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Randomized Clinical Trial of 3 Types of Physical Exercise for Patients With Parkinson Disease
Open accessAbstract
OBJECTIVE: To compare the efficacy of treadmill exercises and stretching and resistance exercises in improving gait speed, strength, and fitness for patients with Parkinson disease. DESIGN: A comparative, prospective, randomized, single-blinded clinical trial of 3 types of physical exercise. SETTING: The Parkinson's Disease and Movement Disorders Center at the University of Maryland and the Baltimore Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center. PATIENTS: A total of 67 patients with Parkinson disease who had gait impairment were randomly assigned to 1 of 3 arms of the trial. INTERVENTIONS; (1) A higher-intensity treadmill exercise (30 minutes at 70%-80% of heart rate reserve), (2) a lower-intensity treadmill exercise (50 minutes at 40%-50% of heart rate reserve), and (3) stretching and resistance exercises (2 sets of 10 repetitions on each leg on 3 resistance machines [leg press, leg extension, and curl]). These exercises were performed 3 times a week for 3 months. MAIN OUTCOME MEASURES: The primary outcome measures were gait speed (6-minute walk), cardiovascular fitness (peak oxygen consumption per unit time [$$ VO2], and muscle strength (1-repetition maximum strength). RESULTS: All 3 types of physical exercise improved distance on the 6-minute walk: lower-intensity treadmill exercise (12% increase; P=.001), stretching and resistance exercises (9% increase; P<.02), and higher-intensity treadmill exercise (6% increase; P=.07), with no between-group differences. Both treadmill exercises improved peak $$ VO2 (7%-8% increase; P<.05) more than did the stretching and resistance exercises. Only stretching and resistance improved muscle strength (16% increase; P<.001). CONCLUSIONS: The effects of exercise were seen across all 3 exercise groups. The lower-intensity treadmill exercise resulted in the greatest improvement in gait speed. Both the higher- and lower-intensity treadmill exercises improved cardiovascular fitness. Only the stretching and resistance exercises improved muscle strength. Therefore, exercise can improve gait speed, muscle strength, and fitness for patients with Parkinson disease. The combination of treadmill and resistance exercises may result in greater benefit and requires further investigation.
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“Studies have reported similar improvements in gait speed and stride length (Pohl et al., 2003) and aerobic capacity (Ridgel et al., 2009; Shulman et al., 2013) for high-intensity (80% of maximum capacity) and low-intensity (50% of maximum capacity) training programs.”
From Perception of Physical Demand, Mental Demand, and Performance: A Comparison of Two Voice Interventions for Parkinson's Disease (2022) · cites this paper as Shulman et al., 2013
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ResultInfluentialEffects of exercise on mobility in people with Parkinson's disease
van der Kolk, N. M., & King, L. A. (2013) · Movement Disorders · doi:10.1002/mds.25658 · Cited by 244
“Schulman et al compared 3 months of high- versus low-intensity treadmill training with stretching and resistance exercises and found similar effects on physical fitness with a dose-response relationship (peak VO2), whereas all intervention arms improved in gait speed (6minute walk test).(38) Significant changes in the…”
BackgroundOsborne, J. A., Botkin, R., Colón-Semenza, C., DeAngelis, T. R., Gallardo, O. G., Kosakowski, H., Martello, J. P., Pradhan, S. D., Rafferty, M. R., Readinger, J. L., et al. (2021) · Physical Therapy · doi:10.1093/ptj/pzab302 · Cited by 268
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On the Run for Hippocampal PlasticityPreprint
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“Furthermore, the combination of different types of exercises led to greater benefits in brain functions [145, 146].”
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“A recent study comparing high- versus low-intensity treadmill training found that the lower-intensity training resulted in the greatest improvement in gait speed in participants with PD [69].”
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Frazzitta, G., Maestri, R., Ghilardi, M. F., Riboldazzi, G., Perini, M., Bertotti, G., Boveri, N., Buttini, S., Lombino, F. L., Uccellini, D., et al. (2013) · Neurorehabilitation and neural repair · doi:10.1177/1545968313508474 · Cited by 160
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Solla, P., Cugusi, L., Bertoli, M., Cereatti, A., Croce, U. D., Pani, D., Fadda, L., Cannas, A., Marrosu, F., Defazio, G., et al. (2019) · The Journal of Alternative and Complementary Medicine · doi:10.1089/acm.2018.0413 · Cited by 137
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“Shulman et al13 used the 16-item Parkinson Fatigue Scale and found no significant change in fatigue after strength training in the strength training intervention group or high- and low-intensity treadmill intervention groups.”
