Exercise as it relates to Disease/Effectiveness of Tai Chi on non motor symptoms of Parkinson's disease

This critique is of the research article: Zhu, M., Zhang, Y., Pan, J., Fu, C., & Wang, Y. (2020). Effect of simplified Tai Chi exercise on relieving symptoms of patients with mild to moderate Parkinson's disease. The journal of sports medicine and physical fitness, vol 60(2), pp 282-288.

What is the background to this research?
Parkinson Disease (PD) is a chronic neurodegenerative disease, which is influenced by both genetics and environmental factors. Typical treatment involves Dopaminergic medication. Familial PD accounts for 5-15% in Europe, and worldwide 10 million are thought to be affected by the disease. Numerous studies have indicated the genes involved such as PINK 1, PARK 2, and PARK 7 which are typically inherited and passed from both parents, increasing your risk of the disease. In Australia 1 in every 308 people live with PD, with 37 newly diagnosed every day, 18% of which are still of working age. 20% of sufferers are under 50 and 10% are diagnosed before the age of 40, and the financial cost of this disease has increased by 103% since 2005.

Tai Chi, a traditional Chinese exercise dating back to the Ming dynasty, is derived from martial arts. Emphasis is on exercising the consciousness, with movements continuous from beginning to end in an integrated circular motion with variations of strength and softness, becoming focused on the body's internal homeostasis with the benefits acting upon the Kinesiology, physiology, and psychology of the body

Where is the research from?
This research was conducted at the Neurology and Rehabilitation Dept. of the Hangzhou Hospital, China. The research was completed by a number of doctors specialising in Neuroscience and the rehabilitation of neurological conditions. One such doctor is Dr. Mingjing Zhu, division of Cognitive and Developmental Psychology at the Chinese Academy of sciences, he drafted the paper and conducted the analysis and interpretation of data.

This study was funded by a grant, from the Project of the Science Technology Dept. of Zhejiang province China and was first published in the October of 2019.

What kind of research was it?
This paper was a randomized control study, with self-reported questionnaires. All participants had a clinical diagnosis of PD and not suffering any severe cognitive impairments, and all were measured using the Unified Parkinson Disease Rating Scale (UPDRS).

What did the research involve?
41 participants into two groups, a control group (22 participants) that conducted their normal exercise routine, which consisted of cycling, walking, and resistance exercises. The remaining group, the Tai Chi group (19 participants), were taught Tai Chi movements, 9 moves in total, as these particular movements were thought to be easier to learn and required repeated bilateral transfer of body weight through each movement. All participants conducted exercises at the rehabilitation hospital, 5 days a week for 12 weeks.

Before any exercise was undertaken the following questionnaires were completed prior to commencing, and upon completion after the 12-week program.


 * Unified Parkinson Disease Rating Scale (UPDRS) part III, a widely used reliable scale of motor skills.
 * The Berg Balance Scale (BBS), a common test for assessing balance impairments which has a highly reliable form of testing in relation to PD.
 * Hamilton Depression scale (HAMD) and Hamilton Anxiety scale (HAMA).
 * The participants also underwent the Montreal Cognitive Assessment (MoCA) as PD patients have a higher risk of developing dementia.
 * Also completed was the Parkinson Disease Sleep Scale (PDSS).
 * A Parkinson Disease Questionnaire 39 (PDQ-39), to assess the quality of life in the PD patients participating.

Whilst many studies have been conducted into the effects of physical activity on PD, and the benefits of aerobic exercise none have conclusively named or agreed upon one form of exercise for non-motor symptoms of PD. Limitations to this study; no follow-ups were done on patients, post the 12 weeks. Did all participants understand the questionnaires, the educational background of the participants could have disadvantaged their understanding of the questions.

What were the basic results?
What the study did show was a significant measurable improvement in cognitive function and sleep quality relating to the Tai Chi group. Both of which have a significant effect on the quality of life in PD patients as a non-motor symptom of PD. Whilst this study did show some improvement to motor control, balance, depressive state, and quality of life, none of these can be attributed to Tai Chi alone. The number of participants in this study was too little. Also the reliability of the results are questionable, the Tai Chi group undertook their normal exercise classes, 2 days of the week also.

What conclusion can we take from the research?
We can gain some insight into the benefits of exercise and Tai Chi as a form of treatment for Parkinsons Disease from this study. The findings of this study did show improvements in most areas, but again not all can be attributed to Tai Chi alone. Further longitudinal studies are needed in the area of non-motor symptoms and with a much larger number of participants, as non-motor symptoms can be just as debilitating as motor function disability.

Provide own insights
From previous studies, Tai Chi as a form of exercise treatment for PD has shown statistically significant reductions in balance impairments, thus improving functional capacity and continued improvement three months post-study. It is my assessment that the findings of improved cognitive function and sleep quality in the Tai Chi group may have something to do with the level of cognitive concentration required to perform Tai Chi, this then provides higher cognitive stimulation.

Parkinson's Disease is a growing neurological condition and is only second in prevalence to dementia, and more prevalent than some cancers. It is estimated 6.1 million people worldwide were diagnosed with PD in 2016 and this number is expected to double by 2030. In Australia 38 people are diagnosed with PD every day, 20% of these are under 50 years old and 10% are under 40 years old.

Practical advise
When it comes to any new diagnosis, knowledge is power. The more we know and understand how this condition works, the better we can learn how to treat it; dopaminergic medication only works for so long before becoming ineffective. PD has long been associated as an "old person's disease", this is not the case. Young-onset Parkinsons Disease refers to people under the age of 50.

Getting diagnosed at a young age is not as common, as the symptoms can be passed off as muscle strain, soreness from occupation, or sports injury. The commonly known symptoms associated with the disease such as tremors and uncontrolled gait, don't show until later in the disease progression. Every person will show different symptoms, non-motor symptoms can pre-date any gait or tremor issues by up to 10 years.

In 2014 an estimated 8461 people with PD were living in aged care facilities, and 201 of these were under 65 years old. Finding treatments and interventions that are more cost-effective for the community, such as exercise treatment, may help to prolong the quality of life and delay the use of dopaminergic medication, whilst also lowering the burden of cost to families and society.

Further information/Resources
For further information, and or help, here are some useful sites and readings;

www.shakeitup.org.au A useful organisation associated with the Michael J Fox foundation.

www.parkinsonsact.org.au This site is a resource of information for Parkinsons and has links to the young onset parkinsons exchange, which is a group of people diagnosed with young onset Parkinsons disease and are a wealth of information and resources.

Zhou, J. et al. (2015) ‘A Meta-Analysis on the Efficacy of Tai Chi in Patients with Parkinson's Disease between 2008 and 2014. Evidence-based complementary and alternative medicine.

Irwin, M. et al. (2014). Cognitive behavioral therapy vs. Tai Chi for late life insomnia and inflammatory risk: a randomized controlled comparative efficacy trial. Sleep, vol37(9).