Aquatic exercise and it's role in the treatment of Parkinson's Disease

What is the background to this research?
Parkinson’s Disease (PD) is a chronic, progressive neurodegenerative disorder that increases in prevalence with age (1). PD is characterized by a variety of different features including impairments in movement and freezing of gait (2). Gait abnormalities make PD sufferers more susceptible to falls, with greater than 60% of these patients reporting 1 or more falls in the past 12 months (3). Falls in the older PD population impact greatly on their health-related quality of life often resulting in physical injuries and loss of independence (4). Traditional therapies for PD centre on early intervention and include: gait retraining (5), strengthening (6), tai chi (7), dancing (8) and walking programs. Aquatic exercise, or hydrotherapy, is a recent addition to the treatment programs for PD with promising evidence from early pilot studies (9, 10, 11). This particular study aims to add to the evidence around the use of aquatic exercise in a PD population.

Where is the research from?
The research was lead by Louise Carroll from the St. Gabriel’s Centre, Ireland and her colleagues: Daniele Volpe, Meg Morris, Jean Saunders and Amanda Clifford. All volunteers were from the Munster Region in Ireland and treatments were carried out in a local hydrotherapy pool. The study was published in the Physical and Medical Rehabilitation Journal in the year 2016.

What kind of research was this?
A randomised control trial of 21 participants, mean age 71.49 ± 4.9, selected via convenience sampling with diagnosed idiopathic PD were selected to take part.

What did the research involve?
The participants in this study were randomly assigned into two groups. The experimental group (n=11) attended a 45-min aquatic exercise group twice a week for 6 weeks, whilst the control group (n=10) received their usual care. The primary outcome was gait variability measured by motion capture technology. The secondary outcomes were quality of life measured via the Parkinson’s Disease Questionnaire-39, freezing of gait questionnaire and the Unified Parkinson’s Disease Rating Scale (UPDRS) to determine motor disability. Baseline measures were collected one week prior to the intervention period and re-done following the 6-week trial. An exit survey was also included to determine feasibility including adverse events, participant enjoyment and attendance rates.

What were the basic results?
Nil differences in gait variability, quality of life or the freezing of gait were detected between the experimental or control groups at follow up. There was, however, a moderate clinically important difference in motor disability in the aquatic therapy group as shown by the UPDRS. Alongside the physical measures examined in this study, the authors also investigated the feasibility of aquatic based exercises via an exit questionnaire. There were no adverse events, extreme events or exacerbations associated with aquatic exercise. The participants found the program to be enjoyable, yet challenging with 90% indicating they have a strong interest in continuing the classes. Moreover, 70% of the participants reported a subjective improvement in their walking and most indicated the exercises had purpose and were beneficial.

What conclusions can we take from this research?
Aquatic based physiotherapy for patients with PD may be a viable option for patients where land based activities may be too difficult. This is due to the increased resistance to movement and increased buoyancy forces, which decrease body weight when walking in water. Furthermore, the strong interest in continuing the classes and enjoyment reported by the participants may increase compliance to therapy in the future. As PD patients have poor motor control and are more likely to fall, exercises in water with sufficient supervision may provide a safe environment to challenge patient’s movement and balance.

There were several limitations to be considered in this study. The small sample size of only 21 may make it more difficult to detect significant changes in gait variability and other measures. Another limitation is the individual variation in medication times and doses. PD is very time sensitive when it comes to medications as different patients can have different times of high functioning (on period) and low functioning (off period) (11). Given the structure and timing of these classes and tests, it may be difficult to ensure patients are tested during times of high functioning.

Practical advice
This research is part of a growing area of research in PD treatment and at this time requires further investigation to determine aquatics exercise true effect. Based on current this research, it may be reasonable to say that aquatic exercise is at least equivalent to traditional treatment for PD (3,9, 10,11). However, further large-scale research comparing water based and land based interventions is needed. To combat difficulties of limited PD patients in one area, research can be widened to include many cities or countries provided the same protocol is followed. Furthermore, synthesis and review of current literature will provide a more substantial evidence base to draw conclusions on aqua therapy’s effectiveness.

When selecting land based or water based interventions, patient personal preference should weigh heavily on the decision as this may increase compliance in exercise. Aquatic intervention may also serve as an appropriate adjunct to land based therapies, used to break up treatment programs without detrimental effect (11). Aquatic therapies may also be useful for PD sufferers that are unable to engage in land based treatments for any reason but can complete aquatic exercise, as it is a safe and practical alternative.