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

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.

Guide to Decomposition of Causal Effects Into Mediation, Interaction, and Direct Effects: Case Study on Aerobic Exercise and Parkinson Disease

Mediation analysis can be applied in medical research with the aim of understanding the pathways that operate between an exposure and its effects on an outcome. This method can help to improve our understanding of pathophysiologic mechanisms and may guide the choice of potential treatment strategies. Traditional mediation analysis decomposes the total effect of an intervention on the outcome into 2 effects: (1) an indirect effect, from exposure using a mediator to the outcome, and (2) a direct effect, directly from exposure to outcome. A limitation of this method is that it assumes no interaction between the exposure and the mediator, which can either lead to an over- or underestimation of clinically relevant effects. The "4-way decomposition" method has the advantage of overcoming this limitation. Specifically, the total effect of an exposure on the outcome is decomposed into 4 elements: (1) reference interaction (interaction only), (2) mediated interaction (mediation and interaction), (3) the pure indirect effect (mediation but not interaction), and (4) the direct effect (no mediation and no interaction). We provide a guide to select the most appropriate method to investigate and decompose any causal effect given the research question at hand. We explain the application of the 4-way decomposition and illustrate this with a real-world example of how aerobic exercise may influence motor function in persons with Parkinson disease.

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.

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

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

Cycling in older adults: a scoping review

Introduction

Regular physical activity provides many health benefits to older adults. As a well-known form of physical activity, cycling can be an appropriate means for older people to meet WHO recommendations and to improve their health. In addition, cycling can help to protect the environment and reduce greenhouse gas emissions. The primary aim of this scoping review is to identify the currently available scientific evidence and gaps of research in this field.

Methods

A systematic search in seven databases resulted in 7,192 studies. After the exclusion of duplicates, studies were screened by two independent reviewers in a two-stage process. Based on previously defined inclusion criteria, 123 studies were included. Data extraction was based on a descriptive analytical method, and seven categories for the main topics of studies were developed. Data were extracted by three reviewers to analyze different characteristics of included articles such as age range, study design, data type, gender, type of bicycle, and country of origin.

Results

The included studies covered the following topics: (1) traffic safety, (2) cycling as physical activity or for transport, (3) health benefits, (4) environmental factors, (5) facilitators and barriers, (6) application of technology and (7) promotion of cycling. Results show that the majority of studies were performed in both younger (60-79 years) and older (80+ years) adults. Most studies had an observational study design, used conventional bicycles, and were based on quantitative methods. Researchers from the United States, Netherlands, and Japan published the highest number of studies related to cycling.

Discussion

Traffic safety was the most prevalent focus of the included studies. Gaps were identified with regard to studies focusing on the promotion of cycling, application of technology, as well as facilitators and barriers of cycling. While research on traffic safety should continue to be a high priority for public health, potentially more research should focus on how to get older people to bicycle more. This is warranted by the proven individual and planetary health benefits of cycling and the urgency of combating climate change.

Walking function determinants in parkinson patients undergoing rehabilitation

BACKGROUND: To date little is known about factors affecting walking rehabilitation in Parkinson’s disease (PD) patients. OBJECTIVE: This prospective observational cohort study evaluated the walking distance covered in 6 minutes (6 MWD) before and after conventional rehabilitation and verified which among PD motor disorders was the most important determinant of walking distance in PD patients undergoing rehabilitation. METHODS: Data were collected from 55 PD patients, performing a conventional outpatient motor rehabilitation program. The 6MWD at the end of rehabilitation and gain in 6MWD were the outcome measures. The Unified Parkinson’s Disease Rating Scale, Hoehn and Yahr scale, Nine Hole Peg Test, Grip and Pinch test, ROM wrist motility, and Berg Balance Scale (BBS) were used to assess PD patients at admission and were considered as dependent variables. Backward multiple regression analyses identified the determinants of 6MWD outcomes. RESULTS: The 6MWD was 246.58±115 meters at admission and 286.90±116 at the end of rehabilitation. At end of rehabilitation, the 6MWD was 42.32±47 meters greater than admission (p <  0.001), corresponding to an increase of +17.16% . At the end of rehabilitation, the 6MWD was significantly longer in PD patients with stages 1–3 of the Hoehn and Yahr scale. Berg Balance Scale (β= 0.47, p <  0.001) and right Grip and Pinch at admission (β= 0.36, p = 0.001) were the only determinants of final 6MWD. The R2 value of the model was 0.47 (R2 adjusted 0.45). No variable was a determinant of gain in 6MWD. CONCLUSIONS: The study indicates that balance and generalized muscle strength are important determinants of walking rehabilitation in PD patients, in whom it is essential to maintain high levels of balance and muscle strength for a time as long as possible. These findings suggest planning more intensive rehabilitation treatments in PD patients with low levels of balance and muscle strength.

