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Resistance Training With Instability For Patients
Resistance Training With Instability For Patients
ABSTRACT
SILVA-BATISTA, C., D. M. CORCOS, H. ROSCHEL, H. KANEGUSUKU, L. T. B. GOBBI, M. E. P. PIEMONTE, E. C. T.
MATTOS, M. T. DE MELLO, C. L. M. FORJAZ, V. TRICOLI, and C. UGRINOWITSCH. Resistance Training with Instability for
Patients with Parkinson_s Disease. Med. Sci. Sports Exerc., Vol. 48, No. 9, pp. 16781687, 2016. Purpose: This randomized controlled
trial compared the effects of resistance training (RT) and RT with instability (RTI) on the timed up and go test (TUG), on-medication
Unified Parkinson_s Disease Rating Scale part III motor subscale score (UPDRS-III), Montreal Cognitive Assessment (MoCA) score,
Parkinson_s Disease Questionnaire (PDQ-39) score, and muscle strength in the leg press exercise (one-repetition maximum) of patients
with Parkinson_s disease (PD). Methods: Thirty-nine patients with moderate to severe PD were randomly assigned to a nonexercising
control group (C), RT group, and RTI group. The RT and RTI groups performed progressive RT twice a week for 12 wk. However, only
the RTI group used high motor complexity exercises (i.e., progressive RT with unstable devices), for example, half squat exercise on the
BOSU device. The primary outcome was mobility (TUG). The secondary outcomes were on-medication motor signs (UPDRS-III),
cognitive impairment (MoCA), quality of life (PDQ-39), and muscle strength (one-repetition maximum). Results: There were no
differences between RTI and RT groups for any of the outcomes at posttraining (P 9 0.05). However, there were differences between RTI
and C groups in the TUG, MoCA, and muscle strength values at posttraining (P G 0.05). Only the RTI group improved the TUG (j1.9 s),
UPDRS-III score (j4.5 score), MoCA score (6.0 score), and PDQ-39 score (j5.2 score) from pre- to posttraining (P G 0.001). Muscle
strength improved for both training groups (P G 0.001). No adverse events were reported during the trial. Conclusions: Both training
protocols improved muscle strength, but only RTI improved the mobility, motor signs, cognitive impairment, and quality of life, likely
because of the usage of high motor complexity exercises. Thus, RTI may be recommended as an innovative adjunct therapeutic
intervention for patients with PD. Key Words: EXERCISE TRAINING, MOTOR COMPLEXITY, MOBILITY, MOTOR SIGNS,
COGNITIVE IMPAIRMENT, QUALITY OF LIFE
P
arkinson_s disease (PD) is a progressive neurodegen- significant mobility impairment. It has been suggested that
erative disorder characterized by motor (i.e., brady- mobility impairment (postural instability and gait difficulty) is
kinesia, rigidity, tremor, and postural instability) and the main determinant of poor quality of life and disability
nonmotor (e.g., cognitive impairment) signs accompanied by (31), and is a predictor of reduced survival (28) in patients
with PD. However, mobility impairment represents a thera-
peutic challenge because pharmacological treatment (dopa-
Address for correspondence: Hamilton Roschel, Ph.D., Department of Sport, minergic medication) has limited effects (45,46). Therefore,
University of Sao Paulo, Av. Prof. Mello Moraes, 65, 05508-030; Sao Paulo, nonpharmacological treatment strategies, such as physical
SP, Brazil; E-mail: hars@usp.br. exercise, which are able to mitigate mobility impairments in
Submitted for publication October 2015.
Accepted for publication March 2016. PD as well as improve motor signs, cognitive impairment,
Supplemental digital content is available for this article. Direct URL cita- and quality of life, are needed.
tions appear in the printed text and are provided in the HTML and PDF Resistance training (RT) improves muscle strength (39)
versions of this article on the journal_s Web site (www.acsm-msse.org). and quality of life (14,16) in patients with PD. However,
0195-9131/16/4809-1678/0 the positive effects of RT on mobility, motor signs (on-
MEDICINE & SCIENCE IN SPORTS & EXERCISE medication state), and cognitive impairment are equivocal.
