The Effects of Exercise on Parkinson’s

Disease
Group 5: Cortney Welch, Chelsea Nagel, and Ethan Skeim
Outline
● Introduction to Parkinson’s disease (PD)
○ Criteria of PD
○ Overview of PD
● Main review article
○ How physical activity (PA) impacts Parkinson’s patients
● Two related articles
○ How the studies were conducted
● Conclusion
○ Summary of articles
● Questions
Parkinson’s Criteria

Detection of bradykinesia and at least one of the following:

● Muscular rigidity
● 4-6 Hz resting tremor
● Postural instability (not caused by primary visual, vestibular,
cerebellar, or proprioceptive dysfunction)

Dayton, W, et.al., Sperling Medical Group, 2016

About Parkinson’s Disease (PD)

- Each and every case is different and

unique to that person.
- Impacts functional capacity, quality
of life(QoL), and activities of daily
living (ADL).
- Affects 7-10 million people
worldwide.
- More common in men than women.

Lauze et al., Journal of Parkinson’s Disease 6, 2016

The Effects of Physical Activity in Parkinson’s
Disease: A Review
Lauze et al.

Highlight health parameters that are most likely to improve

as a result of PA interventions in patients with PD.

Lauze et al., Journal of Parkinson’s Disease 6, 2016

Methods

● PA is advocated as an adjunct intervention for PD. Specific

benefits have yet to be identified.
● Complied multiple studies that examined PA intervention
with PD patients and included statistical analyses.
● Extensive literature search of papers published in 1981-2015.
○ 868 outcome measures (primary & secondary) from 106
papers

Lauze et al., Journal of Parkinson’s Disease 6, 2016

Methods Con.

● Measures were grouped into four main categories:

○ Physical capacities
○ Physical and cognitive functional capacities
○ Clinical symptoms of PD
○ Psychosocial aspects of life
● Criteria for positive effect:
○ Improvement from baseline to post intervention assessment
(p<0.05)
● Effect sizes were compared using a t-test and a significance
threshold at p<0.05.
Lauze et al., Journal of Parkinson’s Disease 6, 2016
Table 1
Physical capacities Overall: 57.2% improvement potential
(a) Lower limbs, trunk, and upper (a) 59.6% , but poor for trunk
limbs strength, endurance, or strength (14.3%)
speed (b) 46.7%
(b) Flexibility or range of motion (c) 52.2%
(c) Motor control (d) 57.1%
(d) Metabolic functions

Physical and cognitive functional

capacities (a) 59.8%
(a) Gait, mobility, posture, and (b) 29%
balance (c) 38.9%
(b) Cognitive functions (d) 59.5%
(c) Depression (e) 41.2%
(d) Activities of daily living (ADL)
(e) Level of activities
Lauze et al., Journal of Parkinson’s Disease 6, 2016
Table 1 Con.

Clinical symptoms of Parkinson’s disease Overall 50% improvement potential

(a) Overall symptoms and disabilities (a) 51.9%
(b) Specific components of UPDRS (b) 38.5%
(c) Specific symptoms of PD (c) 22.2%

Psychosocial aspects of life Overall 45.3% improvement

(a) Quality of life (QoL) (a) 38.1% for specific QoL components
(b) Health management (b) 52.9%

Lauze et al., Journal of Parkinson’s Disease 6, 2016

Results

● Results were either statistically significant with positive effect or no effect.

● Positive results outcome percentages were based on the following scale:
○ 70% excellent, 60-69% very good, 50-59% good, 40-49% fair, 30-39%
poor

● Table 2 displays:
○ Parameters for each category & subcategory.
○ The number of outcome measures that were identified throughout
the review papers.
○ The number of research papers in which they were identified.

Lauze et al., Journal of Parkinson’s Disease 6, 2016

Table 2 Category Number of outcome Positive effect of PA Number of papers
measures intervention

(1) Physical 136 57.2%

capacities
a. Lower limbs 47 59.6% 17

(2) Physical and 485 55.3%

cognitive functional
capacities
a. balance , 121 61.2% 39
posture, and
risk of falls

Motor Examination 45 71.1% 45

(3) Clinical symptoms

of PD
a. Bradykinesia 9 22.2% 7
b. Freezing 7 14.3% 7

Lauze et al., Journal of Parkinson’s Disease 6, 2016

Results con.

● PA seemed to be most effective in improving the physical

capacities and physical cognitive functional capacities. Less
for clinical symptoms.
● Other notable improvements include:
○ Potential for overall improvement 55.3%
○ Gait efficiency 59.8%
○ Balance, posture, and risks of falls 61.2%

Lauze et al., Journal of Parkinson’s Disease 6, 2016

Discussion

● Strengths
○ Several evidence from multiple outcome papers.
○ 1st paper to present compilation of the results published
in the last thirty-four years.
● Limitations
○ Heterogeneity of the studies
○ High variability in PA modalities
○ Possible skewed results

Lauze et al., Journal of Parkinson’s Disease 6, 2016

A Two Year Randomized Controlled Trial of
Progressive Resistance Exercise(PRE) for
Parkinson’s Disease
Corcos et al.

