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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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“A large number of studies have established the efficacy of both PRT strategies for improving muscular strength in subjects with PD, providing conflicting evidence regarding improvements in functional capacity and balance (7,8,12,18,39,40,44).”
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“All included trials were published between 2006 and 2022, 20 eligible RCTswith 811 patients diagnosed with PDwere included in this network meta-analysis (Dibble et al., 2006, 2009b, 2015; Fisher et al., 2008; Kurtais et al., 2008; Schilling et al., 2010; Canning et al., 2012; Qutubuddin et al., 2013; Shulman et al., 2…”
BackgroundTillman, A., Muthalib, M., Hendy, A. M., Johnson, L. G., Rantalainen, T., Kidgell, D. J., Enticott, P. G., & Teo, W. (2015) · Frontiers in Aging Neuroscience · doi:10.3389/fnagi.2015.00040 · Cited by 30
“, focusing on one muscle), open kinetic chain exercises such as leg presses, hamstring curls, leg extensions, and calf raises (Buckley et al., 2008; Schilling et al., 2010; Shulman et al., 2013), while two studies used an eccentric resistance training paradigm on a cycle ergometer (Dibble et al.”
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“Overall, stretching and flexibility exercises should be considered part of the daily life of a PwP.”
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Aburub, A., Ledger, S., Sim, J., & Hunter, S. M. (2020) · Movement Disorders Clinical Practice · doi:10.1002/mdc3.13011 · Cited by 25
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Silva, A. B. G., Pestana, B. C., Hirahata, F. A. A., Horta, F. B. D. S., & Oliveira, E. S. B. E. (2021) · Brazilian Journal of Development · doi:10.34117/bjdv.v7i5.29678 · Cited by 25
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“Studies not included in review due to sample with no elderly also showed that TT without body weight support in patients with PD, compared to other motor therapies, increased speed and stride length.(42,43) Three studies included used TT with body weight support(18-20) and two(19,21) showed superiority of supported tr…”
ResultAerobic capacity in persons with Parkinson’s disease: a systematic review
Thrue, C., Hvid, L. G., Gamborg, M., Dawes, H., Dalgas, U., & Langeskov‐Christensen, M. (2022) · Disability and Rehabilitation · doi:10.1080/09638288.2022.2094480 · Cited by 25
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“The independent negative effect of sedentariness may be a possible explanation why recent exercise trials in PD, despite improved test performance, did not ultimately demonstrate improvements in disability and quality of life in PD [19, 20].”
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Adiponectin, exercise and eye diseases
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“There are many reasons why PwPD may find it difficult to participate in high-intensity exercise interventions, such as deconditioning, fear of falling, low self-efficacy, low expectations, and decreased motivation 3,19,20 .”
BackgroundLi, X., He, J., Yun, J., & Qin, H. (2020) · Frontiers in Neurology · doi:10.3389/fneur.2020.591605 · Cited by 23
Evidence-Based Aquatic Therapy Guidelines for Parkinson’s Disease: An International Consensus Study
Carroll, L. M., Morris, M. E., O’Connor, W. T., Volpe, D., Salsberg, J., & Clifford, A. M. (2021) · Journal of Parkinson s Disease · doi:10.3233/jpd-212881 · Cited by 20
“This recommendation is consistent with other research evidence, suggesting that prolonged strength training [53, 54], aerobic training [55–57], dance therapy [58, 59], and Tai Chi [60, 61] can produce long-term beneficial effects for people with PD engaged in physiotherapy and exercise.”
Current Therapies and Drug Development Pipeline in Lewy Body Dementia: An Update
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“There are multiple studies demonstrating that regular aerobic exercise has a positive impact in patients with PD [43, 44].”
BackgroundMulti-Modal Rehabilitation Therapy in Parkinson's Disease and Related Disorders
Saluja, A., Goyal, V., & Dhamija, R. K. (2022) · Annals of Indian Academy of Neurology · doi:10.4103/aian.aian_164_22 · Cited by 25
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“High-intensity aerobic exercise also significantly affects the lower limb activity and exercise symptoms of PD patients (35-37).”
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THE IMPACT OF BRAZILIAN SAMBA ON PARKINSON’S DISEASE: ANALYSIS BY THE DISEASE SUBTYPES
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“In addition, resistance training strengthens muscle strength and enhances quality of life, but it might also increase the burden on the muscles and joints of some individuals with PD [19, 20].”
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“In this sense, some studies in the literature that only analyzed people with PD, including systematic reviews and meta-analyzes (14, 11, 6, 40), suggest RT as a possibility of functional rehabilitation for patients with idiopathic PD, since it may promote neural adaptations, thus improving the recruitment of motor uni…”
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“A recent study (11) indicated that in PD patients, a low intensity treadmill training program is more efficient in improving gait compared with a high intensity one.”
