Intensive cycle ergometer training improves gait speed and endurance in patients with Parkinson's disease: A comparison with treadmill training

Which aerobic exercise is more effective in Parkinson's patients? Cycle ergometer versus body weight-supported treadmill

Objectives

The study aimed to evaluate the effects of aerobic exercise applied with bodyweight-supported treadmill (BWSTT) or cycle ergometer (CE) in Parkinson's patients.

Patients and methods

In the prospective single-blind study, 38 Parkinson's patients with Hoehn-Yahr Stage 1-3 were randomized into the CE and BWSTT groups between May 2019 and March 2020. Evaluations before and after six weeks of treatment included a six-min walking test with a software device as the primary outcome and functional balance tests (Tinetti balance and gait test, one-leg stance balance test) as secondary outcomes. Both groups received 40 min of aerobic exercise three days per week with conventional rehabilitation and various methods. CE and BWSTT groups were created. The aerobic exercise program was designed based on treatment recommendations for Parkinson's patients of the American College of Sports Medicine (CE test, with the Karvonen formula, 40-60% reserve). Posttreatment and pretreatment evaluations were compared within and between groups.

Results

The six-week aerobic exercise program was completed by 16 participants (9 males, 7 females; mean age: 65.9±8.1; range, 47 to 78 years) in the CE group and 15 participants (9 males, 6 females; mean age: 62.5±7.5; range, 49 to 79 years) in the BWSTT group. The demographic characteristics of the patients were similar. Primary and secondary outcomes were significantly different after treatment than before treatment in both groups. There were no significant differences between the groups in outcomes.

Conclusion

The results showed that both methods are effective and not superior to each other. Aerobic exercise programs led by experienced clinicians can benefit patients.

Can behavioural change interventions improve self-efficacy and exercise adherence among people with Parkinson’s? A systematic review protocol

Background :People with Parkinson’s (PwP) have a higher tendency to adopt sedentary lifestyle behaviours and have lower physical activity levels compared to their healthy peers. Previous research has indicated that personal factors including poor outcome expectation and low self-efficacy are stronger predictors of exercise adherence than disease severity. : The purpose of this review is to synthesize the best available evidence on interventions that encompass self-management strategies to overcome barriers to exercise and improve self-efficacy and exercise adherence among PwP.

Methods : The following databases will be searched using a comprehensive search strategy: EBSCO, Medline, CINAHL, Web of Science, PubMed, Embase, Scopus, Google Scholar and Cochrane Library from database inception to 2020. Interventional studies including behavioural change interventions will be included in this review. The title, abstract and full-text screening will be conducted by two independent reviewers. The Joanne Briggs Institute Checklist will be used to assess the quality of each included study. Data will be extracted by two independent reviewers. The outcomes of interest will be self-efficacy outcomes and measures of exercise adherence. A systematic narrative synthesis will be conducted using a framework analysis, applying the Theoretical Domains Framework and Behaviour Change Wheel, producing findings focusing on practice-orientated outcomes. Presentation of data will include tables and text summarizing the characteristics and findings of the eligible studies. Data synthesis and statistical analysis will be performed in Review manager 5.3. The quality of evidence will be reviewed using the GRADE criteria.

Discussion : The review will comprehensively synthesize the  available evidence on interventions to enhance self-efficacy, improve quality of life, physical function,  ultimately improving exercise adherence among PwP and provide invaluable information for healthcare professionals.. This review will make recommendations for appropriate self-management strategies for maximum effect and may have implications for policy and practice regarding enhancing self-efficacy and long-term exercise adherence among PwP.

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

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

Can behavioural change interventions improve self-efficacy and exercise adherence among people with Parkinson’s? A systematic review protocol

