PD ExpertBriefing The Effects of Exercise on PD · Exercise: Review underlying issues with a...

  PD ExpertBriefing:

The Effects of Exercise on PD

Led By: Margaret Schenkman, P.T., Ph.D., F.A.P.T.A. Associate Dean for Physical Therapy Education, and Director,

Physical Therapy Program, University of Colorado School of Medicine

  To hear the session live on: Tuesday, January 13, 2015 at 1:00 PM ET.

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If you have any questions, please contact: Valerie Holt at vholt@pdf.org or call (212) 923-4700

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Introduction

Robin Anthony Elliott President

Parkinson’s Disease Foundation

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The Effects of Exercise on PD: Evidence and Unanswered

Questions

Margaret Schenkman, P.T., Ph.D., F.A.P.T.A. Associate Dean for Physical Therapy Education,

and Director, Physical Therapy Program, University of Colorado School of Medicine

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Objectives §  Understand the importance of exercise and

activity for living well with PD

§  Recognize current evidence and gaps in knowledge concerning exercise and activity benefits

§  Appreciate evidence suggesting vigorous activity might have neuroprotective benefits

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‘Exercise’ vs. ‘Activity’ Ø Exercise refers to

specific regimens to improve specific underlying problems (e.g., balance, gait, flexibility etc.); often is supervised

refers to any movement of the body that uses energy (e.g., walking, hiking, gardening)

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Which Is More Important?

§  Exercise – helps correct specific underlying problems that interfere with daily function and lead to falls

§  Activity keeps you going, and is critical after supervised exercise

§  Activity, and particularly vigorous activity, is just as important as structured ‘exercise regimens’

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Known Losses Associated With PD

§  Range of motion, especially of the neck and torso

§  Strength §  Cardiovascular condition

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Functional Axial Rotation

Ø Expected values Ø 117.0 (14.2)°;

40-59 yrs, men Ø 127.8 (10.4)°

40-59 yrs, women

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Which People With PD Are Weak? Comparison of age, gender, BMI matched participants

– UPDRS Motor and force •  < 30 no difference •  > 30: 50% reduction in force production

(quadriceps) – UPDRS Motor and force central activation

•  < 30 no difference •  > 30 significant and substantial difference

Stevens-Lapsley, Schenkman, et al. Neurorehab Neurorepair 2012

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VO2 and Speed of Walking

Treadmill Speed (mph)

0 1 2 3 4

VO2 (m

L/m

in/k

g)

0

2

4

6

8

10

12

14

16

18

20

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Controls

Patients with PD

141990 33 53 69 71 56 3444 22 23 44 44 22 21

Patients, NControls, N

Christiansen et al, Mov Disord. 2009

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Focus of Exercise §  Cardinal signs

– Rigidity –  Tremor –  Bradykinesia –  Postural instability

§  Other impairments – Musculoskeletal (e.g. Range of motion, flexibility,

strength) –  Cardiovascular (e.g., Endurance) –  Balance and Gait – Non-motor (e.g., depression, cognition, sleep)

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Cochrane Collaborative – 2012 §  Physiotherapy vs. placebo or no Intervention §  39 studies in qualitative synthesis; 1518

participants §  24 studies in quantitative synthesis (meta-

analysis) §  Conclusions

– Most short-term benefits were small but of a size that patients would consider meaningful.

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Benefits of Exercise §  General physical therapy vs. Control §  Exercise vs. Control §  Treadmill vs. Control §  Cueing vs. Control §  Dance vs. Control §  Martial arts vs. Control

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Short Term Improvements … §  Gait

– Velocity, step length, two- and six-minute walk

§  Functional reach §  Timed Up and Go §  Berg Balance Scale §  Clinician-rated UPDRS §  Absence of evidence in other outcomes does

not necessarily mean lack of benefit

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Findings From Five Additional Recent Studies

§  Flexibility (Schenkman)

§  Aerobic endurance (Schulman)

§  Resistive strengthening (Corcos; Li)

§  Tai Chi (Li)

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Bottom Line Exercise is important

– Long-term exercise habits are necessary because PD is chronic and progressive

– Most appropriate exercise prescription is not yet known

– Many approaches to exercise provide benefits

•  Balance training improves balance; strength training improves strength; aerobic conditioning improves aerobic condition!

