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Commentary

Commentary on A Meta-Analysis of Exercise Intervention and the Effect on Parkinson’s Disease Symptoms: What Activities Are Best?

by
Syed Omar Ahmad
1,*,
Dana Stiles
2,
Emily Born
1,
Julie Scheffler
1 and
Katie Vogel
1
1
Department of Occupational Science and Occupational Therapy, Doisy College of Health Sciences, Saint Louis University, 3437 Caroline St. Allied Health Building, Rm 2016, Saint Louis, MO 63104, USA
2
Department of Psychology, Saint Louis University, 3700 Lindell Blvd, Morrissey Hall, Saint Louis, MO 63108, USA
*
Author to whom correspondence should be addressed.
Appl. Sci. 2024, 14(16), 7236; https://doi.org/10.3390/app14167236 (registering DOI)
Submission received: 24 April 2024 / Revised: 18 July 2024 / Accepted: 31 July 2024 / Published: 17 August 2024
Versions Notes

1. Commentary

Parkinson’s disease (PD) is a debilitating neurodegenerative disorder affecting millions of people worldwide. One of the most common symptoms of Parkinson’s disease is the impairment of motor function, resulting in difficulties with movement, balance, and coordination. Clinical presentation can also include non-motor symptoms, such as pain, sleep problems, behavior changes, memory changes, tremors, and fatigue [1,2,3,4]. The exact cause of PD is unknown, but it has been found to be related to the destruction of dopamine-producing cells. There is also research suggesting that a combination of genetic and environmental factors can increase the risk of PD [5,6]. While there is no proven cure for PD, it is widely agreed upon that aerobic exercises can help slow the progression of the disease and keep some motor-related symptoms at bay [7,8,9]. Exercise has been shown to be a beneficial intervention for individuals with Parkinson’s disease, as it can improve motor function, reduce other non-motor-related symptoms, and enhance a person’s overall quality of life. However, it remains unclear what the most effective forms of exercise are to slow the progression of Parkinson’s disease [7,10,11,12,13].
This research article aims to compare the differences in outcomes between endurance exercise and “other” types of exercise as forms of intervention for PD patients. These “other” types of exercise are typically considered to be more meaningful and engaging for a client and are often occupation-based in nature. Endurance-based exercises are what are most often used in the treatment of PD and in clinical trials. Endurance exercise is typically considered to be some form of aerobic exercise, such as walking, running, or biking [2]. Endurance or aerobic exercise is described as doing the same exercise over a long period of time, which in turn increases the heart rate. This is not to say that the “occupation-based” activities will not have aerobic aspects, but the literature encompasses the stationary bike, walking, and running programs as primarily endurance-based exercises. One of the concerns about aerobic and endurance-based activities is that they fail to be carried on as a lifestyle change after the client study ceases, thus any improvement or reduction in symptomatology for the participants is lost after activity cessation. The “other” types of exercise that will be mentioned in this article are occupationally based and encompass a range of activities; boxing, hydrotherapy, martial arts, dancing, and weight training are often cited in the literature as occupation-based exercises that PD patients partake in. In addition, occupation-based exercises tend to differ in the amount of cognitive “buy-in” they can offer; these types of exercises can, more often than not, hold some form of meaning for clients. The endurance-based activities can still hold meaning and be meaningful occupations for clients; however, endurance-based and aerobic-type activities are generally harder to gain buy-in with a patient if they were not previously engaging in that type of exercise prior to their diagnosis of PD. Occupation-based exercises may also provide options for clients that can hold their interest longer than in the treatment groups, with clients continuing in their chosen intervention exercise beyond their participation study. Many of these occupation-based exercises are self-selected and, in turn, create a sense of community for the clients in relation to their chosen activity [14]. Another separation point in the literature dividing the two types of exercise is that physical activity is often measured by MET or the metabolic equivalent of task, and occupation-based activities tend to rate lower on the MET scale. The MET scale stands for “metabolic equivalent” [15] and explains the amount of energy the body releases at rest. When discussing the MET scale and activities, it becomes a ratio of energy at rest versus energy expended during an activity [15]. This scale has become a staple for understanding the intensity of activity in the human body. While this scale is important to measure the physical demands of exercise, it is also important to measure and consider aspects of occupation-based exercises, such as meaning.
What is the defining characteristic that separates these two groups of activity? This study is looking at meaning as the separation factor between endurance-based and occupation-based exercises cited in this article. Merriam-Webster defines meaning as having significant quality. Meaning-making can also be defined as “the essential nature of human beings’ [16]. Humans, at their core, are meaning-makers. Within the occupation model, it is understood that humans create meaning in the activities they engage in. Humans find ways to create a deeper connection to the tasks they are involved in, which can include exercise. It can increase motivation to engage in a task or create a deeper reason to do something. When adding meaning-making to occupations, an individual can have a sense of motivation to complete the task. Due to the assumption humans are meaning-makers, using meaningful occupations in PD treatment can lead to better outcomes and a higher likelihood of continued participation in patients. It has been shown that “the individual meaning of wellbeing and facilitating engagement in the occupations individuals with Parkinson’s disease identify as meaningful may assist them to maintain wellbeing despite the presence of disease” [16].

