Physical Training Induced Plasticity of Motor Control Mechanisms in Parkinson's Disease Patients
Condition: Parkinson Disease; Physical Activity
MeSH terms: Parkinson Disease
Study type: Interventional

Summary: 
      There are experimental evidences of the important role of exercise in the PD, that induces
      similar effects to pharmacotherapy. So far, the mechanisms of the impact of these changes on
      the brain subcortical and cortical regions functioning, motor activities and cognitive
      functions are still not clear. The aim of this longitudinal human experiment is to examine
      the effects of cycle of 8-week high-intensity interval training (HIIT) on: (i)
      neurophysiological function of cortical motor structures and skeletal muscle actvity, (ii)
      psychomotor behavior critically associated with dopamine dependent neural structures
      functioning and (iii) neurotrophic factors' secretion level in blood. The investigators will
      recruit 40 PD individuals, who will be divided into two groups: one of them will perform two
      8-weeks cycle of HIIT (PD-TR), and the other will not (PD-NTR). The investigators will
      recruit also 20 age-matched healthy controls (H-CO) as additional control group who will not
      perform the HIIT. All PD subjects will be examined during their medication "OFF-phase" pre
      HIIT and 1 week-, 1 month-POST cycle of HIIT. The subject from H-CO will be tested only once.
      To examine the assumed HIIT-induced changes in brain functioning the investigators will use:
      (i) EEG (recorded simultaneously with EMG) methods to assess an amplitude, location and
      directionality of brain electrical current of cortical regions and strength of intra-cortical
      network interactions during motor tasks performance. During the EEG experiments the subjects
      will perform (i) bimanual anti-phase DA level dependent motor tasks (during which the
      investigators will record EMG, force). The investigators will also assess motor and non-motor
      symptoms of PD and functional test of manual dexterity to evaluate a quality psychomotor
      behavior.

      Using these methods the investigators will determine in detail the mechanisms of functioning
      of the CNS in PD patients, with emphasis on the cortical interactions that are dependent on
      synthesis and DA transmission. The results of the study will help to answer the fundamental
      questions about HIIT induced neuroplasticity in PD patients, as well as complement the lack
      in knowledge about the mechanisms of exercise-induced changes in PD, and as a consequence it
      could enrich the golden standard of treatment in PD from pharmacotherapy toward
      implementation of precise evidence based rehabilitation.
    

Detailed description: 
      I. Research Project Objectives

      Aim 1. To characterize an influence of 8-week HIIT cycle on neurophysiological functions
      (NPFs) of: (i) motor cortical structures, (that are critically dependant on the presynaptic
      DA availability), using EEG, and (ii) skeletal muscles engaged in motor task, using surface
      EMG. The following neurophysiological functions of CNS will be tested during performance of
      the DA availability-dependant self initiated bimanual motor tasks: (i) a level of activation
      of cortical structures, and (ii) strength of functional coupling between neural structures.
      For skeletal muscles NPFs', the investigators will study a strategy of motor units
      activation. Also, since the investigators will record EEG and EMG simultaneously, the
      investigators will assess strength of cortico-muscular coupling.

      Hypothesis 1. NPFs will improve after the 8-week HIIT cycle compared to baseline in the PD-TR
      group, and will sustain one month post HIIT. Namely, the investigators speculate that for the
      motor in CNS activity, it will be: (1) primary motor cortex (M1), supplementary motor area
      (SMA); (2) decrease of activation of lateral premotor cortex (PMC) and cerebellum; with
      simultaneous (3) increase of functional coupling of: dorsolateral prefrontal cortex (DLPFC)
      with M1, PMC, SMA and cerebellum; (4) decrease of functional coupling between M1, PMC, SMA,
      cerebellum and parietal cortex. For the skeletal muscle function it will be an improvement in
      recruitment strategy of motor units. Taking into the data from the simultaneous recording of
      electrical activity of brain cortex and skeletal muscles engaged in motor tasks, the
      investigators assume strengthening of corticomuscular coupling. In the PD-NTR group NPFs will
      not improve or even will be worsened in the same time interval.

      Aim 2. To characterize an influence of the 8-week HIIT cycle on the psychomotor behaviors
      (PMBs), critically dependant on the DA availability and brain's NPFs. The following PMBs will
      be tested during several experiments: (1) self initiated bimanual anti-phase movement tasks
      during the simultaneous EEG, EMG and force recordings (2) all motor and non-motor PD symptoms
      evaluation, based on neurological assessment, (3) overall cognitive function and specifically
      aspects of executive function using psychological tests.

