Parkinson Disease (PD) is a complex neurodegenerative disorder associated with a wide range of motor and non-motor features that contribute to balance impairment, functional limitation, reduced mobility and early institutionalization. Aerobic exercise is an important adjunct to pharmacological intervention for promoting functions and delaying motor disability progression in PD over long-term (1). For example, aerobic training with treadmill at high intensity (i.e. at 80%-85% of maximum heart rate) has been found to significantly reduce PD motor symptoms (2). However not all people with PD could tolerate such high intensity of exercise training. In addition, people with PD have balance impairment and fall prevention is essential. Therefore we have designed a 6-month low-to-moderate intensity aerobic brisk-walk aerobic training when combined with balance exercises, and we examine the effect of the training program on alleviating PD motor symptoms, and improving balance ability, gait speed and walking capacity among people with PD.

We have recruited 142 participants who were randomized into either brisk walking and balance (BwB) or control (CON) group, and 131 participants (67 BwB and 64 CON) completed 6 months training. In 6 months, BwB group in groups of 6 received 10 sessions of balance training and brisk walking exercise supervised by physiotherapists (targeting at 40-60% heart rate reserve using smartwatch heart rate monitor), while CON group received stretching and strengthening exercises at the same dosage. All participants were requested to performed self-practice in the community at a frequency of 2-3 times weekly during the intervention and follow-up period. All participants were assessed with MDS-UPDRS-III for PD motor symptoms, mini-BESTest for balance ability, gait speed for walking function, and six-minute walking distance (6MWD) for aerobic capacity at post-training (Post6m) and 6-month follow-up (FU6m).

The results showed that at Post6m, only the BwB group significantly decreased MDS-UPDRS-III (-5.5) and increased Mini-Best score (+2.5), gait speed (+14.8 cm/s) and 6MWD (+41.6m) from baseline. At FU6m, only BwB group significantly decreased MDS-UPDRS-III (-6.0), and increased Mini-Best score (+2.1), gait speed (+16.2 cm/s) and 6MWD (+36.4m) from baseline. Six-month attendance was 96.6% with very few adverse effects during intervention/follow-up. Over 70% of participants completed the assigned 150-minute weekly training during the intervention and follow-up period.

Our findings show that aerobic training augmented with balance components plays an important role in alleviating motor symptoms such as rigidity, bradykinesia and postural instability, as well as promoting walking and aerobic capacity in PD. All outcome measures significantly improved after 6 months of training and the effects were carried over to 6 months after training completion.  Importantly, the improvements of MDS-UPDRS-III, gait speed and aerobic capacity at both Post6m and FU6m, exceed the minimal clinically important differences (MCID) (3-5), implying that the improvement is meaningful to people with PD.

The positive findings highlight the importance of task-specific aerobic and gait training.  Moreover, the balance training that comprised repeated practice of weight-shifting, reaching, stepping, turning and coordinated arm and trunk movements enabled the BwB group to outperform the CON group in MiniBEST scores. Our findings in motor symptoms strongly suggest that there was a remarkable alleviation of the motor manifestations with reversal of symptomatic progression. Review findings in animal and human studies which showed improvements in neurochemical and neuroimaging outcomes could account for the disease-modification of PD following aerobic exercise (6).

Our training paradigm consisted of six weekly-supervised sessions for exercise learning, and followed by ‘spaced’ monthly supervision for skill improvement. In addition, mobile devices and digital exercise diaries were used to provide instant feedback for participants. Other motivational factors such as convenient location, low-cost and social support in groups have been adequately addressed to meet their needs. These strategies could have empowered the participants and boosted their exercise adherence with adequate treatment dosage, especially during the follow-up period. These strategies could have enabled BwB group to establish a regular exercise habit that may associate with better clinical improvements.

Combined brisk walking and balance program at low-to-moderate alleviates motor symptoms and improves walking capacity, balance, and gait functions after training completion and carried over to at least at 6 months in people with mild to moderate PD. The use of mobile devices could have empowered people with PD to enhance their exercise compliance.

References:
1. Okada Y, Ohtsuka H, Kamata N, Yamamoto S, Sawada M, Nakamura J, Okamoto M, Narita M, Nikaido Y, Urakami H, Kawasaki T. Effectiveness of long-term physiotherapy in Parkinson’s disease: a systematic review and meta-analysis. J Parkinsons Dis. 2021;11(4):1619-1630. doi: 10.3233/JPD-212782.
2. Schenkman M, et al. Effect of high-intensity treadmill exercise on motor symptoms in patients with De Novo Parkinson disease. JAMA Neurol 2018;75:219–226.
3. Steffen T, Seney M. Test-retest reliability and minimal detectable change on balance and ambulation tests, the 36-item short-form health survey, and the Unified Parkinson Disease Rating Scale in people with parkinsonism. Phys Ther. 2008;88(6):733-746. doi:10.2522/ptj.20070214.
4. Horváth K, Aschermann Z, Ács P, et al. Minimal clinically important difference on the Motor Examination part of MDS-UPDRS. Parkinsonism Relat Disord. 2015;21(12):1421-1426. doi:10.1016/j.parkreldis.2015.10.006.
5. Bohannon RW, Crouch R. Minimal clinically important difference for change in 6‐minute walk test distance of adults with pathology: a systematic review. J Eval Clin Pract. 2017;23(2):377-381. doi:10.1111/jep.12629
6. Li JA, Loevaas MB, Guan C, Goh L, Allen NE, Lv J, Mak MY, Paul SS. Does exercise attenuate disease progression in people with Parkinson’s disease? A systematic review with meta-analyses. Neurorehabilitation and Neural Repair 2023; 37(5): 328–352 DOI: 10.1177/15459683231172752

Margaret KY Mak PhD is an Adjunct Professor, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University. She has presented at previous WPCs both as a faculty and abstract presenter.

Ideas and opinions expressed in this post reflect that of the author solely. They do not reflect the opinions or positions of the World Parkinson Coalition®