Facilitating Motor Skill Learning by Aerobic Training in Parkinson's Disease III
Phase: NA
Conditions: Parkinson Disease
Sponsor: University of Erlangen-Nürnberg

02.12.2020 
 
 
 
 
 
 
 
Department of Sport Science and Sport  
Friedrich-Alexander-University Erlangen Nürnberg 
Facilitating Motor Skill Learning by  
Aerobic Training in Parkinson’s Disease III 
FaST-PD III 
Study Protocol 
 
 

 
 
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Contact 
Principal Investigator: 
Dr. phil. Simon Steib 
Affiliation: 
Institute of Sports and Sports Sciences 
Heidelberg University 
Tel.:  
 
+6221 54-4643 
E-Mail:   
simon.steib@issw.uni-heidelberg.de 
 
Sub-investigators: 
Florian Ostermair 
Affiliation: 
Department of Sport Science and Sport,  
Friedrich-Alexander University Erlangen-Nürnberg  
Tel.: 
 
+49 9131-8528106 
E-Mail:  
florian.ostermair@fau.de 
 
 
Philipp Wanner 
Affiliation: 
Department of Sport Science and Sport,  
Friedrich-Alexander University Erlangen-Nürnberg  
Tel.:  
 
+49 9131-8528175  
E-Mail:   
philipp.wanner@fau.de 
Collaborators 
Klinik für Neurologie, Klinikum Würzburg Mitte, Standort Juliusspital (Prof. Dr. med. Mathias Mäurer) 
Funding 
Deutsche Stiftung Neurologie (DSN) 
Summary 
The study is designed to assess the effects of cardiovascular (aerobic) exercise on motor skill learning 
in Parkinson patients. Specifically, we examine whether learning a novel motor skill over a six-week 
period is enhanced when skill practice sessions are combined with additional moderate-intense 
aerobic exercise bouts. In this randomized controlled trial, participants will be allocated to either an 
intervention group (motor skill practice + aerobic exercise) or control group (motor skill practice + 
seated rest). 
Background 
Parkinson’s disease (PD) is a progressive neurodegenerative disorder that is characterized by motor 
control impairments, such as gait disturbances and postural instability. Beneficial effects of exercise 
are attributed to mechanisms of neuroplasticity, and task-specific motor training (repeated practice 
of a skill) is consequently considered to be a motor learning process. Importantly, the formation 
(acquisition) and consolidation of motor memories is impaired in PD compared to healthy individuals 
of similar age. 
Thus, it is crucial to identify strategies to enhance motor learning in people with PD. Recent studies 
have accumulated evidence to show that acute (single bouts of) and chronic (multiple bouts of) 

 
 
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cardiovascular exercise can facilitate motor skill learning. However, this evidence is mainly derived 
from studying healthy individuals. In a first study including PD patients, we recently found improved 
motor memory consolidation, but not skill acquisition, when practice was preceded by a single bout 
of cardiovascular exercise.  
These results suggest that acute exercise may enhance motor memory formation processes, but 
could potentially interfere with motor skill acquisition when performed prior to practice. 
Consequently, in a second study including PD patients, we changed the design so that a bout of 
cardiovascular exercise immediately followed skill practice, and found that exercise facilitated motor 
memory consolidation as indicated by improved offline learning gains. 
Going onward from the previous two studies, the present study will investigate the effects of 
performing cardiovascular exercise immediately following skill practice over a six-week intervention 
period on motor memory consolidation. It will be examined how the regular direct coupling of motor 
learning skill practice and cardiovascular exercise influences the consolidation and automation of the 
practiced movements. 
Aims/Hypothesis 
The main question of the study is whether moderate-intense aerobic exercise, performed 
immediately following motor skill practice over a six-week intervention period, facilitates motor 
memory consolidation in Parkinson’s Disease (PD). 
Hypotheses: 
1. Learning a novel balance task over a period of six weeks is enhanced when cardiovascular 
exercise bouts are performed immediately following each skill practice session. 
2. We further hypothesize, that improved learning outcome with exercise will result from 
improved motor memory consolidation (offline gains between practice sessions).  
Outcome measures 
Motor skill learning 
A dynamic balance task will be used to assess participants’ motor learning performance (i.e. motor 
memory formation). The device consists of a 107 x 65 cm wooden platform (stability platform; 
Lafayette Instrument Europe; Loughborough, United Kingdom), which is mounted on a fulcrum and 
has a maximum deviation of 15° to either side. Participants are required to stand with both feet on 
the platform and try to keep the platform as close to the horizontal as possible during a 30 seconds 
trial. A millisecond timer measures angular displacement from horizontal during each 30 seconds 
trial. Participants will be secured with a safety harness and instructed to stand in a comfortable 
position.  
 