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Activity in PD §  People with PD (n=699) are 1/3 less active

than older adults generally (n=1,959)

§  Activity levels decline with increasing disease severity

§  In a longitudinal study: daily steps declined 12% and moderate intensity walking declined 40% in a year van Nimwegen et al, J Neurol. 2011;258:2214-21. Cavanaugh et al. J Neurol Phys Ther. 2012;36:51-7.

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The ParkFit trial (n = 586) §  A two-year study comparing

–  physical therapy with a specific emphasis on promoting a physically active lifestyle (ParkFit Program)

–  general physical therapy (ParkSafe Program)

§  Included goal setting, overcoming barriers to exercise, recruiting social support, coaching by the physical therapist (PT), and activity monitor with visual feedback for daily activity levels.

§  Lasting change in exercise behavior van Nimwegen et al. BMC Neurol 2010; BMJ 2013;346:f576.

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Outcomes - ParkFit

§  14 day physical activity improved

– 90 min. / week increase with ParkFit

– 30 min. / wk increase with ParkSafe.

§  Walking endurance (6 min walk test) greater at 24 months with ParkFit

van Nimwegen et al BMJ. 2013;346:f576

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Bottom Line Regular activity is important

Ø For sedentary people – just get up and move

Ø For more active people – build up to regular, vigorous activity

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Is Vigorous Activity Important?

§  Midlife, regular exercise reduces risk of subsequent PD

§  Exercise reduces cognitive impairment in older people with / without dementia

§  Animal models – physical exercise enhances brain plasticity

J Eric Ahlskog. Neurology 2011;77;288

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Forced Tandem Biking §  Comparison of forced pedaling rate vs. self

selected rate during tandem biking §  Ten participants, random assignment §  Forced rate – 30 percent greater than the

individual's voluntary rate §  Three sessions (1 hr each) for ten weeks Ridgel et al, Neurorehabliation & Neural Repair, 2009

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Is Exercise Neuroprotective for PD?

Ø Studies are needed in humans but are expensive

Ø Before asking this question, first need to determine: �  What is the best dose of aerobic exercise? �  Does exercise provide benefits for people prior to

initiation of dopaminergic or other dopamine related therapies?

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Current Study - Multicenter Trial Does Exercise Slow PD Symptoms?

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Purpose: Define the right intensity of exercise in preparation for a clinical trial of neuroprotection ¡  Compare aerobic exercise at two intensities and

no exercise ¡  People recently diagnosed with PD; not on

medications for PD ¡  Expect to complete the study (126 participants)

next year ¡  Funded by the National Institutes of Health (NIH)

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¡  Compare two intensities of aerobic ex on a treadmill to no ex §  60-65% HRmax §  80-85% HRmax §  Wait listed control

¡  Exercise 4X / wk for 6 mo. with option to exercise for another 6 mo. Moore et al. Contemporary Clinical Trials 2013;36:90-98

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§  97 participants randomized to date §  61 completed 6 mo. (primary end

point) §  36 completed 12 mo. end point § Only 2 withdrew to date prior to 6

mo. (5 prior to 12 mo.)

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Exercise And Activity Across Stages of PD

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Strategies: Early-Stage PD Live an active lifestyle with continued involvement at home, work and leisure §  Activity: Engage in activities that are fun,

challenge balance, aerobic condition, multi-tasking §  Exercise: Think prevention (e.g., prevent future

falls through treating relevant problems) Ø Begin a general exercise program Ø Aerobic Ø Flexibility Ø Strength

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Strategies: Mid-stage PD Stay active!

§  Activity: Vigorous activity that is fun and safe (e.g., walking program, regular dance, kick boxing)

§  Exercise: Review underlying issues with a professional §  targeted exercise to prevent / reduce musculoskeletal

and cardiovascular problems and falls §  combined training (e.g, balance, strength, flexibility,

aerobic) §  Reduce multi-tasking

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Strategies: Later Stage of PD §  Stay active within abilities!

–  e.g., Walk to get your meds; don’t ask your spouse!!!

§  Activity: Engage in safe fun activities

§  Exercise: May be appropriate to improve balance and even in later stages of PD if able to walk –  Few studies have been published from which to

identify guidelines for intervention Ellis et al: Phys Ther, 2009

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Unsolved Issue •  Adherence to an ongoing program of

exercise and/or activity

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Acknowledgments §  Many participants over many years

§  Many collaborators

§  National Institutes of Health

§ R01 HD043770 and MO1 RR00051

§ R01 NS0743

§  Davis Phinney Foundation

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Thank You!

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Questions and Discussion

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