Exercise Prescription for Low Back Pain Management in Parkinson's

40 | J I A N M – V o l u m e 1 9 , I s s u e 2

Exercise Prescription for Low Back Pain Management

in Parkinson’s Disease

Joe H. Ghorayeb, DC, MHA

Gregory Grigoropoulos, BS

Elsa George, MD

Evan Arbit, MD

Hong Wu, MD, MS

University of Medicine & Health Sciences, New York, NY

Loyola University Chicago Stritch School of Medicine, Maywood, IL

Department of Physical Medicine and Rehabilitation, Rush University, Chicago, IL

[email protected]

Published: December 2022

Journal of the International Academy of Neuromusculoskeletal Medicine

Volume 19, Issue 2

This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is

properly cited. The article copyright belongs to the author and the International Academy of Neuromusculoskeletal Medicine and is

ABSTRACT

People with Parkinson’s disease (PD) frequently experience low back pain (LBP). LBP

often causes significant disability and reduced quality of life. A body of literature exists

supporting the utility of exercise for the management of LBP in the general population.

However, no such guideline exists to aid clinicians in exercise prescription for the

management of LBP for individuals with PD. This descriptive literature review summarizes

the current knowledge with respect to the mechanism and utility of physical exercise (PE)

interventions, issues related to exercise prescription, the influence of patient expectations on

exercise adherence and outcomes, and the process of encouraging behavior modification in

the context of managing LBP in individuals with PD. The effects of the interventions

prescribed may vary depending on content-related factors (i.e., type of exercises, dosage,

frequency, stage of disease progression, etc.) and contextual factors (i.e., treatment setting,

41 | J I A N M – V o l u m e 1 9 , I s s u e 2

access to organized programs, etc.). Patient expectations also significantly influence

adherence to, and outcomes of, PE. Treatment goals and timing are also important as they

relate to the amount and type of PE to be prescribed within each stage of the disease and the

expectation of outcomes of both clinicians and patients, respectively. Despite the need for

more quantitative and qualitative investigations to further clarify the formulation and dosage

of PE for patients with PD who experience LBP, this article outlines tailored PE prescription

recommendations in this context based on the current body of knowledge available at this

time.

Key words: Parkinson’s disease; low back pain; exercise

Key Points:

 The prevalence of Parkinson’s disease (PD) is on the rise and is expected to continue

to increase over the next 20 years.

 Low back pain (LBP) is highly prevalent in individuals with PD with a longer

duration and higher pain intensity when compared to the general population.

 Traditional treatment of PD including pharmacotherapy and neurosurgical

procedures can be effective in treating PD-related symptoms, but cannot slow disease

progression.

 Engagement in exercise and physical activity has demonstrated evidence of disease-

modifying capabilities in PD in addition to LBP management.

 A sound exercise program to manage LBP in the context of PD ought to include a

combination of aerobic and resistance training, flexibility exercises, gait and balance

training, postural control exercises, and adjunct therapy, and should be individually tailored

to the abilities, disease stage, precautions, and goals of each person.

INTRODUCTION

Parkinson’s disease (PD) is a progressive neurodegenerative movement disorder defined by

loss of dopaminergic neurons and the presence of alpha-synuclein within the midbrain.

is one of the fastest growing neurologic disorders

, affecting 2-3% of the population over 65

years of age

with a yearly incidence estimated to be as high as 35 in 100,000

, and is

estimated to affect more than 12 million people worldwide by 2040

. PD peak prevalence is

between 85-89 years of age, with the relative risk being 1.4 times higher in men than in

women

. Beta-adrenergic antagonist, pesticide exposure, and dairy product consumption

have been identified as potential risk factors in the development of PD. Coffee consumption

and a history of engagement in physical activity and competitive sports have been shown to

slow motor and cognitive decline with reduced mortality in those with PD.

Pain is a common symptom of PD that negatively impacts quality of life. Patients with PD

have been reported to experience five distinct types of pain: 1) musculoskeletal pain as a

result of rigidity and/or skeletal deformity, 2) radicular-neuropathic pain due to either a root

42 | J I A N M – V o l u m e 1 9 , I s s u e 2

lesion, focal or peripheral neuropathy, 3) dystonia-related pain, 4) central pain, and 5)

akathitic pain.

6,7

Of the many musculoskeletal pain conditions affecting individuals with

PD, low back pain (LBP) is the most prevalent (87.6%) with a longer duration and higher

pain intensity when compared to the general population.

Back pain ranks highest in terms

of disability according to the Global Burden of Disease Study

and accounts for $134 billion

in public and private healthcare spending in the United States

Physical Deficits and PD Staging

The loss of dopaminergic neurons leads to the cardinal physical deficits associated with PD,

beginning with early and prominent tremors of the hands followed by bradykinesia,

whereby patients notice that simple everyday tasks take longer to perform. Rigidity proves

to be the main obstacle to ambulation for the PD patient, resulting in shorter steps, an

altered walking pace, reduced arm swing, and postural alterations. Spinal abnormalities and

gait disturbance appear as a late manifestation of PD with characteristic festination when

standing, initiating a step, and/or turning.

