The Relationship between Exercise

1
The Relationship between Exercise Brain
Function The Parkinsons Example

• Dr. Quincy Almeida
• Movement Disorders Research Rehabilitation
  Centre
• Wilfrid Laurier University

2
Parkinsons Disease

• Progressive neurondegenerative process
• Death of dopamine-producing cells in the basal
  ganglia
• Shortage of striatal dopamine
• Motor dysfunction
• Cardinal symptoms of Parkinsons disease
• Tremor
• Rigidity
• Bradykinesia
• Akinesia/Freezing
• Postural instability
• Secondary issues
• Weakness (force production?)
• Fatigue
• Pain

3
What is the link to aging?

• Parkinsons neurodegeneration might represent
  accelerated aging (Anderson et al., 2007)
• Motor Symptoms slower movement, stiffness, poor
  posture, balance gait defecits
• Cognitive Decline memory, confusion,
  hallucinations, dementia
• Autonomic function - bladder control,
  constipation, cardiovascular issues

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Understanding deficits from a practical
perspective

• Lower limb control in Parkinsons disease
• Slower shorter shuffling steps
• Freezing
• Stooped posture
• Postural instability
• When is walking most affected in PD?
• Confined/crowded spaces
• - Kitchen/Bathroom
• - Shopping Mall
• - Doorways/Elevator doors
• - Changes in floor surface
• Related issues?
• Visual processing
• Attention/Distraction
• Darkness
• Depth Perception

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Perceptual processing impairment

• Measure visual processing speed without
  confounding it with movement speed
• PD require 50-60msec to inspect their
  environment

Johnson Almeida et al., Neuropsychologia, 2004
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Does space perception cause freezing?

• YES!?!
• Step length base of support hint that freezers
  are affected by narrow door
• BOS data shows non-freezers show similar traits
  to freezers

(JNNP, In press)
7
Neuropsychological impairment?

• Loss of ability to link meaning to movement
• May not know how to use a tool even though
  recognized visually
• Movement errors increase with disease severity

8
Neuropsychological impairment?

• Gestural performance seems particularly
  challenging for Parkinsons patients with eyes
  closed
• This may point to issues with sensory perception

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Upper limb coordination impairment?

• Coordination between hands is influenced by
  medication
• Vision of hands appears to help coordination PD
  OFF only

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• How might we translate our understanding of
  underlying causes into treatment strategies?

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Limitations of Medications(Almeida Hyson,
RPCN, 2008)

• Dopamine replacement therapy
• Wearing off with prolonged use
• Motor fluctuations difficulty maintaining
  optimal dose
• Increased potential for dyskinesia
• Dopamine agonist therapy
• Not as effective
• Associated with addictive and compulsive
  behaviours
• Potential valvular dysfunction (regurgitation)
• Both medications strategies associated with
• Decline in cognitive function (memory,
  hallucinations)
• Postural hypotension and poorer overall BP control

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Why exercise for Parkinsons disease

• Why use physical exercise to help a neurological
  disorder?
• Rats and mice induced with Parkinsons disease
  and made to exercise (run on treadmill) (Sutoo
  Akiyama, 2003 Tillerson et al., 2003 Vaynman
  Gomez-Pinilla, 2005)
• Increased dopamine levels
• Increased brain plasticity
• Unfortunately, inconsistent results in humans
• Varied outcome measures
• Different lengths of training period
• Unable to compare trials

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How does exercise influence the cardinal symptoms
of PD?
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Methods

• How do we measure improvement in Parkinsons
  disease?
• Development of an assessment tool is a primary
  objective for the MDRC
• Clinical Exam (Blinded) Functional Outcome (TUG)
• Gait/Balance Upper limb function (GP)
• Self-Report Physiological Measures
• Strength Cognitive function

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Measures

• Gait Dynamic Balance
• Computerized carpet
• Collects all spatiotemporal characteristics of
  gait
• Velocity
• Step length/width
• Centre of pressure excursions
• Grooved Peg Board
• Placing phase
• Measure of accuracy and coordination
• Requires fine visuomotor control
• Removal phase
• Measure of speed because requires less fine motor
  skill