Effects of Lower Limb Cycling Training on Different Components of Force and Fatigue in Individuals With Parkinson’s Disease

The strength of lower extremity is important for individuals to maintain balance and ambulation functions. The previous studies showed that individuals with Parkinson’s disease suffered from fatigue and strength loss of central origin. The purpose of this study was to investigate the effect of lower extremities’ cycling training on different components of force and fatigue in individuals with Parkinson’s disease. Twenty-four individuals (13 males, 11 females, mean age: 60.58 ± 8.21 years) diagnosed with idiopathic Parkinson’s disease were randomized into training and control groups. The maximum voluntary contraction (MVC) force, voluntary activation level (VA), and twitch force of knee extensors were measured using a custom-made system with surface electrical stimulation. The general, central, and peripheral fatigue indexes (GFI, CFI, and PFI) were calculated after a fatiguing cycling protocol. Subjects received 8 weeks of low resistance cycling training (training group) or self-stretching (control group) programs. Results showed that MVC, VA, and twitch force improved (p < 0.05) only in the training group. Compared to the baseline, central fatigue significantly improved in the training group, whereas peripheral fatigue showed no significant difference in two groups. The cycling training was beneficial for individuals with Parkinson’s disease not only in muscle strengthening but also in central fatigue alleviation. Further in-depth investigation is required to confirm the effect of training and its mechanism on central fatigue.

Graded peak cycle ergometer test for cognitively impaired patients with Parkinson's disease: a pilot study

BACKGROUND

Cognitive decline affects up to 50% of patients with Parkinson's disease (PD) in the course of the disease and may be amenable to exercise interventions. To accurately set adequate training intensities, standardized exercise testing is required but such testing takes considerable time and effort. The aim of this pilot study was to investigate the feasibility of a graded peak cycle ergometer exercise test in cognitively impaired patients with Parkinson's Disease (PD), and to define whether age-predicted maximal heart rate (HRmax) matched measured HRmax.

METHODS

A convenience sample of seven patients with PD (Hoehn and Yahr: 2-4, and cognitive impairment (Montreal Cognitive Assessment (MoCA) ≤ 26) completed a graded peak cycle ergometer test to voluntary exhaustion. Borg Rating of Perceived Exertion was used to record the individual's perception of exertion. Pre-defined age-predicted HRmax (calculated as 208-(0.7 × age) was compared with the measured HRmax using Bland-Altman plot and a two-one-sided test.

RESULTS

All PD patients completed the graded exercise test between 8-12 minutes, showing therefore 100% compliance to the test protocol. No adverse events occurred. Predicted HRmax and measured HRmax did not differ.

CONCLUSION

We demonstrate feasibility of graded peak cycle ergometer testing in PD patients with cognitive impairment. The good correspondence of age-predicted HRmax equation with measured HRmax, in this small sample, may in the future provide clinicians with a tool to define training intensities in cognitively impaired PD, without cardiac disease. However, further research is needed to confirm these results.

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.

A randomized controlled trial of exercise on augmenting the effects of cognitive remediation in persons with severe mental illness

BACKGROUND

Preliminary evidence suggests that aerobic exercise may augment the effects of cognitive remediation on improving cognitive functioning in severe mental illness. It has also been hypothesized that increases in cognitive functioning associated with adding exercise are mediated by increases in brain derived neurotrophic factor (BDNF). However, rigorous controlled trials are lacking.

METHODS

A randomized controlled trial was conducted to explore whether adding a 30-h aerobic exercise program over 10 weeks to an equally intensive cognitive remediation program (CR + E) improved cognitive functioning more than cognitive remediation alone (CR-Only). Thirty-four participants with schizophrenia or bipolar disorder were randomly assigned to CR + E or CR-Only, and cognitive functioning was assessed at baseline and post-treatment. Total and mature BDNF were measured in blood serum at baseline, Week-5 pre- and post-exercise, and Week-10 pre- and post-exercise.

RESULTS

Participants in both conditions had high levels of engagement in the interventions and improved significantly in cognitive functioning, but did not differ in amount of cognitive change. The groups also did not differ in changes in BDNF from pre-to post-exercise at Weeks 5 or 10, nor in resting BDNF levels. Exploratory analyses indicated that higher body mass index (BMI) significantly predicted attenuated improvement in cognitive functioning for both groups.

