# Exercise as it relates to Disease/The effect of exercise in reducing the falls risk of older people with Parkinson’s Disease

The following article is a critique of the research paper 'A randomised controlled trial of a home based exercise programme to reduce the risk of falling among people with Parkinson's disease', published in the Journal of Neurology, Neurosurgery, and Psychiatry, 2007.

## What is the background to this research?

Parkinson's Disease (PD) is a long-term degenerative disorder which effects the brain and nervous system. Main symptoms include shaking of the arm or hand, muscle rigidity, slowed gait movement, and postural instability. PD affects around 1 in 1000 individual's over 60 years worldwide, and approximately 81,000 individuals in Australia.
Frequent falls in older adults can have severe consequences, including hip fractures and increased weakness of bones, which decreases quality of life. Falling is the second most common cause for hospitalisation in individuals with PD. 51.9% of all falls resulting in hospitalisation, occurred within the home. Therefore, the effect of home-based exercises on decreasing falls, by increasing muscle strength and reducing the fear of falling, should be of concern. Research into the topic can assist in reducing the economic burden of hospitalisations in PD individuals due to frequent falls.

## Where is the research from?

This research paper was published by the Journal of Neurology, Neurosurgery, and Psychiatry, a well reputed medical-related journal accessible worldwide.
The primary author, Ann Ashburn, has been involved in the production of around 100 research papers. Ashburn's research focuses on physical recovery after sudden medical events, such as a stroke, or long-term disorders, such as PD.
The study took place in Dorest, UK. Participants were chosen from three PD specialists within the area. Average age of the participants was 72 years ± 9.2, and time since PD diagnosis ranged from 1 to 31 years. Similar studies have been conducted in Australia, providing a level of relevance to Australian individuals with PD.

## What kind of research was this?

This research was a randomised controlled trial, considered the gold standard in research, which aims at limiting any discrepancies between the intervention and control groups. Progress made from the intervention is highlighted when compared to the control group.
One limitation of the study was self-reporting. Individuals could have inaccurately defined or underestimated falls events that occurred. Therefore, the intervention may have made a larger impact on patients than the study suggests.

## What did the research involve?

142 participants diagnosed with varying PD severity, were randomised into an intervention group (n=70) and a control group (n=72). Eligibility criteria required individuals to be living at home, independently mobile, and experienced more than one fall 12 months prior to the study. The number of participants declined due to dislike of exercise, hospitalisation, or passed away. The participants were required to self-report fall and near fall events, and any resulting injuries. 134 self-reporting diaries were available at completion of the study (n = 67 from each group).
The study defines a fall as "an event that resulted in a person coming to rest unintentionally on the ground or other lower level, not as a result of a major intrinsic event", and a near fall as "an occasion on which and individual felt that they were going to fall but did not actually do so".
The exercise completed by the intervention group involved muscle strengthening, range of movement, balance training, and walking, which promoted the prevention of falls, initiation of movement, and strength compensation. Exercises were taught by a physiotherapist. After 6 weeks, the intervention group were contacted to discuss any arising problems with the prescribed exercises. Follow ups were then completed after 8 weeks and 6 months.
The control group received their usual care.

## What were the basic results?

A decrease in falls rate and repeat falling for the intervention group (see Table 1), as well as a decreased rate of injuries requiring medical attention (see Table 2) resulted from the study. Although improvements in the individual's quality of life occurred, these particular results did not reach statistical significance. As time progressed, the study revealed a declining pattern in quality of life for the control group, with greater rates of falls (see Table 1) and subsequent related injuries (see Table 2).
Lower rates of near falls were recorded in the intervention group in comparison to the control. This reached statistical significance.
Table 1: Rate of falling, repeated falling, and near falling in participants at 8 week and 6 months follow ups.
| | Intervention | Control | P-Value |
| Falling (8 weeks) | 37/65 (56.9%) | 42/64 (65.6%) | 0.423 |
| Falling (6 months) | 46/63 (73.0%) | 49/63 (77.8%) | 0.645 |
| Repeat Falling (8 weeks) | 21/65 (32.3%) | 28/64 (43.8%) | 0.245 |
| Repeat Falling (6 months) | 35/63 (55.6%) | 42/63 (66.7%) | 0.266 |
| Near Falling (8 weeks) | 46/64 (71.9%) | 55/63 (87.3%) | 0.020 |
| Near Falling (6 months) | 50/62 (80.6%) | 57/62 (91.9%) | 0.048 |
Table 2: Number of Fall Related Injuries occurring over the course of the study requiring medical attention.
| Number of Fall Related Injuries (FRI) | Intervention | Control |
| 0 FRI | 60 (89.6%) | 56 (83.6%) |
| 1 FRI | 6 (8.9%) | 7 (10.4%) |
| 2 FRI | 1 (1.5%) | 3 (4.5%) |
| 3 FRI | 0 (0%) | 1 (1.5%) |