Copyright 2016 by the American College of Sports Medicine For instance, no study has observed minimal detectable
DOI: 10.1249/MSS.0000000000000945 changes (smallest amount of difference in individual scores
1678
Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
that represents true change beyond random measurement by a movement disorders specialist in accordance with UK
error) on the timed up and go test (TUG) after RT (38,40). Parkinson_s Disease Society Brain Bank diagnostic criteria
This test has been reported as a sensitive and reliable tool to (24). Eligibility criteria were as follows: 1) Hoehn and Yahr
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assess the mobility of patients with PD (8). Regarding on- stage between 2 and 3, 2) stable medication, 3) age between
medication motor signs, it showed no changes when mea- 50 and 80 yr, 4) not being engaged in any exercise training
sured by the Unified Parkinson_s Disease Rating Scale part III (e.g., aerobic and RT) in the past 3 yr, 5) not presenting with
motor subscale score (UPDRS-III) (13,14,16,23). Finally, a neurological disorder other than PD, 6) and not having
cognitive impairment is highly prevalent in nondemented significant arthritis, cardiovascular disease, and cognitive
patients with PD. Importantly, the decline in cognitive do- impairment by Mini-Mental State Examination (score G23)
mains, such as attention, executive function, visuospatial, and (20). All of the patients were informed of the inherent risks
memory is considered as a predictor of dementia (17,21). and benefits before signing an informed consent form. This
There is one randomized controlled trial reporting cognitive study was approved by the University_s Ethical Committee
improvements (attention and working memory) in patients (approval number2011/12), and it was registered at the
with PD after RT (15). However, no study has investigated National Clinical Trial (www.ensaiosclinicos.gov.br, RBR-
RT effects on several cognitive domains that are predictors 53S3RK).
of dementia in patients with PD. Thus, it is reasonable to
speculate that the limited effects of RT on mobility, motor Experimental Design
signs, and cognitive impairment in PD may be related to the
We conducted a prospective, single-center, parallel-
characteristics of this exercise mode.
group, randomized controlled trial between March 2013 and
There is evidence suggesting that exercises requiring a
September 2014. All of the patients were assessed in the
high degree of attention, memory, and motor difficult (i.e.,
clinically defined on state (fully medicated) within 1.5 to 2 h
high motor complexity) produce higher cortical activation
of taking their morning dose of dopaminergic medication.
than low motor complexity exercises (10,30). Increases in
The primary outcome measure was mobility because deficits
exercise-induced cortical activation are related to improve-
in mobility (i.e., postural instability and gait difficulty) are
ments in motor control and cognitive function in healthy
strongly associated with disability of patients with PD (31).
individuals (10,30). Thus, exercise interventions with high
The secondary outcome measures included motor signs,
motor complexity may help alleviate deficits in mobility,
cognitive function, quality of life, and muscle strength. Out-
motor signs, and cognitive impairment of patients with PD.
come measures were conducted at baseline and following
RT with instability (RTI) is a training mode in which
3 months of intervention in the same order. On the first day, a
conventional RT is performed using unstable devices (e.g.,
physical therapist blind to the experimental design assessed
balance pad, dyna discs, balance discs, BOSU, and Swiss
the motor signs of the patients in accordance with the
ball) (2,47). It may be considered as a high motor com-
UPDRS-III (18), cognitive function with the Montreal Cog-
plexity intervention for patients with PD (see video, Supple-
nitive Assessment (MoCA) (34), and quality of life with the
mental Digital Content 1, which demonstrates the RTI, http://
Parkinson_s Disease Questionnaire (PDQ-39) (36). During
links.lww.com/MSS/A682) because performing RT on un-
the second day, mobility was assessed by the TUG (37).
stable devices (e.g., half squat exercise on BOSU device)
Afterward, patients underwent two familiarization sessions
requires high attentional and motor control demands, and the
and the pretest, separated by at least 48 h with the leg press
production of muscle force necessary to overcome the load
exercise to determine the one-repetition maximum (1RM)
and also maintain stability (2,47,25), which are enhanced
(9). After baseline assessments, patients were classified into
with the concomitant and progressive increase in the degree
quartiles regarding their mobility scores. Patients from each
of instability and load/resistance of the training exercises.
quartile were randomly assigned to the nonexercising control
Therefore, this randomized controlled trial compared the
group (C), RT group, or RTI group.
effects of RT and RTI on the mobility (primary outcome),
motor signs, and cognitive function of patients with PD.
