The exergaming of Parkinson’s

 

The results of a clinical trial published this week not only provide further evidence that exercise has beneficial effects for people with Parkinson’s, but may also be disease modifying.

Researchers in the Netherlands recruited 130 people with Parkinson’s to take part in a study of clinical exercise. The participants were divided into 2 groups – one instructed to do aerobic exercise (an exergaming activity), while the other group was given stretching activities.

After 6 months, the investigators found that the symptoms of the aerobic exercise group had progressed at a slower rate than the other group, suggesting that the benefits of the exercise regime were clinically relevant.

In today’s post, we will review the study, discuss what exergaming is, and explore what may happen next.

 


A sweet ride. Source: Electricbikereview

I recently bought a bike (not the one above). Why? Because I need to get fit.

Honestly, I am so unfit at the moment. Due to a reconstructed foot, running is not an option. The gym and the pool are too expensive and time consuming (read: I’m cheap and lazy).

So I bought a bike, with the goal of getting out into the country side several times a week. And I have to say: I absolutely love it! The freedom of it has been smiling like an idiot, and reminiscing of a younger age when I was less beautiful.

But all kidding aside, cycling is a great way of keeping fit and there is some REALLY interesting Parkinson’s research being done on cycling at the moment.

What do you mean?

Have a look at this video below.

In it, you will see a gentleman with Parkinson’s who has severe gait issues. But when you put him on a bike….

The person who introduced me to this video is Prof Bas Bloem:

Prof Bloem is a consultant neurologist in the Deptartment of Neurology, Radboud University Medical Center in the Netherlands. In 2002, he founded and became medical director of the Parkinson Centre Nijmegen (ParC), and with Dr. Marten Munneke, he went on to develop Parkinsonnet, an innovative health care networks for Parkinson’s patients covering all of the Netherlands which is fast becoming a template for other countries.

In 2018, he was awarded the Cure Parkinson’s Trust Tom Isaacs award winner for his efforts to engage the Parkinson’s community and get them involved in research (Click here to read more about that).

Here is a video of Prof Bloem describing his vision for the future of Parkinson’s care (video kindly provided by Parkinson’s NZ):

Recently Prof Bloem and his team of researchers have taken their interest in this Parkinson’s cycling phenomenon to the next level, and conducted a clinical trial to assess if the cycling could be beneficial with regards to improving the motor symptoms associated with the condition.

The results of their study were published this week:

Title: Effectiveness of home-based and remotely supervised aerobic exercise in Parkinson’s disease: a double-blind, randomised controlled trial
Authors: van der Kolk NM, de Vries NM, Kessels RPC, Joosten H, Zwinderman AH, Post B, Bloem BR
Journal: Lancet Neurology, September 11th
PMID: 31521532

In this study, Prof Bloem and his team wanted to evaluate the effectiveness of aerobic exercise in the form of cycling on relieving the motor features of Parkinson’s. Critically, they wanted individuals to be able to do their exercise in the comfort of their homes.

To do this, they used exercycles that were enhanced with virtual reality software and real-life videos, which provided an exergaming experience.

What is exergaming?

Exergaming is a portmanteau of “exercise” and “gaming”, which uses technology to enhance the exercise experience. An example of this is racing other individuals on an exercycle using a virtual race track which is provided on a TV monitor (even if those other individuals are in a different country).

Below is a video providing some examples of how exergaming is helping kids:

Between February 2015 and October 2017, Prof Bloem and his team recruited 130 people with mild Parkinson’s (Hoehn and Yahr stage ≤2) to take part in the “Park-in-Shape” study. To be eligible for the study, the participants had to do “less than the recommended aerobic exercise for older adults”. This meant that the participants were starting at a similar level of fitness at the commencement of the study.

Oh, and for those readers who are curious about what is recommended for older adults: “vigorous exercise done ❤ times per week, 20 min per session; or moderate exercise done <5 times per week, 30 min per session”.

The recruited participants were randomly assigned to either the ‘aerobic intervention group’ (who trained on a stationary exercise bike at home) or the ‘active control group’ (who performed stretching exercises). The subjects in the two groups were instructed to do their exercise for 30–45 min (30 min aerobic plus 15 min warming up and cooling down), three times per week for 6 months. Both of the groups in the study were clinically assessed before and after the 6 month period and received a motivational app and remote supervision throughout the study to keep them engaged.

The aerobic intervention group were instructed to cycle at a target heart rate of between 50% and 70% of their heart rate reserve, and this was increased as the participants got fitter (but never about 80% of their heart rate reserve).

Hang on a second. What does heart rate reserve mean?

Heart rate reserve (HRR) is the difference between your maximum heart rate (HRMax) and your resting heart rate (RHR). Heart rate reserve is used when determining exercise heart rates.

This is how you calculate it:

Source: Wikihow

Your maximum heart rate (HRmax) is the fastest that your heart can work in beats per minute (bpm). To guesstimate this, simply multiply your age by 0.7, then subtract that result from 207. For example, say I am 39 years old (I wish), to estimate my HRmax, I simply calculate:

207 – (0.7)(39) = 207 – 28 = ~180 bpm HRmax.

