Parkinson’s Disease Exercise Research
HOW DOES EXERCISE HELP IN PD?
Medical research on the impact of exercise on Parkinson’s disease has produced some exciting results, especially from “goal-based exercise,” which aims to stimulate the development of repairs to areas with particular deficits. These repairs come from “Neuroplasticity” which is the formation of new connections and thus new pathways between nerve cells (called neurons). These new pathways allow the brain to compensate for diseases and adjust to new situations. Sometimes even undamaged neurons form brand-new working pathways: for example, if the left hemisphere of the brain is damaged, the right hemisphere may take over some of its functions.
What makes these new pathways form? Stimulation from activity, such as exercise. Researchers are not sure these new pathways are permanent in PD; they may be temporary effects from the enhanced release of neurotransmitters (signaling chemicals which get formed but then fade, such as dopamine and endorphins). In the meantime, no matter exactly how it works, exercise seems to help brain function in PD.
The literature set out below supports the conclusion that exercise paradigms combining goal-based exercise and aerobic training–vigorous and sustained activity–might work synergistically to promote neuroplasticity and improve motor learning.
1. Scholarly reviews of the scientific literature on exercise and PD
2018 Department of Neurology, Mayo Clinic: Aerobic Exercise: Evidence for a Direct Brain Effect to Slow Parkinson Disease Progression. DOI: https://doi.org/10.1016/j.mayocp.2017.12.015
“Does vigorous exercise have a neuroprotective effect in Parkinson disease?” Review of recent clinical trials published by The Mayo Clinic’s J. Eric Ahlskog, PhD, MD, in Neurology in 2011
“Exercise-enhanced neuroplasticity targeting motor and cognitive circuitry in Parkinson’s disease,” Giselle M Petzinger, Beth E Fisher, Sarah McEwen, Jeff A Beeler, John P Walsh, Michael W Jakowec, Lancet Neurol (2013)(Exercises that incorporate goal-based training and aerobic activity have the potential to improve both cognitive and automatic components of motor control in individuals with mild to moderate disease through experience-dependent neuroplasticity)
“Exercise and neuroplasticity in persons living with Parkinson’s disease,” Mark A. Hirsch, Ph.D and Becky G. Farley, Ph.D,, European Journal of Physical and Rehabilitation Medicine (2009)
“The Cognition-Exercise Interaction in Parkinson’s Disease: A Perspective on Current Rehabilitative Approaches with Promise to Impact the Whole Disease Sequelae,” Nocera JR and Hackney ME, J Gerontol Geriatr Med 2015, 1: 003 (explores possible mechanisms by which exercise may affect cognition in those with PD and lays out a road map for future research on cognitive and motor effects of exercise).
2. Studies and articles supporting the effectiveness of community-based exercise programs to combat PD
“Community-Based Exercise and Wellness Program for People Diagnosed With Parkinson Disease: Experiences From a 10-Month Trial,” Teresa Steffen, PT, PhD, Cheryl Petersen, PT, DHS, Leah Dvorak, PhD, J Geriatr Phys Ter (2012): (free download at bottom of the page)(participants in a long-term community exercise program for people with PD in Wisconsin improved ambulation endurance and maintained walking speed, balance and mobility; program has expanded to 13 locations that are accessible because of low cost and location)
“Promoting exercise in Parkinson’s disease through community-based participatory research,” Mark A. Hirsch, Sanjay S Iyer, Danielle Englert and Mohammed Sanjak, Neurodegener Dis Manag. (2011)(Substantial investments in community infrastructure–supporting and empowering places to exercise–and novel strategies for developing and implementing community-based exercise programs are necessary if we are to expect PWPs to exercise for the long-term starting at diagnosis; we must all work together in multidisciplinary rehabilitation teams with patients and patient advocates in order to achieve this vision)
“Effects of a formal exercise program on Parkinson’s Disease – A pilot study using a delayed start design” A. Park, D. Zid, J. Russell, A Malone, A. Wehr, X. Li, Parkinson and Related Disorders (October 2013)
“Ohio State Study Shows Exercise Improves Depression In Parkinson’s Patients” (findings demonstrate that long-term group exercise programs are feasible in the Parkinson’s disease population. Patients enjoyed exercising, and they stayed with the program that included cardiovascular and resistance training)
3. Studies of the effect of high intensity exercise on PD
“Intensive Rehabilitation Treatment in Early Parkinson’s Disease: A Randomized Pilot Study With a 2-Year Follow-up,” Frazzitta et al., Neurorehabil Neural Repair. 2014 Jul 18 (abstract: intensive exercise in the early stages of the disease might slow down the progression of motor decay, it might delay the need for increasing drug treatment, and thus, it might have a neuroprotective effect).
