Exercise as it relates to Disease/The effects of different exercise programs on Parkinson's disease patients

This is an analysis on the article "Comparison of strength training, aerobic training, and additional physical therapy as supplementary treatments for Parkinson's disease: Pilot Study" by Alessandro Carvalho et al., 2015.

What is the background to this research?
Parkinson's disease (PD) is a neurodegenerative disease second to Alzheimer's. PD prevalence increases with age, with 1% of population over the age of 60 affected by PD. The cause is still unknown however many believe it is due to a combination of genetic, environmental and lifestyle factors.

Motor symptoms Due to the functional disability, daily tasks becomes difficult resulting to loss of independence and reduced standard of living. This generates socioeconomic disparity and occupational impairments. Generally PD is treated using pharmacological and surgical methods, however this is not always beneficial.
 * Tremor
 * Bradykinesia (slowness of the movement)
 * Rigidity
 * Gait disorder
 * Postural instability

There has been growing support in using physical activity as a treatment for PD patients. Currently there is no specific exercise program designed for PD. This study investigates the different exercise programs that will produce the most effective result in treating motor symptoms in a controlled environment.

Where is the research from?
The patients were from an outpatient rehabilitation department at the Federal university of Rio de Janeiro, Brazil. The study was conducted at this university.

What kind of research was this?
This is a prospective longitudinal, randomised controlled trial (RCT) intervention study conducted from September 2010 to September 2012. Patients were randomised by a blinded investigator, controlled for age, motor scores in terms of UPDRS-III and stage of diseased determined by Hoehn and Yahr scale.

What did the research involve?
The study recruited 22 patients and randomised them into three exercise programs: aerobic training (AT), strength training (ST) and physiotherapy (P). Patients participated in their respective intervention twice a week for 12 weeks and were advised not to perform additional exercises.

Aerobic Training (AT)
 * 30min of treadmill walking with 5min warming up and 5min post exercise recovery period.
 * Training intensity was at 60% VO2max (maximum oxygen consumption) or 70% of Heart Rate max.
 * Speed and incline was changed to maintain intensity during the program period.

Strength Training (ST)
 * Exercises for large muscle groups using leg extension, leg curls, leg presses, chest presses and low row.
 * Two series of 8-12 maximum repetition for each exercise with 1.5min rest between sets.
 * Initial training intensity was set 70-80% of 1 repetition maximum (1RM) test. Load was adjusted to maintain 1RM.
 * Warm up: light loads
 * Cooling down: stretching

Physiotherapy (P)
 * Control group
 * Calisthenics (variety of gross motor movements) of the upper and lower limb, stretching and gait training in a 12m hall led by a physiotherapist
 * Session time: 30-40min

Main assessment for motor symptoms was the UPDRS-III. The secondary outcome studied were functional capacity using the Senior fitness test, balance (Berg balance test), walking speed (10m walk test) and electroencephalographic activity (EEG) before and after 12 weeks of intervention. Limitations

The study had a small sample size therefore the results does not accurately reflect the PD community. The intervention shows the short-term effects of exercise, a long-term intervention may provide more information. Furthermore the study excluded PD patients with several comorbidities such as cardiovascular disease which needs to be observed. Other variables the study did not address are different training intensity, combining AT and ST, analysing the hormones and trophic factors associated with PD.

What were the basic results?
PD motor symptoms were measured using UPDRS-III. The results were:
 * AT improved by 35%
 * ST improved by 27.5%
 * P improved by 2.9%.

In relation to functional capacity, ST and AT improved PD patient’s aerobic capacity. Both showed improved agility, strength in upper and lower limbs, lower limb speed, walking speed and dynamic balance. However AT showed improvements in upper limb flexibility. P showed improvements in agility and lower limb strength. Interestingly after P intervention, there were decreases in flexibility and endurance of the lower limbs.

EEG assessments showed increase in cortical activity (increase in blood flow). Exercise possibly promote structural changes in the brain and increases brain derived neurotrophic factors.

In this study AT and ST are the most beneficial and may be due to the physiological changes in response to the frequency, intensity and duration of the exercise. The study concluded that pharmacological treatment combined with AT or ST may improve symptoms in bradykinesia and rigidity.

What conclusions can we take from this research?
ST and AT provides the most benefits in treating PD motor symptoms compared to P. The findings in this study aligns with other studies. Overall any exercise is beneficial. Exercise should incorporate both ST and AT in a moderate to high intensity over a long period. PD symptoms can vary patient to patient and is likely why there is no specific exercise program for PD. Exercise programs need to be tailored for the individual addressing their symptoms as well as respecting their preferences.

Practical advice
Exercise is beneficial in treating PD motor symptoms. For PD patients undertaking exercise consider AT and ST. Supervision is advised to gradually introduce PD patients into the program as well as to prevent any accidents such as falls and to prevent over exertion. Be aware of any side effects from medications taken by PD patients that may be detriment to their health during exercise.