# Exercise as it relates to Disease/Does balance training and high intensity resistance training benefit people with idiopathic Parkinson's disease?
## What is the background to this research?

- Idiopathic Parkinson’s Disease (IDP) is a common neurodegenerative illness which negatively affects the human brain, muscles and movement. The illness weakens the muscles and gradually immobilises functions of the body. This occurs due to the loss of dopamine neurons in the substantia nigra, which is involved in the regulation of movement. Although the cause of this disease is unknown, certain factors can increase risk of IDP. Symptoms and signs include having slow bodily movements, tremor, rigidity and postural instability. Due to these symptoms, people with IDP have a higher rate of falling and risk of injury.
- The resistance training component of this intervention focuses on increasing strength of the knee extensors, knee flexors, and ankle plantar flexors, as these are the main muscles required in the maintenance of optimal stability.
- The balance training component was measuring the individual’s stability under somatosensory sensory conditions and altering their vision.
- This issue is still important for people with IDP as it continues to arise, and many people still do not understand the impact of IDP has on patients. Physical inactivity is common among elderly individuals, which can be quite detrimental as balance and strength can deteriorate in people with IDP. This is why incorporation any type of physical activity (PA) is beneficial in slowing down the process of this disease.

## Where is the research from?

- This study was completed by the Department of Physical Medicine and Rehabilitation at Johns Hopkins University Medical Centre in Baltimore, US.
- The study was approved by the Human Subjects Committee of Florida State University in order for them to continue.
- All the participant’s and their primary care physicians gave written and informed consent.
- The study was conducted by four authors with varying expertise and accreditations, Mark A Hirsch, Tonya Poole, Charles G Maitland and Robert A Rider.
- These four authors have previously worked on a study together related to parkinsonism.

## What kind of research was this?

- The study was a randomized control trial which took a period of 10 weeks in order to test the effects of balance training by itself or combined with high resistance training in improving balance and muscular strength in patients with IPD.
- The 15 participants chosen for the study were all recruited from the Big Bend Parkinson’s Disease Support Group in Tallahassee.
- These participants were only eligible if they had been diagnosed with IPD by their neurologist, and if they had not partaken in any other balance or resistance training activities prior to this study.

## What did the research involve?

- The study involved 15 patients, seven people performing balance training by itself and six people performing both balance and high resistance training.
- All participants begun by going through baseline testing, pre-test for balance on one day, and then another pre-test for muscular strength on another day.
- Balance was measured through a computerised dynamic posturography test, which analyses an individual’s balance control and determines the patient’s response to the different balance exercises given (Sensory Orientation Test [SOT]).
- Strength was measured by the amount of weight the patient could lift during a 4-repetition max test of knee extension, flexion and ankle plantarflexion. Participants continued to take their required medication throughout the study and begun their training two hours after they have consumed their morning dose.
Intervention :
| Balance Training | High Resistance Strength Training |
| - 30 minutes per day. - Three non-consecutive days per week. - The first area consisted of standing with feet shoulder width apart on foam using medium density foam pads. - The second area was the exact same except performing flat on ground. - The exercises included standing with both feet shoulder-width apart with eyes open, eyes closed, neck neutral or neck extended for 20 seconds. This was repeated 5 times. - Foam training consisted of the same training except had to be performed on a single thick piece of foam, with the gradual progression of adding more layers of foam. | - 15 minutes per day - Three times per week. - Concentric and eccentric muscular contractions in a 4-repition max test. - The 4-rep max test consisted of the seated participant lifting the weight 4 times and performing knee extension, knee flexion and ankle extension. - This was done on a standardised weight and pulley system beginning from the lowest weight and gradually added more weight and having a rest period of 30 seconds between each set. - This test was finished when the patient was unable to perform a 4-rep max. |