Outcome Measures
Because of the higher motor complexity in RTI than RT,
we hypothesized that RTI would produce greater improve- Mobilityprimary outcome. The patient was timed
ments in mobility, motor signs, and cognitive impairment while he or she rose from an arm chair (seat height 46 cm),
than RT. Other outcome measures included quality of life and walked as quickly as possible at a comfortable and safe pace
muscle strength. to a line on the floor 3 m away from the chair, turned and
walked back to the chair, and sat down again. Time was
recorded from the instant the patient_s buttocks left the chair
METHODS (standing up) until the next contact with the chair (sitting
down). Before the test, the patients performed two famil-
Participants
iarization attempts separated by at least 1 min. After this,
All of the patients were recruited from the Brazil Parkinson two test trials were performed with a 1-min interval between
Association. The diagnosis of idiopathic PD was confirmed trials (37). The shortest time was used for analysis.
RESISTANCE TRAINING WITH INSTABILITY IN PD Medicine & Science in Sports & Exercised 1679
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Motor signs. The UPDRS-III includes 14 items scored Interventions
from 0 to 4 (0 = no motor signs and 4 = severe motor signs).
The C group did not perform any exercise training activ-
Most of these 14 items have right and left scores, resulting in a
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TABLE 1. Location and progression of the unstable devices throughout the experimental protocol (3 months) on each resistance exercise.
Leg Press Latissimus Dorsi Pulldown Ankle Plantar Flexion Chest Press Half Squat
Weeks 1 and 2 Balance padfeeta Balance padfeeta Balance padfeeta Balance padfeeta Balance padfeeta and
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Swiss ballback
Weeks 3 and 4 Dyna discsfeeta and Dyna discsfeeta and Dyna discsfeeta and Dyna discsfeeta and Dyna discsfeeta and
one dyna discseata one dyna discseata one dyna discseata one dyna discseata Swiss ballback
Weeks 5 and 6 One balance discfeeta One balance discfeeta One balance discfeeta and One balance discfeeta One balance discfeeta
and one balance discseata and one balance discseata one balance discseata and one balance discseata and Swiss ballback
Weeks 7 and 8 One balance discfeeta One balance discfeeta One balance discfeeta and One balance discfeeta one balance discfeeta
and one balance discseata and one balance discseata one balance discseata and one balance discseata and Swiss ballback
Weeks 9 and 10 BOSUfeeta and one BOSUfeeta and one One balance discfeeta and BOSUfeeta and one BOSUfeeta and
balance discseata balance discseata one balance discseata balance discseata Swiss ballback
Weeks 11 and 12 BOSUfeeta and one BOSUfeeta and one One balance discfeeta and BOSUfeeta and one BOSUfeeta and
balance discseata balance discseata one balance discseata balance discseata Swiss ballback
a
Indicates the location of the unstable devices for each resistance exercise.
performed for each outcome (TUG score, UPDRS-III score, assessment) decreased after interventions. The significance
MoCA score, MoCA domains, PDQ-39 score, and 1RM level was set at P G 0.05. Results are expressed as mean T SD.
values), having groups (C, RT, and RTI) and time (before SAS 9.2 software (Institute Inc., Cary, NC) was used to
and after) as fixed factors and patients as a random factor perform the statistical analysis.
(43). Whenever a significant F value was obtained, a post hoc
test with a Tukey_s adjustment was performed. Within-group
RESULTS
(pre- to postchanges) and between-group (postchanges) effect
sizes (ES) were calculated using Cohen_s d (12) for each Ninety-one patients volunteered for the study and signed
outcome. ES values were classified as small (ES e 0.49), the written consent. Thirty did not fulfill the criteria (sig-
medium (ES = 0.500.79), and large (ES Q 0.80). Chi-square nificant arthritis and cardiovascular disease) and 15 had
was used to determine whether the proportion of patients family problems that prevented their participation in the
with mild cognitive impairment (score e25 in the MoCA study. Thus, 46 patients performed baseline testing, but one
FIGURE 1Initial (A1) and final (A2) phase of motion in the leg press exercise performed with dyna discs under the feet and one dyna disc under the
seat. Initial (B1) and final (B2) phase of motion in the half squat exercise performed with dyna discs under the feet and one Swiss ball on the back.
