A.D. Speelman

How might physical activity benefit patients with Parkinson disease

Parkinson disease (PD) is a neurodegenerative disorder characterized by progressive motor and nonmotor impairments. These impairments incline many patients towards a sedentary lifestyle, which has many deleterious consequences. Accumulating evidence suggests that patients with PD might benefit from physical activity and exercise in a number of ways, from general improvements in health to disease-specific effects and, potentially, disease-modifying effects (suggested by animal data). Many issues remain to be addressed, including the need to perform clinical trials to demonstrate these presumed benefits of physical activity and exercise in patients with PD. These trials must also address safety issues, such as an increased risk of falls and cardiovascular complications in more-active patients. Identifying ways to induce a sustained behavioral change, using specifically tailored programs that address potential barriers such as depression, apathy and postural instability, may lead to an improved quality of life in individuals with PD.

Promotion of physical activity and fitness in sedentary patients with Parkinson's disease : randomised controlled trial

Objective To evaluate whether a multifaceted behavioural change programme increases physical activities in patients with Parkinson’s disease. Design Multicentre randomised controlled trial. Setting 32 community hospitals in the Netherlands, collaborating in a nationwide network (ParkinsonNet). Participants 586 sedentary patients with idiopathic Parkinson’s disease aged between 40 and 75 years with mild to moderate disease severity (Hoehn and Yahr stage ≤3). Intervention Patients were randomly assigned to the ParkFit programme or a matched general physiotherapy intervention. ParkFit is a multifaceted behavioural change programme, designed specifically to achieve an enduring increase in the level of physical activity (coaches using motivational strategies; ambulatory feedback). Main outcome measures The primary endpoint was the level of physical activity, measured every six months with a standardised seven day recall (LASA physical activity questionnaire—LAPAQ). Secondary endpoints included two other measures of physical activity (activity diary and ambulatory activity monitor), quality of life (Parkinson’s disease questionnaire—PDQ-39), and fitness (six minute walk test). Results 540 (92.2%) patients completed the primary outcome. During follow-up, overall time spent on physical activities (LAPAQ) was comparable between the groups (adjusted group difference 7%, 95% confidence interval −3 to 17%; P=0.19). Analyses of three secondary outcomes indicated increased physical activity in ParkFit patients, as suggested by the activity diary (difference 30%; P<0.001), the activity monitor (difference 12%; P<0.001), and the six minute walk test (difference 4.8 m; P=0.05). PDQ-39 did not differ between ParkFit patients and controls (difference −0.9 points; P=0.14). The number of fallers was comparable between ParkFit patients (184/299; 62%) and controls (191/287; 67%). Conclusions The ParkFit behavioural change programme did not increase overall physical activity, as measured with the LAPAQ. The analysis of the secondary endpoints justifies further work into the possible merits of behavioural change programmes to increase physical activities in daily life in Parkinson’s disease. Trial registration Clinical trials NCT00748488.

Design and baseline characteristics of the ParkFit study, a randomized controlled trial evaluating the effectiveness of a multifaceted behavioral program to increase physical activity in Parkinson patients

BackgroundMany patients with Parkinsons disease (PD) lead a sedentary lifestyle. Promotion of physical activities may beneficially affect the clinical presentation of PD, and perhaps even modify the course of PD. However, because of physical and cognitive impairments, patients with PD require specific support to increase their level of physical activity.MethodsWe developed the ParkFit Program: a PD-specific and multifaceted behavioral program to promote physical activity. The emphasis is on creating a behavioral change, using a combination of accepted behavioral motivation techniques. In addition, we designed a multicentre randomized clinical trial to investigate whether this ParkFit Program increases physical activity levels over two years in sedentary PD patients. We intended to include 700 sedentary patients. Primary endpoint is the time spent on physical activities per week, which will be measured every six months using an interview-based 7-day recall.ResultsIn total 3453 PD patients were invited to participate. Ultimately, 586 patients - with a mean (SD) age of 64.1 (7.6) years and disease duration of 5.3 (4.5) years - entered the study. Study participants were younger, had a shorter disease duration and were less sedentary compared with eligible PD patients not willing to participate.DiscussionThe ParkFit trial is expected to yield important new evidence about behavioral interventions to promote physical activity in sedentary patients with PD. The results of the trial are expected in 2012.Trial registrationhttp://clinicaltrials.gov (nr NCT00748488).

