People with Parkinson disease (PD) benefit from exercise for their general health, as well as for the treatment of PD-specific motor and nonmotor deficits.1,2 Strong evidence also supports the role of physical therapy to improve walking, functional mobility, and balance.3 Despite the overwhelming research supporting exercise participation, people with PD are less active than people without PD.4 People with PD report that their barriers to exercise include PD-specific symptoms, fear of falling, lack of time, lack of information, inconvenient exercise locations, and low expectations of effectiveness.5–7 Physical therapists can assist people with PD to develop and maintain regular exercise habits.8 This education can take place during traditional restorative episodes of care that include goals for participation in progressive walking programs and home/community-based exercise prescription for improving aerobic fitness and muscle strength.8 In addition, physical therapists are testing new approaches to motivate, guide, monitor, and progress community-based exercise through maintenance and prevention programs.9,10 In this issue of the Journal of Neurologic Physical Therapy, the article by McGough and colleagues11 expands the evidence supporting physical therapists' ability to assist with, and advocate for, the development of evidence-based community exercise programs that address the barriers to exercise for people with PD.
McGough and colleagues11 describe the (1) development, (2) implementation, and (3) outcomes of a novel community-based tandem cycling exercise program that was designed with a patient-centered approach. Their process and results can be translated to other rehabilitation communities. Discussion points from this article also provide information to advance the role of physical therapy in promoting long-term community-based exercise participation in people with PD.
First, developing partnerships with PD patient advocacy groups and local organizations was essential for the development of this exercise group. Building these relationships will help our profession contribute to health, wellness, and physical activity promotion outside our traditional clinic role. McGough and colleagues11 present their partnerships with their city parks and recreation department, local PD organizations, and the Outdoors for All Foundation as necessary to provide the space, bicycles, financial support, and advertising. In addition to these community partnerships, the authors describe their patient-centered approach through the use of participant focus groups during pilot-testing phases to inform program development. The support of both community and patient/client partners is important to create classes that are sustainable, enjoyable, and beneficial.
Second, the volunteer cycling partners were an essential part of implementation of this exercise program. A cycling instructor led the class and the physical therapists were only responsible for performing a physical evaluation to ensure readiness for the cycling program. The volunteer cycling partners appeared to have the largest role: not only were they necessary to drive the high-cadence-forced exercise protocol, they also assisted with class set-up, take-down, bike repair. Most importantly, the volunteer cycling partners discussed weekly goals and exercise readiness with the participants. These interactions are likely to have addressed some of the barriers to exercise including PD-specific apathy, information about exercise, and improving outcomes expectations. The relationship, or “buddy system,” between the individuals with PD and their cycling teammate is likely to have been a source of motivation that helped to support the 100% retention rate of participants in this study. The individualized attention was also likely to have helped the majority of participants to reach and sustain their target heart rate (87% of participants) and cadence (95% of participants), both of which are thought to be important factors in the successful outcomes of this moderate aerobic-intensity, forced high-cadence exercise program. However, volunteer recruitment, training, and retention could be difficult without strong relationships between a research group, a university, and the local nonprofit partnerships. These relationships appear to be critical for the successful implementation of this labor-intensive exercise program.
Third, the outcomes of this study of 41 people included small but significant improvements in the Berg Balance Scale, the Short Physical Performance Battery, the 5 times sit-to-stand test, the Timed Up and Go, and usual gait velocity. These improvements were smaller than, or similar to, functional improvements measured after other types of exercise, including strengthening, general PD-specific exercises, tai chi, and aerobic exercise training.12–14 The small improvements noted in this study failed to meet established clinically meaningful change cutoff values.15,16 It is possible that the small size of the improvements was due to the short nature of the intervention (10 weeks) in comparison to previously published 16- to 104-week programs, measurement ceiling effects, and the very high level of function of the participants at baseline. As physical therapists think about preventive physical therapy evaluations and education for people with mild PD, we need to think beyond traditional functional gains. Instead, facilitating community-based exercise in early PD may have long-term potential to increase regular physical activity and self-efficacy to exercise, which could slow the progression of the disease over the course of years, rather than months. As a profession, we need to identify feasible, valid, reliable, and responsive outcome measures for physical activity and exercise self-efficacy for future studies.
Future longer-term, controlled clinical trials are needed to confirm and extend the positive results of this study. We recommend that these research studies also measure the Movement Disorders Society-Unified Parkinson's Disease Rating Scale17,18 to facilitate communication between physical therapists and neurologists regarding the role of exercise and physical therapy to prevent long-term disease progression, along with preventing declines in physical function. These future studies should also seek to determine which participants will benefit the most from this program, in comparison with other evidence-based PD-specific exercise groups, individualized therapy, or unsupervised exercise programs.13,19–21 It is important to have many community-based exercise options to appeal to people with a wide variety of exercise preferences,22 and McGough's community-based tandem cycling program is one new viable option. Physical therapist clinicians and researchers can use the development and implementation information described by McGough et al to help them become champions of this, or other, community-based exercise program for people with PD.
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