Parkinson’s

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Exercise can be used effectively to help individuals with Parkinson’s. Treadmill walking appears to improve walking speed and stride length and may also improve lower body function, risk of falling, fear of falling, Parkinson’s symptoms and aspects of health-related quality of life. Muscular weakness can be addressed through resistance training, which appears to be effective for increasing muscular strength, balance and some measures of physical function.

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What is Parkinson’s?

Parkinson’s is a chronic neurodegenerative condition. Untreated, it generally leads to progressive disability and reduced health-related quality of life. It is characterized by slowness of movement (also called bradykinesia), postural instability, tremors, stiffness of the limbs and trunk and reduced muscular strength. The condition is thought to arise from a chemical imbalance in the brain (in relation to dopamine), which causes a reduction in the excitatory drive of the motor cortex and therefore reduced neuromuscular performance.


What is the prevalence of Parkinson’s?

The prevalence of Parkinson’s is high and has been extensively studied by researchers in a wide variety of different populations. The crude prevalence of Parkinson’s across all age groups in various populations can be seen in the table below:

Prevalence per 100 000 Population Study
229.3 The L'Aquila district of Italy Totaro et al.
206.7 The Faroe Islands Wermuth et al.
180.3 Yonago City Japan Yamawaki et al.
175 Rural Japan Osaki et al.
156.3 Sicily Morgante et al.
146 Queensland Australia Peters et al.
143.8 American Indians and Alaskan natives Gordon et al.
139 North-East England Walker et al.
130 Cardiff Wales Wickremaratchi et al.
95.3 Thailand Bhidayasiri et al.
59 Northern Jordan Alrefai et al.
43.2 The Arab population within Israel Masalha et al.
30 Rural Tanzania Dotchin et al.

Although many estimates of crude prevalence appear to be in a similar range (i.e. 30 – 200 per 100,000), some reviewers have suggested that there is a very large variance in the estimates of some studies. Indeed, Von Campenhausen et al. observed that the prevalence rate estimates for European countries ranged from 65.6 per 100,000 in Sardinia to 12,500 per 100,000 for institutionalized patients in Germany. In general, researchers have found that urban populations display a greater prevalence of Parkinson’s than rural populations (e.g. Bhidayasiri et al.) and that there is a greater prevalence of Parkinson’s in low-income areas than in high-income areas (Lix et al.). Researchers have also observed that increases in the prevalence of Parkinson’s appear to be associated with an increasingly ageing population (Yamawaki et al.). Whether other factors are contributing to an increase in the prevalence of Parkinson’s is unclear.


What is the rationale for exercise in the treatment of Parkinson’s?

As noted above, Parkinson’s is characterized by neurodegenerative changes leading to slowness of movement (also called bradykinesia), postural instability, tremors, stiffness of the limbs and trunk and reduced muscular strength. A great many researchers have proposed different ways in which exercise could be useful for arresting or reversing some of these changes. For example, Fox et al. have suggested there are several ways in which exercise can improve neuroplasticity in patients with Parkinson’s, as synaptic activity is maximized by intense activity, greater structural adaptation is promoted by more complex movements, dopamine levels are increased by rewarding activities, which promote learning and relearning and dopaminergic neurons are highly responsive to both exercise and inactivity. Additionally, it is well known that exercise, particularly resistance training, can help increase muscular strength. Various studies have assessed the differences in muscular strength between patients with Parkinson’s and age-matched controls, in addition to the unique biomechanical characteristics of patients with Parkinson’s, as follows:

Study Description Finding
Koller and Kase The researchers reported that muscular strength was lower in patients with early-stage Parkinson's in comparison with age-matched controls They suggested that muscular weakness is therefore a primary symptom of Parkinson's disease that may arise from disturbed motor programming.
Brod et al. The researchers performed a survey of 101 individuals with Parkinson’s disease They found that an overwhelming 81% of respondents reported having difficulty performing the sit-to-stand movement when rising from a chair
Inkster et al. The researchers measured maximal concentric isokinetic knee and hip extension torque in addition to self-selected sit-to-stand speed in 10 male patients with mild Parkinson’s and 10 male age-matched controls They reported that both hip and knee extension torques were lower in the patients with mild Parkinson’s and that the greater torque deficit was at the hip. They also observed that greater hip extension torque was related to increased sit-to-stand speed in the patients with mild Parkinson’s
Pääsuke et al. The researchers assessed various aspects of lower body kinetics during leg extension movements in elderly female patients with Parkinson’s and age-matched healthy controls They reported that the patients with Parkinson’s displayed reduced maximal bilateral isometric leg-extension force, reduced maximal bilateral isometric leg-extension force relative to body mass, reduced maximal rate of force development and a significantly slower sit-to-stand speed in the patients with Parkinson’s in comparison with healthy controls
Pang et al. The researchers assessed peak isokinetic concentric and eccentric ankle dorsiflexion and plantar-flexion torque at 45 and 90 degrees/s in 59 patients with Parkinson’s and 37 age-matched controls They found that the patients with Parkinson’s displayed lower peak torque values than controls in all test conditions. However, concentric torque was reduced to a greater extent than eccentric torque, the higher angular velocity was reduced to a greater extent than the lower angular velocity and the end ranges of plantar-flexion range-of-motion were reduced to a greater extent than either dorsiflexion or mid-range.
Corcos et al. The researchers assessed maximum elbow flexor and extensor torque in 9 patients with Parkinson's They found muscular strength was correlated with changes in clinical status as measured by the Unified Parkinson's Disease Rating Scale
Stelmach and Worringham The researchers compared patients with Parkinson's with age-matched controls during an isometric force production task They found that the patients with Parkinson’s displayed a reduced rate of force development peak force and longer contraction durations.