      Hypothesis 2. PMBs will improve after the 8-week HIIT cycle compared to baseline in the PD-TR
      group, and will sustain one month post HIIT, as a consequence of the improvements of
      presynaptic striatal DA availability and NPFs, The PMBs improvement will not be present in
      the PD-NTR group, or even the PMBs will be worsened in the same time interval.

      Aim 3. To evaluate: (i) the effect of the 8-week HIIT cycle on BDNF, NGF, IGF-1 secretion
      level in blood treated as markers of neuroplasticity efficiency (expressed in
      exercise-induced increase of presynaptic DA level, and improvement of NPF' and PMBs).

      Hypothesis 3. The secretion level of the BDNF, NGF and IGF-1 will increase after the first
      and second bout of HIIT cycle compared to baseline in the PD-TR group, and will sustain one
      month post HIIT. In contrary to PD-TR group, the improvement in BDNF, NGF and IGF-1 secretion
      level will not be present in the PD-NTR group or even their level will decrease.

      II. Justification for tackling specific scientific problems by the proposed project.

      II.1. EEG and EMG application to evaluate NPFs of brain cortical structures and skeletal
      muscles II.1.1. A level of activation of neural cortical structures will be evaluated with
      EEG averaging and source analysis (cortical neurons circuits).

      II.1.2. Strength of functional coupling between the neural cortical structures will be
      assessed with EEG-EEG coherence analysis:

      II.1.3. Motor units activation strategy of skeletal muscle engaged during motor task will be
      tested with surface EMG standard analysis and SSA.

      II.1.4. Strength of functional cortico-muscular coupling will be evaluated with analysis of
      coherence between EEG and EMG signals:

      II.2. PMBs will be evaluated based on motor and cognitive tasks performance, and neurological
      and psychological tests/scales:

      II.2.1. Self initiated bimanual anti-phase index finger movements and bimanual dexterity
      tasks will be assessed during simultaneous EEG, EMG and force recordings based on analysis of
      force development, respectively.

      II.2.2. Motor and non-motor PD symptoms evaluation, based on neurological assessment using
      the whole Unified Parkinson's Disease Rating Scale (UPDRS) and Hoehn and Yahr scale (H&Y).
      Also, for the purpose of correlation estimation between the bimanual dexterity function
      described in points II.2.1 the investigators will choose from the UPDRS the scores dedicated
      for manual and bimanual function. Namely, the investigators will analyze parkinsonian
      bradykinesia scores of the affected/more affected upper extremity based on the items 23-25
      from UPDRS (finger tapps, opening and closing hands, pronation-supination hands movement;
      respectively). The investigators will also analyze: (i) a performance of daily life manual
      functions based on the items 8-11 from UPDRS (handwriting, cutting food and handling
      utensils, dressing, hygiene; respectively). Additionally, the investigators will assess the
      quality of life using Schwab and England Daily Living Activity Scale (S&E DLA) (Fahn and
      Elton, 1987).

      II.2.3. Psychological assessment of executive function using two tests: the Trail Making Test
      (TMT) and Stroop Test (ST). In both the TMT and ST tests the time taken to complete the test
      is used as the performance measure with shorter time as better performance. Also, to exclude
      the patients with dementia the investigators will apply Mini Mental State Examination test
      (MMSE) (Folstein et al., 1975).

      II.3. Neurotrophic factors secretion in blood By using the enzyme-linked immunosorbent assay
      (ELISA technique), the investigators will assess secretion of serum BDNF, NGF, IGF-1 in
      blood, that are responsible for neurogenesis, synaptogenesis, angiogenesis.

      III. Work plan The project realization is scheduled for 24 months. The project will enroll
      two PD patients' groups: PD-TR - the PD patients who will perform physical training cycle;
      PD-NTR - non-trained PD patients and one H-CO - healthy control group that will not perform
      the HIIT cycles.

      The project will start with baseline testing session (PRE-HIT) in the both PD groups. Then
      the PD-TR group will perform the 8-week HIIT cycle, and the PD-NTR group will not perform
      HIIT cycle in this time period. Then, 1 week-, and one month post HIIT cycle cessation the
      investigators will perform testing sessions in the PD-TR and PD-NTR group. The healthy
      control group will be tested only in one time point, when the lab space will not be occupied
      with PD patients tests.

      IV. Research methodology

      IV.1. Research design This project will be a longitudinal, randomized (opaque envelopes
      randomization) controlled study with 3 arms. The investigators will recruit 40 PD
      individuals, who will be randomly allocated into two equal groups: PD-TR (N=20) and PD-NTR
      (N=20). The investigators will compare the results from these two groups to explore a
      longitudinal effect HIIT cycles on measurement outcomes. Additionally, the investigators will
      recruit a healthy control group (H-CO; N=20) that will be tested only once, and will
      constitute "healthy state" condition for comparisons with both PD patients groups. The
      comparison of PD-NTR with H-CO will show us the mechanisms of pathological changes in PD
      patients and comparison of PD-TR with H-CO will give us an opportunity to explore the
      character of mechanisms (restoration or compensation) of HIIT induced changes in PD patients.

