Daniel M. Keller, PhD

June 26, 2015

SAN DIEGO — Patients with Parkinson's disease (PD) who exercise consistently have better health-related quality of life (HRQoL) and a slower decline in HRQoL than patients who do not exercise.

From a database of 3000 patients who started exercising at different times, a study found that no matter when patients started exercise, they could benefit.

"Starting is good, but starting earlier is better than starting later," researcher Peter Schmidt, PhD, senior vice president and chief mission officer of the National Parkinson Foundation (NPF) in Miami, Florida, told Medscape Medical News.

The researchers presented their findings here at the 19th International Congress of Parkinson's Disease and Movement Disorders (MDS).

The impetus for the study was the recognition by the authors that patients at some PD treatment centers did better than at other centers, and asked why. "One of the things that we found was that the centers that have the best outcomes really believe that they have this very aggressive approach to exercise and very effective approach to convincing patients that they should exercise," he said.

So as part of the NPF Quality Improvement Initiative Dataset, they asked patients whether they exercised at least 2.5 hours/week, with "exercise" being defined by the patient. If patients met that goal, which is part of the Centers for Disease Control and Prevention Physical Activity Guidelines, they were classified as exercisers (E). If they exercised less than 2.5 hours/week, they were deemed to be "nonexercisers" (N).

Previous reports showed no difference in outcomes between people who were completely sedentary and those who reported less than 2.5 hours/week. "So we validated that cutoff as a reasonable cutoff for exercise vs nonexercise," Dr Schmidt said.

HRQoL was measured on the PD Questionnaire-39 (PDQ-39) at baseline and at 1- and 2-year visits, with a higher score indicating worse quality of life.

Patients were classified according to when they began exercise: at baseline, by 1 year, by 2 years, or not at all. For example, they were classified as EEE if they were exercising at the start of the study and continued throughout; as NEE if they had not been exercising but began at the start of study; and as NNE if they were not exercising at the start or at the 1-year point but were exercising by the 2-year visit.

Exercise Dosage Effect

Using the full patient dataset, the researchers saw that the earlier patients started exercising the better, especially if they continued. The worsening of HRQoL is slowed significantly if people transitioned to exercising earlier (NEE vs NNE; P < .05). The EEE group had a much lower PDQ-39 score at 2 years compared with the NNN group (20.5 vs 30.5; P < .001).

The NEE and NNE groups had intermediate results, with the patients starting earlier doing better at 2 years.

Looking just at a restricted dataset of individuals who were moderately impaired and very similar in terms of HRQoL at baseline, the investigators saw that the NEE patients also did better than NNE patients in the longitudinal follow up (P < .05).

Changes from baseline were apparent at both the 1- and 2-year visits, again with exercise showing a dosage effect.

Table. Moderately Impaired Cohort: Change in PDQ-39 Score From Baseline

Group (Exercise at Baseline/1 Year/2 Years 1-Year Visit 2-Year Visit
EEE (yes/yes/yes) 0 1.8
NEE (no/yes/yes) 0.7 1.3
NNE (no/no/yes) 2.4 3.5
NNN (no/no/no) 3.4 6.2


"This is really comparative effectiveness. It's not exercisers vs sedentary," Dr Schmidt explained. "The NNEs, they exercised for anywhere between a month and a year before the follow-up, so they did have some benefit of exercise. They just did not have 2 years' benefit of exercise, where our NEEs, they had been exercising for between 13 months and 24 months."

Thus, nonexercisers who increased their exercise behavior earlier had a slower decline in HRQoL.

In the NEE group, 52% of the cohort had actually improved over baseline at 2 years vs 41% of the NNE group (P < .05).

The EEE group did significantly better than the NNN group (P <. 001). Their HRQoL decline over 2 years was only 1.3 points on the PDQ-39, which the researchers say is less than the 1.6-point change for patients to "feel a little worse." The decline for the NNN group over the same period was 6.2.

Dr Schmidt noted that patients who stopped exercising declined more. "That was probably a sign that something had gone very badly for them in their disease," he said.

Exercise Does Good Things for the Brain

John Nutt, MD, professor of neurology and emeritus director of the Parkinson's Center at Oregon Health and Science University, commented to Medscape Medical News that there is agreement that exercise is good for people with PD.

"What's not known is exactly what are the best exercise programs and how long and how intense they have to be," he said. Besides these parameters, other factors in designing a program may be strength and agility.

Dr Schmidt said the plan is to include intensity levels in the data that are collected going forward, as well as to include data on falls and cognition. "There's a strong body of evidence that suggests that exercise will help patients improve cognition," he said.

A persistent question has been whether people with less severe disease are the ones who can and do exercise or whether exercise makes them more functional. "That's, I think, the unique piece of this information," Dr Nutt pointed out. "It's not that the patients couldn't exercise. It's just that they weren't and that the exercise really leads to improved quality of life."

Other studies have looked at motor function using the Unified Parkinson's Disease Rating Scale and have seen improvement in that domain as well. This study measures quality of life, "which perhaps is the most important thing," Dr Nutt asserted.

He said the findings suggest that exercise can actually slow the progression of symptoms and be a disease-modifying intervention. As in other neurologic conditions, neuroplasticity is important in PD.

"It's clear that the brain is capable of developing new pathways, and the brain can often shift function and do things differently," he said. "I think that exercise may be helping in that way."

Evidence supports this idea. Giselle Petzinger, MD, from the University of Southern California, reported in Lancet Neurology (2013;12:716-726) that exercise may enhance neuroplasticity in motor and cognitive circuitry in PD.

Advice and Recommendations

Dr Nutt says in his experience, the patients who do best are the ones "who have really adopted exercise and made it a very important part of their life. I tell patients that they ought to look at exercise the same way they look at their medicine and need to be doing this almost daily."

I tell patients that they ought to look at exercise the same way they look at their medicine. Dr John Nutt

He also tells them that people are never too old or too far advanced in their disease that exercise is of no use.

Dr Schmidt said that some patients believe exercise is changing the course of their disease. "Over half the patients who did have the 2 years of exercise reported that they were better 2 years down the road with a neurodegenerative disease than they were at baseline," he noted. Furthermore, "starting exercise will make you more able to exercise."

He said he wants to communicate these results and to engage personal trainers, physical therapists, and similar workers to show them this is a win for everybody: Patients can be better off, and trainers will enhance their business.

But he cautions that before starting an exercise program, patients should talk with their neurologists to choose an appropriate program, stay safe, and avoid falls. Both Dr Schmidt and Dr Nutt said many good programs are available.

There was no commercial finding for the study. Dr Schmidt is an employee of the NPF. Dr Nutt had worked with the NPF in developing the registry that was used for this study but is no longer working with NPF and had no relation to this study.

19th International Congress of Parkinson's Disease and Movement Disorders (MDS). Abstract LBA15. Presented June 16, 2015.


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