Tested PRE and Modified Fitness Counts (mFC) over 24 months to see
which improved the off-medication Unified Parkinson’s Disease Rating
Scale, motor subscale (UPDRS-III) scores, as well as, other measures
in patients with Parkinson’s disease.

Corcos et al., US National Library of Medicine National Institutes of Health, 2013.

Study Design
● Prospective, parallel-group, single-center, randomized
controlled trial
● September 2007 and July 2011

Corcos et al., US National Library of Medicine National Institutes of Health, 2013.

Participants
● Patients with Parkinson’s disease
○ Self-referred
○ Recruited by Rush University Medical Center(RUMC)
● Recruited:
○ 50-67 years old
○ Able to walk for 6 minutes
○ On stable medication

Corcos et al., US National Library of Medicine National Institutes of Health, 2013.

Methods
● Participated in an exercise program 2 times per week for 24
months.
○ One on one exercise with certified personal trainer for
first 6 months.
○ Only one session with trainer after 6 months.

Corcos et al., US National Library of Medicine National Institutes of Health, 2013.

Methods - Exercise Programs
● Modified fitness counts (mFC)
○ Stretches, balance exercises, breathing, non-progressive
strengthening
● Progressive resistance exercises (PRE)
○ Chest press, latissimus pull downs, reverse flys, double leg
press, hip extension, shoulder press, bicep curls, rotary
calf, tricep extension, seated quadricep extension, and
back extension
Corcos et al., US National Library of Medicine National Institutes of Health, 2013.
 Physician/Self-Referred -70

Randomization
Screened for Eligibility -70

Baseline Testing - 58

Randomized -
48

Modified Fitness Counts - 24 Progressive Resistance Exercise - 24

6 month testing - 24 6 month testing - 24

12 month testing - 23 12 month testing - 23

18 month testing - 22 18 month testing - 21

24 month testing - 18 24 month testing - 20

Corcos et al., US National Library of Medicine National Institutes of Health , 2013.

Study Procedures
● Performed at Clinical Motor Control Laboratory at
University of Illinois at Chicago after 12-hour overnight
withdrawal of medication.
● Completed the assessment, took their medication, had lunch,
and then repeated the assessment 60 minutes later.

Corcos et al., US National Library of Medicine National Institutes of Health, 2013.

Study Procedures Cont.
● Motor signs
○ UPDRS-III
● Quality of life (QoL)
○ Parkinson’s Disease Questionnaire (PDQ-39)

Corcos et al., US National Library of Medicine National Institutes of Health, 2013.

Statistical Analysis
● SAS software, version 9.1
● Two-sided statistical tests, with P value < 0.05

Corcos et al., US National Library of Medicine National Institutes of Health, 2013.

Results
Motor Signs at Each Visit by Treatment Group

Corcos et al., US National Library of Medicine National Institutes of Health, 2013.

Results Cont.

Corcos et al., US National Library of Medicine National Institutes of Health, 2013.

Results Cont.
Quality of Life at Each Visit by Treatment Group

Corcos et al., US National Library of Medicine National Institutes of Health, 2013.

Results cont.

Corcos et al., US National Library of Medicine National Institutes of Health, 2013.

Discussion
● PRE had a greater benefit than mFC on signs of Parkinson’s
disease.
● Based on the findings, PRE should be a central component of
exercise programs for patients with PD that also include
balance training and aerobic exercise.

Corcos et al., US National Library of Medicine National Institutes of Health, 2013.

Strengths
● 20 out of 25 participants completed PRE program.
○ Retention rate was 80%.
● Primary outcome as off-medication
○ Eliminates the confounding effect of variable responses to
medication.

Corcos et al., US National Library of Medicine National Institutes of Health, 2013.

Limitations
● Not double blind
● Small sample
● Single-center study
● No control group was used.
● 2 patients replaced before 6 month mark were not randomly
assigned to a group.

Corcos et al., US National Library of Medicine National Institutes of Health, 2013.

 High intensity eccentric resistance training decreases
bradykinesia and improves quality of life in persons with
Parkinson's Disease: A preliminary study
Dibble et al.

Dibble, et al., Parkinsonism & Related Disorders, 2009.

Purpose

● To compare the effect of high intensity eccentric resistance

training to previously established evidence based protocol in
order to reduce bradykinesia and improve self-reported
quality of life in patients with PD.

Dibble, et al., Parkinsonism & Related Disorders, 2009.

Study Design

● Separate 2(group) x 2(time) ANOVA’s for each

dependent variable with the level of significance set at a
p-value of <0.05.
● Assesses both physiological and psychological outcomes
of treatment to determine clinical significance.

Dibble, et al., Parkinsonism & Related Disorders, 2009.