      The 40 PD individuals, will be qualified to our study after being diagnosed to have an
      idiopatic PD, based on neurological assessment. The diagnosis of Parkinson's disease will be
      based on medical history, physical and neurological examinations and response to L-dopa.
      IV.2.2. Subjects recruitment. The PD subjects will be recruited from Neurology Clinic,
      Wroclaw Medical University (WMU) in Wroclaw, Poland, where the person performing the
      neurological PD patients evaluation in our project (Budrewicz Slawomir, M.D, Ph.D.) is
      employed as movement disorders neurologists and consult PD patients there. Taking into
      account the capabilities and top position of the WMU, the investigators are sure that the
      investigators are able to recruit and finally qualify 40 PD patients. The healthy elderly
      control group of subjects will be recruited based on: (i) public advertisement and (ii)
      contacts with the Universities of the Third Age and the Seniors' Clubs around the Warsaw
      city.

      IV.2. Training procedures The patients from PD-TR group will perform 8-week HIIT cycle. The
      8-week HIIT program will consist of three weekly 1-hour training sessions (each consisting of
      a 10-min warm-up, 40 min of high-intensity interval exercise and a 10-min cool-down phase at
      a slow voluntary speed) performed on a stationary cycle ergometer (MONARK, Ergomedic 874E,
      Sweden) that will measure cadence (revolutions per minute; [rpm]) and power [W]. During each
      training session, the interval exercise will consist of 8 sets of 5-min intervals, including
      3 min of cycling at ≥ 60 [rpm] but preferably at 80-90 [rpm] (fast phase of interval) and 2
      min of cycling at ≤ 60 [rpm] (slow phase of interval). The patients in the PD-TR group will
      be rhythmically cued by a metronome and verbally encouraged by an instructor to pedal with
      the set speed appropriate for the fast and slow phases. The cadence values will be presented
      to each subject in real time on a screen as feedback to control the rpm during the different
      interval phases. The heart rate (HR; beats per minute [bpm]) measured using a Polar system
      (Polar, Finland), cadence [rpm], and power [W] will be monitored and collected during each
      training session. Training supervisor will adjust the resistance for each patient to ensure
      cycling at each patient's target heart rate (THR) and with appropriate speed. PD patients
      will cycle at 60%-75% of their individualized HRmax (maximal heart rate). The PD patients
      will be encouraged to cycle faster (80-90 rpm or 30% faster than their voluntary pedaling
      rate) during the fast phase of interval and to increase his/her THR every 2 weeks by 5% (60%
      of the HRmax during 1-2 week, 65% during 3-4 week, 70% during 5-6 week, and 75% during 7-8
      week of training period). Additionally, the patients' perceptions of the exercise intensity
      (for the fast and slow phases of the interval) will be assessed using the Borg Rating of
      Perceived Exertion (RPE) (Borg, 1982).

      IV.3. Measurement procedures All PD subjects will be examined during their medication
      off-phase, i.e. after an overnight 12-hours withdrawal of anti-parkinsonian drugs (24-hours
      for extended release medications). The testing sessions' sequence for specific methods is as
      follows: 1'st day - (i) blood sampling; (ii) psychological, neurological and functional tests
      -> 2'nd day - (i) EEG + EMG + force.

      IV.4. Statistical analysis The investigators will first perform a between-group comparison
      for all demographics and clinical characteristics to check for baseline differences. This
      will be done using the two-tailed Student's t test or Mann-Whitney U tests for normally and
      non-normally distributed data or the Fisher's exact test for contingency data. Repeated
      measures analysis of variance will be used to perform a between-group comparison of changes
      in the testing points. Significant main effects will then be subjected to a post-hoc
      pair-wise comparison primarily between PD-TR and PD-NTR, and PD-TR and H-CO. Correlation
      analysis (Pearson or Spearman correlation coefficient) will be performed between EEG, EMG
      (describing NPFs), PMBs, and neuroplasticity markers outcomes. For all analyses, a
      significance level will be set to α=0.05 with Bonferroni adjustments for multiple comparisons
      when necessary.
    

Intervention name(s): exercise; conventional physical therapy
Intervention type(s): Behavioral; Behavioral
Intervention description(s): exercised three times a week in the 8-week HIIT program
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Parkinson's disease; intensive interval training; motor function; executive function; neuroplasticity