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#382 Exercise for Parkinson’s Disease: More movement = Better movement?


CLINICAL QUESTION
QUESTION CLINIQUE
How effective is exercise in Parkinson’s disease?


BOTTOM LINE
RÉSULTAT FINAL
In patients with Parkinson’s Disease, exercise results in clinically meaningful improvements in motor symptoms similar to changes seen with medications (4-9 points better on a 108-point scale) compared to control over 1-6 months. It doesn’t provide clear improvements in quality of life. Six more patients out of 100 who exercise will avoid one or more falls over 6-12 months compared to control.



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EVIDENCE
DONNÉES PROBANTES
  • Results statistically significant unless stated.
  • 11 systematic reviews [7-78 Randomized Controlled Trials (RCTs), 174-4859 patients]1-11 over the last 5 years evaluated exercise (includes group, individual, home-based such as dance, strength/resistance, balance/functional training, endurance, yoga) versus control (usual care or self-directed activity) in predominantly mild-to-moderate Parkinson’s Disease. At ~1-6 months:
    • Motor symptoms:
      • Unified Parkinson’s Disease Rating Scale (UPDRS III) [0-108 points (lower=better); baseline ~20-30; clinically meaningful change: 3 points]:12,13
        • 3.6 to 9.3-point improvement versus control3-5 [Example:~2 to 11 point improvement from baseline versus 0-2 point improvement (control)]
        • No clear differences between exercise types.1,3-5
    • Depressive symptoms:
      • Symptom scores (various scales) improved versus non-active comparators:7-10
        • Clinically meaningful change (>20% improvement on Beck Depression Inventory) seen in 8/9 RCTs.8,14,16
    • Quality of life:
      • Parkinson’s Disease Questionnaire-39 [0 to 100-points (lower=better); baseline ~25-35; clinically meaningful change 4.5 points]:15
        • 0.5 to 3.1-point improvement.2,4,6 Not clinically meaningful.
    • Proportion of people who fell (at least once). At 6-12 months:6,11
      • 57% versus 63% (non-active comparators).
      • Injurious falls or fractures: no difference.
  • Limitations: Non-blinded intervention (assessors unblinded in ~1/3 of RCTs), different exercise types and intensities, often short durations (4-6 weeks) and small sample sizes (10-20 patients); baseline depression scores commonly suggest no to mild depression; inconsistent reporting of medication status and few severe patients complicates generalizability.

CONTEXT
CONTEXTE
  • Levodopa-carbidopa improves motor score (UPDRS III) by 2-4 points over baseline (3.5-11.5 points over placebo).17
    • Adding a second medication improves motor scores by only 2-3 points more versus levodopa alone.18,19
  • Guidelines recommend early exercise initiation.20,21
  • Compliance dependent on ability to integrate physical activity into daily life.22 Patients should choose activities that they can easily access and enjoy.23


Dennis Neufeld February 1, 2025

Good information. Exercise is always good.

Virinder Singh February 6, 2025

Very informative

Deborah Semeniuk February 19, 2025

good reminder to recommend early exercise initiation when diagnosing and treating Parkinson’s


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Author(s)
Auteur(s)
  • Matthew Exner PharmD candidate
  • Scott Thomas PharmD candidate
  • Michael R Kolber MD CCFP MSc
  • Jamie Falk PharmD

1. Ernst M, Folkerts A, Gollan R, et. al. Cochrane Database Syst Rev. 2024 Apr 8;4(4):CD013856.

2. Li H, Cao C, Li Y. Arch Gerontol Geriatr 2024 Jan;116:105159.

3. Palm D, Swarowsky A, Gullickson M, et. al. Phys Ther 2024 Apr 2;104(4):1.

4. Yang Y, Fu X, Zhang H, et. al. BMC Geriatr 2023 Dec 19;23(1):873.

5. Yang C, Huang J, Wang, T, et. al. BMC Neurol. 2022 Dec 29;22(1):505.

6. Allen NE, Canning CG, Almeida LRS, et al. Cochrane Database Syst Rev 2022 Jun 6;6(6):CD011574.

7. Costa V, Prati JM, de Oliveira Barreto Suassuna A, et al. J Geriatr Psychiatry Neurol 2024 Nov;37(6):415–435.

8. Feller D, Fox I, Gozzer P, et al. Arch Phys Med Rehabil 2023 Feb;104(2):331−9.

9. Kim R, Lee TL, Lee H, et al. Neurology. 2023 Jan 24;100:e377-e387.

10. Tian J, Kang Y, Liu P, et al. Int J Environ Res Public Health. 2022 Jun 3;19(11):6849-6864.

11. Feng F, Xu H, Sun Y, et al. Front Endocrinol 2023 Jul 14;14:1187325.

12. Schulman LM, Gruber-Baldini AL, Anderson KE, et. al. Arch Neurol 2010 Jan; 67(1):64-70.

13. Mishra B, Sudheer P, Rajan R, et. al. Heliyon 2024 Feb 20;10(5):e26479.

14. Kounali D, Button KS, Lewis G, et al. Psychol Med 2022 Jul; 52(10):1875–1882.

15. Horváth K, Aschermann Z, Kovács M, et al. Neuroepidemiology 2017;48(1-2):1-8.

16. Masson SC, Tejani AM. J Clin Epidemiol. 2013 Jul;66(7):805-807.

17. Fahn S, Oakes D, Shoulson I, et. al. N Engl J Med 2004 Dec 9;351(24):2498-2508.

18. Stowe R, Ives N, Clarke CE, et al. Cochrane Database Syst Rev. 2010 Jul 7:(7):CD007166.

19. Liao X, Wu N, Liu D, et al. J. Neurol Sci. 2020 Aug;41(8):2045-2054.

20. Parkinson Canada. Canadian Guideline for Parkinson Disease, 2nd Edition. https://www.parkinsonclinicalguidelines.ca/wp-content/uploads/2019/10/canadian-guideline-for-parkinson-disease-full.pdf. Accessed Oct 2024.

21. National Institute for Health and Care Excellence. Parkinson’s disease in adults. https://www.nice.org.uk/guidance/ng71/resources/parkinsons-disease-in-adults-pdf-1837629189061. Accessed Oct 2024.

22. Schootemeijer S, van der Kolk NM, Ellis T, et al. J Parkinsons Dis. 2020;10(4):1293-1299.

23. Parkinson Canada, Exercise and wellness resources. https://www.parkinson.ca/resources/exercise-and-wellness/. Accessed Nov 2024.

Authors do not have any conflicts of interest to declare.