PD may be staged descriptively for impairment and disability using the Hoehn & Yahr

(H&Y) scale

, which outlines an approximation of symptom progression by assessing

impairment and disability, with the former equating to objective indicators of the disease

and the latter being the apparent functional deficits as described in Table 1. The Unified

Parkinson's Disease Rating Scale (UPDRS) is another rating tool used to gauge the severity

and progression of PD.

Table 1. Stages of PD Progression

Stage

Hoehn and Yahr Scale

Modified Hoehn and Yahr Scale

1 Unilateral involvement only, usually

with minimal or no functional

disability

Unilateral involvement only

1.5

Unilateral and axial involvement

2 Bilateral or midline involvement

without

impairment of balance

Bilateral involvement without impairment

of balance

2.5 - Mild bilateral disease with recovery on

pull test

3 Bilateral disease: mild to moderate

disability with impaired postural

reflexes; physically independent

Mild to moderate bilateral disease; some

postural instability; physically

independent

4 Severely disabling disease; still able

to walk or stand unassisted

Severe disability; still able to walk to

stand unassisted

5 Confined to bed or wheelchair unless

aided

Wheelchair-bound or bedridden unless

aided

43 | J I A N M – V o l u m e 1 9 , I s s u e 2

Mechanisms of Low Back Pain Development in PD

In addition to age-related degenerative changes that contribute to the development of LBP,

two prevailing theories have been proposed as mechanisms that describe the increased

prevalence of LBP among individuals with PD; altered posture and aberrant muscle tone,

intensifying stress on the soft tissues and bony structures of the lumbar spine.

Watanabe et

al. established that increased thoracic and/or thoracolumbar kyphosis as well as reduced

lumbar range of motion occur in conjunction with progressive sagittal malalignment in the

absence of sufficient compensatory postural alterations such as reduced thoracic kyphosis

and pelvic retroversion, correlating strongly with the complaint of LBP and reduced walking

ability.

Parkinsonian central pain is also implicated in the development and persistence of

PD-related LBP due to diminished descending inhibitory control

and the influence of

dopaminergic pathways on the basal ganglia and pain pathways

PD-related rigidity has also been implicated with higher pain frequency and intensity. Allen

et al. found that increased rigidity is strongly associated with pain and interfered with

engaging in work and activities of daily living, even after adjustment for age and gender.

Some evidence suggests that changes in muscle structure and quality may contribute to the

development of LBP in PD. Margraf and colleagues interpreted focal myopathy among

patients with PD with camptocormia by way of identifying fatty infiltration in the

paravertebral muscles as a potential reason for disease progression and muscle

degeneration.

Though, the mechanism behind how these findings might contribute to the

clinical presentation of LBP in the context of PD remains to be understood.

Treatment of PD and the Role of Exercise in PD

Pharmacologically, PD is typically managed with Levodopa in combination with Carbidopa

to reduce adverse effects and improve CNS bioavailability. Anticholinergics or Amantadine

may be employed if tremors are the primary symptom to be controlled. Selegiline, a

selective MAO-B inhibitor, is typically used to treat early-stage PD and offers mild

symptom relief.

While most anti-Parkinson medications may provide effective symptom

control, the disease eventually progresses and becomes resistant to pharmacotherapy. In

such instances, deep brain stimulation is an effective therapy to treat severe motor

fluctuations or tremors in advanced PD.

21,22

Though, neither pharmacotherapy nor

neurosurgical procedures confer disease-modifying capabilities in PD.

23,24

On the other

hand, exercise, among other lifestyle factors, has been shown to slow PD progression.

animal models of PD, regular exercise produces neuroprotective effects against the

neurotoxins 6-hydroxydopamine (6-OHDA) and 1-methyl-4-phenyl-1,2,3,6-

tetrahydropyridine (MPTP)

26,27

, which decidedly cause a loss of dopaminergic neurons

Exercise further induces the accumulation of the ketone body D-b-hydroxybutyrate (DBHB)

in the hippocampus, which in turn promotes the expression of brain-derived neurotrophic

factor (BDNF); an important protein involved in plastic changes related to learning and

memory.

29-32

Exercise dose has also been shown to play a factor, with greater physical

activity conferring greater protection.

In addition to the aforementioned observations,

attenuation of α-synuclein expression in conjunction with reduced α-synuclein-mediated

inflammation via downregulation of toll-like receptor 2 and decreased NADPH oxidase

expression has been observed in MPTP-induced mice following an 8-week treadmill

44 | J I A N M – V o l u m e 1 9 , I s s u e 2

exercise program.