Context: People with Parkinson’s (PwP) have a higher tendency to engage in sedentary lifestyle behaviours and have lower physical activity levels compared to their healthy peers. Previous research has indicated that personal factors including poor outcome expectation and low self-efficacy are stronger predictors of exercise adherence than disease severity. Objectives: The purpose of this review is to synthesize the best available evidence on interventions that encompass self-management strategies to overcome barriers to exercise and improve self-efficacy and exercise adherence among PwP. Methods: The following databases will be searched using a comprehensive search strategy: EBSCO, Medline, Cinhal, Web of Science, PubMed, Embase, Scopus, Google Scholar and Cochrane Library from database inception to 2020. The title, abstract and full-text screening will be conducted by two independent reviewers. The Joanne Briggs Institute Checklist will be used to assess the quality of each included study. The quality of evidence will be reviewed using the GRADE criteria. Data will be extracted by two independent reviewers. The outcomes of interest will be self-efficacy outcomes and measures of exercise adherence. A systematic narrative synthesis will be conducted using a framework analysis, applying the Theoretical Domains Framework and Behaviour Change Wheel, producing findings focusing on practice-orientated outcomes. Presentation of data will include tables and text summarizing the characteristics and findings of the eligible studies. Discussion: The review will synthesize the best available evidence on interventions to enhance self-efficacy, improve quality of life, physical function, and ultimately improve exercise adherence among PwP and provide invaluable information for healthcare professionals. The findings of this review will be disseminated through publication in a peer-reviewed journal and presented at relevant conference proceedings. This review will make recommendations for appropriate self-management strategies for maximum effect and may have implications for policy and practice regarding enhancing self-efficacy and long-term exercise adherence among PwP.

Parkinson's disease patients benefit from bicycling - a systematic review and meta-analysis

Many Parkinson's disease (PD) patients are able to ride a bicycle despite being severely compromised by gait disturbances up to freezing of gait. This review [PROSPERO CRD 42019137386] aimed to find out, which PD-related symptoms improve from bicycling, and which type of bicycling exercise would be most beneficial. Following a systematic database literature search, peer-reviewed studies with randomized control trials (RCT) and with non-randomized trials (NRCT) investigating the interventional effects of bicycling on PD patients were included. A quality analysis addressing reporting, design and possible bias of the studies, as well as a publication bias test was done. Out of 202 references, 22 eligible studies with 505 patients were analysed. An inverse variance-based analysis revealed that primary measures, defined as motor outcomes, benefitted from bicycling significantly more than cognitive measures. Additionally, secondary measures of balance, walking speed and capacity, and the PDQ-39 ratings improved with bicycling. The interventions varied in durations, intensities and target cadences. Conclusively, bicycling is particularly beneficial for the motor performance of PD patients, improving crucial features of gait. Furthermore, our findings suggest that bicycling improves the overall quality-of-life of PD patients.

Effects of treadmill training on gait of elders with Parkinson's disease: a literature review

Parkinson's disease is the second most common neurodegenerative disorder in old age. Aging process for elders with Parkinson's disease can induce gait disturbances with more functional disabilities than for elders without the disease. Treadmill training as a therapy has resulted in notable effects on the gait of patients with Parkinson's disease and may be a resource for geriatric neurological rehabilitation. This review aimed to study the effects on gait after treadmill training in elderly patients with Parkinson's disease. The search was performed in the databases PubMed®, LILACS, PEDro and EMBASE, with the following keywords: "Parkinson's disease", "elderly", "treadmill training" and "gait evaluation". The quality of the studies included was assessed by PEDro Scale. Eleven studies met the inclusion and exclusion criteria. Eight studies were randomized, and only one did a follow-up. One can observe in this review that treadmill training with or without weight support (at least 20 minutes, two to three times a week, with progressive increase of loads, for minimum of 6 weeks) in elderly patients with the Parkinson's disease was effective to improve gait. In addition, both were considered safe (since some studies described the use of belts, even in unsupported training) and can be associated with therapies complementary to gait, such as repetitive transcranial magnetic stimulation, visual cues or anodal transcranial direct current stimulation. Treadmill training in elderly patients with Parkinson's disease is an intervention that improves gait outcomes, but further studies are required for better proofs.

Effects of stretching exercises on human gait: a systematic review and meta-analysis