And to calculate resting heart rate (RHR), you simpy count your number of heart beats for 30 seconds when you first wake up in the morning and then multiple that number by 2. You can do it 2-3 times and average across the counts. Let’s say, my RHR is 63 bpm (as in the example provided by Wikihow).

So if my maximum heart rate (HRmax) is 180 bpm and my resting heart rate (RHR) is 63 bpm, then my heart rate reserve (HRR) will be 180 – 63 = 117 bpm.

And if 70% of HRR was the target for this clinical study we are reviewing today, then we simply multiply my HRR by 0.7. And we get (117) x (0.7) = 81.9 bpm, and then add your resting heart rate (63 bpm) to get a target rate of 144.9 bpm.

aid24371-v4-728px-Calculate-Your-Target-Heart-Rate-Step-5-Version-5Source: Wikihow

Luckily in the current study, the participants had chest heart monitors which provided immediate feedback to the screens on their exercycles.

So what did the results of the study say?

The results suggest that after the 6 months of these two treatments, there was a statistically significant difference between the groups in their clinical motor scores (as measured by the MDS-UPDRS clinical rating scale in the OFF medication state) of 4·2 points in favour of aerobic exercise (p=0·0020). In other words, while the ‘active control group’ experienced a continued increase in their clinical motor score of 5.6 (indicating further progression of the condition), the ‘aerobic intervention group’ was found to increase their score by only 1·3 points.

This result suggests a slowing of disease progression.

Wow!

Wow indeed. Big WOW in fact!

This is a really exciting result for several important reasons:

  1. It is a positive result!
  2. The results were achieved by peope with Parkinson’s in their own home.
  3. No hard-to-get medication was required.
  4. The results were clinically relevant.
  5. And the participants were fitter at the end of the study as well!

What about non-motor symptoms?

Interesting question.

And Prof Bloem was asked this on social media. His answer:

Prof Bloem and his colleagues are now seeking to determine whether this intervention has long-term effectiveness and also to investigate what possible disease-modifying mechanisms could be involved. And we can be sure that there will be a lot of other research groups investigating this area. So stay tuned.

The race is on!

Source: FS

So what does it all mean?

Researchers in the Netherlands have published the results of a double-blind clinical trial in which participants performed an aerobic exercise routine in their own home and experienced a clinically relevant benefit after 6 months, compared to an active control group. This is a very exciting result.

It is nice to finally have a post on this website that contains immediately applicable content (similar to previous SoPD posts on nutrician/diet – click here to read an example).

It should be noted, however, that the participants in this study were carefully monitored over the 6 month study. While falls were apparently not a problem in the study, but musculoskeletal complaints did occur in both the groups (approximately 10% of participants). Thus, prescribing exercise for patients with Parkinson’s is not without risk and efforts should be made to monitor.

And with the completion of this post, my bike is calling me.

 


The banner for today’s post was sourced from cyclingtips

7 comments

  1. gavinmogan

    Good stuff and great news indeed! I have a few additional observations/recommendations.

    1) Presumably, this means high-intensity exercise is not required for disease modification, which contradicts previous study conclusions.

    2) As an avid exercise specialist and PWP, I speculate that the lack of benefit to non-motor symptoms lies in the relative tediousness and solitude of riding a bike indoors for 6 months, even with the benefit of exer-gaming. I’m a big proponent of stimulating, passionate, neuro-challenging exercise when capable.

    3. Be your own study. Just pay attention to how’s, whats, whens, how much exercise makes you feel. My own exercise practically doubles as meditation.

    4. Prepare yourself for it. Lose yourself in it Take your newly discovered athlete with you!

    5. Nothing wrong with slowing disease progression. But why simply settle for that? Choose exercise and attitude that progress you! Play offense and defense. Less fear of PD, more belief in you!

    Like

  2. jeffreyn

    There is a somewhat similar 12 month trial (N=250) getting underway in the US (Jay Alberts, Cleveland Clinic). The trial is using Peloton bikes and accessories, plus the Peloton website (to record and store the data).

    PwPs in the high-intensity home exercise group will be given an aerobic-intensity target range of 60-80 percent of heart rate reserve, and a cadence target range of 80-90 RPM.

    Recruitment Status: Not yet recruiting

    https://clinicaltrials.gov/ct2/show/NCT04000360?term=NCT04000360&rank=1

    Like

  3. hans

    You made a slight mistake in calculating your excercise target heart rate. You should add your resting heart rate to the percentage heart rate reserve.

    Like

  4. John Turner

    Simon,

    Thank you for delving into such a practical subject as exercise. Unfortunately, the paper is behind a paywall. I can only see the Summary. So, I apologize if the questions I ask are addressed in the rest of the paper.

    As I understand the results, things got worse over the 6 month period, even for the group doing aerobic exercise (MDS-UPDRS motor test, aerobic mean=1.3 points, high, positive is bad).

    What precautions did the researchers take to ensure that the test wasn’t biased by the content of MDS-UPDRS III, I don’t remember this as having any stretching tests.

    Interestingly, 14 years post diagnosis, and always having done lots of fast walking (c. 5 miles per day) I am getting more and more problems crossing stiles, which tends to inhibit the length of my walks. So, I would probably get more benefit from doing stretching exercises.

    Like

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