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Methods

• How do we measure improvement in Parkinsons
  disease?
• Development of an assessment tool is a primary
  objective for the MDRC
• UPDRS (blinded-rater) Functional Outcome
  (TUG, GP)
• Gait/Balance Upper limb function
  (GP)
• Self-Report Physiological
  Measures (HR,BP,VO2)
• Strength Tremor

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Methods

• 4 sites across Ontario (progressively farther
  away)
• Movement Disorders Research Rehab. Groups
• Multiple groups plus control group
• YMCA Kitchener
• YMCA Cambridge
• YMCA Oakville
• Hundreds of participants across Ontario
  exercising 3 x per week
• Variables
• Type of exercise (Strength, Aerobic, Pool, PD
  SAFEx)
• Number of weeks (8, 12, 24, 52)
• Attendance (100, 90, 66)

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Exercise Trials at MDRC

• Multiple sites involving 200 individuals with PD

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PD SAFEx group - Clinical Assessment
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Functional Outcomes (TUG)
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Place Phase of Grooved Pegboard
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Removal Phase of Grooved Pegboard
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Self-rating of symptom improvement
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Results so far

• Nearly all groups self-report improvement
• In spite of least symptom improvement (i.e. Pool
  exercise, controls)
• Quantitative assessment tools appear to be
  helpful in determining influence of exercise on
  PD
• Results suggest PD SAFEx training may be the most
  effective rehabilitation strategy for PD
• Are there benefits from aerobic and resistance
  training?
• Strength training does appear to improve strength
• Aerobic benefits for aerobic training

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Strength Improves over time
24 wk
12 wk
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Treadmill training for PD?

• HR data indicates improved capacity after
  training
• BUTLittle improvement in disease severity from
  aerobic training
• (Movement
  Disorders, 2009)

Vo2/kg indicates improved efficiency after
training
27
Visual feedback during treadmill training for PD?

• Improvement in HR and VO2
• BUT, no improvement in disease severity or step
  length!

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Further Questions Directions

• Assessment battery needs to be further validated
• Canada takes lead on an international standard
• Can patients maintain at home after 12 weeks?
• Combinations of aerobics plus SAFEx?
• PD SAFEx appears to provide the most benefit to
  PD patients
• Does eyes closed really make a difference?

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Visual Compensation for Proprioceptive Defecit?

• 26 PD participants exercise for 12 wks, followed
  by a 6 week non-exercise washout
• 13 EYES CLOSED -13 EYES OPEN
• Maintained consistency
• Primary outcome measure
• Symptom severity (UPDRS)
• Secondary measures
• Grooved pegboard
• Timed-up-and-Go
• Step length, velocity of self-paced gait

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Does closing the eyes really matter?
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Secondary Measures

• Grooved pegboard Improves for both groups on for
  affected limb only
• Gait Velocity and step length improves for both
  groups
• Timed-Up Go Faster times in both groups
• Overall, symptom severity is the ONLY measure
  influenced by vision!

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Discussion

• Improved musculoskeletal function?
• Minimal non-aerobic, non-strengthening focus
• Improved neurological function?
• Likely lasting symptomatic change
• Specific impairments (i.e. gait) more easily
  influenced than neurological symptoms (i.e.
  tremor) (Deane et al., 2002 de Goede et al.,
  2001)

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Conclusions/Future Directions

• EYES CLOSED or focused attention on
  proprioceptive feedback is important component of
  exercise rehabilitation
• Future work
• Investigate underlying neurophysiologic changes
  resulting from PD SAFEx
• Combine intervention strategies to maximize
  benefits
• How else might we stimulate proprioception?

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Increased sensory awareness through the foot?
(Parkinsonism Related Disorders, 2009)
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Acknowledgements

• Collaborators
• Dr. Michael Cinelli, Dr. Jayne Kalmar, Dr. Peter
  Tiidus, Dr. S. Perry, Dr. P. Bryden (WLU)
• Dr. Eric Roy (UW),
• Dr. Andrew Johnson, Dr. Scott Adams (UWO)
• Dr. D. Connelly, Dr. S. Spaulding (PT OT, UWO)
• Dr. Heidi Ahonen-Eerikainen (Music Therapy, WLU)
• Dr. Dwight Stewart, Dr. Chris Hyson, Dr. Mary
  Jenkins, Dr. Jog (Neurologists)
• Research Institute for Aging (UW)
• Movement Disorders team volunteers