# Exercise as it relates to Disease/Aerobic home-based exercise program and its impact on Parkinson's symptoms

This Wiki page is an assignment where the article titled 'Effectiveness of home-based and remotely supervised aerobic exercise in Parkinson's disease: A double-blind, randomised controlled trial' is critically appraised.

## What is the background to this research?

As Parkinson's disease symptoms progress over-time, research has found that participating in physical activity can slow down the rate at which these symptoms advance, while also providing a range of other benefits. This studies aim was to provide an insight into the effect that high-intensity aerobic exercise can have on the motor symptoms of those diagnosed with mild Parkinson's using the Park-in-Shape intervention. This study is unique to others as it is administered at home with monitoring taking place remotely, while also being conducted using a cycling machine which is important to examine, as treadmills have predominantly been assessed in past research. Recent data projects that there are currently over 100,000 Australians diagnosed with Parkinson's disease. Therefore, the findings and methodisation of this study is relevant and necessary for future exercise interventions to be developed to help those suffering from the disease.

## Where is the research from?

This study was published in 2019 in The Lancet Neurology journal by a collective group of researchers in the Netherlands, with funding from the Netherlands Organisation for Health Research and Development. The article declared that none of the researchers involved in the study had any conflict of interest and provided an extensive list of the author's associations and credentials, creating transparency and honesty with the readers, enhancing the integrity of the article.

## What kind of research was this?

This study was conducted as a double-blind, randomised controlled trial. This type of design requires the blinding of participants as well as a large sample population to make findings more reliable. This was evident as a large sample of participants were involved in a variety of screening protocols before they were randomly allocated to an exercise group. A recent review found that this study presents a low risk of bias compared to other randomised controlled trials in this area of research due to it's large sample size, use of an active control group and its ability to effectively blind those involved in the study. It is worth noting that three of the author's of the Park-in-Shape study were also author's on this review. No conflict of interest was stated, however one of the author's was also partly responsible for the investigation into the bias found in the trials. When compared to previous literature, the study did provide a very clear method and analysis as well as a detailed explanation and descriptions of the sample population throughout the screening and provided details into the reasoning behind participants leaving and/or reasons for exclusion. Therefore, this supports the findings that very little chance of bias was indeed evident, making the reviews claims plausible.

## What did the research involve?

This study implements the use of the Park-in-Shape intervention over six months, to further understand the effects that high-intensity aerobic exercise has on alleviating symptoms of Parkinson's disease. Participants were recruited from a clinic in the Netherlands and underwent a variety of screening processes to check for eligibility.
Table 1: Screening Process: Inclusion and Exclusion Criteria :
| Inclusion | Exclusion |
| Mild severity Parkinson's symptoms (Hoehn and Yahr) | Beta-blocking or antipsychotic medications |
| Stable use of Dopaminergic Pharmacotherapy | Comorbidities affected by physical activity |
| Sedentary lifestyle | Dementia |
| | Psychiatric diseases diagnosed by a psychiatrist (last 12 months) |
| | No internet access |
| | Availability Issues |
130 participants (50 females, 80 males) were allocated to either the aerobic intervention which took part in exercise on a stationary cycling machine for 30-45 minutes or the active control group which participated in a half hour stretching program, with both groups participating in their exercises 3 times a week. Both exercise groups were administered at home with remote supervision and intensity was individualised for participant's. Heart rate data was collected and stored on the cycle's computer while a motivational application was provided to help keep participant's on track and provide information regarding their progress. Limitations to this study includes it's reliance on technology, which was discussed by the author's, as there is a high risk of technical difficulties and accessibility issues, specifically for older participants as they may not be equiped to handle such technology which they found to be true as five participants exited the study due to this. The remotely supervised aspect also presents a risk for injuries and/or complications, which was evident as eleven participants experienced adverse events that may have been related to the program, with three causing withdrawal from the study.

## What were the basic results?

Table 2: MDS-UPDRS within-group scores (Pre and Post Intervention in an off-state) :
| Aerobic Intervention Group (n=65) | Active Control Group (n=65) |
| 1.3 | 5.6 |
Note: 3.5 points between intervention difference is clinically significant
Off-state= over 12hrs after dopaminergic medication
The main result measured was the Movement Disorders Society- Unified Parkinson's Disease Rating Scale (MDS-UPDRS), with results finding a between groups difference of 4.2 points, indicating a positive outcome for the aerobic intervention group regarding motor control, while improvements in VO2 max were also evident in the aerobic group. Of the 130 participants involved in the study, 10 from each group did not complete their exercise intervention, while 5 were not involved in the follow-up.

## What conclusions can we take from this research?

* This studies inclusion of gaming stimulation, motivational technology, cycling and remote supervision provides a new approach to exercise prescription for people living with Parkinson's disease.
* The author's conclusion seems plausible as they do not overestimate their findings, rather reinforce the idea that aerobic exercise can have positive effects on the motor symptoms of Parkinson's disease as well as overall fitness levels.
* Provides new insight into to the efficacy of remotely supervised exercise programs.
* Adherence to the program was good overall, which raises the question of how programs can be administered remotely in the future.
* Further research is necessary as this study is limited, due to testing taking place during an off-state from medication.

## Practical advice

It has never been so important to find ways to be physically active in the comfort of your own home due to the current global pandemic, as a decline in physical activity levels has emerged. Research suggests that the pandemic may lead to long-term negative implications regarding the progression of Parkinson's symptoms if changes cannot be made to ensure that exercise and rehabilitation programs are able to continue remotely. The Park-in-Shape intervention shows that home-based, high-intensity exercise programs can work to improve motor symptoms in mild severity Parkinson's disease patients which may inform future interventions regarding the implementation of remotely supervised exercise programs.

## Further information/resources

For more information/support please visit:
Parkinson's Australia Website
Parkinson's Foundation

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 van der Kolk NM. et al. (2019) 'Effectiveness of home-based and remotely supervised aerobic exercise in Parkinson's disease: a double-blind, randomised controlled trial'. The Lancet Neurology. 18 (11): 998-1008.
* ↑ Goodwin VA. et al. (2008) 'The effectiveness of exercise interventions for people with Parkinson's disease: A systematic review and meta-analysis. Movement Disorders. 23 (5): 631-640
* 1 2 3 4 5 6 7 Schootemeijer S. et al. (2020) 'Current perspectives on aerobic exercise in people with Parkinson's disease'. Neurotherapeutics. (17): 1-16
* ↑ Parkinson's Australia (2021) 'About Parkinson's'. Parkinson's Australia Website.
* ↑ Hariton E. et al. (2018) 'Randomised controlled trials- the gold standard for effectiveness research: Study design: randomised controlled trials'. International Journal of Obstetrics and Gynaecology. 125 (13): 1716-1716
* ↑ Barrett S. et al. (2021) 'Exercise and COVID-19: reasons individuals sought coaching support to assist them to increase physical activity during COVID-19. Australian and New Zealand Journal of Public Health. 45 (2): 133-137
* ↑ Yogev-Seligmann G. et al. (2021) 'COVID-19 social distancing: negative effects on people with Parkinson's disease and their associations with confidence for self-management'. BMC Neurology. 21(1): 1-8