2. Methods

2.1. Inclusion Criteria

As the current dataset was previously gathered the same inclusion criteria, literature search, and review process methodology were applied to the current study [7]. All studies selected for inclusion had to examine the effect of activity on motor-related outcomes of Parkinson’s disease as measured by the Unified Parkinson’s Disease Rating Scale (UPDRS) total score or UPDRS part III (motor score) or their equivalents from the Movement Disorders Society UPDRS (MDS-UPDRS) to be considered for inclusion. The following criteria were used to select appropriate studies:
  • Included individuals with a Parkinson’s disease diagnosis;
  • Performed assessment using the UPDRS or MDS-UPDRS part III or total score (parts I through IV);
  • Used a physical activity for treatment or intervention;
  • Written in the English language and with available full text;
  • Published in a peer-reviewed journal;
  • Published between 2017 and March 2022.
Studies were excluded if they did not meet all of the inclusion criteria or if they studied only animals.

2.2. Literature Search and Review Process

As the data had been previously collected, a brief review of the literature search and review process is presented here (the complete list of search terms, the PRISMA Flow, and results are in the primary article, [7]. Key search terms were entered simultaneously across three electronic databases (PubMed, SCOPUS, and CINAHL) from March 2022 to May 2022. A total of 3963 citations were retrieved from the database search, with an additional 7 identified through an ancestral bibliography search. Duplicate citations were removed, resulting in 1196 remaining citations that were screened and sorted through Rayyan by two raters. One thousand and twelve articles were excluded from analysis, while the remaining 184 were further assessed for eligibility using the established inclusion criteria. Twenty-five articles were ultimately selected for inclusion, and two raters coded them for variables of interest.

2.3. Comparison Group Identification

After selecting 25 articles for analysis, researchers grouped studies by exercise type for comparison. Studies were first grouped into aerobic and non-aerobic groups using the groupings determined in [7]. Following this, studies were then re-grouped based on 6 common exercise types and a reconfigured aerobic group. The common exercise categories included dance, aquatic exercise, yoga/tai chi/martial arts, strength, and balance/gait/stretching activities. There were 16 studies in the original non-aerobic category with 33 effect sizes, and there 9 studies with 20 effect sizes in the original [7] aerobic category. For the reconfigured exercise groups, there were 6 studies in the dance category with 13 effect sizes. The aquatic category contained 3 studies with 6 effect sizes. The yoga/tai chi/martial arts category included 5 studies with 10 effect sizes. The strength category contained 3 studies with 7 effect sizes, and the balance/gait/stretching category included 5 studies with 11 effect sizes. The newly determined aerobic category included 3 studies with 6 effect sizes.

2.4. Analytic Approach

As the included studies had previously been meta-analyzed in [7], the current study aimed to compare the different activity categories on Parkinson’s disease. In order to do so, multiple independent sample t-tests were used to compare the average unweighted effect sizes of the aerobic and non-aerobic groups as determined by [17], along with comparisons of each activity category and aerobic groups. Furthermore, a one-way ANOVA was used to compare all non-aerobic exercise categories.

