Parkinson’s Disease May Have Link to Stroke March 2017
Vigorous Exercise May Hold Benefit in Early Parkinson's
Intense, but not moderate, exercise in early-stage disease may delay disease worsening
In the SPARX trial, patients with de novo Parkinson's disease who got regular exercise at 80% to 85% of their maximum heart rate about 3 days a week for 6 months had an average change in their Unified Parkinson's Disease Rating Scale (UPDRS) motor score of 0.3, compared with 3.2 in the usual care group ( These patients -- but not ones who exercised at a moderate heart rate -- reached the study's predefined non-futility threshold with no severe adverse musculoskeletal events. This is the first study to test the effects of high-intensity exercise in de novo Parkinson's disease patients, the authors noted. "High-intensity treadmill exercise can be safely prescribed for patients with Parkinson's disease," they wrote. "Further investigation with a phase III exercise study is warranted to establish efficacy." Miriam Rafferty, PhD, PT, DPT, of Northwestern University, who was not involved in the study, told "This study," she added, "presents an important step to understanding dose-response to treadmill-based endurance exercise interventions for people with Parkinson's disease."
SPARX was a multi-center randomized clinical trial that compared high- and moderate-intensity treadmill exercise with usual care in early Parkinson's disease. Its primary clinical outcome was the 6-month change in participants' UPDRS motor score, assessed by study neurologists. The investigators selected de novo patients to control the potential confounding of medication.
A total of 128 patients participated in the study from May 1, 2012 through Nov. 30, 2015. Participants were 40 to 80 years old, had stage 1 or 2 Parkinson's disease on the Hoehn and Yahr scale, were within 5 years of diagnosis, were not exercising at a moderate intensity more than 3 times a week, and were not expected to need dopaminergic drugs within 6 months.
The researchers randomly assigned 43 patients to high-intensity treadmill exercise (80% to 85% of maximum heart rate), 45 patients to moderate-intensity treadmill exercise (60% to 65% of maximum heart rate), and 40 patients to usual care, which was a wait-listed control group. They instructed the usual care group to maintain exercise habits. They prescribed treadmill exercise for 4 days per week for 26 weeks, anticipating participants actually would exercise 3 days per week. The workout included 5 to 10 minutes of warm-up, 30 minutes of treadmill exercise at the target heart rate, and 5 to 10 minutes of cool-down. The researchers increased patients' exercise frequency and intensity over the first 8 weeks to reach target levels; after that, patients maintained target heart rates by adjusting treadmill speed or incline. Participants used a heart rate monitor to record their exercise intensity. The research team supervised all sessions in weeks 1 and 2. In later weeks, participants downloaded heart rate data and exercised at the study site at least monthly. Patients and study coordinators also had monthly conference calls to ensure patients adhered to the study's protocol.
Over 6 months, both exercise groups met their targeted exercise intensity. Patients in the high-intensity group had average heart rates that were 80.2% of maximum, and patients in the moderate-intensity group had average heart rates of 65.9% of maximum. The high-intensity group exercised an average of 2.8 days a week, while the moderate-intensity group worked out an average of 3.2 days per week. Adverse musculoskeletal events were as expected. In each group, a similar proportion of participants (12% in the high-intensity group, 22% in the moderate-intensity group, and 15% in the usual care group) started using medication before 6 months. Overall attrition was 8.6%. While the mean change in UPDRS motor score in the high-intensity group was 0.3, compared with 3.2 in the usual care group, mean change in UPDRS motor score in the moderate intensity group was 2.0 (95% CI 0.38 to 3.7), indicating that further investigation of this strategy was futile. Rafferty noted that one limitation is that the "vigorous-intensity exercise group experienced more minor adverse events categorized as musculoskeletal and connective tissue disorders. While minor orthopedic injuries and pain can be expected with exercise interventions, they can negatively impact willingness and ability to continue exercising over the long-term." Monthly supervised sessions like the ones outlined in the SPARX study may be a way for real-world clinicians to monitor and address patients' orthopedic injuries, she added. Schenkman and colleagues noted several other limitations to their study. It was highly controlled, with only treadmill training allowed. To make the study easier for patients, the researchers did not measure gait speed, gait endurance, or movement economy. Other forms of exercise like strength training and tai chi also are important in Parkinson's disease, they added, and further research could identify the mix of physical activity with the greatest effect on motor and other symptoms. The SPARX trial was funded by a grant from the National Institute of Neurologic Disease and Stroke, and received additional support from the University of Pittsburgh Clinical and Translational Science Institute, the University of Colorado Clinical and Translational Science Award program, the Nutrition and Obesity Research Center, the National Institutes of Health, and the Parkinson's Disease Foundation.
The researchers reported no conflicts of interest.
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