Report #039

#038 – Parkinson’s Disease Recent Assessment and Treatment Guideline

ByAl-Jallad

Estimated reading time: 3 minutes, 21 seconds.

Guidelines on exercise testing and prescription for patients at different stages of Parkinson’s disease

🎯Aim

  • Review the Parkinson’s disease literature, on exercise testing, personalized training programs, and the impact of exercise on antiparkinsonian drug-treatment.
  • The findings are summarized as indications for exercise-based non-pharmacological approaches to manage PD symptoms in each stage of the Hoehn and Yahr (H&Y) classification.

This review is very long and filled with the most valuable information, you can see how the authors spent a lot of effort and time on it, I’ll be covering some of the recommendations, but you should read the full article here.

📊Results

50 articles included in this review, 20 articles on exercise testing, 24 articles on training protocol prescription, and 7 articles on the interaction between exercise and medication.

Endurance and balance assessment

The following indications are recommended for all patients with PD (1–5 H&Y):

  • PD patients often suffer from cardiac dysrhythmias. • Exercise should start 45–60 min after the medication has been taken.
  • Inquire about changes in medication. • Patients with significant fluctuation should be tested while in the “on” and the “of” status.
  • Individuals unable to perform a GXT (due to risk of falling, severely stooped posture, deconditioning) may require a radionuclide stress test or stress echocardiography.
  • Continuously monitor heart rate, blood pressure, ECG, RPE, and other signs.
  • Standard procedures, contraindications, recommended monitoring intervals, and standard termination criteria are used in exercise testing of individuals with PD.
  • For deconditioned patients with lower limb weakness, compromised balance or a history of falling, precautions should be taken (gait belt, harness, and technician assistance), especially at the final stages of the test when fatigue occurs, and the individual’s walking may worsen.
  • Deep brain stimulation device, if present, should be deactivated to avoid interference with ECG recording. Remember that, without stimulation, the patient will be in a compromised mobile state and will not be able to achieve maximal tolerance (physical discomfort, tremor, cramping, and emotional symptoms).

Resistance assessment

The following indications are recommended for all patients with PD (1–5 H&Y):

  • The standard index for strength assessment is the 1-RM, which is determined after completing a series of submaximal repetitions of a specific exercise.
  • Resistance is initially within the patient’s perceived capacity (50–70% of capacity). Only when the series is completed correctly it can be progressively increased.
  • It may be necessary to use very light weights or substitute them with household items.
  • A metronome is useful to measure how long the patient can keep up with the rhythm.
  • A warm-up phase of 5–10 min is always recommended.
  • Patients at risk for cardiovascular, pulmonary or metabolic diseases should perform adapted tests.

Flexibility assessment

  • Have the patient warm-up before the evaluation and use adapted protocols as needed.
  • Show the patient how to perform the movement being evaluated.
  • Encourage the patient to stretch to the point of slight discomfort without pain.
  • Perform all tests during peak medication when the patient’s mobility is optimal.

General Recommendations:

Clinical testing and training for Early PD diagnosis

Clinical testFrequency trainingIntensity trainingTime trainingType training
EnduranceTUG; Tinetti Balance and Gait Test; RPT; SLST;FRT; BESTest; MiniBESTest; BBS3 days/weekVigorous: 60–89% of HRR, 14–17 on 6–20
RPE scale		45 minProlonged activities, running, cycling, swimming, walking over a variety of terrains and obstacles
ResistanceHST; Isokinetic StrengthTest; MMT; ACT; CST;
FTSTS; 1-RM		3 days/weekHigh: 60–80% 1-RM2–4 sets, 8–12 repetitionsMajor muscle groups exercise, weight machines, other resistance devices, free weights
FlexibilityGoniometer; Inclinome- 30 min/day ter; Leighton flexometer;
SRT; BST		Not beyond the point of
discomfort		60 s for each of the 3
repetitions		Major muscle group and calf stretches, prone lying, static stretches
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Clinical testing and training for Moderate PD diagnosis

Clinical testIntensity trainingTime trainingType training
EnduranceTUG; Tinetti Balance and DailyGait Test; RPT; SLST;
FRT; BESTest; MiniBESTest; BBS		Moderate: 40–59% HRR, 12–13 on 6–20 RPE scale30–40 min in multiple sessionsWalking, cycling, swimming over a variety of terrains, obstacles under supervision and attentional cues
ResistanceHST; Isokinetic Strength 30 min/dayTest; MMT; ACT; CST; FTSTS; 1-RMNot beyond the point of discomfort30–60 s for each of the 3 repetitionsCalf stretches while standing, prone lying and positioning program
FlexibilityGoniometer; Inclinometer; 2–3 days/week, Leighton flexometer; SRT; BSTVery light: < 30 1-RM≥ 1 set, 10–15 repetitions Avoid free weights, Supervised stair climbing, repetitive stepping, orthosis

Clinical testing and training for Advanced PD diagnosis

Clinical testFrequency trainingIntensity trainingTime trainingType training
EnduranceTinetti Balance and Gait Test; RPT; SLST; FRT;BESTest; Mini-BESTestDailyLight: 30–59 of HRR, 9–11 on 6–20 RPE scale20 min or multiple sessionsof 10 minWalking under supervision, with assistive devices and palliative approaches, stationary cycle, arm ergometer with safety harness
ResistanceMMT; FTSTS2–3 days/weekVery light: < 30 1-RM≥ 1 sets, 10–15 repetitionsAvoid free weights Supervised stair climbing, repetitive stepping, orthosis
FlexibilityGoniometer; Inclinometer; Leighton flexometer; SRT; BST15 min twice a dayNot beyond the point of discomfort10–30 s for each repetitionAssisted calf stretches while standing, hamstring stretches while sitting, lying supine or prone

Conclusions

  • The most effective training protocol is the one that combines multiple exercise modalities to be performed routinely during the week and in the long term, to maintain benefits on endurance, resistance, and flexibility.

📥 Recently on Parkinson’s Disease

  • 🎵Music-based movement therapy is an effective treatment approach for improving motor function, balance, freezing of gait, walking velocity, and mental health for patients with Parkinson’s disease. A systematic review and meta-analysis, 2021. (Open Access)
  • 🎮Virtual rehabilitation training patients with Parkinson’s disease significantly improved balance, quality of life, activities of daily living, and depressive symptoms compared to the control group. A systematic review and meta-regression analysis, 2021. (Open Access)
  • 🏗️Interventions with body weight support (BWS) gait training could improve the general and motor clinical severity of patients with PD, as well as other parameters such as stride length and balance. However, the effect does not appear to be statistically significant in improving gait parameters such as velocity, cadence, and distance. A systematic review and meta-analyses, 2021. (Restricted Access)

Thank You for Reading, See you in The Next One.

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