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. DIAL: 1 (888) 272-8710 and enter the passcode 6323567#. To also view the session live on the computer by visiting: http://event.netbriefings.com/event/pdeb/live/exercise/ If you have any questions, please contact: Valerie Holt at vholt@pdf.org or call (212) 923-4700 1
Introduction Robin Anthony Elliott President Parkinson s Disease Foundation 2
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 3
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 4
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) 5
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 6
Known Losses Associated With PD Range of motion, especially of the neck and torso Strength Cardiovascular condition 7
Functional Axial Rotation Ø Expected values Ø 117.0 (14.2) ; 40-59 yrs, men Ø 127.8 (10.4) 40-59 yrs, women 8
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 9
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VO2 and Speed of Walking 22 20 18 Patients with PD Controls 16 VO 2 (ml/min/kg) 14 12 10 8 6 4 2 0 0 1 2 3 4 Treadmill Speed (mph) Patients, N Controls, N 90 19 33 53 69 71 56 34 44 22 23 44 44 22 21 14 Christiansen et al, Mov Disord. 2009 11
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Cardinal signs Rigidity Tremor Focus of Exercise 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) 13
Cochrane Collaborative 2012 Physiotherapy vs. placebo or no Intervention 39 studies in qualitative synthesis; 1518 participants 24 studies in quantitative synthesis (metaanalysis) Conclusions Most short-term benefits were small but of a size that patients would consider meaningful. 14
Benefits of Exercise General physical therapy vs. Control Exercise vs. Control Treadmill vs. Control Cueing vs. Control Dance vs. Control Martial arts vs. Control 15
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 16
Findings From Five Additional Recent Studies Flexibility (Schenkman) Aerobic endurance (Schulman) Resistive strengthening (Corcos; Li) Tai Chi (Li) 17
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! 18
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. 19
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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. 21
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 22
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 23
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 24
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 25
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? 26
Current Study - Multicenter Trial Does Exercise Slow PD Symptoms? 27
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) 28
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 29
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.) 30
Exercise And Activity Across Stages of PD 31
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 32
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 33
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 34
Unsolved Issue Adherence to an ongoing program of exercise and/or activity 35
Acknowledgments Many participants over many years Many collaborators National Institutes of Health R01 HD043770 and MO1 RR00051 R01 NS0743 Davis Phinney Foundation 36
Thank You! 37
Questions and Discussion 38
Resources from PDF 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 Parkinson s HelpLine Available at (800) 457-6676 or info@pdf.org Monday through Friday 9:00 AM 5:00 PM ET 39
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 40
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