With respect to the effect of exercise on individuals with PD, Shulman et al.

conducted an

important randomized clinical trial (RCT) of three types of exercise in order to determine

whether superiority of outcomes exists in favor of one exercise modality compared to

another. The authors randomized study participants with a diagnosis of PD (H&Y1-3) with

at least two of the three cardinal signs of tremor, bradykinesia or rigidity in addition to the

presence of mild to moderate gait impairment across three exercise groups: 1) high-intensity

treadmill training; consisting of 30 minutes at 70%-80% of heart rate reserve (HRR), 2)

low-intensity treadmill training (50 minutes at 40%-50% of HRR), and 3) stretching and

resistance training (2 sets of 10 repetitions on each leg on 3 resistance machines [leg press,

leg extension, and curl]). All three groups engaged in exercise 3 times per week for 12

weeks, for a total of 36 sessions. At the conclusion of the interventions, it was determined

that both types of treadmill training improved cardiovascular fitness with no difference

between groups. Unsurprisingly, stretching and resistance training resulted in the greatest

increases in muscle strength and were the only group that improved in the UPDRS motor

subscale (p<0.05). Moreover, the study authors reported no adverse effects with the

engagement of either of the aforementioned exercise interventions, and no changes of

antiparkinsonian medications were made during the trial.

The aim of this article is to summarize how exercise therapy exerts its effects on pain

control, postural correction and control, flexibility, general fitness, gait performance, and

balance in the context of PD, in addition to offering exercise prescription recommendations

for this patient population.

METHODS

Search Strategy

A literature search using MEDLINE was conducted from inception to June 2022. The

search terms included (e.g., MeSH in MEDLINE) are depicted in Appendix 1.

Study Selection

A two-phase approach to screening was used with two independent reviewers screening

each citation and article. Phase one included screening of titles and abstracts for possible

relevance. Phase two included full-text screening of possibly relevant studies. Any

disagreement was resolved by discussion between the paired reviewers.

Inclusion Criteria

Studies were included if they met the following criteria: 1) published in English and in a

peer-reviewed journal; 2) study designs included experimental (Randomised Clinical Trials)

and observational (Cohort and Case-Control) studies; 3) study populations included adults

(19+years old); 4) study populations confined to individuals with PD (H&Y 1-5); and 5)

studies addressed one or more of the physical deficits and/or symptoms associated with PD

such as aerobic fitness, muscle strength, gait performance, postural correction, flexibility,

45 | J I A N M – V o l u m e 1 9 , I s s u e 2

balance and pain control with some form of exercise as the primary intervention.

Exclusion Criteria

Studies which did not include some form of exercise as the primary intervention along with

perspective articles, opinions, comments, letters to the editor, and articles without scientific

data or a report of their methodology were excluded.

RESULTS

A total of 618 entries were identified after conducting the database searches, of which 44

were removed due to duplication. A total of 574 abstracts were then screened, and 48 full-

text articles were selected for full-text review. Following this process, 22 studies were

included in the review. Nine articles related to enhancing general fitness

51-56,61,69,74

, 4 related

to improving postural correction

77,79-81

, 2 related to increasing flexibility

85,86

, and 7 related to

balance improvement

90-96

in the context of PD. Experimental studies describing the

mechanisms in which exercise exerts its pain modulating effects in individuals with PD

were unavailable. Therefore, a broad summary regarding the analgesic properties of exercise

is offered based on review of 7 articles.

38-44

Pain Control

Exercise has been shown to be a powerful intervention to lessen the perception of pain as

well as improve mood and reduce stress.

The Center for Disease Control and Prevention’s

opioid prescribing guideline, published in 2016, recommends exercise as a first-line

treatment in pain management.

Three distinct mechanisms explain how exercise modulates

pain symptoms. The first is the reconceptualization of pain-related fear via the development

of new inhibitory associations that compete with and suppress the original conditioned

response to movement and physical activity in the individual with pain.

38-40

The second

mechanism describes the effect of painful exercise on the activation of the conditioned pain

modulation response, where an individual may report a lower pain rating of a primary pain

complaint in the presence of a secondary painful stimulus.

Finally, the third mechanism

highlights exercise’s role in blunting the immune system’s function in exacerbating pain

states, in turn promoting an anti-inflammatory state with long-term engagement in exercise

and physical activity.

42-44

Various modalities of exercise are capable of exerting pain

modulating effects in addition to developing favorable phenotypic and functional

adaptations as described below.

General Fitness and Gait Performance

Aerobic training improves general fitness

45,46

as well as gait performance and speed in

patients with PD.

47-49

The risk of all-cause and cause-specific mortality is also greatly

reduced in individuals who engage in both aerobic and muscle strengthening activities at the

levels recommended by the 2018 physical activity guidelines for Americans.

Of the

various modes of aerobic training to enhance cardiorespiratory fitness for individuals with

PD, treadmill training, overground walking, and cycling have consistently produced the

greatest improvements in gait performance, speed, stride length, and cadence.

51,52

Moreover,

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the addition of auditory cueing by way of rhythmic auditory stimulation (RAS) may be a

useful adjunct to gait training, as evidenced by the finding of an RCT conducted by Calabro

et al.

, in which 50 patients with PD (H&Y 2&3) were randomly allocated to one of two

groups: 1) treadmill gait training with RAS; where patients were instructed to synchronize

their footsteps to the beat of the music played during the training sessions, and 2) treadmill

gait training without the assistance of RAS. Each session lasted 30 minutes in duration and

was completed 5 days per week over an 8-week period. While both groups demonstrated

improvements in gait performance at the conclusion of the study, the RAS group

demonstrated superior improvement in functional gait assessment (FGA), falls efficacy

scale (FES), timed up-and-go test (TUG), and UPDRS (p<0.001). Both moderate-intensity

aerobic exercise (50% of HRR) and high-intensity training (HIIT) (85% of HRR)

have been

shown to improve pain symptoms. However, HIIT also improves cardiorespiratory fitness.