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“In a comparative trial of 3 types of exercise (high-intensity treadmill training, lower-intensity treadmill training, and stretching/resistance training), no changes in depression were observed for any group after 3 months of exercise (30-50 minutes, 3 times per week), although participants reported only mild levels o…”
BackgroundResultInfluentialExercise activates lysosomal function in the brain through AMPK‐SIRT1‐TFEB pathway
Huang, J., Wang, X., Zhu, Y., Li, Z., Zhu, Y., Wu, J., Qin, Z., Xiang, M., & Lin, F. (2019) · CNS Neuroscience & Therapeutics · doi:10.1111/cns.13114 · Cited by 130
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“…that physical exercise needs to be prescribed to PD patients and be an essential component of the treatment for PD (Ahlskog, 2011; Vina et al., 2012; Shulman et al., 2013; Bloem et al., 2015; Pedersen and Saltin, 2015; LaHue et al., 2016; Lauzé et al., 2016; Reynolds et al., 2016) (Figure 1).”
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“Shulman et al.(74) suggested the importance of a combination of treadmill training and resistance exercise to obtain a greater benefit in patients with PD.”
BackgroundTwo-Year Exercise Program Improves Physical Function in Parkinson’s Disease
Prodoehl, J., Rafferty, M. R., David, F. J., Poon, C., Vaillancourt, D. E., Comella, C. L., Leurgans, S. E., Kohrt, W. M., Corcos, D. M., & Robichaud, J. A. (2014) · Neurorehabilitation and neural repair · doi:10.1177/1545968314539732 · Cited by 94
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“1 points) [39], and also exceeds high-intensity aerobic exercise (AE) [40], BGT [41] and Stretch [42], but less than PT and Yoga [43].”
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“Two studies [35,41] compared RT alone with a control group that received standard medical practice; one study (RCT) [40] compared RT with another intervention (Tai Chi or Stretching); four studies [36–38,43] including one RCT [36] compared an intervention that comprised RT combined with another form of exercise (aerob…”
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“Countless studies have shown that a variety of exercises improve the symptoms of PD, including home based exercise [3], treadmill [4], resistance exercise [5], tango dancing [6], tai chi [7], and robot-assisted gait training [8].”
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“The different extent to the loss of neurons may be due to changes in exercise duration and intensity, which could affect the motor benefits of PD patients [89].”
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“Results of exercise trials in PD reveal the benefits of moderate-intensity walking to reduce disability [9,10].”
Song, J., Ahn, J. H., Choi, I., Mun, J. K., Cho, J. W., & Youn, J. (2020) · Parkinsonism & Related Disorders · doi:10.1016/j.parkreldis.2020.09.034 · Cited by 60
Abou, L., Alluri, A., Fliflet, A. M., Du, Y., & Rice, L. A. (2020) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2020.06.025 · Cited by 59
Helgerud, J., Thomsen, S. N., Hoff, J., Strandbråten, A., Leivseth, G., Unhjem, R., & Wang, E.-L. (2020) · Journal of Applied Physiology · doi:10.1152/japplphysiol.00208.2020 · Cited by 59
“In contrast, resistance training is documented to enhance efferent neural drive (39), alleviate cardinal motor symptoms (12), and improve FGC (30, 38) in PD patients.”
BackgroundResultLifestyle Interventions for the Prevention of Parkinson Disease
Daalen, J. M. J., Schootemeijer, S., Richard, E., Darweesh, S. K. L., & Bloem, B. R. (2022) · Neurology · doi:10.1212/wnl.0000000000200787 · Cited by 63
“As expected, an increase in VO2max was only seen in the treadmill arm, but an improvement in walking speed after 3 months was seen in the aerobic and nonaerobic arms, without between-group differences.(26)”
BackgroundMattson, M. P. (2014) · Journal of Parkinson s Disease · doi:10.3233/jpd-130335 · Cited by 60
“High intensity treadmill exercise improves gait and quality of life in PD [75], low intensity treadmill exercise improves gait speed but not muscle strength, whereas resistance exercise improves muscle strength but not gait speed [76].”