## What conclusions can we take from this research?

As this study was relatively small (n = 142), only representing 0.09% of the PD population within the UK (estimated 145,000 cases recorded in 2018), the evidence of using exercise as a disease intervention in individuals with PD can be taken into consideration when prescribing treatment plans. However, interventions used in this research cannot be recommended for the whole population as each individual is different.
The research findings suggest that near fall preventions become effective after implementing an exercise intervention program. Number of fall related injuries also decrease. As a result, quality of life and overall health can increase.
The study shows that those with lower disease severity and lower fall rate benefited greatly from the intervention, and became more receptive to a change in their movement behaviour through an exercise intervention. Therefore, it is suggested that an exercise program should be prescribed shortly after diagnosis, to decrease the risk of falls, as disease severity worsens.

## Practical advice

Even though there is currently no known cure, there are a number of different ways PD symptoms can be treated. Possible treatments include medication (increases dopamine activity in the brain), surgery (reduces the tremor or shakiness in limbs), and exercise (improves balance, stability and movement). General exercise recommendations for individuals with PD are explained in Table 3, though the prescription of each treatment is dependent on disease severity and should be prescribed by an accredited health professional.
Individuals with PD should remain active while still maintaining skills required for everyday living. Assistance may be required in performing these skills; however, it is critical for the individual to remain as independent as possible to improve their quality of life.
Table 3: ACSM's General Exercise Recommendations for Individuals with Parkinson's Disease.
| | Aerobic | Resistance | Flexibility |
| Frequency | 3 days/week | 2–3 days/week | ≥2–3 days/week |
| Intensity | Moderate (40-50% VO$_2$R*) | Beginners (40-50% 1RM) Advanced (60-70% 1RM) | Stretch to point of slight discomfort |
| Time | 30 mins continuous or accumulated | ≥1 set 8-12 reps | Hold for 10-30 sec. 2-4 reps |
| Type | Prolonged, rhythmic activities. Eg. running, swimming | Focus on machine weights and other resistance. Eg. Bands, body weight | Static stretches for all major muscle groups |

## Further information/resources

Below are a list of websites that further explain PD and ways it can be managed.
It is worth noting that these websites do not substitute for medical advice. It is best to consult with a medical professional to manage and prescribe PD treatments.
* Exercise for People with Parkinson's
* Living with Parkinson's Information Sheets
* Parkinson's Disease Information

## References

* ↑ Parkinson's Disease [Internet]. Healthdirect.gov.au. 2018 [cited 27 August 2019]. Available from: https://www.healthdirect.gov.au/parkinsons-disease
* ↑ Tysnes O, Storstein A. Epidemiology of Parkinson's disease. Journal of Neural Transmission [Internet]. 2019 [cited 29 August 2019];124(8):901-905. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28150045
* ↑ Statistics about Parkinson's [Internet]. Parkinsons.org.au. 2017 [cited 12 September 2019]. Available from: https://www.parkinsons.org.au/statistics
* ↑ Johnson C. Falls in Parkinson’s Disease – Causes, Effects, Prevention Tips – Patient Doctor Ring [Internet]. Pdring.com. 2019 [cited 2 September 2019]. Available from: http://pdring.com/falls-in-parkinsons-disease-causes-effects-prevention-tips.htm
* ↑ Trends in hospitalised injury due to falls in older people 2002–03 to 2014–15 [Internet]. Aihw.gov.au. 2018 [cited 5 September 2019]. Available from: https://www.aihw.gov.au/getmedia/39e62afd-7207-460d-aaa6-4f0c95ae665a/aihw-injcat-191.pdf.aspx?inline=true
* 1 2 3 4 5 6 7 8 Ashburn A, Fazakarley L, Ballinger C, Pickering R, McLellan L, Fitton C. A randomised controlled trial of a home based exercise programme to reduce the risk of falling among people with Parkinson's disease. Journal of Neurology, Neurosurgery & Psychiatry [Internet]. 2007 [cited 23 August 2019];78(7):678-684. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117667/
* ↑ Statistics for Journalists [Internet]. Parkinson's UK 2019 [cited 12 September 2019]. Available from: https://www.parkinsons.org.uk/about-us/statistics-journalists
* ↑ Parkinson’s disease treatments [Internet]. Healthdirect.gov.au. 2019 [cited 3 September 2019]. Available from: https://www.healthdirect.gov.au/parkinsons-disease-treatments
* ↑ Riebe D, Ehrman J, Liguori G, Magal M. ACSM's Guidelines for Exercise Testing and Prescription. 10th ed. Philadelphia: Wolters Kluwer; 2018.