## What were the basic results?

- Balance analysis included the summary balance score from the SOT, latency to fall and proportion of trials resulting in falls.
- Strength analysis included the muscular strength of the knee extensors, knee flexors and ankle plantar flexors.
- These were all measured at baseline, after the intervention was finished and four weeks after the study was finished. At baseline testing, characteristics between both groups did not differ significantly.
Important Findings:
* Balance training improved performance on the summary balance measure from the SOT. The combined group had a significantly higher mean compared to balance group. Effect was greater by the addition of resistance training.
* The intervention increased latency to falling and reduced the amount of trials resulting in falls, this effect continued for at least 4 weeks. Latency to fall was increased by 15% and percentage of trials resulting in falls had decreased by 20%, this result remained the same for 4 weeks post-treatment.
* Although the balance group’s main focus was not to increase strength, both groups had an increase in muscular strength post treatment, but the combined group had a significantly higher score. The combined group increased strength in those three components by 52% with the balance group having an increase by 9%. Overall, muscular strength was increased, and this effect also continued for at least 4 weeks post-treatment.
* The benefits of the intervention post-treatment had also continued for 4 weeks, even if the participants did not continue with their training.

## What conclusions can we take from this research?

- Currently, there is no cure in preventing this disease, but this study had proven that utilising both resistance and balance training is beneficial and can improve muscular strength and balance within an individual’s with IDP. As IDP impairs these features, incorporating the regular use of balance training by itself or with strength training can help to slow down the process.
- All the points the intervention was targeting at had all resulted in positive outcomes with an increase in strength or an improvement in balance. Although, the intervention had been proven to be beneficial for people with IDP, the intervention could have been simplified for the target audience: elderly people.
- Comparing this study to other research papers relating to Parkinson’s and PA, majority of the studies have shown that incorporating PA into one’s daily routine is extremely beneficial.

## Practical advice

- Patients should seek medical advice from their doctor and take the recommended medication needed to treat IPD.
- Any type of PA is useful for the patients as long as they are moving their body and using their motor skills. The main goal is to make sure they implement exercises that improve on balance or strength which can be done through keeping the exercises simple and entertaining. This can be done with partners or in a group, where if help is needed, it can be given.
- To improve upon balance within people with IDP, balance exercise such as standing on one leg for a certain time limit is extremely beneficial.
- To improve on muscular strength for adults with IDP, performing exercises focused on lower extremity is beneficial in increasing strength and maintaining optimal balance. Examples of body weight lower body exercises include squats, lunges or holding a wall sit.
- Training sessions should last at least 15 - 30 mins.
- Training should be performed on three non-consecutive days to decrease risk of injury.

## Further information/resources

Further Readings:
- About Parkinson's Disease
- Postural Control in Elderly subjects with Balance training
- Strength Training in Parkinson's Disease
- Physical Activity for people with IPD
Support Groups for patients with PD:
- https://www.parkinson.org/
- https://www.parkinsonsnsw.org.au/services/support-groups/

## References

* ↑ Nussbaum R, Ellis C. Alzheimer's Disease and Parkinson's Disease | NEJM. New England Journal of Medicine. 2003
* ↑ Dauer W, Przedborski S. Parkinson's Disease: Mechanisms and Models. Cell Press. 2003;39(6):889-909.
* ↑ Schapira A. Neurobiology and treatment of Parkinson’s disease. Cell Press. 2009;30(1):41-47.
* ↑ Pickering R, Grimbergen Y, Rigney U, Ashburn A, Mazibrada G, Wood B et al. A meta-analysis of six prospective studies of falling in Parkinson's disease. Movement Disorders. 2007;22(13):1892-1900. It has been hypothesized that performing balance training and/or resistance training can aid in the prevention of some of these symptoms.
* ↑ Hirsch M, Toole T, Maitland C, Rider R. The effects of balance training and high-intensity resistance training on persons with idiopathic Parkinson’s disease. Archives of Physical Medicine and Rehabilitation. 2003;84(8):1109-1117.