DISCUSSION

Exercise did not augment the effects of cognitive remediation in persons with severe mental illness, possibly because the cognitive remediation program resulted in strong gains in cognitive functioning. Moderate aerobic exercise does not appear to reliably increase BDNF levels in persons with severe mental illness. CLINICALTRIALS.

GOV IDENTIFIER

NCT02326389.

Effect of the combination of automated peripheral mechanical stimulation and physical exercise on aerobic functional capacity and cardiac autonomic control in patients with Parkinson's disease: a randomized clinical trial protocol

BACKGROUND

Automated peripheral mechanical stimulation (AMPS) has been proposed as a new complementary therapy with potential for improving motor and cardiovascular abnormalities in Parkinson's disease (PD). However, AMPS long-term effects and its combination with physical exercise are unknown. Thus, this study aims to compare the effects of a program of 12 weeks of physical exercise with a 12-week intervention program combining physical exercise and AMPS on the aerobic capacity, cardiac autonomic control, and gait parameters in patients with PD.

METHODS

A randomized, controlled clinical trial will be conducted. Older volunteers with PD will be randomly assigned to one of the two groups studied: (1) exercise or (2) AMPS + exercise. Both groups will undergo an exercise program of 24 sessions, for 12 weeks, performed twice a week. Before exercise sessions, the group AMPS + exercise will receive a session of active AMPS, while the group exercise will receive an AMPS sham intervention. Shapiro-Wilk's and Levene's tests will be used to check for data normality and homogeneity, respectively. In case parametric assumptions are fulfilled, per-protocol and intention-to-treat analyses will be performed using a mixed model analysis of variance to check for group*time interaction. Significance level will be set at 5%.

DISCUSSION

Several non-pharmacological treatment modalities have been proposed for PD, focusing primarily on the reduction of motor and musculoskeletal disorders. Regular exercise and motor training have been shown to be effective in improving quality of life. However, treatment options in general remain limited given the high prevalence and adverse impact of these disorders. So, developing new strategies that can potentiate the improvement of motor disabilities and also improve non-motor symptoms in PD is relevant. It is expected that the participants from both groups will improve their quality of life, gait parameters, and their cardiac autonomic control, with greater improvements being observed in the group combining active AMPS and physical exercise.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04251728 . Registered on February 05, 2020.

Sigma-Lognormal Modeling of Speech

Human movement studies and analyses have been fundamental in many scientific domains, ranging from neuroscience to education, pattern recognition to robotics, health care to sports, and beyond. Previous speech motor models were proposed to understand how speech movement is produced and how the resulting speech varies when some parameters are changed. However, the inverse approach, in which the muscular response parameters and the subject’s age are derived from real continuous speech, is not possible with such models. Instead, in the handwriting field, the kinematic theory of rapid human movements and its associated Sigma-lognormal model have been applied successfully to obtain the muscular response parameters. This work presents a speech kinematics-based model that can be used to study, analyze, and reconstruct complex speech kinematics in a simplified manner. A method based on the kinematic theory of rapid human movements and its associated Sigma-lognormal model are applied to describe and to parameterize the asymptotic impulse response of the neuromuscular networks involved in speech as a response to a neuromotor command. The method used to carry out transformations from formants to a movement observation is also presented. Experiments carried out with the (English) VTR-TIMIT database and the (German) Saarbrucken Voice Database, including people of different ages, with and without laryngeal pathologies, corroborate the link between the extracted parameters and aging, on the one hand, and the proportion between the first and second formants required in applying the kinematic theory of rapid human movements, on the other. The results should drive innovative developments in the modeling and understanding of speech kinematics.

Development and piloting of a perturbation stationary bicycle robotic system that provides unexpected lateral perturbations during bicycling (the PerStBiRo system)

Background

Balance control, and specifically balance reactive responses that contribute to maintaining balance when balance is lost unexpectedly, is impaired in older people. This leads to an increased fall risk and injurious falls. Improving balance reactive responses is one of the goals in fall-prevention training programs. Perturbation training during standing or treadmill walking that specifically challenges the balance reactive responses has shown very promising results; however, only older people who are able to perform treadmill walking can participate in these training regimes. Thus, we aimed to develop, build, and pilot a mechatronic Perturbation Stationary Bicycle Robotic system (i.e., PerStBiRo) that can challenge balance while sitting on a stationary bicycle, with the aim of improving balance proactive and reactive control.