3. Results

The purpose of this study was to compare various types of exercise to determine if there were significant differences on the effect of Parkinson’s disease. Using an independent sample t-test, when the original [7] aerobic and non-aerobic studies were compared, there was no significant difference in the effect on Parkinson’s disease, t(51) = 1.77, p = 0.083 (Table 1). Additionally, when comparing each activity category with the aerobic category individually, only the aquatic exercise group showed significant differences in the effect on Parkinson’s disease compared to the aerobic group, t(10) = 2.42, p = 0.036 (Table 1). Those in the aquatic group (M = 0.63, SD = 0.63) showed better outcomes than those in the aerobic group (M = −0.33, SD = 0.75). The dance, yoga/tai chi/martial arts, strength, and balance groups did not show significant differences in the effect on Parkinson’s disease when compared to the aerobic group. Further, using a one-way ANOVA, all of the determined non-aerobic group activity categories were compared. The results showed that there were no significant differences between any of the exercise activity categories, F(4, 42) = 1.221, p = 0.316 (Table 1).

4. Discussion

It has been shown that despite the presence of PD, participating in meaningful occupations assists them in maintaining their overall wellbeing [16]. Heightening the meaning of interventions for PD patients can be important for improving their occupational engagement, especially after study cessation. When patients with PD engage in exercises that hold more meaning to them than traditional aerobic exercises or when the activities are more occupationally based in nature, it leads to higher levels of satisfaction with treatment and better treatment outcomes for PD patients in these studies [45]. Engaging in an activity or an occupation that an individual with PD wants or chooses to do can facilitate their “mental and emotional state” in a positive way [16]. The goal of engaging in meaningful occupations is to create a state of full concentration in which patients and clients are fully immersed in their occupations of choice. Being able to provide a wide variety of treatment options to patients, rather than traditionally used aerobic exercises for PD patients, will hopefully lead the client to believe that they have a higher sense of control in their treatment plan. The goal is that this, in turn, will help PD patients find or make meaning in their chosen rehabilitation occupation and encourage them to continue their occupation after study cessation to create a lifelong meaningful occupation [46]. The hope is that this will increase the ability for the client to have a deeper investment and concentration in the task they are performing and that this investment will carry on post-study treatment, turning the study task into a meaningful occupation rather than a short-term activity.
Essentially, meaning is what separates occupations from activities. Meaning can provide clients with purpose and contentment (Table 2). Offering patients meaningful options that fit their activity level and lifestyle preferences can motivate PD patients to continue with their treatment and change their lifestyle habits, thus leading to the hope of continuing to slow the progression of their PD motor-related symptoms [47]. The meaning of the occupation can exist where the competency of the activity does not; the meaning of the activity can even assume the role of competency, causing the competency of the activity to be irrelevant to one’s chosen occupation [16]. Providing patients with meaningful options that fit their activity level and lifestyle preferences can help PD patients wish to continue with their treatment and give them more motivation to change their lifestyle habits [47], whereas if they were feeling incompetent in their given rehab activity, there may not be much of a desire to continue with treatment. Adding meaning to their daily occupations and rehabilitation will hopefully provide PD clients with the agency of desire.
In a 1998 paper by Dr. Crabtree, there are four main aspects of an occupation to consider, the first of which proclaims that an occupation promotes a “spiritual state of total engagement” [16] (Table 2). This is found in a person when they are participating in an occupation or an activity that holds meaning to them. Engagement can also cause a feeling of contentment when the participant is fully invested in what they are engaged in. When someone achieves this flow of engagement, the task can become more enjoyable and fulfilling. The second aspect of Crabtree’s article is that occupations provide a sense of actuality. This means that an individual is “aware of the effect they are having on something” [16], which creates meaning. The impact of an occupation can be seen literally when an effect is made on the occupation. The third aspect of Crabtree’s article is a sense of authorship. Authorship can be viewed as the “sense of being the source and origination of a thing or deed” [16]. This ties into the aspect of providing choices for clients with PD to find a personal connection to the occupation they participate in. This can make clients feel a sense of accomplishment and power within their treatment. The final aspect that is discussed in the article is a sense of identity. It demonstrates “that we exist and why we exist” [16]. Tying identity into an occupation creates a deeper connection between an activity and an individual. This can be important for clients with PD to create more meaning in an activity they engage in. It can also create a community for the individual that they did not have before.

