treatments, performed 20 weeks of resistance training. The control group maintained their pharmacological treatments. Depressive symptoms, quality of life, unified Parkinson's Disease scale, and functional capacity were evaluated in both groups.

RESULTS

The RTG presented a significant reduction (P < .05) of depressive symptoms (pre = 17.9 ± 8 score; post = 10.3 ± 6 score; effect size: -0.48), improved quality of life (pre = 40.3 ± 21.1 score; post = 30.2 ± 16.8 score; effect size: -0.26), and improved UPDRS (pre = 64 ± 34.6 score; post = 49.1 ± 24.1 score; effect size: -0.24). No significant changes in the control group regarding depressive symptoms (pre = 18.7 ± 5.4 score; post = 19.4 ± 5.2 score; effect size: 0.07), quality of life (pre = 39 ± 16.1 score; post = 40.6 ± 15.6 score; effect size: 0.05), and UPDRS (pre = 61.1 ± 24.3 score; post = 64.9 ± 23.4 score; effect size: 0.08) after 20 weeks.

CONCLUSION

Resistance training reduces depressive symptoms and improves the quality of life and functionality of elderly with PD.

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

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