# Exercise as it relates to Disease/Aquatic exercise and its role in the treatment of Parkinson's disease

This is an analysis of the journal article "Aquatic Exercise Therapy for People With Parkinson Disease: A Randomized Controlled Trial" By Carroll et al., (2017)

### What is the background to this research?

Parkinson’s Disease (PD) is a chronic, progressive neurodegenerative disorder that increases in prevalence with age. PD is characterized by a variety of different features including impairments in movement and freezing of gait. Gait abnormalities make PD sufferers more susceptible to falls, with greater than 60% of these patients reporting 1 or more falls in the past 12 months. Falls in the older PD population impact greatly on their health-related quality of life often resulting in physical injuries and loss of independence. Traditional therapies for PD centre on early intervention and include: gait retraining, strengthening, tai chi, dancing and walking programs. Aquatic exercise, or hydrotherapy, is a recent addition to the treatment programs for PD with promising evidence from early pilot studies. This particular study aims to add to the evidence around the use of aquatic exercise in a PD population.

### Where is the research from?

The research was lead by Louise Carroll from the St. Gabriel’s Centre, Ireland and her colleagues: Daniele Volpe, Meg Morris, Jean Saunders and Amanda Clifford. All volunteers were from the Munster Region in Ireland and treatments were carried out in a local hydrotherapy pool. The study was published in the Physical and Medical Rehabilitation Journal in the year 2016.

### What kind of research was this?

The study conducted was a randomised control trial of 21 participants. These participants had a mean age of 71.49 ± 4.9 and were selected based on strict inclusion and exclusion criteria. Each participant had a diagnosis of idiopathic PD as confirmed by a neurologist and informed consent was gained prior to the commencement of the study.

### What did the research involve?

The participants in this study were randomly assigned into two groups. The experimental group (n=11) attended a 45-min aquatic exercise group twice a week for 6 weeks, whilst the control group (n=10) received their usual care. The primary outcome was gait variability measured by motion capture technology. The secondary outcomes were quality of life measured via the Parkinson’s Disease Questionnaire-39, freezing of gait questionnaire and the Unified Parkinson’s Disease Rating Scale (UPDRS) to determine motor disability. Baseline measures were collected one week prior to the intervention period and re-done following the 6-week trial. An exit survey was also included to determine feasibility including adverse events, participant enjoyment and attendance rates (table 1).

### What were the basic results?

Nil differences in gait variability, quality of life or the freezing of gait were detected between the experimental or control groups at follow up. There was, however, a moderate clinically important difference in motor disability in the aquatic therapy group as shown by the UPDRS. Alongside the physical measures examined in this study, the authors also investigated the feasibility of aquatic based exercises via an exit questionnaire. There were no adverse events, extreme events or exacerbations associated with aquatic exercise. The participants found the program to be enjoyable, yet challenging with 90% indicating they have a strong interest in continuing the classes. Moreover, 70% of the participants reported a subjective improvement in their walking and most indicated the exercises had purpose and were beneficial.

### What conclusions can we take from this research?

Aquatic based physiotherapy for patients with PD may be a viable option for patients where land based activities may be too difficult. This is due to the increased resistance to movement and increased buoyancy forces, which decrease body weight when walking in water. As PD patients have poor motor control and are more likely to fall, exercises in water with sufficient supervision may provide a safe environment to challenge patient’s movement and balance. Furthermore, the strong interest in continuing the classes and enjoyment reported by the participants may increase compliance to therapy in the future.
There were several limitations to be considered in this study. The small sample size of only 21 may make it more difficult to detect significant changes in gait variability and other measures. Another limitation is the individual variation in medication times and doses. PD is very time sensitive when it comes to medications as different patients can have different times of high functioning (on period) and low functioning (off period). Given the structure and timing of these classes and tests, it may be difficult to ensure patients are tested during times of high functioning.

### Practical advice

This research is part of a growing area of research in PD treatment and at this time requires further investigation to determine aquatic exercise's true effect. Based on current this research, it may be reasonable to say that aquatic exercise is at least equivalent to traditional treatment for PD. However, further large-scale research comparing water based and land based interventions is needed. To combat difficulties of limited PD patients in one area, research can be widened to include many cities or countries provided the same protocol is followed. Furthermore, synthesis and review of current literature will provide a more substantial evidence base to draw conclusions on aqua therapy’s effectiveness.
When selecting land based or water based interventions, patient personal preference should weigh heavily on the decision as this may increase compliance in exercise. Aquatic intervention may also serve as an appropriate adjunct to land based therapies, used to break up treatment programs without detrimental effect. Aquatic therapies may also be useful for PD sufferers that are unable to engage in land based treatments for any reason but can complete aquatic exercise, as it is a safe and practical alternative.