Participants
● Patients with Parkinson’s Disease
○ Diagnosis of mild to moderate idiopathic PD(Hoehn and
Yahr Stages 1-3)
○ Receiving treatment at movement disorder clinics in local
Salt Lake City, UT area.
● Recruited:
○ Ages 40-85
○ Excluded if they had any history of cardiovascular,
neurological, hematological, or orthopedic condition that
limited ability to conduct interventions.
Dibble, et al., Parkinsonism & Related Disorders, 2009.
Participants Cont.

Dibble, et al., Parkinsonism & Related Disorders, 2009.

Randomization Assessed for Eligibility - 30

Excluded:
- Did not meet inclusion criteria - 6
- Refused to participate - 2
- Other reasons - 2

Matched assessment - 20

Allocated to experimental intervention - 10 Allocated to control intervention - 10

Discontinued intervention - 1

Analyzed: Analyzed:
Within and between group analysis - 10 Within and between group analysis - 9

Dibble, et al., Parkinsonism & Related Disorders, 2009.

Procedures
● 45-60 min, 3 days/week for 12 weeks resistance training
program for experimental and active control group.
● Experimental groups only variance from control is the
substitution of high intensity eccentric quadriceps
contractions.
● Testing and training was performed 60-90 min after
taking PD medication to control for effects of
medication status on functional performance.

Dibble, et al., Parkinsonism & Related Disorders, 2009.

Procedures Cont.

● Quadriceps muscle force

● Gait Speed
● Timed Up and Go
● Parkinson’s Disease Questionnaire-39(PDQ-39)

Dibble, et al., Parkinsonism & Related Disorders, 2009.

Procedures Cont.
● Statistical analysis completed with SPSS Version 13.0
(SPSS Inc., Chicago, IL).
● Quadriceps muscle strength was measured using
unilateral maximum voluntary isometric force(MVIC)
on a KinCom dynamometer (Chattanooga Inc., Hixon,
TN).

Dibble, et al., Parkinsonism & Related Disorders, 2009.

Results Muscle Force

Force (Newtons)

Exp
Pre Post Control
Pre Post
More Affected Less Affected

Dibble, et al., Parkinsonism & Related Disorders, 2009.

Results Cont.
Gait Speed

Gait Velocity (m/sec)

Exp
Pre Control
Post

Dibble, et al., Parkinsonism & Related Disorders, 2009.

Results Cont.

Dibble, et al., Parkinsonism & Related Disorders, 2009.

Results Cont.

Dibble, et al., Parkinsonism & Related Disorders, 2009.

Discussion

● This study demonstrated that a 12 week program of high

intensity eccentric resistance training can improve
muscle force production, reduce bradykinesia, and
improve quality of life in patients with mild to moderate
PD.

Dibble, et al., Parkinsonism & Related Disorders, 2009.

Strengths & Limitations
● Strengths:
○ First study to use resistance training as an intervention to
reduce bradykinesia and improve self-reported quality of life.
● Limitations:
○ Small sample size(n=19) which lessens external validity.
○ Study duration was only 12 weeks so long term impact can’t
be determined without further research.

Dibble, et al., Parkinsonism & Related Disorders, 2009.

Conclusion
● Broad statement
○ Looking at Dibble et al. there was reduction of

bradykinesia ind improved QOL in the absence of

significant changes in the UPDRS-III score after 12 weeks,
but looking at Corcos et al. there was an improvement in
the UPDRS-III score after 6 months. We hypothesize
these improvements to be amplified if high intensity
eccentric resistance training is to be prolonged greater
than 6 months.
References

1. Parkinson’s Disease Guidelines. UK National Institute for Health and Clinical Excellence (NICE).
http://www.nice.org.uk/guidance/CG35
2. Dayton W, Collins P, Smith M, & Selker T. “Measuring Hand Tremor with a Mobile Device.”
https://www.cmu.edu/silicon-valley/research/tech-showcase/pdfs/2010/HandTremor.pdf
3. Lauzé, Martine; Daneault, Jean-Francois; & Duvala, Christian. (2016). The Effects of Physical
Activity in Parkinson’s Disease: A Review. Journal of Parkinson’s Disease, 6(4). 685-698.
4. Corcos DM, Robichaud JA, David FJ, Leurgans SE, Vaillancourt DE, Poon C, Rafferty MR, Kohrt
WM, & Comella CL. (2013). A two-year randomized controlled trial of progressive resistance
exercise for Parkinson’s disease. Mov Disord. 28(9).1230–1240.
5. Dibble LE, Hale TF, Marcus RL, Gerber JP, & LaStayo PC. (2009). High intensity eccentric
resistance training decreases bradykinesia and improves Quality Of Life in persons with Parkinson's
disease: a preliminary study. Parkinsonism & Related Disorders 15(10). 752-757.
 Questions?
Cortney Welch, Chelsea Nagel, Ethan Skeim