Evaluation of implementation of the ParkFit program: A multifaceted intervention aimed to promote physical activity in patients with Parkinson's disease

OBJECTIVES We recently completed the ParkFit study, a two-year randomized controlled trial including 586 sedentary Parkinsons disease (PD) patients, that evaluated a multifaceted intervention (ParkFit program) to promote physical activity. The results showed that the ParkFit program enables PD patients to become physically more active, suggesting that this intervention should now be further implemented into clinical practice. To facilitate this process, we here evaluate the implementation of the ParkFit program. METHODS The ParkFit program was evaluated in three ways: (a) experiences of patients and physiotherapists, as investigated using interviews and questionnaires; (b) factors associated with changed activity levels; and (c) subgroup analyses to identify differential effects in subgroups of patients based on baseline physical activity level, age, gender, disease severity, disease duration, and mobility. RESULTS The ParkFit program was well received: 73% of patients indicated they would recommend the program to other patients, and 90% of physiotherapists indicated they wanted to use the ParkFit program in other patients. Multiple forward regression analysis resulted in a model with two variables: less baseline physical activity, and better mobility were associated with larger changes in levels of physical activity (R(2)=38%). The program was effective in almost all subgroups. In women, most sedentary patients and patients with higher disease severity, the estimated effect size was largest. CONCLUSION We conclude that the ParkFit program was effective in almost all specific subgroups. Therapists and patients experienced no major hurdles. Suggestions for improvement are: (1) improve education for therapists with respect to theories about behavioral change; (2) formulate concrete and specific examples of exercise goals; and (3) pay more specific attention to patients with co morbidities, cognitive dysfunction and a lack of motivation during education.

Monitoring of walking in Parkinson's disease: validation of an ambulatory activity monitor

Nearly all patients with Parkinson’s disease (PD) experience gait problems, often already in early disease stages, with clear worsening as the disease progresses. It would be helpful to have a simple and objective tool to quantify gait, both in the laboratory setting and in the patient’s own home environment. This could facilitate clinical decision making, or can be used as outcome measure in clinical trials. It is currently possible to provide very detailed assessments in the gait laboratory, for example using motion analysis systems. While accurate, such evaluations are also expensive, and not necessarily reflective of real-life performance. Moreover, the gait laboratory only documents walking impairments, but does not investigate the subject’s actual walking behavior. To address these limitations, ambulatory gait monitors have been introduced to quantify movements of the limbs or trunk during a prolonged time in daily life. In healthy subjects, ambulatory monitors can record spatiotemporal gait parameters such as stride cycles, numbers of left and right steps, step length and walking speed over ground walking [1]. Later work also concentrated on applying activity monitors in patients with PD [2–4]. However, none of these studies evaluated the ability of activity monitors to estimate walking distances in patients with PD. We therefore evaluated the ability of a simple activity monitor (based on tri-axial accelerometers) to estimate walking distance in PD.

Cardiovascular Responses During a Submaximal Exercise Test in Patients with Parkinson's Disease

BACKGROUND Patients with Parkinsons disease (PD) are physically less active than controls, and autonomic dysfunction may contribute to this sedentary lifestyle. Specifically, an altered cardiovascular response to physical effort may restrict physical activities. OBJECTIVE To assess the cardiovascular responses to a submaximal exercise test in PD patients and controls, 546 sedentary PD patients and 29 sedentary healthy controls performed the Åstrand-Rhyming submaximal cycle exercise test. METHODS Average heart rate was used to estimate maximal oxygen consumption (VO2max). Variables that may affect submaximal activity in PD patients, including disease severity, fatigue, and level of physical activity in daily life, were recorded. RESULTS Fewer PD patients (46%) completed the submaximal exercise test successfully than the controls (86%). The estimated VO2max of patients with a successful test was 34% lower than the controls (p < 0.001). Multivariate regression analyses revealed that higher body weight, lower systolic blood pressure, lower resting heart rate, and lower maximal workload were associated with an increased risk of an inadequate heart rate increase during submaximal exercise (R2 = 27%). PD patients with a successful submaximal exercise test had lower estimated VO2max values than controls. CONCLUSIONS Importantly, half of the PD patients had an inadequate heart rate increase during submaximal exercise, which was likely caused by cardiac sympathetic denervation leading to autonomic dysfunction. PD patients should therefore be screened to identify their limitations in exercise performance. Caution should be applied when prescribing beta blockers, as they might limit physical activities further.