Methods

This paper describes the development, and building of the PerStBiRo using stationary bicycles. In addition, we conducted a pilot randomized control trial (RCT) with 13 older people who were allocated to PerStBiRo training (N = 7) versus a control group, riding stationary bicycles (N = 6). The Postural Sway Test, Berg Balance Test (BBS), and 6-min Walk Test were measured before and after 3 months i.e., 20 training sessions.

Results

The PerStBiRo System provides programmed controlled unannounced lateral balance perturbations during stationary bicycling. Its software is able to identify a trainee’s proactive and reactive balance responses using the Microsoft Kinect™ system. After a perturbation, when identifying a trainee’s trunk and arm reactive balance response, the software controls the motor of the PerStBiRo system to stop the perturbation. The pilot RCT shows that, older people who participated in the PerStBiRo training significantly improved the BBS (54 to 56, p = 0.026) and Postural Sway velocity (20.3 m/s to 18.3 m/s, p = 0.018), while control group subject did not (51.0 vs. 50.5, p = 0.581 and 15 m/s vs. 13.8 m/s, p = 0.893, respectively), 6MWT tended to improve in both groups.

Conclusions

Our participants were able to perform correct balance proactive and reactive responses, indicating that older people are able to learn balance trunk and arm reactive responses during stationary bicycling. The pilot study shows that these improvements in balance proactive and reactive responses are generalized to performance-based measures of balance (BBS and Postural Sway measures).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02015-1.

The Effects of Bicycle Simulator Training on Anticipatory and Compensatory Postural Control in Older Adults: Study Protocol for a Single-Blind Randomized Controlled Trial

Background: Falls are the leading cause of fatal and non-fatal injuries among older adults. Perturbation-Based-Balance Training (PBBT) is a promising approach to reduce fall rates by improving reactive balance responses. PBBT programs are designed for older adults who are able to stand and walk on a motorized treadmill independently. However, frail older adults, whose fall rates are higher, may not have this ability and they cannot participate. Thus, there is a critical need for innovative perturbation exercise programs to improve reactive balance and reduce the fall risks among older adults in a wider range of functioning. Trunk and arms are highly involved in reactive balance reactions. We aim to investigate whether an alternative PBBT program that provides perturbations during hands-free bicycling in a sitting position, geared to improve trunk and arm reactive responses, can be transferred to reduce fall risks and improve balance function among pre-frail older adults.

Methods: In a single-blinded randomized-controlled trial, 68 community-dwelling pre-frail older adults are randomly allocated into two intervention groups. The experimental group receives 24-PBBT sessions over 12-weeks that include self-induced internal and machine-induced external unannounced perturbations of balance during hands-free pedaling on a bicycle-simulator system, in combination with cognitive dual-tasks. The control group receives 24 pedaling sessions over 12-weeks by the same bicycle-simulator system under the same cognitive dual-tasks, but without balance perturbations. Participants' reactive and proactive balance functions and gait function are assessed before and after the 12-week intervention period (e.g., balance reactive responses and strategies, voluntary step execution test, postural stability in upright standing, Berg Balance Test, Six-meter walk test, as well as late life function and fear of falling questionnaires).

Discussion: This research addresses two key issues in relation to balance re-training: (1) generalization of balance skills acquired through exposure to postural perturbations in a sitting position investigating the ability of pre-frail older adults to improve reactive and proactive balance responses in standing and walking, and (2) the individualization of perturbation training to older adults' neuromotor capacities in order to optimize training responses and their applicability to real-life challenges.

Clinical Trial Registration:www.clinicaltrials.gov, NCT03636672 / BARZI0104; Registered: July 22, 2018; Enrolment of the first participant March: 1, 2019. See Supplementary File.

Current Perspectives on the Assessment and Management of Gait Disorders in Parkinson's Disease