RESISTANCE TRAINING WITH INSTABILITY IN PD Medicine & Science in Sports & Exercised 1681
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had back pain, one died, and five did not want to continue the RTI and the C groups at posttraining (MD = j2.5 s; CI,
in the study. Therefore, 39 patients, 13 in each group, com- j4.9 to j0.1; P = 0.038; ES = 1.05) (Fig. 3A).
prised the final sample (Fig. 2). Motor signs. There was a significant grouptime inter-
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At baseline, there were no between-group differences in action for the on-medication UPDRS-III scores (F[2,36] =
any demographic, anthropometric, and clinical characteristic 17.82, P G 0.0001). The RTI group significantly decreased
and outcomes (P 9 0.05) (Table 2). the mean on-medication UPDRS-III scores at posttraining
Both training protocols were well tolerated by the pa- (MD = j4.5 score; CI, j6.1 to j2.2; P G 0.001; ES = 0.55),
tients. No adverse effects were reported during the trial, and whereas the RT group (MD = j1.1 score; CI, j1.3 to 3.3;
adherence to the protocol was high for both training groups P = 0.790; ES = 0.08) and the C group (MD = 1.6 score; CI,
(23.6 T 0.5 sessions (98%) for RT and 23.3 T 0.7 sessions j0.5 to 4.1; P = 0.230; ES = 0.18) showed no significant
(97%) for RTI). changes. The post hoc analysis revealed no between-group
Mobilityprimary outcome. There was a significant differences in UPDRS-III scores (P 9 0.05) (Fig. 3B).
grouptime interaction for TUG (F[2,36] = 34.44, P G Cognitive function. There was a significant group
0.0001). The RTI group significantly decreased the TUG time interaction for the mean MoCA scores (F[2,36] = 41.00,
values at posttraining (mean difference (MD) = j1.9 s; 95% P G 0.0001). The RTI group significantly decreased the
confidence interval (CI), j2.6 to j1.2; P G 0.001; ES = mean MoCA scores at posttraining (MD = 6.0 score; CI, 4.2
0.82), whereas the RT group showed no significant changes to 7.7; P G 0.001; ES = 1.90), whereas the RT group (MD =
(MD = j0.7 s; CI, j1.4 to j0.1; P = 0.054; ES = 0.36). The 0.4 score; CI, j2.2 to 1.2; P = 0.996; ES = 0.11) and the C
C group increased the TUG values at posttraining (MD = group (MD = j1.1 score; CI, j2.8 to 0.6; P = 0.446; ES =
1.1 s; CI, 0.2 to 1.7; P = 0.002; ES = 0.51). The post hoc 0.19) showed no significant changes. The post hoc analysis
analysis revealed differences in TUG values only between revealed differences in MoCA scores only between the RTI
FIGURE 2The trial profile with schematic representation of participant recruitment and allocation.
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TABLE 2. Characteristics of the patients with PD (n = 39) at baseline, by group (mean T SD). and C groups did not present any change from pre- to post-
Characteristics C RT RTI training (P 9 0.05).
Demographic For the MoCA domains, there were significant group
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Men/women (number) 9/4 10/3 10/3
Age (yr) 64.2 T 8.3 64.1 T 9.1 64.2 T 10.6 time interactions for the visuoexecutive (F[2,36] = 8.78, P =
Educational level (yr) 8.7 T 2.1 8.5 T 2.5 8.1 T 3.1 0.0008), attention (F[2,36] = 12.63, P = 0.0001), abstraction
Anthropometrical
Body mass (kg) 69.2 T 11.4 70.8 T 10.1 71.3 T 8.2
(F[2,36] = 9.65, P = 0.0004), delayed recall (F[2,36] = 8.20,
Height (cm) 1.69 T 0.1 1.68 T 0.2 1.69 T 0.2 P = 0.0012), and orientation, (F[2,36] = 3.46, P = 0.0421).
Body mass index (kgImj2) 24.3 T 3.8 25.5 T 5.2 25.0 T 3.0 The RTI group significantly increased the visuoexecutive
Clinical
Mini-Mental State 28.5 T 1.8 28.5 T 1.9 28.8 T 1.7 (P = 0.001; ES = 1.49), attention (P G 0.001; ES = 1.95),
Examination (score) abstraction (P G 0.001; ES = 1.21), delayed recall (P =
Years since diagnosis (yr) 10.7 T 6.1 9.6 T 3.9 10.5 T 4.1
Hoehn and Yahr staging 2.5 T 0.4 2.5 T 0.5 2.5 T 0.4
0.007; ES = 0.49), and orientation (P = 0.031; ES = 1.54) at
scale (a.u.) posttraining. The post hoc analysis revealed differences in
j1
L-DOPA equivalent units (mgId ) 796.7 T 151.3 835.8 T 287.0 875.9 T 223.4
the visuoexecutive (P = 0.018; ES = 1.55) and orientation
Primary outcome
TUG (s) 9.2 T 1.9 9.4 T 2.1 9.5 T 2.4 (P = 0.035; ES = 1.37) only between the RTI and the C
Secondary outcomes groups at posttraining (Table 3).