5. Conclusions

These meaningful options for rehabilitation support the emerging theory of neuro-occupation. Neuro-occupation is a theory within neuroscience and healthcare that looks at the complexities of the human brain relating to engagement in activities or occupations. It is the idea that “humans are neuro-occupational beings whose occupations influence and are influenced by their nervous system and concept” [48]. Purpose plays an important role in neuro-occupation due to the impact it can have on performance [48]. Purpose combines meaning and reason together to produce answers as to why an individual engages in an activity. The term purpose is also further explained through the IMP model. The IMP is another model that can be used when looking at neuro-occupation. IMP stands for, “intention, meaning, and perception” [48]. The IMP model strengthens the argument from neuro-occupation that perceptions of outcomes can lead to success in occupational performance. The concepts found in the IMP model of neuro-occupation can help to develop assessment tools based in neuro-occupation [49]. Neuro-occupation can and should be applied and considered when looking at Parkinson’s disease intervention. Resiliency and the ability to adapt can be found within neuro-occupation-based treatment [50]. While this theory has been more commonly used with stroke treatment, the concept of resiliency is found within all healthcare fields and clients of many diagnoses. In early research, it was found that when individuals have a “drive for restoration of occupational performance” [48], there is positive change. While these are preliminary studies, the usage of the IMP model of neuro-occupation can make a difference for clients. These concepts of neuro-occupation can be reflected in a variety of populations that have goals towards engagement in activities. Parkinson’s disease is a complex disease that affects the nervous system, and these effects alter one’s ability to participate in activities and occupations. Since neuro-occupation ties together meaning and the nervous system, PD treatment should utilize this theory to create better results for PD clients in support of their chosen occupations. The conclusion of this further study is that all of the studied exercises (minus the aquatic therapy, which showed a slight significant advantage) showed statistically significant improvement over the sedentary or pre-performance condition and that all would be equally beneficial given the engagement of the client. This is good news for therapists, as engaging the client will increase adherence and positively impact their Parkinson’s disease symptoms.

6. Limitations

This meta-analysis supports two things: first, that endurance exercise has positive outcomes with PD and, second, that activity-based exercises also have positive outcomes. There are several notable limitations that should be considered when evaluating these results. While it can be considered a strength that the results of this review are based upon primarily recent evidence, it is possible that including studies published prior to 2017 or after 2023 may have changed the results. Uhrbrand et al. identified many randomized control trials investigating the impact of exercise in PD [13]; however, they identified few studies that evaluated the impact of exercise on PD symptoms and UPDRS scales. Though we have made efforts to include studies that did not use the UPDRS as the primary standardized statistical device, the use of non-standardized tools was excluded, which could have affected results. Additionally, as is a limitation for all systematic reviews, this meta-synthesis and meta-analysis relies upon the body of published literature, which may be biased by a tendency for trials showing positive results to be more prioritized by publishers and authors. While this is a consideration, the relatively large number of studies included (n = 25), and the distribution of findings (between positive and negative results) provide support to indicate a relatively low risk for this bias. Another limitation of synthesis research is that it relies on previously collected data, which distributes the risk of bias but precludes the ability of the synthesis researcher to determine causation. This is a reason these data are presented as a commentary, proposing elements of meaning, which is not typically considered with current causative mechanisms. There may be other factors that determine the equivalency of endurance-based activities and occupation-based activities. The nature of the different activities should provide a rich and broad palette for therapists to prescribe activities and exercises, though some may be limited by facilities and time. Reimbursement will have to keep up with best practice. Lastly, while availability bias and selection bias are common in this type of review, attempts were made to minimize these sources bias in the following ways. To minimize selection bias, the inclusion of studies was based upon selection from two independent assessors, following screening for eligibility. For availability bias, attempts were made to obtain the full text for all eligible studies.