Gait dysfunction is a key defining feature of Parkinson's disease (PD), and is associated with symptoms of freezing and an increased risk of falls. In this narrative review, we cover the putative mechanisms of gait dysfunction in PD, the assessment of gait abnormalities, and the management of symptoms caused by the inherent difficulty in walking. Our understanding of the causes of gait problems in PD has progressed in recent times, moving from neurocognitive theory to correlates of affected neuronal pathways. In particular, this can be shown to correspond with abnormalities in responses to dual-task paradigms and dysfunction in cholinergic signaling. Great progress has been made in the sophistication and precision of gait assessment; however, it has firmly remained in the research domain. There is significant momentum behind wearable technologies that can be used by patients in their own environment, acting as digital biomarkers that can not only reflect progression but also independently discriminate PD from non-PD individuals. The treatment of gait dysfunction has historically relied on physical therapies and training combined with a view to mitigating the impact of such consequences as falls. Pharmacological therapies that are the mainstay of treatment in PD have tended to address symptoms like bradykinesia; however, optimization of dopaminergic therapies likely has a positive effect on quality of gait. Other targets have been assessed with the goal of improving gait, of which medications that improve cholinergic signaling appear most promising. Neuromodulation techniques are increasingly used in the form of deep-brain stimulation; however, standard targets, such as the globus pallidus interna, have a modest effect on gait. Considerable benefit has been seen through targeting the pedunculopontine nucleus, and a dual-target approach may be warranted. Stimulation of the spinal cord and brain through direct or magnetic approaches has been assessed, but requires further evidence.

PasoDoble, a Proposed Dance/Music for People With Parkinson's Disease and Their Caregivers

Managing the heterogeneity of Parkinson's disease symptoms and its progressive nature demands strategies targeting the hallmark disrupted neurotransmission but also the comorbid derangements and bolstering neuroprotection and regeneration. Strong efforts are done to find disease-modifying strategies, since slowing disease progression is not enough to hamper its burden and some motor symptoms are resistant to dopamine-replacement therapy. The inclusion of non-pharmacological strategies can provide such a multitarget umbrella approach. The silent long-term biological process that precedes the clinical onset of disease is a challenge but also an opportunity to reinforce healthy lifestyle known to exert preventive/therapeutic effects. These non-pharmacological strategies are foreseen as able to reduce the prevalence and the global impact of long-term diseases demanding strong management of patient-caregiver quality of life. In this regard, European guidelines for Parkinson's disease recommend physical-related activities such as aerobic exercise and dancing known to improve functional mobility and balance in patients. Here, we propose “PasoDoble,” a novel dance/music patient-caregiver intervention with additional preventive value. The rationale is founded on evidence-based therapeutic benefits of dance/music therapy and the singular features of this widely extended Hispanic dance/music targeting motor symptoms, mood/cognition, and socialization: (i) As a dance, an easy and simple double-step pattern (back-and-forward and lateral movements) that evolves from a spontaneous individual dance to a partnered dancing, performed in social groups and involving dancing-figures of increasing complexity; (ii) “PasoDoble,” as a music that can be sung, has musical rhythmicity with high groove and familiarity that will help to synchronize the steps to the rhythm of music; (iii) Widely extended (Spain, Mexico, Puerto Rico, Colombia, and USA) and easy-to-learn for others. As a regular dancing “PasoDoble” can improve and preserve function, mood and socialization, as an intervention the method is structured to improve gait and balance; facilitate movement, reaching and grasping; muscle power and joint mobility; reduce of risk of falls, and increase of aerobic capacity. Finally, this easy-to-implement into patient care and free-living environments (elderly social centers, home care) rehabilitation programs can promote positive emotions and self-esteem, with added general improvement of social attachment and recognition, thus improving the quality of life of patient-caregiver.

The efficacy of cognitive-cycling dual-task training in patients with early-stage Parkinson's disease: A pilot study

BACKGROUND

Recent studies have suggested that cognitive-motor dual-task (DT) training might improve gait performance, locomotion automaticity, balance, and cognition in patients with Parkinson's disease (PD).

OBJECTIVE

We aimed to investigate the efficacy of cognitive-cycling DT training in patients with early-stage PD.

METHODS

Participants were scheduled to perform cognitive tasks simultaneously with the cycling training twice per week for eight weeks for a total of 16 sessions during their on-states. Clinical assessments were conducted using the unified Parkinson's disease rating scale (UPDRS), modified Hoehn and Yahr stage, Timed Up and Go (TUG) test, gait and cognitive performances under dual-task paradigm, the new freezing of gait questionnaire, Schwab and England Activities of Daily Living scale, 39-item Parkinson's disease questionnaire, and cognitive performance.

RESULTS

Thirteen eligible patients were enrolled in the study. The mean age was 60.64±5.32 years, and the mean disease duration was 7.02±3.23 years. Twelve PD patients completed 16 serial cognitive-cycling sessions for two months. After 16 sessions of training (T2), the UPDRS III scores improved significantly in both the off- and on-states, and TUG were significantly less than those at pretraining (T0). During both the single-task and the DT situations, gait performance and spatial memory cognitive performance significantly improved from T0 to T2.

