Exercise as it relates to Disease/Home-based treadmill training as a safe form of exercise for individuals with Parkinson’s disease

Topic article
Home-based treadmill training for individuals with Parkinson’s disease: a randomised controlled pilot trial by Canning, Allen, Dean, Goh & Fun [1]

What is the background to this research?
Parkinson's disease is a degenerative disorder of the central nervous system[2]. It involves four primary characteristics: a resting tremor, slowness of movement (known as bradykinesia), stiffness (rigidity) and postural instability[3]. While there is currently no cure for Parkinson's disease, there are ways in which its symptoms can be managed to maintain quality of life for the individual. These strategies include:
 * Drug treatments
 * Surgical intervention
 * Complementary therapies e.g. tai chi, pilates, massage therapy
 * Specific symptom management
 * Multidisciplinary support[4].

Where is the research from?
This research was funded by a University of Sydney Research and Development grant, and conducted with the support of the Westmead Hospital (Sydney, Australia)[1]. The study was headed by Professor Colleen Canning, an international expert in the development and trialling of methods for reducing disability and falls in people with Parkinson’s disease[1,5].

What kind of research was it?
The authors conducted an assessor-blinded, prospective, randomised controlled pilot trial, meaning: All twenty participants were recruited through advertising in the Parkinson's New South Wales newsletter and from clinics at the Westmead Hospital[1]. The level of evidence in this trial was not as great as the authors had intended; the recruitment target was 140 participants, but the trial was discontinued due to a lack of funding, after only twenty participants had completed the trial process[1].
 * This study was the first to follow the development of Parkinson's disease in relation to home-based treadmill training, as well as the associated risks and benefits, over an extended period of time.
 * The participants were randomly allocated into either of the treatment groups by a staff member not involved in the study to minimise the possibility selection bias[1].
 * The assessors were not aware of the intervention that each participant had received when conducting assessments throughout the trial[1].

What did the research involve?
There were limitations to the amount of data the researchers were able to collect as a result of the low number of participants that were able to partake in the trial due to funding restrictions[1]. Being a pilot trial, inclusion and exclusion criteria were particularly restrictive for participant safety, which also limited data collection[1].
 * Twenty participants with mild Parkinson's disease, aged between thirty and eighty years.
 * A semi-supervised training program that involved walking on a treadmill for 20–40 minutes, four times a week, for six weeks[1].
 * Sessions included a five minute warm-up and cool down, as well as sit-to-stand exercises and stretching[1].
 * The walking intensity began at 50% of the individual’s average speed maintained during their pre-trial six minute walk test, increasing gradually to 80% over subsequent sessions[1].
 * Measurements were taken before the commencement of training, after six week of training and six weeks post[1].

What were the basic results?
In regards to the feasibility of a home-based treadmill training program for individuals with Parkinson’s disease:
 * No adverse events associated with the treadmill training were reported.
 * Of the eight treadmill training participants, the average percentage of sessions completed was 94%, with four of the eight completing 100% of their prescribed sessions[1].

In regards to the possible effects of treadmill training specifically:
 * The treadmill training group did not improve their walking capacity or speed.
 * The participants walking distance increased from an average of 1.05 km to 2.12 km.
 * The only difference at follow-up between the two experimental groups was rating of quality of life[1].

How did the researchers interpret the results?
The authors accepted that this pilot study has limited “generalisability” due to the strict inclusion and exclusion criteria and the limited number of participants[1]. They stated that while treadmill training is deemed feasible and sustainable for individuals with Parkinson’s disease, further investigation is warranted[1].
 * No meaningful improvement in walking capacity, walking speed or consistency may be as a result of insufficient training intensity, to ensure participant safety at home[1]
 * There were no reported falls recorded during this study, indicating the training was conducted safely. The researchers also contributed this to the fact that this study involved only mild Parkinson’s disease sufferers, who trained at only conservative speeds and were required to hold the treadmill handrail with at least one hand at all times[1].
 * The increased quality of life rating at follow-up may be due to self-reported increases in the amount of walking completed by the participants in the follow-up period[1].

What conclusions can we take from this research?
The only difference at follow-up between the two experimental groups was rating of quality of life. As there is no current cure, the main aim of treatment is to reduce the negative impact that the disease has on an individual's daily functioning[6]. Therefore, this quality of life rating is considered to be a meaningful evaluation of the effectiveness of a treatment[6]. Another pilot study showed that the use of a smartphone application with home-based treadmill training also helped individuals with Parkinson’s disease maintain their quality of life[7]. Such technology could aid the implementation of home-based training, with ongoing feedback and training support readily available.

What are the implications of this research?
The authors highlight the fact that ongoing treatment for individuals with Parkinson’s disease is labour-intensive for the health professionals involved and often inflexible in the timing and location, often making participation challenging for affected individuals[1]. If individuals can safely complete unsupervised or semi-supervised home-based training, it could not only reduce pressure on the health-care system, but allow for more flexible and accessible training, potentially leading to higher adherence rates and better outcomes. Further research into the possibility of greater training intensity may also allow for improvement in walking performance, such as speed and distance, that allow individuals with Parkinson’s disease to maintain a higher quality of daily functioning.

Practical considerations
The most significant consideration that must be made before commencing a home-based training program is the need for a comprehensive screening before and constant monitoring during the program to ensure participant safety[1]. It is recommended that individuals seek guidance from the appropriate health professional(s) to ensure the program is appropriate and safe in regards to the individual's disease severity. Additionally, a tailored program allows for the maximisation of potential results, while ensuring training will not be result in any detrimental effects to the everyday functioning of the individual.

Further information
Parkinson's Australia

Website: http://www.parkinsons.org.au/

Free Call: 1800 644 189

Shake It Up Australia

Funding research to find a cure for Parkinson's disease

Website: https://shakeitup.org.au/

Reference List
[1] Canning, C.G., Allen, N.E., Dean, C.M., Goh, C. & Fun V.S.C. (2012). Home-based treadmill training for individuals with Parkinson’s disease: a randomised controlled pilot trial, Clinical Rehabilitation, 26(9), pp. 818–826

[2] National Institute of Neurological Disorders and Stroke, (2016). NINDS Parkinson's Disease Information Page [online]. Available at: http://www.ninds.nih.gov/disorders/parkinsons_disease/parkinsons_disease.htm

[3] Parkinson's Disease Foundation, (2016). Primary Motor Symptoms. [online] Available at: http://www.pdf.org/symptoms_primary

[4] Parkinson's Australia (2015). Symptom management. [online] Available at: http://www.parkinsons.org.au/symptom-management

[5] University of Sydney (2013). Professor Colleen Canning. [online] Available at: http://sydney.edu.au/health-sciences/about/people/profiles/colleen.canning.php

[6] Opara, J.A., Brola, W., Leonardi, M. & Blaszczyk, B. (2012). Quality of Life in Parkinson's Disease. Journal of Medicine and Life, 5(4), pp. 375–381

[7] Ginis, P., Nieuwboer, A., Dorfman, M., Ferrari, A., Gazit, E., Canning, C., Rocchi, L., Chiari, L., Hausdorff, J., Mirelman, A. (2015). Feasibility and effects of home-based smartphone-delivered automated feedback training for gait in people with Parkinson's disease: A pilot randomized controlled trial. Parkinsonism and Related Disorders, 22, pp. 28–34.