A 6-week moderate-intensity treadmill walking program (50% of HRR) for 52 sedentary

patients with chronic LBP was compared to a 6-week program involving specific

strengthening exercises targeting the trunk and upper and lower limbs.

Walking and

resistance training were shown to be equally effective in reducing LBP symptoms with no

significant difference between the two exercise modalities.

Twenty study subjects with chronic LBP (CLBP) and similar baseline characteristics were

enrolled in an RCT conducted by Chatzitheodorou et al.

and were randomly allocated to

an intervention group consisting of a 12-week high-intensity exercise treadmill program

(85% of HRR) or a passive treatment group, which included the administration of 10

minutes of shortwave diathermy, 5 minutes of continuous pulse therapeutic ultrasound, 10

minutes of low-level laser therapy laser, and 12 minutes of electrotherapy at varying

intensities per each subject’s tolerance. Study subjects in the high-intensity exercise

program reported significant reductions in LBP, disability, and psychological strain

compared to no improvement in the passive treatment group. These findings are further

supported by a subsequent RCT carried out by Chatzitheodorou and colleagues

, with a

larger sample size (n=64), in which study subjects with CLBP were randomized into a

dexamethasone suppression group (dex+) and a control group without dexamethasone

suppression, and both groups engaged in high-intensity aerobic exercise. Subjects in the

dex+ group reported a significant reduction in pain complaints and anxiety/depression, in

addition to improved physical function and adrenocortical responsiveness (p<0.001) when

compared to subjects in the control group. These findings suggest that for individuals with

CLBP and associated psychological strain, engagement in high-intensity aerobic exercise

may be a preferred strategy to induce a cortisol response, as a direct relationship between

the strength of the cortisol response to a stressor (e.g., exercise) and developing a higher

pain threshold has been reported in a number of studies.

57-60

A more recent RCT by Harvey et al.

found that 36 HIIT sessions (85% of maximal heart

rate) over a 12-week period among patients with PD (H&Y 1-3) with a mean age of 68.5

years resulted in an increase in peak oxygen consumption by 2.8mLkg

-1

min

-1

in the

intervention group compared to 1.5mLkg

-1

min

-1

in the control group, suggesting that HIIT

may be a feasible and acceptable exercise strategy in people with early to mid-stage

Parkinson’s disease.

47 | J I A N M – V o l u m e 1 9 , I s s u e 2

Because muscle strength declines in almost all patients with PD

, the general physical

requirements necessary to execute a controlled gait pattern, rise from a chair, and negotiate

stairs are compromised, in turn increasing the risk of falls. If an individual with PD also

presents with concomitant low bone mass, the risk of fractures with falls increases, resulting

in a medical emergency. Strength training, characterized as contracting muscles against

resistance, is accomplished using free weights, resistance machines, elastic bands, and

resistance against water or one's own body weight is not only an effective hypoalgesic in

patients with PD

but also derives desirable adaptations that counteract the development

and progression of chronic disease in aging populations

in addition to reducing all-cause

mortality.

65-68

In individuals with mild to moderate PD, high-force eccentric resistance

training is both a safe and feasible strategy to bring about favorable adaptations in muscle

structure and mobility with clinically insignificant serum CK and muscle pain levels

following training sessions.

In this landmark study, 10 patients with PD (H&Y 1-3)

between the ages of 40 and 85 engaged in a 12-week course of high-force eccentric

resistance training on an eccentric ergometer 3 times per week

and responded similarly to

both young

and frail elderly people

71,72

without PD who were exposed to high-force

eccentric exercise. These findings illustrate the benefits of high force eccentric training for

patients with PD due to the high levels of muscle force generated in eccentric exercise with

associated low metabolic demands.

Corcos et al.

conducted a two-year RCT involving pairs of patients with PD who were

matched by age, sex, disease stage, and off-medication UPDRS-III, and engaged in either

progressive resistance exercise (PRE), which consisted of a weight lifting program, or the

Fitness Counts (FC) exercise program, recommended by the Parkinson’s Foundation

which focuses on performing stretches, balance exercises, breathing, and non-progressive

strengthening exercises. Study subjects engaged in exercise twice per week for 24 months at

a gym under the supervision of a personal trainer, and were followed for 24 months at 6-

month intervals. At the conclusion of the study, the mean off-medication UPDRS-III score

decreased more with the PRE group than with the FC group (mean difference: - 7·3 points;

95% CI: -11·3 to -3·6; p<0.001), denoting a significant improvement in motor signs,

strength, and movement speed, and physical function.

Postural Correction

Common postural abnormalities occurring among patients with PD include camptocormia,

antecollis, Pisa syndrome, and scoliosis.

While no formal treatment has been established to

correct postural abnormalities associated with PD, which may contribute to LBP symptoms,

several studies have demonstrated positive clinical outcomes with conservative care.