CONCLUSION

The present study demonstrated that cognitive-cycling DT training improves the motor functions, gait and cognitive performances of PD patients.

Effectiveness of 6-Week Nordic Walking Training on Functional Performance, Gait Quality, and Quality of Life in Parkinson's Disease

Background and objectives: Motor rehabilitation improves physical mobility and quality of life in Parkinson’s disease (PD). As specialized rehabilitation is expensive and resource-consuming, there is a need for simpler, cost-effective methods. The purpose of the study was to determine whether Nordic Walking (NW) training may support the management of motor disability in PD. Materials and Methods: Forty patients (median age 64.0 years, range 50–75 years) with idiopathic PD, Hoehn and Yahr stages II–III, were randomly assigned to NW or standard rehabilitation (SR) programs, comprising twelve rehabilitation sessions conducted bi-weekly throughout the 6-week study period. Results: Median Unified Parkinson’s Disease Rating Scale part III scores were significantly reduced with NW, by 8.5, and with SR, by 6.0 points (both p < 0.001), with significantly greater improvement with NW than with SR (p = 0.047). Gait quality and balance control, measured using the Dynamic Gait Index, improved with NW by a median of 8.0 and with SR by 5.5 points (both p < 0.001), with slightly greater improvement with NW, compared to the SR group (p = 0.064). Quality of life, assessed using the Parkinson’s Disease Questionnaire (PDQ-39), improved with NW by a median of 15 and with SR by 12 points, p = 0.001 and p = 0.008, respectively. Conclusions: The 6-week Nordic Walking program improves functional performance, quality of gait, and quality of life in patients with PD and has comparable effectiveness to standard rehabilitation.

Rehabilitation of older people with Parkinson's disease: an innovative protocol for RCT study to evaluate the potential of robotic-based technologies

Background

Parkinson’s disease is one of the most frequent causes of disability among the older adults. It is a chronic-progressive neuro-degenerative disease, characterized by several motor disorders. Balance disorders are a symptom that involves the body axis and do not respond to dopaminergic therapy used in Parkinson’s disease. Therefore, physiotherapy becomes an important intervention for the management of motor disorders. Originally, these rehabilitative approaches were based on empirical experiences, but several scientific evidences suggests that neuronal plasticity is exercise-dependent. In this context, robotic rehabilitation plays an important role because it allows to perform task-oriented exercises and to increase the number of repetitions and their intensity. This protocol study aims to evaluate the effectiveness of robotic-based intervention of the older adults with Parkinson’s disease, designed to improve the gait and to reduce the risk of falling.

Methods

This study is a single-blinded randomized controlled trial. The primary outcomes are: risk of falling, gait performance and fear of falling measured through Performance-Oriented Mobility Assessment (POMA), instrumental gait analysis and Short Falls Efficacy Scale – International (FES-I), respectively. One hundred ninety-five patients with PD will be recruited and randomly divided into three groups, to receive a traditional rehabilitation program or a robotic rehabilitation using Tymo system or Walker View in addition to the traditional therapy. Assessments will be performed at baseline, at the end of treatment and 6 months, 1 year and 2 years from the end of the treatment. A 10-treatment session will be conducted, divided into 2 training sessions per week, for 5 weeks. The control group will perform traditional therapy sessions lasting 50 min. The technological intervention group will carry out 30 min of traditional therapy and 20 min of treatment with a robotic system.

Discussion

The final goals of the present study are to propose a new approach in the PD rehabilitation, focused on the use of robotic device, and to check the results not only at the end of the treatment but also in the long term.

Trial registration

NCT04087031, registration date September 12, 2019.

Impact of Exercise Intervention in Parkinson's Disease can be Quantified Using Inertial Sensor Data and Clinical Tests

Parkinson's Disease (PD) has the second-highest prevalence rate of all neurodegenerative disorders. It effects approximately 1% of the population over the age of 60, with this proportion rising further, in more elderly cohorts. PD manifests as several motor and non-motor disfunctions, which develop progressively over time. Gait and mobility problems are amongst the most debilitating symptoms for people with PD. They severely affect a person's ability to carry out daily activities of living and can lead to a decreased quality of life. However, recent research has shown exercise intervention to be effective in improving gait, and overall functional mobility, in persons with PD. In this paper, we study the effect of an exercise intervention, comprised of three separate methods of exercise - all which have been shown previously to be effective individually - on a cohort with early-to-moderate stage PD. We also examine the ability of the Timed Up and Go (TUG) test - instrumented with inertial sensors (QTUG) - and the Unified Parkinson's Disease Rating Scale (UPDRS) Part III in measuring the response to the exercise intervention. We found that TUG time and the QTUG-derived frailty index - along with many additional parameters derived from QTUG - showed a significant change between baseline and post-intervention, while the UPDRS Part III score did not. The direction of the changes in the QTUG parameters also align with the expected exercise effect from the literature. Our results suggest QTUG may be a more sensitive measure than UPDRS Part III for assessing the effect of exercise intervention on functional mobility in people with early-to-moderate stage PD.