“The impact of high intensity physical training on motor and non-motor symptoms in patients with Parkinson’s disease (PIP): A preliminary study,” Morberg, Jensen, et al., NeuroRehabilitation. 2014 Jan 1;35(2):291-8 (abstract: a personal high intensity exercise program may favorably influence both motor and non-motor symptoms in patients with mild to moderate PD).
“Forced, not voluntary, exercise improves motor function in Parkinson’s disease patients,” Ridgel AL, Vitek JL, Alberts JL, Neurorehabil Neural Repair (2009)
“Parkinson’s Disease and Forced Exercise: A Preliminary Study,” Abu Qutubuddin, Timothy Reis, Raed Alramadhani, David X. Cifu, Alan Towne, and William Carne, Rehabil Res Pract. (2013) [suggests early enthusiasm about forced exercise may need tempering]
4. The Parkinson’s Outcome Project: The National Parkinson Foundation’s (NPF) Parkinson’s Outcomes Project shows that people with Parkinson’s disease (PD) who start exercising earlier experience a significant slower decline in quality of life than those who start later.
5. Studies demonstrating the effectiveness of particular forms of exercise in combating PD
a. Boxing Training
“Boxing Training for Patients With Parkinson Disease: A Case Series,” Stephanie A. Combs, M. Dyer Diehl, William H. Staples, Lindsay Conn, Kendra Davis, Nicole Lewis, Katie Schaneman, PHYS THER 2011.
University of Indianapolis Provost’s Lecture Features Latest PT Research on Boxing Training and PD: new research by Stephanie Combs-Miller of the University of Indianapolis provides evidence for the first time that people with Parkinson’s disease who participate in boxing training maintain greater physical ability and quality of life than those who participate in other modes of exercise.
“Effects of Dance on Gait and Balance in Parkinson Disease: A Comparison of Partnered and Non-Partnered Dance Movement,” Madeleine E. Hackney, BFA and Gammon M. Earhart, PhD, PT, Neurorehabil Neural Repair (2010)
“Effects of Dance on Movement Control in Parkinson’s Disease: A Comparison of Argentine Tango and American Ballroom,” Madeleine E. Hackney, BFA and Gammon M. Earhart, PhD, PT, J Rehabil Med. 2009
“Dance as Therapy for Individuals with Parkinson Disease,” Gammon M. Earhart, PhD, PT, Eur J Phys Rehabil Med. 2009
c. Tai Chi
“Tai Chi and Postural Stability in Patients with Parkinson’s Disease,” Fuzhong Li, Ph.D., Peter Harmer, Ph.D., M.P.H., Kathleen Fitzgerald, M.D., Elizabeth Eckstrom, M.D., M.P.H., Ronald Stock, M.D., Johnny Galver, P.T., Gianni Maddalozzo, Ph.D., and Sara S. Batya, M.D., N Engl J Med (2012)
Li, F., Harmer, P.; “Tai Chi training to reduce falls in patients with Parkinson’s disease – A cost-effectiveness analysis,” [abstract]. Movement Disorders 2013;28 Suppl 1 :280 (Average healthcare cost of a fall by an older adult is over $18k; preliminary results posted in this abstract indicate tremendous cost savings could be achieved by preventing falls with a tai chi intervention)
“The influence of Iyengar Yoga on the quality of life of patients with Parkinson’s disease“, Rajvi H. Mehta, Maria Barretto, Jimmy Lalkaka, Charu SankhalaScientific, Evidence on the Therapeutic Efficacy of Iyengar Yoga: A Compilation of Research Papers (p. 46) (Preliminary study demonstrated that practice of Iyengar Yoga significantly improves the quality of life of PD patients)
“Effect of Yoga on Motor Function in People with Parkinson’s Disease: A Randomized, Controlled Pilot Study,” Colgrove et al., J Yoga Phys Ther 2012, 2:2 (Findings suggest that yoga practice improves motor function which may be partially explained by improvements in balance, strength, posture and gait)
“Exploring the therapeutic effects of yoga and its ability to increase quality of life,” Woodyard, Int J Yoga. 2011 Jul-Dec; 4(2): 49–54 (study assesses the findings of selected articles regarding the therapeutic effects of yoga and provides a comprehensive review of the benefits of regular yoga practice–not PD-specific).