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Salvatore, M. F., Soto, I., Kasanga, E. A., James, R., Shifflet, M. K., Doshier, K., Little, J. T., John, J., Alphonso, H. M., Cunningham, J. T., et al. (2022) · Journal of Parkinson s Disease · doi:10.3233/jpd-223157 · Cited by 15
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“In support of this, Shulman et al. [38] compared three exercise interventions (high-and low-intensity endurance training and resistance training) and found that only the resistance training group significantly decreased in UPDRS III score following 12 weeks of training.”
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“…evidence indicates aerobic exercise (AE) can slow the rate of progressive motor impairment in Parkinson ’ s disease (PD) (Ridgel et al., 2009; Shulman et al., 2013; Schenkman et al., 2018; Ridgel and Ault, 2019; van der Kalk et al., 2019; Tiihonen et al., 2021; Tsukita et al., 2022), there…”
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“Randomized clinical trials published in the literature have concluded that exercise as a single intervention can prevent falls among community-dwelling patients with PD and can be particularly beneficial for maintaining postural control, mobility, and daily living activities [12].”
BackgroundAlleviating Stress in Parkinson’s Disease: Symptomatic Treatment, Disease Modification, or Both?
Goltz, F., van der Heide, A., & Helmich, R. C. G. (2024) · Journal of Parkinson s Disease · doi:10.3233/jpd-230211 · Cited by 14
“So far, the largest intervention trials investigating physical exercise ( N > 100) have not found effects on depression, anxiety, or other stress-related symptoms [27, 30, 33].”
BackgroundEffects of an Ai Chi fall prevention programme for patients with Parkinson's disease
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“Eighty patients were recruited for a study investigating treadmill exercise at high and low intensity compared to stretching for a three-month study and is most similar to our study, albeit shorter in length [9].”
Spatiotemporal quantification of gait in common marmosets
Pickett, K. A., SCHULTZ‐DARKEN, N. J., Bradfield, A., Malicki, K. B., Pape, B., Ausderau, K., & Emborg, M. E. (2019) · Journal of Neuroscience Methods · doi:10.1016/j.jneumeth.2019.108517 · Cited by 12
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“…and physical exercise ability to a certain extent; they also improved in nonexercise areas, such as prevention of depressive symptoms, executive function, language, and other related areas (Shulman et al., 2013; Cugusi et al., 2015; Altmann et al., 2016; Ferraz et al., 2018; Marusiak et al., 2019).”
BackgroundBosch‐Barceló, P., Climent‐Sanz, C., Martínez-Navarro, O., Masbernat, M. A., Pakarinen, A., Ghosh, P. K., & Fernández‐Lago, H. (2024) · PLoS ONE · doi:10.1371/journal.pone.0307304 · Cited by 15
Joseph, C., Brodin, N., Leavy, B., Hagströmer, M., Löfgren, N., & Franzén, E. (2018) · Clinical Rehabilitation · doi:10.1177/0269215518800832 · Cited by 12
“27,28 The HiBalance training program under investigation in this study is one of the few effective physiotherapy interventions directed at targeting functional decline among persons with PD.”
Parkinson’s disease: recent advances
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Aerobic and resistance exercises in Parkinson's disease: a narrative review
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Guide to Decomposition of Causal Effects Into Mediation, Interaction, and Direct Effects
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The Handbook of Wellness Medicine
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“Randomized controlled trials have demonstrated that regular aerobic exercise is achievable for people with PD and can contribute to improved fitness [11, 12] and slowing the progression of symptoms over 3 to 6 months [13, 14].”
BackgroundGriffith, G. J., Mehta, N., Lamotte, G. J., McKee, K. E., Suttman, E., Haus, J. M., Joslin, E., Balfany, K., Kohrt, W. M., Christiansen, C. L., et al. (2025) · Journal of Parkinson s Disease · doi:10.1177/1877718x241308813 · Cited by 10
Ramírez‐Sanz, J. M., Garrido‐Labrador, J. L., Olivares‐Gil, A., García‐Bustillo, Á., González, Á. A., Díez-Pastor, J.-F., Jahouh, M., González‐Santos, J., Gonzalez-Bernal, J. J., Allende‐Río, M., et al. (2023) · Healthcare · doi:10.3390/healthcare11040507 · Cited by 10
“Several metaanalyses published in the literature have concluded that exercise as a single intervention can prevent falls among community-dwelling patients with PD and can be particularly beneficial for maintaining postural control, mobility, and daily living activities [20].”