Koo, J., & Cho, J. (2017) · Neurotoxicity Research · doi:10.1007/s12640-017-9770-5 · Cited by 61
“Our results corroborate those of a previous study, which suggested that the duration and intensity of physical exercise can influence the benefits of exercise in patients with PD (Shulman et al. 2013).”
A Stage-Based Approach to Therapy in Parkinson’s Disease
Carrarini, C., Russo, M., Dono, F., Pietro, M. D., Rispoli, M. G., Stefano, V. D., Ferri, L., Barbone, F., Vitale, M., Thomas, A., et al. (2019) · Biomolecules · doi:10.3390/biom9080388 · Cited by 58
“Specifically, it has been reported that intensive training modalities including stretching and resistance training could improve muscle strength and mobility, therefore giving a better control of some of MS [218,219], whereas aerobic activity is also helpful for cardiovascular fitness [220].”
BackgroundKanegusuku, H., Silva‐Batista, C., Peçanha, T., Nieuwboer, A., da Silva, N. D., Costa, L. A. R., de Mello, M. T., Piemonte, M. E. P., Ugrinowitsch, C., & Forjaz, C. L. M. (2017) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2017.06.009 · Cited by 56
Augmented reality-based dance intervention for individuals with Parkinson’s disease: A pilot study
Tunur, T., DeBlois, A., Yates-Horton, E., Rickford, K., & Columna, L. A. (2019) · Disability and health journal · doi:10.1016/j.dhjo.2019.100848 · Cited by 55
“05) and subjects matching (F(4, 8)1⁄4 22.”
Tollár, J., Nagy, F., Kovács, N., & Hortobágyi, T. (2018) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2018.05.007 · Cited by 60
The Effect of Physical Activity in Parkinson’s Disease: A Mini-Review
Fayyaz, M., Jaffery, S. S., Anwar, F., Zil‐E‐Ali, A., & Anjum, I. (2018) · Cureus · doi:10.7759/cureus.2995 · Cited by 56
Mancini, M., Afshari, M., Almeida, Q. J., Huffmaster, S. L. A., Balfany, K., Camicioli, R. M., Christiansen, C. L., Dale, M. L., Dibble, L. E., Earhart, G. M., et al. (2025) · npj Parkinson s Disease · doi:10.1038/s41531-025-00897-1 · Cited by 52
“…overground 101,102 , walking on a traditional treadmill 103 – 107 , walking on treadmills that apply concurrent perturbations to the participant 108 – 111 , robot-assisted walking 112 , Nordicwalking 113,114 ,walkinginavirtual-realityenvironment 115 ,walkingon a curved treadmill 116,117 , and…”
Therapies for Parkinson’s diseases: alternatives to current pharmacological interventions
Li, S., Dong, J., Cheng, C., & Le, W. (2016) · Journal of Neural Transmission · doi:10.1007/s00702-016-1603-9 · Cited by 50
Effort training in Parkinson's disease: A systematic review
Tambosco, L., Percebois-Macadré, L., Rapin, A., Nicomette-Bardel, J., & Boyer, F. C. (2014) · Annals of Physical and Rehabilitation Medicine · doi:10.1016/j.rehab.2014.01.003 · Cited by 56
Harvey, M., Weston, K. L., Gray, W. K., O’Callaghan, A., Oates, L. L., Davidson, R., & Walker, R. W. (2018) · Clinical Rehabilitation · doi:10.1177/0269215518815221 · Cited by 52
Progressive resistance training in Parkinson's disease: a systematic review and meta-analysis
Saltychev, M., Bärlund, E., Paltamaa, J., Katajapuu, N., & Laimi, K. (2016) · BMJ Open · doi:10.1136/bmjopen-2015-008756 · Cited by 49
“Six studies compared progressive resistance training with weakly defined ‘usual activities’, 16–18 four with different low-intensity strengthening, endurance or balance exercises,(14) 15 19 20 one with the use of vitamins,(17) and one with treadmill training.(22) It is selfevident that most of the patients with PD hav…”
BackgroundEndurance exercise improves function in individuals with Parkinson’s disease: A meta-analysis
Flach, A., Jaegers, L. A., Krieger, M., Bixler, E. A., Kelly, P., Weiss, E. P., & Ahmad, S. O. (2017) · Neuroscience Letters · doi:10.1016/j.neulet.2017.08.076 · Cited by 47
Dahmen-Zimmer, K., & Jansen, P. (2017) · Frontiers in Medicine · doi:10.3389/fmed.2017.00237 · Cited by 47
“, for example, proved that endurance as well as strength and flexibility improved by a treadmill, strength and flexibility training (5).”