A retrospective pilot study by Lee et al.

involving 9 patients with PD (6 inpatient, 3

outpatient) (H&Y stages 2-4) with camptocormia who engaged in core strengthening and

back extensor strengthening exercises of varying frequencies (once per week for 3 months v

twice daily for 5 weeks) in addition to walking with a weighted low-slung backpack showed

that 8/9 patients achieved a mean camptocormia flexion angle reduction of 20º (p=0.012) at

3 months post-treatment, in addition to mean changes of 2.788 (p=0.011) and 3.788

(p=0.012) in UPDRS II and III scores, respectively, reflecting a clinically important

difference.

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Ye et al.

reported a case of a 70-year-old man with PD and hyperflexion of the

thoracolumbar supine, which would resolve on recumbent positioning. The patient was

instructed to perform neck and back extensor exercises daily for 30 minutes and was fitted

with a cruciform anterior spinal hyperextension brace (CASH). After four months, his

functional ambulation categories (FAC) score improved from 3 to 5 and his TUG improved

from 16 seconds to 9 seconds. At the end of a 5-month follow-up, he was reportedly able to

maintain an improved posture without the brace.

A pilot study conducted by Lena et al.

followed 6 patients with PD (H&Y 2-3) with Pisa

syndrome, and lateral flexion of the trunk (LFT) >10º, who engaged in 10 consecutive 90-

minute exercise sessions, under physiotherapist supervision, to correct postural trunk

deviation. The patients presented with one of two patterns of muscle hyperactivity,

confirmed by EMG; either ipsilateral or contralateral to the bending side. At the conclusion

of the intervention, all participants demonstrated improvement in UPDRS-II, UPDRS-III,

back pain rating, and LFT degree. Only 1 participant did not show improvement on

UPDRS-III.

Gandolfi et al.

conducted a single-blind RCT involving 37 patients with PD (H&Y ≤4) and

≥ 5º of forward trunk flexion (FTF) to determine whether a trunk-specific rehabilitation

program was more efficacious than conventional exercise at improving both postural

orientation and FTF severity. The experimental group (n=19) engaged in 60-minute

individualized sessions consisting of active self-correction exercises, trunk stabilization

exercises, and functional tasks. The control group (n=18) intervention consisted of joint

mobilization, muscle strengthening and stretching, and overground training and balance

exercises. Participants in both groups engaged in individualized 60-minute sessions with a

physiotherapist twice daily for 4 weeks. FTF significantly improved in the experimental

group at the end of the intervention course (p=0.003) and at the 1-month follow-up

(p=0.004).

Flexibility

Engaging in regular stretching is widely accepted as an essential component of a sound PD

exercise program

82,83

, though an optimal dose of stretch therapy remains unknown. When

coupled with resistance exercise, stretching helps diminish muscle rigidity.

Some evidence

demonstrates positive acute effects of stretching, as seen in a recent RCT by Vialleron et

al.

In this study, 19 age-matched patients with PD (H&Y 2&3) were randomly allocated to

a stretching group (n=10); who were exposed to 4 minutes (4 sets x 60 seconds) of triceps

surae stretching, a sham stretching group (n=9); who were exposed to 4 minutes of forearm

stretching, and a control group consisting of 10 age-matched healthy older adults who were

not exposed to any form of stretching. The acute effects of the triceps surae stretching

intervention demonstrated appreciable improvements in ankle mobility and gait initiation

with large effect sizes (d ≥ 0.8). The authors concluded that triceps surae stretching ought to

be integrated into a multicomponent exercise program to include strength, balance, and gait

training. This notion comports with the findings reported in an RCT by Santos and

colleagues

, in which patients with PD (H&Y 1&2) with akinesia and rigidity (AR-

subtype), also defined as the “postural instability gait difficulty subtype” (PIGD- subtype)

engaged in 16 PRE training sessions over 8 weeks, beginning with workloads at 40-50% of

49 | J I A N M – V o l u m e 1 9 , I s s u e 2

their tested 1 repetition maximum (1RM) and progressing to 80-85% of 1RM. The PRE

group realized significant improvements in static posturography, gait, and quality of life

when compared to AR-subtype patients with PD with matched baseline characteristics in the

control group.

Balance

PD-related axial rigidity also causes various biomechanical impairments that result in

unfavorable postural alterations such as abnormally stooped posture, which impacts range of

motion, brings about low back pain, and negatively impacts postural control

88,89

Because

stooped posture has a destabilizing effect on postural control, and the condition may not

always be fully corrected with exercise or adjunct therapy, patients with PD need to retrain

their spatial awareness with the postural alterations that they have acquired in order to

improve their balance and gait so as to prevent falls. Balance training, of various forms, has

been studied in isolation and in combination with resistance training for individuals with

early-to-mid stage PD with the general consensus being that highly challenging balance

exercises yield the greatest positive effects

90-94

. More recently, Capato and colleagues

conducted an RCT to evaluate the effectiveness of balance training in individuals with

advanced-stage PD (H&Y 4). The study results demonstrated that patients who engaged in

10 45-minute balance training sessions twice weekly, over a 5-week period, supported by

RAS, realized significant improvements in balance and fall prevention when compared to

age- and stage-matched controls who engaged in the same balance training program but

without RAS support. Furthermore, the improvements were retained at 1-month and 6-

month follow-ups.