UPDRS-III (score) 43.4 T 8.6 43.7 T 13.4 45.1 T 8.2
MoCA (score) 22.7 T 5.7 21.8 T 4.3 20.8 T 3.2
Quality of life. There was a significant grouptime in-
PDQ-39 score (%) 41.8 T 14.5 41.3 T 9.5 40.4 T 10.8 teraction for the mean PDQ-39 score (F[2,36] = 19.98, P G
Leg press 1RM (kg) 91.3 T 26.1 90.3 T 23.3 92.4 T 28.5 0.0001). The RTI group significantly decreased the mean
PDQ-39 score at posttraining (MD = j5.2 score; CI, j7.2
to j3.1; P G 0.001; ES = 0.50), whereas the RT group
and the C groups at posttraining (MD = j5.2 score; CI, (MD = j1.2 score; CI, j3.2 to 0.8; P = 0.521; ES = 0.12)
j10.4 to 0.01; P = 0.050; ES = 0.80) (Fig. 3C). and the C group (MD = 0.7 score; CI, j2.7 to 1.3; P = 0.883;
The proportion of patients who scored e25 on the MoCA ES = 0.05) showed no significant change. The post hoc
decreased from 92.3% (n = 12) to 15.4% (n = 2) only for analysis revealed no between-group differences in the PDQ-
the RTI group from pre- to posttraining (P G 0.001). The RT 39 score (P 9 0.05) (Fig. 3D).
FIGURE 3Mean T SD for the TUG (A), UPDRS-III (B), MoCA (C), PDQ-39 (D), and leg press 1RM (E) outcomes at pre- and posttraining for the control
group, RT group, and RTI group. *Different from pretraining values (P e 0.05). #Different from posttraining values of the control group (P e 0.05).
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TABLE 3. MoCA cognitive domains in the pre- and posttraining assessments for each group of patients with PD.
Change from Pre- to Posttraining Difference at Posttraining: RTI vs C Difference at Posttraining: RTI vs RT
Groups MoCA Domains MD (95% CI) P MD (95% CI) P MD (95% CI) P
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Visuoexecutive (score)
C pre 3.6 T 1.3
C post 3.5 T 1.3 j0.1 (j0.4 to 0.5) 0.996
RT pre 3.8 T 1.3
RT post 4.0 T 1.3 0.2 (j0.6 to 0.3) 0.931
RTI pre 4.2 T 0.8
RTI post 5.0 T 0.0 0.8 (0.3 to 1.3) 0.001 1.4 (0.1 to 2.7) 0.018 1.0 (j2.2 to 0.2) 0.206
Naming (score)
C pre 2.8 T 0.4
C post 2.8 T 0.4 0 (j0.2 to 0.2) 1.000
RT pre 2.8 T 0.3
RT post 3.0 T 0.0 0.2 (j0.1 to 0.3) 0.821
RTI pre 2.9 T 0.3
RTI post 3.0 T 0.0 0.1 (j0.1 to 0.3) 0.821 0.2 (j0.5 to 0.2) 0.693 0 (j0.3 to 0.3) 1.000
Attention (score)
C pre 4.4 T 1.5
C post 4.2 T 1.8 j0.2 (j0.8 to 1.2) 0.985
RT pre 3.7 T 1.4
RT post 3.5 T 1.4 0.2 (j1.1 to 0.9) 0.999
RTI pre 3.2 T 1.0
RTI post 5.5 T 1.0 2.3 (1.0 to 3.1) G0.001 j1.1 (j2.7 to 0.4) 0.301 j1.5 (j3.1 to 0.1) 0.076
Language (score)
C pre 2.9 T 0.3
C post 2.9 T 0.3 0 (j0.2 to 0.2) 1.000
RT pre 2.8 T 0.4
RT post 3.0 T 0.0 0.2 (j0.1 to 0.4) 0.331
RTI pre 2.9 T 0.3
RTI post 3.0 T 0.0 0.1 (j0.1 to 0.3) 0.905 0.1 (j0.2 to 0.4) 0.967 0.1 (j0.3 to 0.3) 1.000
Abstraction (score)
C pre 1.8 T 0.4
C post 1.5 T 0.8 0.3 (j0.3 to 0.7) 0.787
RT pre 1.7 T 0.6
RT post 1.8 T 0.6 0.1 (j0.6 to 0.4) 0.998
RTI pre 1.2 T 1.0
RTI post 2.0 T 0.0 0.8 (0.3 to 1.3) G0.001 0.5 (j0.3 to 1.2) 0.470 0.2 (j0.9 to 0.5) 0.942
Delayed recall (score)
C pre 2.4 T 1.9
C post 1.9 T 2.1 0.5 (j0.4 to 1.3) 0.589
RT pre 1.9 T 1.3
RT post 1.8 T 1.2 0.1 (j0.7 to 1.0) 0.994
RTI pre 1.3 T 1.4
RTI post 2.2 T 2.0 0.9 (0.2 to 1.9) 0.007 0.5 (j2.4 to 1.5) 0.978 0.6 (j2.5 to 1.3) 0.928
