# Exercise as it relates to Disease/Does exercise benefit patients with early to mid-stage Parkinson's disease?
## What is the background to this research?

Parkinson’s disease is a neurological condition that progressively affects the persons control of their movements and motor control. It can cause shaking of the hands, arms, legs, and face, it can cause the persons movements to become very slow and unstable. This decline in motor control is caused by a lack of dopamine, a chemical in the brain responsible for fine tuning movement. Dopamine would normally be produced by neurons in the brain however these neurons begin to die off in individuals with Parkinson’s disease. This study attempts to show the short and long term benefits that physical activity can provide for people suffering from early- to mid-stage Parkinson’s Disease, the study was run over 16-months on 121 patients with assessments being done at 4, 10 and 16 months. They used three different types of exercise, flexibility/ balance/ function exercises, aerobic exercises and a control group that did basic exercises at home.
What makes this study different to the ones done previously is that this study was done over a longer period of time into order to determine the long-term benefits of physical activity. There has been previous research done on Parkinson’s disease and physical activity, however they were run over a far shorter period.
If physical activity can reduce or even just slow down the progressive nature of Parkinson’s disease it would increase the indepedance of someone suffering for Parkinson's disease meaning they could live a normal life for longer. This would also take pressure off the patients family and the health care system.

## Where is the research from?

The research was done in Colorado, US. All baseline testing was completed at the University of Colorado. Majority of the exercises throughout the 16 months were done at the University of Colorado. This may be of some significance as Colorado is the fittest state in America, having the lowest rate of adult obesity and highest rate of physical activity.
Margaret Schenkman is a Professor and Associate Dean at the University of Colorado Anschutz Medical Campus Rehabilitation Sciences Program in Colorado. Margaret’s research has been around the rehabilitation of individuals who suffer from a neurological impairment, including Parkinson’s disease. She has done multiple other studies based around exercise and Parkinson’s disease.

## What kind of research was this?

This research was a 16-month randomized controlled intervention. The benefits of this type of research is that having the three groups selected randomly means that there is no bias when assigning the groups. Bias could skew the research results in the favour of the study. One limitation with randomised control trials when done with individuals suffering from chronic diseases such as Parkinson’s disease is that it can be unethical to have a true placebo group (no exercise in this case).

## What did the research involve?

The study involved randomly assigning the 121 patients into three separate groups, each group was given a different type of exercise to complete over the course of 16-months. These three exercise types were flexibility/ balance/ function (FBF), aerobic exercise (AE) and a control group. The FBF and AE groups participated in a supervised exercise session three time a week for the first four months, from month five the supervised sessions were eased back to one per month. The control group participated in supervised exercise sessions once a month for all 16 months. All groups were encouraged to exercise five to seven times per week. The FBF group spent the first two months doing one on one sessions and the next two months participating in small group exercises. The FBF exercises focused on balance and flexibility as well as movements that aid in movements that will be able to directly transfer into daily task. The AE groups exercise session consisted of a five to ten-minute warm-up, 30 minutes of conditioning (65-80% of heart rate max) followed by a five to ten-minute cool-down. Participants in the AE group were encouraged to use a treadmill but a stationary bike and elliptical were also allowed. The control group did home-exercises from the National Parkinson Foundation Fitness Counts Program, after the initial induction they only participated in supervised exercise once a month.
Prior to the start of exercise all participants sat down with their trainers to discuss what barriers and motivations struggles they think they may have to build good exercise habits. As one of the goals of this stud was to build long-term exercise habits this is a good way to build exercise habits.
Throughout the research the participants were asked to record their exercises in a diary.
A clear limitation of this study is adherence. Although exercise diaries were used the accuracy was inefficient to determine exact adherence from participants. This research did not include any resistance training, a type of training that has been shown to reduce UPDRS scores over long periods of time.

## What were the basic results?

The results for this research were looked at according to a few different criteria's. The FBF exercise programs had substantial improvements on functional ability at the 4-month assessment however experienced a decline at the 10- and 16-month assessment for functional ability. The decline is thought to be due to lack of adherence when the supervised exercise sessions tapered off. In regard to balance all exercise groups experienced a slight increase over the 16-months. Due to the stiffness and poor motor control associated with Parkinson’s disease the energy expenditure of walking is greater than average. The AE group experienced a substantial improvement in walking economy at the 4-, 10- and 16-month assessments, however the other two groups did not see this improvement. The research used the Unified Parkinson’s Disease Rating Scale (UPDRS) as a measure of effectiveness for each intervention, this a score that takes all aspects of Parkinson’s disease into account to determine its severity and progression. There was very little to no improvement in the UPDRS score. However due to the progressive nature of Parkinson’s disease the estimated score progression for an individual taking Levodopa (a medication commonly used for people suffering from Parkinson’s disease) is an increase of two to three points per year. Therefore, an having no increase in the score is a good sign.

## What conclusion can we take from this?

Based on the research and data provided we can determine that a long-term exercise program would be beneficial for people who are suffering from early- to mid-stage Parkinson’s disease. All three groups experienced some form of benefit in different ways and levels of significance. A combination of flexibility/ balance/ function and aerobic exercise seems to be effective for improving walking economy, UPDRS scores and functional ability.

## Practical advice

Although this study has shown that exercise can be beneficial for people suffering from Parkinson's disease there are some precautions that need to be taken. Due to decreased motor control and stiffness associated with Parkinson’s disease there is an increase risk of falls and tumbles. This means that exercise, especially on a machine such as a treadmill needs to be done with care. The reduction in motor control means that all exercises need to be simple and effective in order to ellicit benefits without overwhelming the patient.

## Further information and resources

Further information on Parkinson's Disease
Further information about the UPDRS
Further information for what you can do if you are, know or are a career for someone with Parkinson's Disease

## References

* ↑ Parkinson's Disease Brain Foundation [Available from: https://brainfoundation.org.au/disorders/parkinsons-disease/#:~:text=Parkinson's%20disease%20is%20a%20progressive,posture%20and%20difficulty%20in%20walking.
* ↑ Triarhou LC. Dopamine and Parkinson's Disease Madame Curie Bioscience Database.
* ↑ Parkinson's Disease NHS2019 [Available from: https://www.nhs.uk/conditions/parkinsons-disease/causes/#:~:text=Parkinson's%20disease%20is%20caused%20by,producing%20a%20chemical%20called%20dopamine.
* ↑ Spraul T. These are the 10 Fittest States in America Exercise.com [Available from: www.exercise.com/learn/ten-fittest-states-in-the-us/#:~:text=Colorado%20the%20fittest%20state%20in%20our%20entire%20country.
* ↑ Prof. Margaret Schenkman - USA Insight Into Parkinson's [Available from: https://www.insightintopd.com/team_member/margaret-schenkman/.
* ↑ Daniel M. Corcos PhD Julie A. Robichaud PT PFJDPSELPDEVPCPPMRRD. A two‐year randomized controlled trial of progressive resistance exercise for Parkinson's disease. Movement Disorders 2013;28(9).
* ↑ UPDRS Scale Thera Cycle [Available from: https://www.theracycle.com/resources/links-and-additional-resources/updrs-scale/.