BackgroundTargeting exercise intensity and aerobic training to improve outcomes in Parkinson’s disease
Panassollo, T. R. B., Mawston, G. A., Taylor, D., & Lord, S. (2024) · Sport Sciences for Health · doi:10.1007/s11332-024-01165-0 · Cited by 12
“Conversely, Shulman et al., [22] reported an improvement of around 6% in VO2peak in 22 PD participants exercising at 40–50% HRR (moderate training zone -ACSM) in a training protocol that incorporated a comparatively higher weekly volume of training (50 min per session, 3 × per week for 12 weeks).”
InfluentialConsiderations on How to Prevent Parkinson’s Disease Through Exercise
Oosterhof, T. H., Darweesh, S. K. L., Bloem, B. R., & de Vries, N. M. (2024) · Journal of Parkinson s Disease · doi:10.3233/jpd-240091 · Cited by 11
“However, only a few flexibility trials have been performed in the PD field, and these demonstrated little positive symptomatic effects on gait speed when combined with resistance exercise [24].”
BackgroundResultGodi, M., Giardini, M., Nardone, A., Turcato, A. M., Caligari, M., Pisano, F., & Schieppati, M. (2017) · Frontiers in Neurology · doi:10.3389/fneur.2017.00053 · Cited by 10
Kanegusuku, H., Peçanha, T., Silva‐Batista, C., Miyasato, R. S., da Silva, N. D., de Mello, M. T., Piemonte, M. E. P., Ugrinowitsch, C., & Forjaz, C. L. M. (2021) · Einstein (São Paulo) · doi:10.31744/einstein_journal/2021ao5940 · Cited by 10
“The main finding of this study was that RT increased lower limb muscle strength but had no impact on metabolic and cardiovascular responses obtained at maximal or absolute and relative submaximal intensities during maximal cardiopulmonary exercise testing in patients with PD. Lower limb muscle strength increase in RTG…”
BackgroundResultInfluentialMikami, K., Shiraishi, M., & Kamo, T. (2022) · Scientific Reports · doi:10.1038/s41598-022-05587-z · Cited by 10
Saegner, K., Romijnders, R., Hansen, C., Holder, J., Warmerdam, E., & Maetzler, W. (2024) · Journal of NeuroEngineering and Rehabilitation · doi:10.1186/s12984-024-01416-8 · Cited by 9
“Usual physiotherapy interventions focus on training gait as a whole, e.g., on a treadmill [48, 49], or by resistance training [50], which has shown positive results in increasing gait velocity and reducing fall risk.”
BackgroundSmaili, S. M., Bueno, M. E. B., Barboza, N. M., Terra, M. B., de Almeida, I. A., & Ferraz, H. B. (2018) · Motriz Revista de Educação Física · doi:10.1590/s1980-6574201800020004 · Cited by 9
Paz, T. D. S. R., Guimarães, F. S., de Britto, V. L. S., & Corrêa, C. L. (2019) · Fisioterapia em Movimento · doi:10.1590/1980-5918.032.ao01 · Cited by 11
“[13] evaluated three different protocols of physical intervention: high-speed treadmill training, low-speed treadmill training, and stretching and strengthening in subjects with PD.”
BackgroundInfluentialPhysical Exercise Interventions on Quality of Life in Parkinson Disease: A Network Meta-analysis
Lorenzo‐García, P., de Arenas‐Arroyo, S. N., Cavero‐Redondo, I., Guzmán‐Pavón, M. J., Priego-Jiménez, S., & Álvarez‐Bueno, C. (2022) · Neurology Report · doi:10.1097/npt.0000000000000414 · Cited by 12
Effects of Nordic walking on Parkinson’s disease: a systematic review of randomized clinical trials
da Silva, F. C., Iop, R. D. R., Arancibia, B. A. V., Ferreira, E. G., Hernández, S. S. S., & da Silva, R. (2016) · Fisioterapia e Pesquisa · doi:10.1590/1809-2950/15861023042016 · Cited by 10
Pilates Exercise and Functional Balance in Parkinson's Disease
Bakhshayesh, B., Sayyar, S., & Daneshmandi, H. (2017) · Caspian Journal of Neurological Sciences · doi:10.18869/acadpub.cjns.3.8.25 · Cited by 9
“Research results suggest that aerobic exercises are significantly more effective than stretching and strengthening exercises on improving parameters such as walking, balance, motor function and muscle strength and reducing the risk of falls [3-9].”
BackgroundRichardson, K., Huber, J. E., Kiefer, B., & Snyder, S. (2022) · American Journal of Speech-Language Pathology · doi:10.1044/2022_ajslp-22-00026 · Cited by 9
Korivi, M., