Exercise prescription as effective as drugs in mild Parkinson’s disease

Movement disorders

By Sunalie Silva

26 Sep 2019

Aerobic exercise can be recommended for patients with mild Parkinson’s disease because it can have symptom-modifying effects similar to that of pharmacotherapy, new research shows.

A randomised controlled exercise trial from the Netherlands compared the effects of a home-based high-intensity aerobic exercise with a non-aerobic active control intervention in 130 patients aged 30-75 years with mild Parkinson’s disease (Hoehn and Yahr stage ≤2).

Patients were eligible for inclusion if they were on stable dopaminergic medication and reported doing less than the recommended aerobic exercise for older adults.

The aerobic exercise group engaged in stationary cycling for three sessions a week for six months, which was enhanced with virtual reality and gamification techniques to encourage adherence. The target heart rate zone began at 50–70% heart rate reserve (HRR) and increased to a maximum of 80% HRR as fitness increased.

Researchers said they opted for cycling because this type of exercise is typically well accepted in patients with Parkinson’s disease, even in those with severe walking difficulties, and has a low risk of falling when patients exercise at home without physical supervision.

The active control group was instructed to do stretching, flexibility, and relaxation exercises three times per week for 30 min per session.

Both groups used a tablet-based motivational app and received remote coaching.

The primary outcome was a change in the Movement Disorders Society–Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) motor section at 6 months, tested during the off state, defined as 12 or more hours after the last dopaminergic medication.

Results revealed a significant and clinically meaningful difference in favour of aerobic exercise of 4·2 points (95% CI 1·6–6·9; p=0·0020) measured during a standardised ‘off state’ (12 h since last dopaminergic medication and, if applicable, deep brain stimulation switched off during measurements).

Researchers said the aerobic exercise had an effect similar to that of several conventional Parkinson drugs in patients with mild severity, noting the effect of levodopa initiated in early Parkinson’s disease ranges between 3·8 and 6·6 points depending on the prescribed dose.

However they acknowledged that home-based strenuous exercise with minimal supervision could increase risk of musculoskeletal injuries, cardiac events, and falls.

“Taken together, our intervention can be considered safe for patients with Parkinson’s disease of mild severity, with a small and acceptable risk of exercise-related injuries,” maintained the researchers.

A linked commentary said the findings strengthened previous evidence on the beneficial effects of aerobic exercise on Parkinson’s disease symptoms.

Associate Professor Terry Ellis from the Department of Physical Therapy & Athletic Training at Boston University  said the SPARX trial of treadmill training involving 128 patients with de-novo Parkinson’s disease had shown a similar statistically and clinically significant decline of the UPDRS motor score in the exercise group compared with usual care.

“The collective evidence suggests that high-intensity aerobic exercise should be recommended in people with mild Parkinson’s disease with the goal of motor symptom modification,” she wrote.

The aerobic nature of the exercise and not the mode of exercise (treadmill walking or cycling) was the ‘crucial ingredient’ she added.

However, benefits beyond the off-state MDS-UPDRS motor scores should be considered when recommending one mode of exercise over another, said Professor Ellis, noting the lack of improvement in motor symptoms during the ‘on state’ in the current study.

“[This] suggests the patients might not notice the gains; if functional changes are not apparent, patients will be much less likely to sustain engagement in exercise over the long term. Improvements in walking outcomes in treadmill exercise trials suggest a potential specificity of training effect.”

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