Orientation (score)
C pre 4.6 T 1.5
C post 4.5 T 1.5 0.1 (j0.8 to 1.0) 0.999
RT pre 4.8 T 1.2
RT post 4.8 T 1.2 0.0 (j1.0 to 0.9) 0.995
RTI pre 5.0 T 0.9
RTI post 6.0 T 0.0 1.0 (0.5 to 1.9) 0.031 1.5 (0.1 to 2.8) 0.035 1.2 (j2.5 to 0.2) 0.153
Pre, pretraining; post, posttraining.
Muscle strength. There was a significant grouptime quality of life of patients with PD from pre- to posttraining
interaction for the leg press 1RM values (F[2,36] = 21.18, P G (Fig. 3 and Table 3). However, RTI and RT both increased
0.0001). The RT and RTI groups increased leg press 1RM maximum strength (Fig. 3).
values similarly at posttraining (MD = 21.7 kg; CI, 7.9 to We hypothesized that RTI would produce greater im-
35.4; P G 0.001; ES = 0.93, and MD = 34.7 kg; CI, 21.0 provements in mobility, motor signs, and cognitive impair-
to 48.5; P G 0.001; ES = 1.22, respectively) whereas the ment than RT. Although we did not observe differences
C group showed no significant change (MD = j6.4 kg; CI, between RTI and RT, only RTI was effective in improving
j7.3 to 20.2; P G 0.720; ES = 0.25). The post hoc analysis these outcomes, which produced significant differences from
revealed differences in the leg press 1RM values only be- the C group at posttraining for mobility, cognitive function,
tween the RTI and the C groups at posttraining (MD = 42.3 kg; and muscle strength. Mobility impairment is strongly asso-
CI, 8.5 to 76.1; P = 0.007; ES = 1.61) (Fig. 3E). ciated with disability (31), and it is a predictor of reduced
survival (28) in patients with PD. Mobility represents a ther-
apeutic challenge because the pharmacological treatment has
DISCUSSION
limited effects on it (45,46). Thus, our results are clinically
This randomized controlled trial showed that only RTI relevant for these patients because lower TUG values (change
improved mobility, motor signs, cognitive impairment, and score of j1.9 s) after RTI were greater than the minimal
Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
detectable change of 1.6 s suggested for patients with PD at with PD. We did not observe changes in any cognitive do-
moderate stages of the disease (27). Such changes have not main after RT (Table 3). However, one previous study
been observed after RT (38,40) or after a modified fitness demonstrated that longer RT intervention (i.e., Q12 months
CLINICAL SCIENCES
counts exercise program consisting of low-intensity of intervention) may improve some cognitive domains in
stretching, constant load strengthening, breathing, and bal- patients with PD, such as attention and working memory
ance exercises (38). Taken together, it is conceivable that the (15). Taken together, these findings support the notion that
improvements not only in muscle strength but also in motor either longer RT interventions or training methods with high
signs and cognitive impairment observed after RTI are nec- motor complexity (i.e., RTI) in short time intervention are
essary to enhance mobility. A recent review suggests that for required to achieve significant improvements in cognitive
optimal mobility in patients with PD, studies should design function as observed in this study.