Non-Motor Symptoms after One Week of High Cadence Cycling in Parkinson's Disease

The objective was to investigate if high cadence cycling altered non-motor cognition and depression symptoms in individuals with Parkinson's disease (PD) and whether exercise responses were influenced by brain-derived neurotrophic factor (BDNF) Val66Met polymorphism. Individuals with idiopathic PD who were ≥50 years old and free of surgical procedures for PD were recruited. Participants were assigned to either a cycling (n = 20) or control (n = 15) group. The cycling group completed three sessions of high cadence cycling on a custom motorized stationary ergometer. The primary outcome was cognition (attention, executive function, and emotion recognition were assessed via WebNeuro® and global cognition via Montreal Cognitive Assessment). Depression symptoms were assessed via Beck Depression Inventory-II. There was a main effect of time for emotional recognition (p = 0.048), but there were no other changes in cognition or depression symptoms. Regardless of intervention or Val66Met polymorphism, high cadence cycling does not alter cognition or depression symptoms after three sessions in one week.

A 12-Week Cycling Training Regimen Improves Upper Limb Functions in People With Parkinson's Disease

Background: It has been proposed that physical exercise can help improve upper limb functions in Parkinson’s disease (PD) patients; yet evidence for this hypothesis is limited.

Objective: To assess the effects of aerobic exercise training (AET) on general upper limb functions in sedentary people with PD and healthy adults (HA).

Methods: Two groups, 19 PD patients (Hoehn & Yahr ≤ 2) and 20 HA, matched on age and sedentary level, followed a 3-month stationary bicycle AET regimen. We used the kinematic theory framework to characterize and quantify the different motor control commands involved in performing simple upper-limb movements as drawing lines. Repeated measures ANCOVA models were used to assess the effect of AET in each group, as well as the difference between groups following the training regimen.

Results: At baseline, PD individuals had a larger antagonist response, a longer elapsed time between the visual stimulus and the end of the movement, and a longer time of displacement of the stylus than the HA. Following the 12-week AET, PD participants showed significant decreases of the agonist and antagonist commands, as well as the antagonist response spread. A significant group ^∗ session interaction effect was observed for the agonist command and the response spread of the antagonist command, suggesting a significant change for these two parameters only in PD patients following the AET. Among the differences observed at baseline, only the difference for the time of movement remained after AET.

Conclusion: A 3-month AET has a significant positive impact on the capacity to draw lines in a more efficiency way, in PD patients, indicating an improvement in the upper limb motor function.

Daily Bicycling in Older Adults May be Effective to Reduce Fall Risks-A Case-Control Study

Older adults gain many health benefits from riding bicycles regularly. We aimed to explore whether older persons who ride bicycles regularly have better balance than controls. Balance control and voluntary stepping were assessed in 20 older adults aged 65-85 years who live in an agricultural community village and who ride bicycles regularly, and 30 age- and gender-matched nonbicycle riders (NBR). Self-reported function and fear of fall were also assessed. Bicycle riders (BR) showed significantly better balance, faster voluntary stepping, and better self-reported advanced lower-extremity function compared with NBR. The results might suggest that bicycling regularly preserves balance control and speed of voluntary stepping in older adults because bicycling might maintain specific balance coordination patterns. The results should be treated with caution as bicycle riders were older adults who selected an active lifestyle (i.e., bicycling as well as living in an agricultural village) that may bias the results.

An 8-Week Low-Intensity Progressive Cycling Training Improves Motor Functions in Patients with Early-Stage Parkinson's Disease

BACKGROUND AND PURPOSE

The effects of high-intensity cycling as an adjuvant therapy for early-stage Parkinson's disease (PD) were highlighted recently. However, patients experience difficulties in maintaining these cycling training programs. The present study investigated the efficacy of cycling at a mild-to-moderate intensity in early-stage PD.