These findings are encouraging and suggest that improving balance and

preventing falls is still possible and a worthwhile goal at this stage of PD progression.

An RCT conducted by Silva-Batista and colleagues

compared the effects of three types of

exercise on balance improvement in patients with PD (H&Y 2&3). Patients were

randomized into a resistance training group (RT) (n=13), a resistance training with

instability group (RTI) (n=13), and a placebo-control group (n=13). Study participants in the

RT and RTI groups engaged in challenging exercises that demanded standing and balance

for execution twice per week for 12 weeks. The RTI group also utilized various devices

such as a BOSU ball and balance discs to progressively induce instability that challenged

balance and postural control during resistance exercise. The control group engaged in upper

body machine-based exercises that did not require a standing or balance component for

execution, at the same frequency and duration as the other groups. While both the RT and

RTI groups showed improvements in muscle strength, only the RTI group produced

significant improvements in balance testing per the BESTest; a widely used clinical balance

examination with good validity and reliability.

97-99

The RTI group showed improved post-

intervention balance test scores with a mean difference of 18% (95% CI=12.7-23.4, p<

0.001), while the RT group showed no significant changes in balance performance

(MD=2.9%; CI=−2.4 to 8.2; p=0.579), and the control group showed a significant decrease

in balance performance (MD=−6.0%; CI=−11.4 to −0.7; p=0.018). The authors concluded

that the balance improvements realized by the RTI group came as a result of increased force

production capacity of the plantar flexors and knee extensors, in addition to enhanced

anticipatory postural adjustments. The RTI group also demonstrated a reduced fear of

50 | J I A N M – V o l u m e 1 9 , I s s u e 2

falling (p<0.05), supporting the notion that challenging balance training in combination with

resistance training can decrease barriers to exercise and allow individuals with PD to

become more confident in executing demanding motor tasks.

Complementary Physical Interventions

In addition to the aforementioned exercise modalities, various complementary physical

interventions have been shown to confer improvements in both motor and non-motor PD

symptoms. Tai Chi and Qigong, mind-body intervention with roots in martial arts training,

have demonstrated small-to-medium effects on motor function and balance.

100-106

Various

styles of dance have been shown to improve balance and motor symptom severity in

individuals with mild to moderate PD.

107-110

Technologies that promote healthy behaviors by

combining video games and exercise have also been employed in the context of PD

rehabilitation, with evidence demonstrating some effectiveness in the utilization of these

technologies to improve balance, functional mobility, and cognitive skills.

111-114

Aerobic

boxing programs for patients with PD have surged in popularity and have been promoted as

an effective means to improve PD motor symptoms.

115,116

Though, recent reports suggest

that the utilization of boxing as an established intervention for PD symptom management

has expanded beyond the current evidence to substantiate its utilization.

117

DISCUSSION

Exercise Prescription for LBP in Patients with PD

While no evidence currently exists to suggest that specific exercises or a specific exercise

program is superior to another in the context of managing low back pain in the context of

PD, strong evidence supports the recommendation of programs prescribed for patients with

PD that involve at least 3 hours of exercise per week, as prescribed by the American College

of Sports Medicine’s Physical Activity Guidelines for Adults

118

and the U.S. Department of

Health and Human Services Physical Activity Guidelines for Americans

119

, which

recommend engagement in a minimum of 150 to 300 minutes per week of moderate-

intensity aerobic physical activity or 75 to 150 minutes per week of vigorous-intensity

aerobic physical activity or a combination of both and muscle building and bone

strengthening exercises a minimum of 2 days per week. In addition to the aforementioned

recommendations, we have modified and adapted our exercise prescriptions to also include

flexibility and balance training as supported by several high-quality studies

120-122

, as well as

prescription exercises for postural correction in those patients who present with postural

deformities.

77,79-81

It is the responsibility of clinicians to tailor the specific exercise programs

chosen for each patient, based on individual physical deficits and impairments. Therefore,

the exercises selected must be meaningful to each patient and relevant for them to carry out

their activities of daily living. Working with experienced rehabilitation professionals at the

outset in a skilled exercise facility is crucial to reduce the risk of falls and to ensure that the

prescribed exercises are appropriate and well-tolerated. Providing patient and family

education regarding exercise therapy, precautions, and injury/fall prevention, in addition to

enhancing family and community support and advice regarding exercise adherence will help

to improve clinical outcomes.

51 | J I A N M – V o l u m e 1 9 , I s s u e 2

We have stratified general exercise prescriptions to improve pain control, general fitness,

and gait performance, in addition to enhancement of balance and flexibility, and improved

postural correction, where necessary, across the 5 H&Y stages of PD.

For individuals with early-stage PD (H&Y 1-2)

The general goals of treatment during the early stage of PD are to educate patients about the

disease, promote increased activity and improve strength, endurance, balance, and flexibility

to enhance functional capacity. Exercise recommendations doses for patients with PD in

these stages are aligned with the American College of Sports Medicine’s Physical Activity

Guidelines for Adults

123

with modifications to include daily engagement in stretching

exercises, and balance training performed 3 days per week. Complete exercise prescription

recommendations for patients with PD in these stages (H&Y 1-2) are summarized in Table

2. These recommendations are modified and adapted to also include balance training and

postural correction exercises, where necessary.