Background: Stretching is commonly used in physical therapy as a rehabilitation tool to improve range of motion and motor function. However, is stretching an efficient method to improve gait, and if so, for which patient category? Methods: A systematic review of randomized and non-randomized controlled trials with meta-analysis was conducted using relevant databases. Every patient category and every type of stretching programs were included without multicomponent programs. Data were meta-analysed where possible. Estimates of effect sizes (reported as standard mean difference (SMD)) with their respective 95% confidence interval (95% CI) were reported for each outcome. The PEDro scale was used for the quality assessment. Results: Twelve studies were included in the analysis. Stretching improved gait performance as assessed by walking speed and stride length only in a study with a frail elderly population, with small effect sizes (both SMD= 0.49; 95% CI: 0.03, 0.96; PEDro score: 3/10). The total distance and the continuous walking distance of the six-minute walking test were also improved only in a study in an elderly population who had symptomatic peripheral artery disease, with large effect sizes (SMD= 1.56; 95% CI: 0.66, 2.45 and SMD= 3.05; 95% CI: 1.86, 4.23, respectively; PEDro score: 5/10). The results were conflicting in healthy older adults or no benefit was found for most of the performance, spatiotemporal, kinetic and angular related variables. Only one study (PEDro score: 6/10) showed improvements in stance phase duration (SMD=-1.92; 95% CI: -3.04, -0.81), swing phase duration (SMD=1.92; 95 CI: 0.81, 3.04), double support phase duration (SMD= -1.69; 95% CI: -2.76, -0.62) and step length (SMD=1.37; 95% CI: 0.36, 2.38) with large effect sizes. Conclusions: There is no strong evidence supporting the beneficial effect of using stretching to improve gait. Further randomized controlled trials are needed to understand the impact of stretching on human gait.

Effects of stretching exercises on human gait: a systematic review and meta-analysis

Background: Stretching is commonly used in physical therapy as a rehabilitation tool to improve range of motion and motor function. However, is stretching an efficient method to improve gait, and if so, for which patient category? Methods: A systematic review of randomized and non-randomized controlled trials with meta-analysis was conducted using relevant databases. Every patient category and every type of stretching programs were included without multicomponent programs. Data were meta-analysed where possible. Estimates of effect sizes (reported as standard mean difference (SMD)) with their respective 95% confidence interval (95% CI) were reported for each outcome. The PEDro scale was used for the quality assessment. Results: Twelve studies were included in the analysis. Stretching improved gait performance as assessed by walking speed and stride length only in a study with a frail elderly population, with small effect sizes (both SMD= 0.49; 95% CI: 0.03, 0.96; PEDro score: 3/10). The total distance and the continuous walking distance of the six-minute walking test were also improved only in a study in an elderly population who had symptomatic peripheral artery disease, with large effect sizes (SMD= 1.56; 95% CI: 0.66, 2.45 and SMD= 3.05; 95% CI: 1.86, 4.23, respectively; PEDro score: 5/10). The results were conflicting in healthy older adults or no benefit was found for most of the performance, spatiotemporal, kinetic and angular related variables. Only one study (PEDro score: 6/10) showed improvements in stance phase duration (SMD=-1.92; 95% CI: -3.04, -0.81), swing phase duration (SMD=1.92; 95 CI: 0.81, 3.04), double support phase duration (SMD= -1.69; 95% CI: -2.76, -0.62) and step length (SMD=1.37; 95% CI: 0.36, 2.38) with large effect sizes. Conclusions: There is no strong evidence supporting the beneficial effect of using stretching to improve gait. Further randomized controlled trials are needed to understand the impact of stretching on human gait.

Proposal of a new conceptual gait model for patients with Parkinson's disease based on factor analysis

BACKGROUND

Gait impairment is a risk factor for falls in patients with Parkinson's disease (PD). Gait can be conveniently assessed by electronic walkways, but there is need to select which spatiotemporal gait variables are useful for assessing gait in PD. Existing models for gait variables developed in healthy subjects and patients with PD show some methodological shortcomings in their validation through exploratory factor analysis (EFA), and were never confirmed by confirmatory factor analysis (CFA). The aims of this study were (1) to create a new model of gait for PD through EFA, (2) to analyze the factorial structure of our new model and compare it with existing models through CFA.

RESULTS

From the 37 variables initially considered in 250 patients with PD, 10 did not show good-to-excellent reliability and were eliminated, while further 19 were eliminated after correlation matrix and Kaiser-Meyer-Olkin measure. The remaining eight variables underwent EFA and three factors emerged: pace/rhythm, variability, and asymmetry. Structural validity of our new model was then examined with CFA, using the structural equation modeling. After some modifications, suggested by the Modification Indices, we obtained a final model that showed an excellent fit. In contrast, when the structure of previous models of gait was analyzed, no model achieved convergence with our sample of patients.