e. Progressive Resistance Training
“A Two-Year Randomized Controlled Trial of Progressive Resistance Exercise for Parkinson’s Disease, ” Daniel M. Corcos, PhD, Julie A. Robichaud, PT, PhD, Fabian J. David, PhD,Sue E. Leurgans, PhD, David E. Vaillancourt, PhD,Cynthia Poon, PhD, Miriam R. Rafferty, DPT,Wendy M. Kohrt, PhD, Cynthia L. Comella, MD, Mov Disord. (2013) [Abstract]
6. Studies demonstrating the effectiveness of other alternative therapies in combating PD
“Music Improves Motor and Nonmotor Symptoms in Parkinson’s,” Anderson, P. , MedScape Today (July 2011)
Current American Academy of Neurology Guidelines
The current AAN guideline on neuroprotective strategies and alternative therapies for Parkinson’s disease (see below for links) contains a Level C recommendation (“possible effectiveness”) that exercise therapy may be considered to improve function, but notes that the magnitude of observed benefit is small and benefits are not sustained when therapy is discontinued. The physiotherapy interventions included multidisciplinary rehabilitation including standard physical therapy and occupational therapy components; “cued” exercises with visual (mirror), auditory (metronome), and tactile feedback; treadmill training with body weight support; balance training and high-intensity resistance training; and active muscle therapy. The guideline was adopted in 2006 and reaffirmed in 2009 and July 2013, but the underlying report does not cite the results of any clinical trials published after 2003.
The results of many clinical trials relating to the effect of vigorous exercise on the progression of PD have been published in the past decade, and we understand that the AAN is reevaluating an updated evidence-based guideline in accordance with its guideline development process for a recommended protocol regarding the effectiveness of various types of exercise therapy in improving motor function in PD patients. Any new proposed guideline would be subject to a rigorous review, including public comment.
In the meantime, the most recent scientific literature on exercise and PD suggests that practicing neurologists should not wait for an AAN guideline before advising their Parkinson’s patients to step up their exercise regimens. The evidence is mounting that intense exercise–activity outside the patient’s comfort zone–has neuroprotective value, and there is minimal downside to counseling patients to improve their level of fitness. The studies cited in Section 2 below are only a small sample of the work done in the last decade, but the results are compelling.
“Practice Parameter: Neuroprotective strategies and alternative therapies for Parkinson disease (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology,” O. Suchowersky, MD; G. Gronseth, MD; J. Perlmutter, MD; S. Reich, MD; T. Zesiewicz, MD; and W.J. Weiner, MD (April 2, 2006)
American Academy of Neurology Slide Presentation: 2006 Guideline on Neuroprotective Strategies and Alternative Therapies for Parkinson’s Disease (Guideline adopted in 2006 and reaffirmed in 2009 and 2013 without further report)