PD ExpertBriefing The Effects of Exercise on PD PDEB6.3 Exercise.pdf · Benefits of Exercise ! General physical therapy vs. Control ! Exercise vs. Control ! Treadmill vs. Control
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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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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
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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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Resources from PDF
Parkinson’s HelpLine • Available at (800) 457-‐6676 or info@pdf.org • Monday through Friday • 9:00 AM – 5:00 PM ET
PD ExpertBriefings • Gait, Balance and
Falls in PD • Physical Therapy
and PD: What You Need to Know
PD Resource List • 750 Resources,
including chapters on exercise and physical therapy
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Upcoming PD ExpertBriefings
More Than Meets the Eye: Vision Symptoms of PD Tuesday, March 3, 2015, 1:00 PM - 2:00 PM ET Daniel Gold, D.O., Assistant Professor of Neurology and Assistant Professor of Ophthalmology, The Johns Hopkins School of Medicine Maximizing PD Medications: How to Get the Most Out of Your Treatment Plan, Tuesday, April 28, 2015, 1:00 PM - 2:00 PM ET Connie Marras, M.D., Ph.D., Associate Professor of Neurology, University of Toronto, Morton and Gloria Shulman Movement Disorders Centre and the Edmond J. Safra Program in Parkinson’s Disease, Toronto Western Hospital, Canada Challenges of Advanced Parkinson’s and Tips for Better Living Tuesday, June 23, 2015, 1:00 PM - 2:00 PM ET Peter Fletcher, M.B.Ch.B., M.Sc., Consultant Physician, Department of Old Age Medicine, Gloucestershire Hospitals NHS Foundation Trust, United Kingdom
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