For individuals with mid-stage PD (H&Y 3)

The general goals of treatment during the mid-stage of PD are to preserve early-stage goals

in addition to improving transfer, gait, and reaching performance, improving posture,

improving steadiness, freezing control, and fall prevention in addition to caregiver

education.

For individuals with late-stage PD (H&Y 4-5)

The general goals of treatment during the late stage of PD are to preserve mid-stage goals in

addition to maintaining vital functions, preventing contractures and pressure sores, and

educating caregivers about bed mobility, transfer, ADLs, and exercise.

Complete exercise prescription recommendations for patients with mid-to-late-stage PD

(H&Y 3-5) are summarized in Table 3. These recommendations are modified and adapted

to also include balance training and postural correction exercises, where necessary, and

align with the most recent recommendations made by the ACSM’s Guidelines for Persons

with Chronic Diseases and Disabilities (Basic CDD4 Recommendations).

124

52 | J I A N M – V o l u m e 1 9 , I s s u e 2

Table 2. Exercise Prescription for PD H&Y 1&2 modified and adapted from American

College of Sports Medicine Physical Activity Guidelines for Adults

RPE based on modified RPE scale

Mode

Frequency

Duration

Intensity

Progression

Warm-up and cool-down

Before and

after each

session

10-15 min

Easy

RPE <3/10

Should be

maintained

as transition phase,

especially for those

doing higher-

intensity physical

activity

Aerobic Training

• Large-muscle easily

accessible activities such

as walking as the basic

program

• Types include walking,

jogging, cycling,

swimming/water-based

exercise, or other enjoyable

physical activities that may

be sustained over a

prolonged period of time

5+ days/

week

Start at any duration, as

tolerated

Ultimate weekly goal is to

build up to a minimum of

150 to 300 minutes per week

of moderate-intensity aerobic

physical activity or 75 to 150

minutes per week of

vigorous-intensity aerobic

physical activity or a

combination of both

Light (casual walk)

RPE of 2

Moderate (brisk

walk) RPE of 3

Vigorous (like

jogging) RPE of 4-6

Progression week

over week in either

intensity, volume, or

a combination of

both should not

exceed 10%

Strength Straining

• High force eccentric

training

• Functional gravity-based

exercises

• Weight training is an

alternative for those

who are interested and

motivated to do it

2-3 days/

week

8-12 repetitions x 2-4 sets

RPE of 3-7

Build gradually to as

many sets a day as

tolerated

Stretch Therapy

Major muscle groups and

calf stretches

Daily

60 s/stretch, repeat 3x

Entire stretching session

~ 30 min

Maintain stretch

below discomfort

point

Discomfort point

should occur at a

ROM that does

not cause instability.

This discomfort

point will vary

between people and

with different joints

each person.

Balance Training

3 days/

week

~45 min

Somewhat

challenging

Supervised side to

side sways and

weight shifting,

along with variable

footwork exercises

with the support of

walkers and other

assistive devices

Postural Correction

1-7

days/week

20-90 min/session

1-2x/day per PT

recommendation

To tolerance

Supervised exercises

to correct postural

trunk deviation,

individually tailored

to the patient in

addition to wearing a

weighted low-slung

backpack or brace, as

needed

53 | J I A N M – V o l u m e 1 9 , I s s u e 2

Table 3. Exercise Prescription for PD H&Y 3-5 modified and adapted from Basic CDD4

Recommendations

RPE based on modified RPE scale

Mode

Frequency

Duration

Intensity

Progression

Warm-up and cool-down

Before and

after each

session

10-15 min

Easy

RPE <3/10

Should be maintained

as transition phase,

especially for those

doing higher-intensity

physical activity

Aerobic Training

• Large-muscle easily

accessible activities such

as walking as the basic

program

• Types include walking,

jogging, cycling,

swimming/water-based

exercise, or other enjoyable

physical activities that may be

sustained over a prolonged

period of time

• Walking under supervision

with assistive devices and

safet

y harness

5+ days/

week

Start at any duration, as

tolerated

Ultimate weekly goal is to

build up to a minimum of 150

to 300 minutes per week of

moderate-intensity aerobic

physical activity or 75 to 150

minutes per week of vigorous-

intensity aerobic physical

activity or a combination of

both

Light (casual walk)

RPE of 2

Moderate (brisk walk)

RPE of 3

Vigorous (like

jogging) RPE of 4-6

Progression week over

week in either

intensity, volume, or a

combination of both

should not exceed

10%

Strength Straining

• High force eccentric training

• Functional gravity-based

exercises (avoid free weights

in advanced PD)

• Weight training is an

alternative for those

who are interested and

motivated to do it

2-3 days/

week

8-12 repetitions x 2-4 sets

RPE of 3-7

Build gradually to as

many sets a day as

tolerated

Stretch Therapy

Major muscle groups and calf

stretches

Independent and assisted

stretching exercises

Daily

60 s/stretch, repeat 3x

Entire stretching session

~ 30 min

Maintain stretch

below discomfort

point

Discomfort point

should occur at a

ROM that does

not cause instability.