Based on these studies, it appears that not only are Parkinson’s patients generally weaker than age-matched controls but they also display lower rates of force development, reduced strength at higher joint angular velocities, reduced strength and end ranges of joint range-of-motion, poorer sit-to-stand ability and markedly lower hip extension torque. These features might therefore usefully be addressed in a specially-designed resistance training program for patients with Parkinson’s.


Is treadmill walking useful for Parkinson’s?

A large number of studies and reviews have investigated or assessed the use of treadmill walking interventions for the treatment of Parkinson’s, as follows:

Study Description Finding
Pohl et al. The researchers performed a randomized, multiple intervention crossover pilot study to compare the effects of various exercise interventions on gait parameters in 17 patients with early Parkinson's disease. They randomly assigned the patients to varying sequences of 4 different protocols: structured speed-dependent treadmill walking, limited progressive treadmill walking, conventional gait training and a control. They found that both structured speed-dependent treadmill walking and limited progressive treadmill walking protocols improved all basic gait parameters, including walking speed and stride length, but there were no improvements after either conventional gait training or after the non-training control conditions.
Miyai et al. The researchers performed a randomized, controlled trial in 24 patients with Parkinson’s to investigate whether body weight-supported treadmill training would be of long-term benefit. The patients were randomly allocated to groups receiving either a 45-minute session of body weight-supported treadmill training (up to 20% of bodyweight supported) or conventional physical therapy, 3 days a week for 1 month. The researchers reported that the body weight-supported treadmill training group displayed significantly greater increases in walking speed and stride length than the conventional physical therapy group and some benefits were maintained after a 4-month follow-up.
Miyai et al. The researchers performed a prospective crossover trial to assess the effects of body weight-supported treadmill training in 10 patients with Parkinson's. They randomly allocated the patients randomized to either a 4-week program of body weight-supported treadmill training with up to 20% of their body weight supported followed by a 4-week program of conventional physical therapy or the same treatments in the reverse order. The researchers reported that the patients displayed significantly greater improvements in walking speed and stride length with body weight-supported treadmill training than with conventional physical therapy.
Toole et al. The researchers performed a study to determine whether unloaded or loaded treadmill walking would lead to improvements in function, gait and balance in 23 patients with Parkinson’s in comparison with age-matched, healthy controls. They allocated the subjects to perform a 6-week treadmill walking program of 20 minutes per day, 3 days per week with either (1) no loading or unloading, (2) a 25% bodyweight reduction, (3) a 5% bodyweight increase. The researchers reported improved balance, reduction in the risk of falling and improved gait parameters similarly for all groups.
Herman et al. The researchers performed an open-label, before-after pilot study to evaluate the effects of treadmill walking on gait, function, and quality of life in 9 patients with Parkinson's. The patients walked on a treadmill for 30 minutes, 4 times a week, for 6 weeks. The researchers found that quality of life improved, as measured by a reduction from 32 to 22 on the 39-item Parkinson's Disease Questionnaire (PDQ-39). They reported that Parkinson’s symptoms also improved, as measured by a reduction from 29 to 22 in the Unified Parkinson's Disease Rating Scale (UPDRS). They reported that gait speed increased from 1.11 to 1.26m/s and that function, as measured by the Short Physical Performance Battery (SPPB), also improved. The researchers observed that many of the benefits were sustained at a 4-week follow-up.
Cakit et al. The researchers performed a randomized controlled trial to assess the effects of a twice-weekly, 8-week, incremental speed-dependent treadmill training program on postural instability, balance and fear of falling in 54 patients with Parkinson's and 31 control subjects. The total walking distance of the training group was increased from 266.45 ± 82.14m to 726.36 ± 93.1m. The researchers reported that the maximum tolerated speed was improved in the training group from 1.9 ± 0.75km/h to 2.61 ± 0.77km/h and that postural instability, balance and fear of falling were all also significantly improved, as measured by changes in the Berg Balance Test, Dynamic Gait Index and Falls Efficacy Scale scores.
Bello et al. The researchers examined the gait adaptations following a single session of treadmill walking session in patients with Parkinson's with different degrees of disease severity and age-matched controls (8 with moderate Parkinson's 8, with advanced Parkinson's and 8 control subjects). The researchers took measurements of gait parameters while the subjects walked over-ground on a 10m walkway at a self-selected speed before and after a 20-minute treadmill walking session. The researchers reported that post-treadmill walking, all subjects walked over-ground significantly faster and with a longer stride length than pre-treadmill walking.
Kurtais et al. The researchers performed a randomized controlled trial to investigate whether treadmill walking would lead to improvements in lower body function in patients with Parkinson’s. They recruited 30 consecutive patients with Parkinson’s and randomly allocated them to either a treadmill walking group or to a non-training control for a 6-week intervention. The researchers reported significant improvements in lower-body function tests (walking down a corridor, performing a U-turn, turning around a chair, ascending stairs, standing on one foot, and sit-to-stand) in the treadmill walking group but not in the control group.
Shulman et al. The researchers performed a randomized, single-blinded clinical trial to compare three types of exercise for improving gait speed, lower body strength, and cardiovascular fitness in patients with Parkinson’s. They randomly assigned 67 patients with Parkinson’s to 1 of 3 groups: (1) high-intensity treadmill walking (30 minutes at 70 – 80% of heart rate reserve), (2) low-intensity treadmill walking (50 minutes at 40 – 50% of heart rate reserve), and (3) a combined stretching and resistance exercise program (2 sets of 10 repetitions on each leg on 3 lower body machines [leg press, leg extension, and curl]). The training was performed 3 times a week for 3 months. The researchers found that all 3 groups 6-minute walk distance but there were no significant differences between groups. VO2-max was improved significantly more in both walking groups than in the stretching and resistance exercise group but only the stretching and resistance exercise group improved lower body strength.
Carda et al. The researchers performed a randomized, single-blind controlled trial to assess the use of robots for gait training in Parkinson’s in comparison with standard treadmill walking. They randomly allocated 30 patients with Parkinson’s to 1 of 2 groups: 30 minutes of treadmill walking or 30 minutes of robotic gait training using the Lokomat for 3 days per week for 4 weeks. After the intervention and after a 6-month follow-up, the researchers found that both groups had improved performance in the 6-minute walk test similarly and that there were no significant differences between groups.
Canning et al. The researchers performed a pilot randomized controlled trial to assess the feasibility and effectiveness of home-based treadmill walking in patients with mild Parkinson's. They recruited 20 patients with mild Parkinson's and allocated them to either a treadmill walking group or to a usual care control group. The treadmill walking group performed a semi-supervised, home-based program of treadmill walking, 20 – 40 minutes, 4 times a week for 6 weeks. The researchers reported that the treadmill walking group improved performance in the 6-minute walk test while the control group did not. The researchers observed that home-based, semi-supervised treadmill walking was feasible and safe and led to good adherence, with subjects completing 78% of the training sessions.
McNeely et al. The researchers performed a randomized controlled study to assess the effects of a 5-day program of rotating treadmill walking on walking speed and turning ability in 26 patients with Parkinson’s and in 27 age-matched controls. The researchers reported that maximum walking speed and turning speed were not enhanced by the rotating treadmill walking program.
Filippin et al. The researchers assessed the effects of 6-week programs of treadmill walking training with and without added loading on quality of life and function in 9 patients with Parkinson’s. The researchers reported that there was improvement in the total 39-item Parkinson's Disease Questionnaire (PDQ-39) score and in the Unified Parkinson's Disease Rating Scale (UPDRS) score as a result of the programs.
Frazzitta et al. The researchers assessed the effects of a combined protocol of treadmill walking with auditory and visual cues in 40 patients with Parkinson’s who displayed freezing. They randomly allocated them to 1 of 2 groups, involving (1) auditory and visual cues combined with treadmill walking, (2) auditory and visual cues without treadmill walking. The researchers observed that both group improved function, as measured by the Unified Parkinson's Disease Rating Scale Motor Section (UPDRS III). They observed that groups improved freezing, as measured by Freezing of Gait Questionnaire (FOGQ), ad both groups improved 6-minute walking test, walking speed, and stride length. However, they observed that the treadmill walking group improved to a greater extent in the FOGQ, 6-minute walking test, walking speed and stride length. The difference in improvement in the 6-minute walking test was particularly marked, with the treadmill group achieving an average increase of 130m and the non-treadmill group achieving an average increase of just 57m.
Skidmore et al. The researchers performed a pilot study to assess the safety and feasibility of a 3-month program of treadmill walking in 8 patients with Parkinson’s. The researchers employed the use of harness supports to prevent injury from falls. The researchers reported that in 136 treadmill walking sessions, there were 11 falls or near falls and 9 episodes (8 asymptomatic) of systolic blood pressure drops >20mmHg. The researchers reported that the treadmill walking program produced significant improvements in total Unified Parkinson's Disease Rating Scale scores and walking ability. They concluded that treadmill walking is feasible for patients with Parkinson’s but that precautions must be taken to prevent falls.
Mehrholz et al. The reviewers performed a Cochrane review of randomised controlled trials comparing treadmill walking programs with non-training controls in patients with Parkinson’s. They found 8 relevant studies. They reported that treadmill training did lead to increases in gait speed, stride length and walking distance but not cadence.
Herman et al. The reviewers performed a short review of 14 studies investigating the effects of treadmill walking on gait parameters in patients with Parkinson’s. Of the 14 studies, 3 reported on acute effects and 11 reported on chronic effects. The reviewers concluded that the reviewed studies provide support for the proposal that treadmill walking in Parkinson’s patients is safe, feasible and efficacious for improving gait parameters, in addition to lower-body function, risk of falling and quality of life.

Based on these studies and reviews, it appears that treadmill walking is almost certainly useful for improving walking speed and stride length in patients with Parkinson’s. It also appears that treadmill walking is probably also beneficial for improving lower body function (e.g. walking down a corridor, performing a U-turn, turning around a chair, ascending stairs, standing on one foot, and sit-to-stand), risk of falling, fear of falling, Parkinson’s symptoms and health-related quality of life in patients with Parkinson’s.


Is martial arts training useful for Parkinson’s?

A number of studies have investigated the use of martial arts training for the treatment of Parkinson’s, as follows:

Study Description Finding
Amano et al. The researchers examined the effects of Tai Chi on dynamic postural control during gait initiation and gait performance in 45 patients with Parkinson’s. They randomly assigned the subjects to either a Tai Chi group or to a either a non-training control group or to a placebo group that performed Qi-Gong for a 16-week intervention. The researchers reported that Tai Chi did not significantly improve Unified Parkinson's Disease Rating Scale (UPDRS) Part III score, gait initiation parameters or gait performance in either trial.
Li et al. The researchers reported on a single-blind, randomised, controlled trial in 195 patients with Parkinson’s. They randomly allocated the subjects to either Tai Chi, resistance-training, or stretching groups for a 24-week intervention. The resistance training group performed 8 – 10 leg exercises and the stretching group performed upper and lower body stretches. All 3 groups trained for 1 hour, twice per week. The researchers found that the Tai Chi group improved direction control, stride length and functional reach by significantly more than the other two groups. The researchers also found that the Tai Chi group improved peak knee flexion and extension torques, timed-up-and-go test, and UPDRS III score by significantly more the stretching group and to a similar extent to the resistance-training group.
Li et al. The researchers performed a preliminary study to assess the feasibility, safety, and efficacy of Tai Chi in 17 patients with Parkinson's. The subjects performed a 5-day, Tai Chi program for 90 minutes per day. The researchers reported that adherence to the program was 100% and there were no adverse events. The participants subjectively-rated the program highly in terms of appropriateness, satisfaction and enjoyment, as well as for intention to continue. There were also indications of improvement in physical performance measures.
Lee et al. The researchers reviewed the literature in respect of the use of Tai Chi as an exercise treatment for Parkinson's and found 7 studies, including 3 randomised controlled trials (RCTs).  "They reported that 1 RCT found that Tai Chi achieved better improvements than conventional exercise in the Unified Parkinson’s Disease Rating Scale (UPDRS) and improved falls prevention to a greater extent. They reported that a second RCT found that Tai Chi had no effect on locomotor ability in comparison with with Qi-Gong. They reported that the third RCT found that Tai Chi had no effect on the UPDRS compared with a non-training control. The reviewers concluded that the evidence is currently insufficient to assess whether Tai Chi is an effective exercise treatment for Parkinson’s."
Combs et al. The researchers performed a case series to assess the effects of boxing training on balance, mobility and quality of life in patients with mild, moderate or severe Parkinson’s in addition to the feasibility and safety of such programs. The researchers followed 6 patients with Parkinson’s as they attended 24 – 36, 90-minute boxing training sessions over 12 weeks. The training sessions included boxing drills, stretching, strengthening and endurance exercises. Before and after the training, the researchers assessed the patients with the Functional Reach Test, Berg Balance Scale, Activities-specific Balance Confidence Scale, Timed Up-and-Go Test, 6-Minute Walk Test, walking speed, walking cadence, stride length, step width, Activities of Daily Living and Motor Examination subscales of the Unified Parkinson Disease Rating Scale (UPDRS), and Parkinson Disease Quality of Life Scale. The researchers reported that no adverse events occurred and that there were improvements in balance, walking speed, Activities of Daily Living, and quality of life as a result of the boxing training.

Based on these studies and reviews, it appears that we cannot currently be certain whether Tai Chi or boxing as an exercise method are useful for patients with Parkinson’s.


Is dancing useful for Parkinson’s?

A number of studies have investigated the use of dancing for the treatment of Parkinson’s, as follows:

Study Description Finding
Cameron et al. The researchers observed that patients with Parkinson’s are able to initiate automatic eye movements towards visual stimuli (pro-saccades) but have an impairment in respect of intentional eye movements away from visual stimuli (anti-saccades). They therefore hypothesized that either dancing or watching a dance class could lead to acute changes in pro- and anti-saccades in patients with Parkinson’s. To assess this, they examined the ability of patients to perform both pro- and anti-saccades both pre- and post-dancing and pre- and post-watching dancing. The researchers reported that there was an improvement in anti-saccade performance following watching dancing but there was not an improvement in anti-saccade performance following dancing. The researchers also reported that there was a reduction in pro-saccade performance following dancing but there was not a reduction in pro-saccade performance following watching dancing. The chronic effects of these changes is unclear.
Volpe et al. The researchers performed a pilot randomized controlled trial to compare the effects of Irish set dancing and routine physiotherapy in 24 patients with mild-to-moderate Parkinson’s. The patients were randomly allocated to either an Irish dancing group or to a physiotherapy group and both groups performed the relevant exercise once per week for 6 months. The researchers found that both the Irish dancing and the physiotherapy programs were feasible and safe and there were no differences between groups in respect of adverse events, adherence and compliance. The researchers reported that the Irish dancing group displayed significantly better results in respect of freezing of gait, balance and motor disability.
Houston et al. The researchers performed a mixed-methods study to assess the effects of a 12-week dancing project in patients with Parkinson’s, led by English National Ballet. The researchers reported improvements in balance and stability but not in posture as a result of the project. They also noted that the patients rated the experience positively and there was 100% adherence.
Foster et al. The researchers performed a randomized controlled trial to assess the effects of a 12-month, community-based Argentine tango dance program in 62 patients with Parkinson’s. The subjects were randomly allocated to either a dance group or to a non-treatment group. The researchers reported that total current participation in physical activity in the dance group was higher at 3, 6, and 12 months compared to baseline but there was no change in the control group. The researchers reported that total activity retention since the onset of Parkinson’s increased in the dance group from 77% to 90% but did not change in the control group. The researchers reported that the dance group displayed a significant increase in the number of new social activities but the control group did not. The researchers concluded that a community-based Argentine tango dance program increased participation in complex daily activities, recovery of activities lost since the onset of Parkinson’s, and increased engagement in new activities.
Hackney et al. The researchers performed a study to compare the effects of partnered and non-partnered dance in 39 patients with mild-to-moderate Parkinson’s. They randomly assigned the subjects to either partnered or non-partnered tango groups and both groups attended 1-hour classes twice per week for 10 weeks. The researchers reported that both groups improved significantly and similarly in respect of Berg Balance Scale, self-selected and maximum walking speeds and walking cadence both after the 10-week intervention and at the 1-month follow-up.
Hackney et al. The researchers performed a randomized, prospective, repeated measures study to assess the effects of different types of dance in 58 patients with mild-to-moderate Parkinson's. The researchers randomly allocated the subjects to either (1) tango, (2) waltz/foxtrot, or (3) control groups. The dance classes were performed for 1-hour, twice per week for 13 weeks. The researchers reported that the two dance groups improved significantly and similarly on the Berg Balance Scale, 6-minute walk distance, and backward stride length.

Based on these studies, it appears that dance might be a useful exercise training method for improving balance, walking speed and gait characteristics in patients with Parkinson’s, although the evidence is not yet substantial. Future research may help ascertain whether dance has certain unique benefits for patients with Parkinson’s that are not provided or which are provided to a lesser extent by more conventional methods, such as  increased participation in complex daily activities and subjective enjoyment.


Is resistance-training useful for Parkinson’s?

A number of studies have investigated the use of resistance training interventions for the treatment of Parkinson’s, as follows:

Study Description Finding
Scandalis et al. The researchers performed a controlled trial in order to assess whether patients with Parkinson's performing resistance training program were able to gain strength to a similar extent to healthy control subjects and whether any gains in strength would improve gait function. They recruited 14 patients with mild-to-moderate Parkinson's and 6 healthy, age-matched controls who all participated in an 8-week, twice-per-week, lower-body resistance training program. The researchers reported that the patients Parkinson's made similar strength gains to the healthy controls and also improved gait parameters, including stride length, walking speed and postural angles.
Li et al. The researchers performed a single-blind, randomised, controlled trial in 195 patients with Parkinson’s. They randomly allocated the subjects to either Tai Chi, resistance-training, or stretching groups for a 24-week intervention. The resistance training group performed 8 – 10 leg exercises and the stretching group performed upper and lower body stretches. All 3 groups trained for 1 hour, twice per week. The researchers found that the Tai Chi group and the resistance training group both improved peak knee flexion and extension torques, Timed Up-And-Go test, and UPDRS III scores by significantly more the stretching group.
Shulman et al. The researchers performed a randomized, single-blinded clinical trial to compare three types of exercise for improving gait speed, lower body strength, and cardiovascular fitness in patients with Parkinson’s. They randomly assigned 67 patients with Parkinson’s to 1 of 3 groups: (1) high-intensity treadmill walking (30 minutes at 70 – 80% of heart rate reserve), (2) low-intensity treadmill walking (50 minutes at 40 – 50% of heart rate reserve), and (3) a combined stretching and resistance exercise program (2 sets of 10 repetitions on each leg on 3 lower body machines [leg press, leg extension, and curl]). The training was performed 3 times a week for 3 months. The researchers found that all 3 groups 6-minute walk distance but there were no significant differences between groups. VO2-max was improved significantly more in both walking groups than in the stretching and resistance exercise group but only the stretching and resistance exercise group improved lower body strength.
Hass et al. The researchers examined the effects of progressive resistance training on gait initiation in 18 patients with Parkinson's. They randomly allocated the subjects to either a resistance training program or to non-training control group. The resistance training group performed strength training twice per week for 10 weeks. The researchers found that the progressive resistance training group displayed significant improvements in posterior displacement of the center of pressure, initial stride length and initial walking velocity but the control subjects did not display any changes in these variables.
Schilling et al. The researchers performed a pilot study to assess the benefits of resistance training for strength and physical function in 18 patients with Parkinson’s. The researchers randomly allocated the subjects to either a resistance training group or to a standard care group for an 8-week intervention. The resistance training group performed 3 sets of 5 – 8 repetitions of the leg press, leg curl, and calf raise twice weekly. The researchers reported that the resistance training group improved leg press strength relative to body mass but not Timed Up-And-Go, 6-minute walking performance, or score on the Activities-specific Balance Confidence questionnaire.
Dibble et al. The researchers assessed the effects of resistance training on measures of muscle damage and injury in 10 patients with mild-to-moderate Parkinson's. The subjects all performed bilateral, lower-body eccentric resistance training 3 days per week for 12 weeks while the researchers measured serum creatine kinase concentrations, scores of muscle pain, and changes in isometric force production. The researchers reported that creatine kinase levels did not exceed the threshold of muscle damage at any time point but isometric force production increased significantly over time.
Dibble et al. The researchers assessed the effects of resistance training on quadriceps muscle volume, muscular force production and mobility in 19 patients with Parkinson’s. They randomly allocated the subjects to either a resistance training group or to a standard-care control group. The resistance training group performed a 12-week program of high-force, eccentric resistance training for the quadriceps, 3 days a week for 12 weeks. The standard-care group performed exercise according to current guidelines. The researchers reported that the resistance training group displayed significant increases in muscle volume, muscle force, and functional status (stair descent and 6-minute walk).
Dibble et al. The researchers assessed the effects of resistance training on slowness of movement (bradykinesia) and quality of life (assessed using the Parkinson's disease questionnaire-39 [PDQ-39]) in 20 patients with mild-to-moderate Parkinson’s. The researchers randomly allocated the subjects to either a resistance training group or to an active control group. The resistance training group performed 12 weeks of high-intensity eccentric resistance training for the quadriceps. The active control group performed a current best-practice exercise program for the treatment of Parkinson’s. The researchers reported that muscular strength, bradykinesia, and quality of life were improved to a greater degree in the resistance training group in comparison with the active control group.
Hirsch et al. The researchers performed a randomized controlled trial to assess the effects of 10 weeks of either combined balance and resistance training or balance training only in patients with Parkinson's. The combined balance and resistance training group performed high-intensity resistance training for the knee extensors and flexors and ankle plantar-flexors in addition to balance training, 3 times a week on non-consecutive days. The researchers reported that both groups improved muscular strength and balance, as measured by the Sensory Orientation Test, but the size of these improvements were greater in the combined group. The researchers also found that both groups improved the ability to balance before falling.
Lima et al. The reviewers performed a systematic review with meta-analysis of randomised and quasi-randomised controlled trials assessing the effects of progressive resistance exercise on strength and measures of physical performance (i.e. sit-to-stand time, fast and self-selected walking speeds, 6-minute walking test, stair descent and ascent, the Activities-specific Balance Confidence scale, the Timed Up and Go test, and the Short Physical Performance Battery) in patients with Parkinson's. The reviewers identified 4 studies, of which 3 included data that could be pooled in a meta-analysis. The reviewers found that progressive resistance training did improve strength and walking capacity (as measured by the 6-minute walking test) in patients with mild-to-moderate Parkinson's but did not improve other physical performance measures to a clinically meaningful extent.
Brienesse et al. The reviewers performed a systematic review was to assess the evidence from controlled trials for whether resistance training is effective for the treatment of Parkinson’s. The reviewers identified 5 studies, including 3 randomized controlled trials and 2 non-randomized controlled trials. The reviewers found that resistance training had a positive effect on both muscular strength and physical function.

Based on these interventions, resistance training appears to be effective for increasing muscular strength, balance and some measures of physical function, including walking speed, in patients with Parkinson’s.


Is motor control training useful for Parkinson’s?

A number of studies have investigated the use of motor control interventions, such as cueing, balance or specific gait training tasks, for the treatment of Parkinson’s, as follows:

Study Description Finding
Nieuwboer et al. The researchers performed a single-blind randomized crossover trial and allocated 153 patients with Parkinson’s to either an early-intervention group or to a late-intervention group. The early-intervention group received a 3-week home cueing programme involving a prototype cueing device, followed by 3 weeks without training. The late-intervention group received the same intervention and control period in the opposite order. The researchers measured combined posture and gait score, freezing, balance, functional activities, quality of life and carer strain before and after the trial and after 6 weeks of follow-up. The researchers reported a significant (4.2%) improvement in the combined posture and gait score, a significant reduction of freezing (5.5%) in freezers only as well as significant improvements in gait speed, stride length and balance. The researchers observed that the effects reduced considerably after 6-weeks at the follow-up. They therefore concluded that home-based cueing is effective for improving gait, freezing and balance. They also concluded that the lack of a persistent effect indicates the need for continued training.
Protas et al. The researchers performed a randomized controlled trial to assess the effects of an 8-week treadmill walking program including gait training on walking speed, gait parameters and risk of falls in 18 male patients with Parkinson’s. They randomly assigned the subjects to either a treadmill gait training group or to a control group. The treadmill gait training program comprised walking on a treadmill in 4 directions or stopping the treadmill during walking. The patients were supported in a harness for safety. The treadmill gait training was performed for 1 hour per day, 3 times per week for 8 weeks. The researchers reported the incidence of falls significantly reduced in the treadmill gait training group but not in the control group. They also reported that walking speed increased significantly in the treadmill gait training group (from 1.28 ± 0.33 to 1.45 ± 0.37m/s) but did not increase in the control group. Similarly, stride length also increased in the treadmill walking group but not in the control group. Whether the effects in this study arose from simply treadmill walking or whether the gait training had an additional benefit, however, is unclear.
Hirsch et al. The researchers performed a randomized controlled trial to assess the effects of 10 weeks of either combined balance and resistance training or balance training only in patients with Parkinson's. The combined balance and resistance training group performed high-intensity resistance training for the knee extensors and flexors and ankle plantar-flexors in addition to balance training, 3 times a week on non-consecutive days. The researchers reported that both groups improved muscular strength and balance, as measured by the Sensory Orientation Test, but the size of these improvements were greater in the combined group. The researchers also found that both groups improved their ability to balance before falling.
Pompeu et al. The researchers performed a parallel, prospective, single-blind, randomised clinical trial to compare the effects of Nintendo Wii™-based motor cognitive training and conventional balance training on activities of daily living in 32 patients with Parkinson's. The researchers allocated the subjects to either a Nintendo Wii™-based motor cognitive training group or to a conventional balance training group. The researchers reported that both groups displayed significant improvements in section II of the Unified Parkinson's Disease Rating Scale (UPDRS) and that there were no significant differences between groups.
Rossi-Izquierdo et al. The researchers examined the effects of balance training using a biofeedback system on stability and incidence of falls in 10 patients with Parkinson's. The researchers reported that the subjects displayed significant improvements in body sway, Sensory Organization Test (SOT) score, Dizziness Handicap Inventory (DHI) score, and Activity-specific Balance Confidence (ABC) scale score, as well as number of falls.
Smania et al. The researchers assessed the effects of balance training on postural instability in 64 patients with Parkinson’s. They randomly the subjects either to a balance training group or to a control group who performed general physical exercise. A total of 21 exercise sessions of 50 minutes each were carried out. The researchers reported that the balance training group displayed significant improvements in the Berg Balance Scale (BBS), the Activities-Specific Balance Confidence Scale (ABC), a postural transfer test, a self-destabilization of the center of foot pressure test, number of falls and the and Geriatric Depression Scale (GDS) but not in the Unified Parkinson's Disease Rating Scale (UPDRS), or modified Hoehn and Yahr (H&Y) Staging Scale.
Lim et al. The reviewers reviewed the literature in order to assess the effect of cueing on symptoms of Parkinson’s. They identified 24 studies of which just 2 were randomized controlled trials (RCTs), which were of high methodological quality. Of these 2 RCTs, 1 did not focus specifically on external cueing but included walking with cues within group exercise. Therefore, based on the available literature, the reviewers concluded that only 1 high-quality study was able to support the contention that walking speed of patients with Parkinson's can be increased using cueing.
Allen et al. The reviewers performed a systematic review and a meta-analysis to assess the effects of exercise and motor training on balance and the risk of falls in patients with Parkinson's. They identified 16 randomized and quasi-randomized controlled trials. The reviewers found evidence that exercise and motor training significantly improved balance but they did not find evidence that exercise or motor training can reduce the risk of falls.

Based on these studies, it appears that there is some limited evidence to suggest that balance training, gait training or cueing can help improve balance and/or walking performance in patients with Parkinson’s.


Do reviews of general exercise confirm its usefulness for Parkinson’s?

A small number of reviews have assessed the use of exercise interventions for the treatment of Parkinson’s, as follows:

Study Description Finding
Goodwin et al. The reviewers reviewed the literature for studies reporting on randomized controlled trials including individuals with Parkinson’s who participated in an exercise or physical activity intervention. They identified 14 studies that met the relevant criteria. The reviewers reported that pooled data demonstrated that there was evidence of improvement in physical functioning and health-related quality of life in patients with Parkinson’s as a result of exercise interventions. The reviewers also observed that a number of studies indicated improvements in muscular strength, balance and walking speed as a result of an exercise intervention. They noted that no study reported any improvement in either the incidence of falls or in measures of depression, although these were measured in several papers. The reviewers concluded that exercise is of benefit to patients with Parkinson’s in respect of physical function, health-related quality of life, strength, balance and walking speed.
Allen et al. The reviewers reviewed the literature for randomized controlled trials (RCTs) of exercise and/or motor training interventions involving patients with Parkinson’s in order to assess drop-out rates, adherence and adverse events. They included all studies that contained any kind of exercise and/or motor training interventions, such as aerobic exercise (including treadmill walking), all resistance training modalities, cueing and movement strategy training. They did not consider whole-body vibration training to fall into either of these categories. With these criteria, the reviewers identified 53 trials involving 90 intervention groups. The reviewers observed that 62 (69%) of the 90 intervention groups retained at least 85% of the subjects and they considered that this was a good retention rate. They observed that adherence and adverse events were infrequently reported in the 53 trials and therefore it was difficult to assess these factors. They reported in 15 trials that reported adverse events, 11 adverse events occurred of which 4 were unspecified cardiac problems and the remaining 7 were minor factors such as muscular soreness or fatigue. The reviewers did not comment on whether these adverse events were a matter for concern or not.

Based on these reviews, it appears that general exercise can help improve physical function, health-related quality of life, strength, balance and walking speed in patients with Parkinson’s.


What is the economic burden of Parkinson’s?

A small number of studies have either reviewed the economic burden of Parkinson’s or have assessed the cost-effectiveness of exercise treatments in relation to Parkinson’s, as follows:

Study Description Finding
Kaltenboeck et al. The researchers assessed the annual direct healthcare costs of newly diagnosed patients with Parkinson’s and compared them with those of non-Parkinson’s age-matched controls. They found that direct healthcare costs in patients with Parkinson’s were higher than those of controls ($7423 vs. $5,024).
Fletcher et al. The researchers performed an economic evaluation to compare the cost-effectiveness of a targeted exercise program versus usual care for patients with Parkinson’s who were at risk of falling. They recruited 130 subjects and randomly allocated them to either an exercise group or to a usual care group for a 20-week study. They assessed the incremental cost per quality adjusted life year (QALY) as associated with the exercise group. The researchers reported that the average cost of the exercise program was £76 per patient and there was no significant difference between groups in total healthcare costs, combined health and social care costs or QALYs although there was a >80% probability that the exercise intervention was a more cost-effective strategy than usual care.

Based on these studies, it appears that Parkinson’s leads to greater direct healthcare costs than the average aged-matched control and that an exercise program is an economically cost-effective treatment option for this condition.


Conclusions

On the basis of these studies and reviews, the following conclusions might be drawn:

Area Conclusion
Treadmill walking A large number of studies have shown that treadmill walking almost certainly improves walking speed and stride length in patients with Parkinson’s. Studies also indicate that treadmill walking is probably beneficial for improving lower body function, risk of falling, fear of falling, Parkinson’s symptoms and health-related quality of life in patients with Parkinson’s. This indicates that treadmill walking should be a part of any exercise program for patients with Parkinson’s.
Safety during treadmill walking Patients with Parkinson’s are at a greater risk of falling than age-matched controls. Therefore, care should be taken during treadmill walking exercise programs to reduce the risk of falls, either through a safety harness or by other means.
Muscular weakness in Parkinson’s Studies have identified that Parkinson’s patients are generally weaker than age-matched controls and that they also display lower rates of force development, poorer sit-to-stand ability and markedly lower hip extension torque. These features might therefore usefully be addressed in a specially-designed resistance training program for patients with Parkinson’s.
Resistance training Studies indicate that resistance training appears to be effective for increasing muscular strength, balance and some measures of physical function (including walking speed) in patients with Parkinson’s.

Exercise can be used effectively to help in the treatment of Parkinson’s. Treadmill walking appears to improve walking speed and stride length and may also improve lower body function, risk of falling, fear of falling, Parkinson’s symptoms and health-related quality of life. Muscular weakness can be addressed through resistance training, which appears to be effective for increasing muscular strength, balance and some measures of physical function.


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