Funding

This research received no external funding.

Acknowledgments

The authors thank Jason K. Longhurst, Lana Downard and Stephanie Martin.

Conflicts of Interest

The authors declare no conflicts of interest.

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Table 1. Comparison of activities.
Table 1. Comparison of activities.
ComparisonGroupN (di)Mdi (SD)t (df)p
Non-aerobic vs. Aerobic 1.77 (51)0.083
Non-Aerobic470.19 (0.67)
Aerobic6−0.33 (0.75)
Dance vs. Aerobic 1.87 (17)0.078
Dance130.33 (0.71)
Aerobic6−0.33 (0.75)
Aquatic vs. Aerobic 2.42 (10)0.036 *
Aquatic60.63 (0.63)
Aerobic6−0.33 (0.75)
Yoga/Tai Chi/Martial Arts vs. Aerobic 0.81 (14)0.432
Yoga/Tai Chi/Martial Arts100.01 (0.87)
Aerobic6−0.33 (0.75)
Strength vs. Aerobic 0.77 (11)0.460
Strength 7−0.01 (0.75)
Aerobic6−0.33 (0.75)
Balance vs. Aerobic 1.67 (15)0.115
Balance110.08 (0.26)
Aerobic 6−0.33 (0.75)
One-Way ANOVA Non-Aerobic Group comparisons F(df)p
1.22 (4, 42)0.316
Note. * p < 0.05; n = sample size, di = unweighted effect size, Mdi = average unweighted effect size, SD = standard deviation, t = t-statistic, df = degrees of freedom, F = f-statistic. [9,12,14,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44]
Table 2. Characteristics of meaning.
Table 2. Characteristics of meaning.
Characteristics
State of Engagement The first of which proclaims that occupation promotes a “spiritual state of total engagement” (Crabtree, 1998). This is found in a person when they are participating in an occupation or an activity that holds meaning to them. Engagement can also cause a feeling of contentment when the participant is fully invested in what they are engaged in. When someone achieves this flow of engagement, the task can become more enjoyable and fulfilling.
Sense of ActualityThe second aspect of Crabtree’s article is that occupations provide a sense of actuality. This means that an individual is “aware of the effect they are having on something” (Crabtree, 1998), which creates meaning. The impact of an occupation can be seen literally when an effect is made on the occupation.
Sense of AuthorshipThe third aspect of Crabtree’s article is a sense of authorship. Authorship can be viewed as the “sense of being the source and origination of a thing or deed” (Crabtree, 1998). This ties into the aspect of providing choices for clients with PD to find a personal connection to the occupation they participate in. This can make clients feel a sense of accomplishment and power within their treatment.
Sense of Identity The final aspect that is discussed in the article is a sense of identity. It demonstrates “that we exist and why we exist” (Crabtree, 1998). Tying identity into an occupation creates a deeper connection between activity and an individual. This can be important for clients with PD to create more meaning in an activity they engage in. It can also create a community for the individual that they did not have before.
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Ahmad, S.O.; Stiles, D.; Born, E.; Scheffler, J.; Vogel, K. Commentary on A Meta-Analysis of Exercise Intervention and the Effect on Parkinson’s Disease Symptoms: What Activities Are Best? Appl. Sci. 2024, 14, 7236. https://doi.org/10.3390/app14167236

AMA Style

Ahmad SO, Stiles D, Born E, Scheffler J, Vogel K. Commentary on A Meta-Analysis of Exercise Intervention and the Effect on Parkinson’s Disease Symptoms: What Activities Are Best? Applied Sciences. 2024; 14(16):7236. https://doi.org/10.3390/app14167236

Chicago/Turabian Style

Ahmad, Syed Omar, Dana Stiles, Emily Born, Julie Scheffler, and Katie Vogel. 2024. "Commentary on A Meta-Analysis of Exercise Intervention and the Effect on Parkinson’s Disease Symptoms: What Activities Are Best?" Applied Sciences 14, no. 16: 7236. https://doi.org/10.3390/app14167236

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