insights

Parkinson’s disease (PD) is a complex and progressive neurological condition that is associated with dopamine deficiency and both motor and nonmotor deficits. While an exact cause of PD is not known and there is no cure, reducing progression of the disease, abating symptomology, and improving quality of life are key treatment goals.

Lifestyle-based and complementary treatments have been explored as adjunctive therapies that support patients with PD. Mind-body therapies such as yoga, qi gong, Pilates, and tai chi and other treatments such as music, art, and acupuncture-related therapies have all shown potential motor and non-motor symptom benefit for patients.^1-7 Therapeutic exercise programs have also shown benefit. From aerobic and strength training to balance and flexibility conditioning, these therapies may be appropriate for a patient’s PD treatment plan to help maintain mobility for everyday activities and to help manage overall disease progression.⁸

Determining the appropriate intensity level of exercise programs is also an important component for personalized PD interventions. Recently, two meta-analyses investigated the efficacy of moderate-intensity self-directed physical activity and high-intensity training on mobility, motor function, and quality of life among patients with mild, moderate, or severe PD. The reported results are compelling and may be pertinent for treatment strategies.

High-Intensity Exercise Programs: Endurance, Strength, and Power

A November 2023 systematic review and meta-analysis (n=13 randomized controlled trials and two clinical trials; 654 total male and female participants; mean age 65.4 years) evaluated the feasibility and effect of high-intensity interval training (HIIT) and other high-intensity exercise programs versus controls on PD symptomology and disease progression among patients with mild, moderate, or severe PD.⁹ The trials were conducted in the US, Canada, Hungary, Brazil, the United Kingdom, Spain, Denmark, and Colombia and included high-intensity exercise protocols in different modalities, including bike training, walking, jogging, and treadmill. Some studies also combined HIIT with strength, power, flexibility, balance, cardiorespiratory endurance, and functional training.⁹

For this meta-analysis, “high-intensity” was defined as 70% or more above an individual’s maximum heart rate (HR_max).⁹ While the interventions of six studies lasted 12 weeks at three sessions per week, the other intervention lengths varied widely from a few sessions to several months; however, on average, the participants trained two to three days per week, with each session lasting 25 to 60 minutes. Most trials compared high-intensity training with moderate-intensity training, a control group, or groups that performed only usual care (i.e., low-intensity training). Against these comparisons, the high-intensity exercise interventions showed the following:⁹

• Overall, using a Parkinson’s disease rating scale (UPDRS) to evaluate motor symptoms, high-intensity exercise significantly improved disease severity by reducing total UPDRS scores (MD = -4.80; CI: -6.38, -3.21) compared to controls.
• Compared specifically to moderate-intensity exercise, high-intensity exercise programs significantly improved disease severity measured by UPDRS (MD = -2.70; CI: -5.06, -0.33).
• As a measurement of cardiorespiratory fitness, researchers analyzed the effect of high-intensity exercise compared to controls on VO2 peak and found that high-intensity exercise participation resulted in a significant improvement in maximum oxygen consumption compared to controls.
• Compared to control groups, high-intensity exercise significantly improved the quality of life of PD patients measured by the Parkinson’s Disease Questionnaire (PDQ-39) (MD = -0.54; CI: -0.94, -0.13).
• Compared to moderate-intensity exercise, the high-intensity exercise programs increased circulating levels of brain-derived neurotrophic factor (BDNF) after training sessions to a greater extent.

In addition to these statistically significant benefits, the investigators also found that training adherence was high for those studies that reported this component, ranging from 66% to 100% participation from the beginning to the end of the interventions.⁹ The researchers concluded that while more detail is needed about adherence and any adverse events related to high-intensity exercise programs among this population, results from this meta-analysis indicate that prescriptions of high-intensity exercises performed as a continuous or interval exercise may be beneficial as part of an individual’s PD treatment strategy.⁹

Moderate-Intensity Self-Directed Physical Activity: Aerobic, Dance, and Flexibility

A meta-analysis with an upcoming publication date of January 2024 (n=15 RCTs; 498 total patients and controls; age range of 56-75 years) investigated the health impacts of self-directed physical activity (SDPA) on patients with early and mid-stage PD in the areas of motor symptoms and quality of life.¹⁰ The included RCTs were conducted in multiple countries, including Korea, Italy, China, Turkey, Brazil, Australia, and the US. The interventions included primarily moderate-intensity exercises and were highly varied in specific exercise modalities. Aerobic exercise, dance, strength and flexibility exercise, strength and focus exercise, Nordic walking, tai chi, gait training, yoga, qigong, and circuit training are all examples of the self-directed physical activities included in the analysis. The intervention durations varied between four and 24 weeks, with activity frequency ranging from one to five times per week. All included clinical trials were compared to a control group, which also varied from usual care to no exercise to low-intensity exercise. Against these comparisons, the moderate-intensity SDPA interventions showed the following:¹⁰