### Further information/resources

Parkinson’s Disease: All you need to know via Better Health Government Website
Parkinson's Disease Australia Information Sheets
Parkinson’s Disease Support ACT Website Phone: 6290 1984
Neurological and Falls Rehabilitation Clinic – University of Canberra Student Led Clinic Website Phone: 6201 5843
Offbeat! Dance for people with Parkinson’s in the ACT Website Phone: 6173 3300

### References

* 1 2 3 4 5 Carroll LM, Volpe D, Morris ME, Saunders J, Clifford AM. Aquatic Exercise Therapy for People With Parkinson Disease: A Randomized Controlled Trial. Archives of physical medicine and rehabilitation. 2017 Apr 30;98(4):631-8.
* ↑ Northeast Rehab Hospital. (2017). Aquatic therapy provides a safe and comfortable environment to improve balance reactions and assist in acquisition of walking, transferring and reaching skills. [online] Available at: http://www.northeastrehab.com/services/aquatic-therapy/ [Accessed 18 Sep. 2017].
* ↑ Can We Reduce Falls in Parkinson's Disease?. (2016). [image] Available at: https://www.linkedin.com/pulse/can-we-reduce-risk-falls-parkinsons-disease-jack-florin/ [Accessed 11 Sep. 2017].
* ↑ Hirsch L, Jette N, Frolkis A, Steeves T, Pringsheim T. The incidence of Parkinson's disease: a systematic review and meta-analysis. Neuroepidemiology. 2016;46(4):292-300.
* ↑ Tessitore A, Amboni M, Esposito F, Russo A, Picillo M, Marcuccio L, Pellecchia MT, Vitale C, Cirillo M, Tedeschi G, Barone P. Resting-state brain connectivity in patients with Parkinson's disease and freezing of gait. Parkinsonism & related disorders. 2012 Jul 31;18(6):781-7.
* ↑ Allen NE, Schwarzel AK, Canning CG. Recurrent falls in Parkinson’s disease: a systematic review. Parkinson’s disease. 2013 Mar 5;2013.
* ↑ Tickle‐Degnen L, Ellis T, Saint‐Hilaire MH, Thomas CA, Wagenaar RC. Self‐management rehabilitation and health‐related quality of life in Parkinson's disease: A randomized controlled trial. Movement Disorders. 2010 Jan 30;25(2):194-204.
* ↑ Ellis T, de Goede CJ, Feldman RG, Wolters EC, Kwakkel G, Wagenaar RC. Efficacy of a physical therapy program in patients with Parkinson’s disease: a randomized controlled trial. Archives of physical medicine and rehabilitation. 2005 Apr 30;86(4):626-32.
* ↑ Li F, Harmer P, Fitzgerald K, Eckstrom E, Stock R, Galver J, Maddalozzo G, Batya SS. Tai chi and postural stability in patients with Parkinson's disease. New England Journal of Medicine. 2012 Feb 9;366(6):511-9.
* ↑ Aguiar LP, da Rocha PA, Morris M. Therapeutic dancing for Parkinson's disease. International Journal of Gerontology. 2016 Jun 30;10(2):64-70.
* 1 2 Vivas J, Arias P, Cudeiro J. Aquatic therapy versus conventional land-based therapy for Parkinson's disease: an open-label pilot study. Archives of physical medicine and rehabilitation. 2011 Aug 31;92(8):1202-10
* 1 2 Ayán C, Cancela J. Feasibility of 2 different water-based exercise training programs in patients with parkinson's disease: A pilot study. Archives of physical medicine and rehabilitation. 2012 Oct 31;93(10):1709-14.
* 1 2 3 Volpe D, Giantin MG, Maestri R, Frazzitta G. Comparing the effects of hydrotherapy and land-based therapy on balance in patients with Parkinson’s disease: a randomized controlled pilot study. Clinical rehabilitation. 2014 Dec;28(12):1210-7.
* ↑ Jankovic J. Parkinson’s disease: clinical features and diagnosis. Journal of Neurology, Neurosurgery & Psychiatry. 2008 Apr 1;79(4):368-76.