Primary outcome measure  
Description: Change of time in balance (mean angular displacement ±5° from horizontal 
within each 30 seconds trial) from pre- to post-assessment.  
Secondary outcome measures 
- 
Motor skill automatization: 
Description: Change of time in balance (angular displacement ±5° from horizontal) in 
addition to error score of a backwards-counting-task from pre- to post-assessment 

 
 
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- 
Transfer effect: 
Description: Change of the achieved score on the FAB - Scale from pre- to post-
assessment 
 
- 
Muscular endurance: 
Description: Change of time necessary to rise five times from a chair 
 
- 
BDNF – Levels: 
Description: Change of peripheral BDNF - concentration from pre- to post-assessment 
 
- 
Cardiorespiratory fitness: 
Description: Change in maximum oxygen uptake (VO2max) from pre- to post-assessment 
 
- 
General motor function: 
Description: Change in the Parkinson Disease Rating Score (UPDRS) part III (motor part) 
from pre- to post-assessment 
 
- 
Cognitive function: 
Description: Change in the Montreal Cognitive Assessment (MoCA) Score from pre- to 
post-assessment. 
Memory consolidation (offline learning): 
To assess motor skill consolidation (offline learning) primary and secondary outcomes will be 
calculated as change scores from the final performance (last practice block) of every practice session 
to the performance of the first practice block of the following practice session, respectively. 
 
Study design 
In an experimental trial, participants will be randomly allocated to one of two groups (Figure 1). Each 
experimental arm includes i) a pre-examination 2 - 14 days before ii) six acquisition sessions where 
the motor skill will be practiced, followed by a retention test iii) 7 days later (Figure 1). On acquisition 
days, the experimental group will perform a single bout of aerobic exercise (cycle ergometer) 
immediately following motor practice, whereas the control group will rest in a seated position. 
Conditions: 
1. Experimental condition: Participants in the experimental group will practice the motor learning 
task followed by a single bout of moderate-intensity aerobic exercise on a cycle ergometer during 
acquisition days. 

 
 
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2. Control condition: Participants in the control group will practice the motor learning task followed 
by a seated rest period during acquisition day.  
 
 
Aerobic exercise bout:  
The acute cardiovascular exercise bout comprises a 5-minutes warm-up (intensity will be 
progressively increased until target intensity), followed by 25 minutes of pedaling at 60–80 rpm and 
60% of maximal power output reached in a graded exercise test during pre-examination. 
Rest: 
The resting phase includes seated rest on a chair for 30 minutes. Participants will be permitted to 
watch selected TV shows during the 30 minutes. 
Motor skill practice: 
Irrespective of group allocation, participants will follow the identical skill practice routine. On  
acquisition day, participants will perform a familiarization trial followed by 15 practice trials (30 
seconds), clustered into 5 blocks of 3 trials, with 60 seconds rest between trials and 120 sec rest 
between blocks. At a baseline test 7 days prior to and at a retention test 7 days after the intervention 
period, participants will perform a test consisting of one familiarization trial (to account for potential 
warm-up effects) and one practice block (3 trials) on the stability platform, respectively. 
Study population 
Inclusion criteria: 
Patients are eligible if they have 
• 
a Hoehn and Yahr score of ≤3; 
• 
a score of  ≤1 in the UPDRS item ‘postural instability’; 
• 
are able to stand and walk independently; and 
• 
are naïve to the motor task.  
Fig. 1 Study design. 
Experimental Flow for FaST-PD III
Motor control and Health Lab | Division Exercise and Health 
skill practice
1 familiarization trial
15 acquisition trials
seated rest
30 min
60% Wmax
OR
pre-examinations
Experiment
(experimental design, group allocation randomized)
Weeks of Training
1x/week
1     –
2     –
3    –
4    –
5     –
6 
Follow-Up
clinical examination
blood sampling
(e.g., dopamine, BDNF)
retention test
clinical examination
GXT
blood sampling
(e.g., dopamine, BDNF)
GXT
blood sampling
(e.g., dopamine, BDNF)
Figure 1 Study Design FaST-PD 3  

 
 
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Exclusion criteria: 
Criteria for exclusion are 
• 
higher level of cognitive impairment indicated by a score of <21 in the Montreal Cognitive 
Assessment (MoCA);  
• 
other clinically relevant neurological, internal or orthopedic conditions besides Parkinsonism 
that would interfere with the exercise paradigm or motor learning task;  
• 
musculoskeletal conditions or surgery 1 year before the study enrolment;  
• 
smoking>10 cigarettes/day or drinking>6 cups of coffee/day or >50 g of alcohol (equivalent 
of two glasses of wine) consumption/day (Winter et al., 2007). 
Statistical analysis plan 
Power calculation: 
Considering data from previous experiments (Wanner et al., 2020), an a priori estimation of the 
required sample size for the primary analysis was performed using the statistics program G*Power 
(version 3.1.9.4). The estimation was performed for the primary analysis, a 2 (groups) x 6 (training 
sessions) mixed ANOVA with repeated measures. In order to identify a significant interaction effect 
of moderate effect size (f=0.25), with a statistical power of 80%, and a significance level of p≤.05, 20 
subjects (n=10 per group) need to be included. 
Statistical analysis: 
The effect of aerobic exercise on motor skill learning will be examined by a 2 (groups) x 6 (sessions) 
mixed ANOVA with repeated measures, testing for the within-subject factor TIME (mean time in 
balance of all 15 trials in each of the 6 training sessions, respectively) and between-subject factor 
GROUP (AEX, REST). A separate 2 (AEX, REST) x 6 (last practice block during each training day, first 
block during subsequent session) ANOVA will be performed to test skill retention between practice 
sessions.