• Overall, researchers found that the exercise therapies significantly enhanced gait function and balance while also improving mobility, function, and postural control.
• Specifically, compared to controls, SDPA interventions significantly enhanced or improved timed up and go (TUG) test results (SMD: -0.55), gait (SMD: 0.38), stride/step length (SMD: 0.56), gait velocity (SMD: 0.42), disease symptomology measured by UPDRS-III (SMD: -0.76), and balance measured by the enhanced Berg Balance Scale (BBS) (SMD: 0.88).
• Investigators noted that the SDPA interventions did not significantly improve freezing of gait (FOG) measurements or quality of life; however, only two included studies reported on quality of life using the PDQ-39.

Based on the meta-analysis results, researchers concluded that SPDA interventions may be beneficial adjunctive therapies for patients with early and mid-stage Parkinson’s disease.¹⁰ In addition, only two studies included adverse event information in their study, with no mention of negative impacts.¹⁰

Conclusion

Research studies continue to define the benefits associated with different types and intensity levels of exercise programs as part of lifestyle-based adjunctive PD treatments. As the evidence expands, clinicians and patients will have additional options for their personalized therapies that aim to slow Parkinson’s disease progression and improve quality of life. To read more about the functional medicine approach to neurodegenerative diseases such as Parkinson’s diseases, please read the IFM-authored articles mentioned below.

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References

1. Mustafaoglu R, Ahmed I, Pang MYC. Which type of mind-body exercise is most effective in improving functional performance and quality of life in patients with Parkinson’s disease? A systematic review with network meta-analysis. Acta Neurol Belg. 2022;122(6):1433-1446. doi:1007/s13760-022-02070-4
2. Yang Y, Wang G, Zhang S, et al. Efficacy and evaluation of therapeutic exercises on adults with Parkinson’s disease: a systematic review and network meta-analysis. BMC Geriatr. 2022;22(1):813. doi:1186/s12877-022-03510-9
3. Aras B, Seyyar GK, Fidan O, Colak E. The effect of tai chi on functional mobility, balance and falls in Parkinson’s disease: a systematic review and meta-analysis of systematic reviews. Explore (NY). 2022;18(4):402-410. doi:1016/j.explore.2021.12.002
4. Lee H, Ko B. Effects of music-based interventions on motor and non-motor symptoms in patients with Parkinson’s disease: a systematic review and meta-analysis. Int J Environ Res Public Health. 2023;20(2):1046. doi:3390/ijerph20021046
5. Cucca A, Di Rocco A, Acosta I, et al. Art therapy for Parkinson’s disease. Parkinsonism Relat Disord. 2021;84:148-154. doi:1016/j.parkreldis.2021.01.013
6. Ettinger T, Berberian M, Acosta I, et al. Art therapy as a comprehensive complementary treatment for Parkinson’s disease. Front Hum Neurosci. 2023;17:1110531. doi:3389/fnhum.2023.1110531
7. Wen X, Li K, Wen H, et al. Acupuncture-related therapies for Parkinson’s disease: a meta-analysis and qualitative review. Front Aging Neurosci. 2021;13:676827. doi:3389/fnagi.2021.676827
8. Ernst M, Folkerts AK, Gollan R, et al. Physical exercise for people with Parkinson’s disease: a systematic review and network meta-analysis. Cochrane Database Syst Rev. 2023;1(1):CD013856. doi:1002/14651858.CD013856.pub2
9. Sena IG, Costa AVD, Santos IKD, et al. Feasibility and effect of high-intensity training on the progression of motor symptoms in adult individuals with Parkinson’s disease: a systematic review and meta-analysis. PLoS One. 2023;18(11):e0293357. doi:1371/journal.pone.0293357
10.  Li H, Cao C, Li Y. Self-directed physical activity interventions for motor symptoms and quality of life in early and mid-stage Parkinson’s disease: a systematic review and meta-analysis. Arch Gerontol Geriatr. 2024;116:105159. doi:1016/j.archger.2023.105159