CONCLUSIONS

Our model for spatiotemporal gait variables of patients with PD is the first to be developed through an accurate EFA and confirmed by CFA. It contains eight gait variables divided into three factors and shows an excellent fit. Reasons for the non-convergence of other models could be their inclusion of highly inter-correlated or low-reliability variables or could be possibly due to the fact that they did not use more recent methods for determining the number of factors to extract.

Walking Along Curved Trajectories. Changes With Age and Parkinson's Disease. Hints to Rehabilitation

In this review, we briefly recall the fundamental processes allowing us to change locomotion trajectory and keep walking along a curved path and provide a review of contemporary literature on turning in older adults and people with Parkinson's Disease (PD). The first part briefly summarizes the way the body exploits the physical laws to produce a curved walking trajectory. Then, the changes in muscle and brain activation underpinning this task, and the promoting role of proprioception, are briefly considered. Another section is devoted to the gait changes occurring in curved walking and steering with aging. Further, freezing during turning and rehabilitation of curved walking in patients with PD is mentioned in the last part. Obviously, as the research on body steering while walking or turning has boomed in the last 10 years, the relevant critical issues have been tackled and ways to improve this locomotor task proposed. Rationale and evidences for successful training procedures are available, to potentially reduce the risk of falling in both older adults and patients with PD. A better understanding of the pathophysiology of steering, of the subtle but vital interaction between posture, balance, and progression along non-linear trajectories, and of the residual motor learning capacities in these cohorts may provide solid bases for new rehabilitative approaches.

Exercise Guidelines for Gait Function in Parkinson’s Disease: A Systematic Review and Meta-analysis

This systematic review and meta-analysis is to provide comprehensive evidence-based exercise recommendations targeting walking function for adults with Parkinson’s disease. Methods. Fixed- or random-effect meta-analyses estimated standardized effect sizes (Hedge’s g), comparing treatment effects from exercise with nonexercise and another form of exercise (non-EXE control and EXE control). Cuing and exercise duration were used as moderators for subanalyses. Results. The 40 included randomized controlled trials comprised 1656 patients. The exercise group showed significantly superior performance in timed up-and-go ( g = −0.458; g = −0.390) compared with non-EXE control and EXE control; significantly greater improvement in comfortable walking speed ( g = 0.449), fast walking speed ( g = 0.430), and stride or step length ( g = 0.379) compared with non-EXE control; and significantly greater cadence ( g = 0.282) compared with EXE controls. No significant differences between intervention and control groups were observed for double-leg support time (DLST), dynamic gait index (DGI), 6-minute walk test, or freezing of gait questionnaire (FOG-Q). Notably, treatment effect from the exercise of interest compared with a standard exercise was greater than for nonexercise for cadence and FOG-Q. Moreover, EXE control was favored for DLST and DGI. Cuing had a significantly positive effect on stride length alone. Exercise duration significantly, but negatively, influenced the treatment effect on comfortable walking speed. Conclusion. Gait-specific training, rather than a general exercise program, should be emphasized if gait is the outcome of interest. Further investigation is needed on exercise dosage and its selective effect on more challenging walking tasks, endurance, and freezing of gait.

Instrumental or Physical-Exercise Rehabilitation of Balance Improves Both Balance and Gait in Parkinson's Disease

We hypothesised that rehabilitation specifically addressing balance in Parkinson's disease patients might improve not only balance but locomotion as well. Two balance-training protocols (standing on a moving platform and traditional balance exercises) were assessed by assigning patients to two groups (Platform, n = 15, and Exercises, n = 17). The platform moved periodically in the anteroposterior, laterolateral, and oblique direction, with and without vision in different trials. Balance exercises were based on the Otago Exercise Program. Both platform and exercise sessions were administered from easy to difficult. Outcome measures were (a) balancing behaviour, assessed by both Index of Stability (IS) on platform and Mini-BESTest, and (b) gait, assessed by both baropodometry and Timed Up and Go (TUG) test. Falls Efficacy Scale-International (FES-I) and Parkinson's Disease Questionnaire (PDQ-8) were administered. Both groups exhibited better balance control, as assessed both by IS and by Mini-BESTest. Gait speed at baropodometry also improved in both groups, while TUG was less sensitive to improvement. Scores of FES-I and PDQ-8 showed a marginal improvement. A four-week treatment featuring no gait training but focused on challenging balance tasks produces considerable gait enhancement in mildly to moderately affected patients. Walking problems in PD depend on postural instability and are successfully relieved by appropriate balance rehabilitation. This trial is registered with ClinicalTrials.gov NCT03314597.