exercise programs able to improve multiple aspects of the Thus, the improvements in mobility, motor signs, and
postural control system impaired in these patients, such as cognitive impairment were perceived as extremely positive
muscle strength, motor coordination, sensory organization, by the patients of the RTI group. Only this group presented
and cognition (44). Because RTI encompasses most of the robust changes in quality of life (decreased the PDQ-39 score
cited aspects, it is reasonable to suggest that this intervention by j5.2 points) (Fig. 3D). Other studies have demonstrated
is beneficial for improving mobility of the patients with PD. decreases in the PDQ-39 score of j5.1 and j6.5 points after
A recent systematic review suggested that RT can improve 6 months of RT (14) and 3 months of high-intensity eccen-
motor signs of patients with PD (26). However, these findings tric RT (16), respectively. Thus, these findings support the
should be interpreted with caution because on-medication notion that long-term RT (i.e., 6 months) and short-term
motor signs showed no changes when measured by the full training with either high motor complexity (i.e., RTI) or high
UPDRS-III after either 3 months (16,23) or 24 months of intensity (i.e., eccentric RT) are necessary to improve the
RT (14). We found no significant changes in on-medication PDQ-39 score.
UPDRS-III scores after 3 months of RT (Fig. 3B). Taken to- It is important to highlight that both training protocols
gether, these findings suggest that increases in muscle strength increased maximum strength. The RT group exercised using
itself do not cause significant changes in on-medication motor larger loads compared with the RTI group (data not shown).
signs. Thus, interventions that require increased motor com- Despite this fact, the RT and the RTI groups presented
plexity and that also increase muscle strength may be more similar increases in lower limb muscle strength (Fig. 3E).
effective to improve on-medication motor signs because This finding is aligned with electromyography data showing
only the RTI group decreased the on-medication UPDRS-III similar muscle activation when performing chest press ex-
score by j4.5 points, which exceeds the moderate range ercises on a Swiss ball and on a flat bench (3). In this sense,
of clinically important changes in motor signs (41). Improv- RTI may play a great role in joint stability because of high
ing the UPDRS-III score after such a short intervention is muscle activation with the use of lower loads. Thus, because
critical as motor severity progresses on average 3.3 points the training protocols produced similar improvements in
per year (1). maximum strength, although only RTI used high motor
Regarding cognitive function, the overall MoCA score complexity exercises, one may suggest that the improve-
increased ~6.0 points after RTI (Fig. 3C); as a result, there ments observed after RTI in mobility, motor signs, cognitive
was an 84% reduction in the proportion of patients with mild impairment, and quality of life were due to the usage of high
cognitive impairment. To the best of our knowledge, this is motor complexity exercises.
the first study that observed improvements in not only the The present study has some limitations that should be
overall MoCA but also several cognitive domains, such as considered when interpreting our findings. First, the lack of
visuoexecutive, attention, abstraction, delayed recall, and significant differences between RTI and RT groups, despite
orientation in patients with PD after RTI (Table 3). These the robust changes in TUG values after RTI, may have oc-
findings are vital for nondemented patients with PD be- curred because of low statistical power. An exploratory
cause executive function, attention, memory, and visuospa- sample size estimate suggests that a sample of more than 27
tial abilities worsen with PD progression and are predictors patients would be needed to obtain a significant interaction
of the development of dementia (21). Although MoCA has effect for the TUG. Even though the present study had an
been considered as a screening test for dementia and mild appropriate sample size, it is likely that the small improve-
cognitive impairment, it was used as an outcome in this ments in TUG observed in the RT group prevented from
study because evidence has shown that the MoCA can be finding significant differences between RTI and RT groups,
used to observe changes in cognitive function after exercise after the experimental period. However, it should be em-
training in different populations (29,32,33). Moreover, the phasized that we did observe a significant interaction effect,
PD task force recommends the use of MoCA as an outcome because RTI improved TUG values from pre- to posttrain-
measure if evidence demonstrates its ability to detect treat- ing and produced significantly lower TUG values than the
ment effects (11). Our findings in this study demonstrated C group, at the posttraining assessment. Second, it was
that MoCA has indeed the ability to detect the effects of not feasible to blind the patients to the training program, be-
exercise interventions on the cognitive function of patients cause they trained in the same facility. However, the patients
RESISTANCE TRAINING WITH INSTABILITY IN PD Medicine & Science in Sports & Exercised 1685
Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
were blinded to the expected outcomes and the reasons for demands to the CNS (i.e., high motor complexity) in pa-
carrying out the interventions. Third, off-medication as- tients with PD. Therefore, this randomized controlled trial
sessment has been shown to be important in the literature, describes an innovative intervention able to counteract some
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