This discomfort point

will vary between

people and with

different joints in

each person.

Balance Training

3 days/

week

~45 min

Somewhat challenging

Supervised side to

side sways and weight

shifting, along with

variable footwork

exercises with the

support of walkers and

other assistive devices

Postural Correction

1-7

days/week

20-90 min/session

1-2x/day per PT

recommendation

To tolerance

Supervised exercises

to correct postural

trunk deviation,

individually tailored to

the patient in addition

to wearing a weighted

low-slung backpack or

brace, as needed

54 | J I A N M – V o l u m e 1 9 , I s s u e 2

Barriers to Exercise Engagement and Strategies to Enhance Exercise Adherence

Perceived barriers to exercise engagement are predictive of exercise behavior. The most

commonly reported perceived barriers to exercise in healthy older adults include lack of

interest, poor health, weakness, fear of falling, pain, bad weather, lack of time, and limited

access to exercise resources.

125

In the context of PD, these aforementioned concerns in

addition to scheduling issues, commuting challenges, medical comorbidities,

hospitalizations, family demands, and low outcome expectations appear to be the major

perceived barriers to exercise.

126

Moreover, a lack of structured community-based PD-

specific exercise programs may further reduce the motivation for engagement, though

efforts are being made to adapt and scale such exercise programs to serve the needs of

patients with PD.

127

Working with an experienced physical therapist, rehabilitation-oriented chiropractor, and/or

physical trainer who understands how to optimally dose exercise prescription for each

individual in order to ensure that engaging in exercise is tolerable and sustainable has been

shown to enhance exercise adherence in this patient population.

128

Once individuals are able

to engage in exercise independently, booster supervised sessions have been shown to

improve exercise adherence.

129

Exercise snacking, a strategy that calls for breaking up daily exercise recommendations into

several shorter bouts of physical activity or “exercise snacks” throughout the day has

demonstrated improvements in cardiorespiratory fitness, metabolic markers of health

and

muscle mass and function

in small proof of concept studies

130-132

. This strategy may prove to

be worthwhile in enhancing exercise adherence among people with PD.

Autoregulation

Autoregulation describes the means of selecting and adjusting training intensity based on

one’s performance during a given training session. Because consistency of effort during

every exercise session is unlikely for a variety of reasons, in order to maintain adherence to

exercise, rate of perceived exertion (RPE), a validated and reliable psycho-physical tool may

be taught to patients for them to assess their subjective perception of effort exerted during

physical activity in order to allow them to adjust their level of exertion during physical

training based on real-time psychological and physiological feedback (Table 4).

133

Table 4. Modified RPE Scale Reproduced from (Haddad 2017)

Rating

Descriptor

Rest

Very, Very Easy

Easy

Moderate

Somewhat Hard

Hard

Very Hard

Maximal

55 | J I A N M – V o l u m e 1 9 , I s s u e 2

CONCLUSION

Low back pain in the context of PD is a complex condition that may be influenced by

pathology, pain intensity, physical impairment, and psychosocial reinforcements, resulting

in disability. To date, multiple lines of empirical evidence demonstrate that activities and

exercises that challenge physical impairments result in improvements in low back pain and

quality of life among individuals with PD. The exercise prescription recommendations

outlined in this article exemplify an approach that combines strength training, aerobic

training, stretching, and balance training, in addition to postural correction exercises, where

necessary, that is modified across the stages of PD progression based on the current body of

knowledge available at this time. Future high-quality studies with longer intervention and

follow-up periods would help to further ascertain the effects of exercise dose and type on

managing both LBP and PD progression in addition to exploring strategies to enhance

behavior modification in order to improve adherence, and ultimately, outcomes.

AUTHOR CONTRIBUTIONS

Conceptualization, J.G., H.W..; methodology, J.G., H.W.; formal analysis, J.G., G.G.;

investigation, J.G., G.G.; original draft preparation, J.G., G.G., H.W.; writing—review and

editing, J.G., G.G., H.W., E.G., E.A. All authors have read and agreed to the published

version of the manuscript.

FUNDING

This research received no external funding.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

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APPENDIX 1

MEDLINE search terms

("exercise"[MeSH Terms] OR "exercise"[All Fields]) AND ("parkinson disease"[MeSH

Terms] OR ("parkinson"[All Fields] AND "disease"[All Fields]) OR "parkinson

disease"[All Fields] OR ("parkinson's"[All Fields] AND "disease"[All Fields]) OR

"parkinson's disease"[All Fields]) AND ("back pain"[MeSH Terms] OR ("back"[All Fields]

AND "pain"[All Fields]) OR "back pain"[All Fields]) AND ("pain"[MeSH Terms] OR

"pain"[All Fields]) OR ("pliability"[MeSH Terms] OR "pliability"[All Fields] OR

"flexibility"[All Fields]) OR strength[All Fields] OR ("posture"[MeSH Terms] OR

"posture"[All Fields]) OR "balance"[All Fields] OR endurance[All Fields]