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

The purpose of this study was to investigate the effectiveness of strength training, performed against a different resistance from body weight, in improving motor and nonmotor symptoms in patients with Parkinson’s disease (PD). The following electronic databases were searched: PubMed, Physiotherapy Evidence Database, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science. The review was conducted and reported in accordance with the PRISMA statement. Thirteen high-quality randomized controlled trials were included. Strength training performed against external resistance is well tolerated and appears to be a suitable physical activity to improve both physical parameters and quality of life parameters of PD subjects. However, although the study intervention included strength training, only a few selected studies assessed the improvement of muscle strength. Despite the encouraging results, it is difficult to establish a correlation between strength training and the improvements made. Our review highlights the lack of common intent in terms of study design and the presence of different primary and secondary outcomes. Accordingly, further studies are needed to support the beneficial effects of different types of strength training in PD subjects and to underline the superiority of strength training in PD patients with respect to other training.

Curved Walking Rehabilitation with a Rotating Treadmill in Patients with Parkinson's Disease: A Proof of Concept

Training subjects to step-in-place eyes open on a rotating platform while maintaining a fixed body orientation in space [podokinetic stimulation (PKS)] produces a posteffect consisting in inadvertent turning around while stepping-in-place eyes closed [podokinetic after-rotation (PKAR)]. Since the rationale for rehabilitation of curved walking in Parkinson's disease is not fully known, we tested the hypothesis that repeated PKS favors the production of curved walking in these patients, who are uneasy with turning, even when straight walking is little affected. Fifteen patients participated in 10 training sessions distributed in 3 weeks. Both counterclockwise and clockwise PKS were randomly administered in each session. PKS velocity and duration were gradually increased over sessions. The velocity and duration of the following PKAR were assessed. All patients showed PKAR, which increased progressively in peak velocity and duration. In addition, before and at the end of the treatment, all patients walked overground along linear and circular trajectories. Post-training, the velocity of walking bouts increased, more so for the circular than the linear trajectory. Cadence was not affected. This study has shown that parkinsonian patients learn to produce turning while stepping when faced with appropriate training and that this capacity translates into improved overground curved walking.

A 12-Week Cycling Training Regimen Improves Gait and Executive Functions Concomitantly in People with Parkinson's Disease

Background: There is increasing evidence that executive functions and attention are associated with gait and balance, and that this link is especially prominent in older individuals or those who are afflicted by neurodegenerative diseases that affect cognition and/or motor functions. People with Parkinson’s disease (PD) often present gait disturbances, which can be reduced when PD patients engage in different types of physical exercise (PE), such as walking on a treadmill. Similarly, PE has also been found to improve executive functions in this population. Yet, no exercise intervention investigated simultaneously gait and non-motor symptoms (executive functions, motor learning) in PD patients.

Objective: To assess the impact of aerobic exercise training (AET) using a stationary bicycle on a set of gait parameters (walking speed, cadence, step length, step width, single and double support time, as well as variability of step length, step width and double support time) and executive functions (cognitive inhibition and flexibility) in sedentary PD patients and healthy controls.

Methods: Two groups, 19 PD patients (Hoehn and Yahr ≤2) and 20 healthy adults, matched on age and sedentary level, followed a 3-month stationary bicycle AET regimen.

Results: Aerobic capacity, as well as performance of motor learning and on cognitive inhibition, increased significantly in both groups after the training regimen, but only PD patients improved their walking speed and cadence (all p < 0.05; with no change in the step length). Moreover, in PD patients, training-related improvements in aerobic capacity correlated positively with improvements in walking speed (r = 0.461, p < 0.05).

Conclusion: AET using stationary bicycle can independently improve gait and cognitive inhibition in sedentary PD patients. Given that increases in walking speed were obtained through increases in cadence, with no change in step length, our findings suggest that gait improvements are specific to the type of motor activity practiced during exercise (i.e., pedaling). In contrast, the improvements seen in cognitive inhibition were, most likely, not specific to the type of training and they could be due to indirect action mechanisms (i.e., improvement of cardiovascular capacity). These results are also relevant for the development of targeted AET interventions to improve functional autonomy in PD patients.