BackgroundParkinson disease in the elderly adult.
Willis, A. W. (2013) · Europe PMC (PubMed Central) · Cited by 47
Complementary and Alternative Medicine and Exercise in Nonmotor Symptoms of Parkinson's Disease
Subramanian, I. (2017) · International review of neurobiology · doi:10.1016/bs.irn.2017.05.037 · Cited by 46
“Shulman et al. (2013) studied 67 patients in a RCT of 30 min of high-intensity treadmill vs 50 min of low-intensity treadmill vs stretching and resistance 3 times per week for 3 months.”
BackgroundMethodMustafaoğlu, R., Ahmed, I., & Pang, M. Y. C. (2022) · Acta Neurologica Belgica · doi:10.1007/s13760-022-02070-4 · Cited by 49
Chuang, C., Chang, J., Cheng, F., Liu, K., Su, H., & Liu, C. (2017) · Life Sciences · doi:10.1016/j.lfs.2017.10.003 · Cited by 44
Cherup, N. P., Buskard, A. N. L., Strand, K. L., Roberson, K. B., Michiels, E. R., Kuhn, J. E., Lopez, F. A. P., & Signorile, J. F. (2019) · Experimental Gerontology · doi:10.1016/j.exger.2019.110740 · Cited by 46
Patterson, C. G., Joslin, E., Gil, A. B., Spigle, W. A., Nemet, T., Chahine, L. M., Christiansen, C. L., Melanson, E., Kohrt, W. M., Mancini, M., et al. (2022) · Trials · doi:10.1186/s13063-022-06703-0 · Cited by 48
“Second, the distance walked in the 6-min walk test is sensitive to change with respect to endurance exercise [69, 88, 89].”
BackgroundQuinn, L., & Morgan, D. W. (2017) · Neurology Report · doi:10.1097/npt.0000000000000166 · Cited by 46
Treatment options for postural instability and gait difficulties in Parkinson’s disease
Müller, M. L. T. M., Marušič, U., Boas, M. V. E., Weiß, D., & Bohnen, N. I. (2019) · Expert Review of Neurotherapeutics · doi:10.1080/14737175.2019.1656067 · Cited by 48
“direct comparison of aerobic treadmill exercise to combined stretching and resistance exercises showed that both types of exercise can improve gait speed in PD patients, with differential benefits of the treadmill exercises for cardiovascular fitness and the combined stretching and resistance exercise for muscle stren…”
BackgroundKoo, J., & Cho, J. (2017) · Neurotoxicity Research · doi:10.1007/s12640-017-9779-9 · Cited by 41
An Evidence-Based Exercise Regimen for Patients with Mild to Moderate Parkinson’s Disease
Salgado, S. M., Williams, N., Kotian, R., & Salgado, M. W. (2013) · Brain Sciences · doi:10.3390/brainsci3010087 · Cited by 45
Devasahayam, A. J., Downer, M. B., & Ploughman, M. (2017) · Multiple Sclerosis International · doi:10.1155/2017/4815958 · Cited by 40
“[60] found that treadmill and resistance training did not differ in improving gait among people with Parkinson’s disease.”
Chang, H., Lu, C.-S., Chiou, W.-D., Chen, C.-C., Weng, Y.-H., & Chang, Y. (2018) · Journal of Clinical Neurology · doi:10.3988/jcn.2018.14.2.225 · Cited by 39
Ferrazzoli, D., Carter, A., Üstün, F. S., Palamara, G., Ortelli, P., Maestri, R., Yücel, M., & Frazzitta, G. (2016) · Frontiers in Behavioral Neuroscience · doi:10.3389/fnbeh.2016.00121 · Cited by 40
“Shulman et al. (2013) suggested the importance of a combination of treadmill training and resistance exercise to obtain a greater benefit in patients with PD.”
BackgroundBearss, K. A., & DeSouza, J. F. X. (2021) · Brain Sciences · doi:10.3390/brainsci11070895 · Cited by 38
“A growing body of evidence demonstrates that high-intensity interval training (HIIT) can serve as an effective alternate to traditional PD exercise programs, inducing similar or even superior physiological adaptations in healthy individuals and diseased populations [38,39].”
Backgroundde Almeida, F. O., Santana, V. P., Corcos, D. M., Ugrinowitsch, C., & Silva‐Batista, C. (2022) · Sports Medicine · doi:10.1007/s40279-022-01650-x · Cited by 38
“(2013) [30] 3 12 36 50 Trigueiro et al.”
BackgroundMethodInfluentialMoore, C. G., Schenkman, M. L., Kohrt, W. M., Delitto, A., Hall, D. A., & Corcos, D. M. (2013) · Contemporary Clinical Trials · doi:10.1016/j.cct.2013.06.002 · Cited by 39
“In one of these studies, Shulman and colleagues [8] found that of 945 patients assessed for eligibility, 169 (18%) did not meet inclusion criteria, 696 (74%) declined to participate in the exercise trial, and among 80 randomized, 12 (15%) discontinued their exercise intervention.”
BackgroundResultvan der Kolk, N. M., Overeem, S., de Vries, N. M., Kessels, R. P. C., Donders, R., Brouwer, M. A., Berg, D., Post, B., & Bloem, B. R. (2015) · BMC Neurology · doi:10.1186/s12883-015-0312-6 · Cited by 37
“Similar results were seen in small treadmill studies in PD patients, showing improvement in gait parameters and enhanced physical fitness [5-7].”
ResultGollan, R., Ernst, M., Lieker, E., Caro-Valenzuela, J., Monsef, I., Dresen, A., Roheger, M., Skoetz, N., Kalbe, E., & Folkerts, A. (2022) · Journal of Parkinson s Disease · doi:10.3233/jpd-223252 · Cited by 37
“Eight studies were held as group sessions [9, 15, 37, 39, 42–44, 46] , whereas Regarding training frequency, in 14 studies RT was conducted on two non-consecutive days of the week [6, 8, 9, 31–33, 38–41, 43–45, 47], in three studies on three non-consecutive days [37, 42, 46], and in one study the…”
InfluentialEarhart, G. M., Duncan, R. P., Huang, J. L., Perlmutter, J. S., & Pickett, K. A. (2015) · BMC Neurology · doi:10.1186/s12883-015-0261-0 · Cited by 36
“preferred speed for longer durations is more effective in enhancing gait than training at higher intensity for shorter blocks of time [31,32].”
Background
Metadata
- Authors
- Shulman, L. M., Katzel, L. I., Ivey, F. M., Sorkin, J. D., Favors, K., Anderson, K. E., Smith, B. A., Reich, S. G., Weiner, W. J., & Macko, R. F.
- Affiliations
- University of Maryland, Baltimore (US)
- Corresponding author
- Shulman, Lisa M.
- ORCID
- Venue
- JAMA Neurology
- Publisher
- American Medical Association (AMA)
- Published
- 2013-02-01
- Volume
- 70
- Issue
- 2
- Pages
- 183
- ISSN
- 2168-6149 (ISSN-L)
- PMC
- PMC4574905
- OpenAlex
- W2124808208
- Cited by
- 410
- References
- 40
- Citations by year
- 2026: 16 · 2025: 25 · 2024: 33 · 2023: 19 · 2022: 32 · 2021: 36 · 2020: 78 · 2019: 34 · 2018: 27 · 2017: 25 · 2016: 21 · 2015: 24 · 2014: 21 · 2013: 16
- FWCI
- 50.17
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- JAMA Neurology (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute on Aging (T32AG000219, R01AG034161, P30AG028747)
- National Heart, Lung, and Blood Institute (R01HL095136, K30HL004518)
- National Institute of Diabetes and Digestive and Kidney Diseases (R01DK090401)
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (U01AR057967)
- Topics
- Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Balance, Gait, and Falls Prevention
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Physical Activity and Health
- Health Sciences › Medicine › Clinical Neurology › Parkinson's Disease Mechanisms and Treatments
- Keywords
- Parkinson's disease, physical activity, treadmill exercise, resistance training, stretching, walking speed, cardiorespiratory fitness, peak oxygen uptake, muscle strength, exercise intensity, 6-minute walk test
- MeSH terms
- Adult, Aged, Electrocardiography, Exercise Test, Female, Gait, Humans, Male, Middle Aged, Parkinson Disease, Prospective Studies, Exercise, Single-Blind Method, Muscle Stretching Exercises, Resistance Training
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