METHODS

Thirteen PD patients were enrolled for 16 serial cycling sessions over a 2-month period. Motor function was assessed using the Unified Parkinson's Disease Rating Scale part III (UPDRS III) and Timed Up and Go (TUG) test as primary outcomes. The Montreal Cognitive Assessment (MoCA), modified Hoehn and Yahr Stage (mHYS), total UPDRS, Falls Efficacy Scale, New Freezing of Gait Questionnaire, Schwab and England Activities of Daily Living, 39-item Parkinson's Disease Questionnaire, Patient Global Impression of Change, and gait performance were assessed as secondary outcomes.

RESULTS

The age and the age at onset were 59.67±7.24 and 53.23±10.26 years (mean±SD), respectively. The cycling cadence was 53.27±8.92 revolutions per minute. The UPDRS III score improved significantly after 8 training sessions (p=0.011) and 16 training sessions (T2) (p=0.001) in the off-state, and at T2 (p=0.004) in the on-state compared to pretraining (T0). The TUG duration was significantly shorter at T2 than at T0 (p<0.05). The findings of MoCA, total UPDRS, double limb support time, and mHYS (in both the off- and on-states) also improved significantly at T2.

CONCLUSIONS

Our pioneer study has demonstrated that a low-intensity progressive cycling exercise can improve motor function in PD, especially akinesia. The beneficial effects were similar to those of high-intensity rehabilitation programs.

Mild Cognitive Impairment in Parkinson's Disease-What Is It?

PURPOSE OF REVIEW

Mild cognitive impairment is a common feature of Parkinson's disease, even at the earliest disease stages, but there is variation in the nature and severity of cognitive involvement and in the risk of conversion to Parkinson's disease dementia. This review aims to summarise current understanding of mild cognitive impairment in Parkinson's disease. We consider the presentation, rate of conversion to dementia, underlying pathophysiology and potential biomarkers of mild cognitive impairment in Parkinson's disease. Finally, we discuss challenges and controversies of mild cognitive impairment in Parkinson's disease.

RECENT FINDINGS

Large-scale longitudinal studies have shown that cognitive involvement is important and common in Parkinson's disease and can present early in the disease course. Recent criteria for mild cognitive impairment in Parkinson's provide the basis for further study of cognitive decline and for the progression of different cognitive phenotypes and risk of conversion to dementia. Improved understanding of the underlying pathology and progression of cognitive change are likely to lead to opportunities for early intervention for this important aspect of Parkinson's disease.

Engaging Undergraduate Kinesiology Students in Clinically-Based Research

Many undergraduate students in kinesiology are interested in clinical careers and seek research opportunities for advanced study and unique learning experiences. This paper describes a process of engaging undergraduate students in a multi-disciplinary, NIH-funded Program Project investigating factors that may affect pelvic floor support and symptoms in primiparous women during the first year postpartum. Students complete general and protocol-specific training prior to engagement, have specific tasks that reinforce skill development and require independence, and are invited to participate in additional opportunities with the investigative team. The topic of pelvic floor health is novel to most students and participation in this research expands their knowledge beyond a mainstream kinesiology curriculum. Institutionalizing this type of program could formalize undergraduate student research experiences and facilitate ongoing clinical research efforts with a kinesiology focus.

Treadmill Exercise Improves Motor Dysfunction and Hyperactivity of the Corticostriatal Glutamatergic Pathway in Rats with 6-OHDA-Induced Parkinson's Disease

Hyperactivity in the corticostriatal glutamatergic pathway (CGP) induces basal ganglia dysfunction, contributing to parkinsonian syndrome (PS). Physical exercise can improve PS. However, the effect of exercise on the CGP, and whether this pathway is involved in the improvement of PS, remains unclear. Parkinson's disease (PD) was induced in rats by 6-hydroxydopamine injection into the right medial forebrain bundle. Motor function was assessed using the cylinder test. Striatal neuron (SN) spontaneous and evoked firing activity was recorded, and the expression levels of Cav1.3 and CaMKII in the striatum were measured after 4 weeks of treadmill exercise. The motor function in PD rats was improved by treadmill exercise. SN showed significantly enhanced excitability, and treadmill exercise reduced SN excitability in PD rats. In addition, firing activity was evoked in SNs by stimulation of the primary motor cortex, and SNs exhibited significantly decreased stimulus threshold, increased firing rates, and reduced latency. The expression of Cav1.3 and p-CaMKII (Thr286) in the striatum were enhanced in PD rats. However, these effects were reversed by treadmill exercise. These findings suggest that treadmill exercise inhibits CGP hyperactivity in PD rats, which may be related to improvement of PS.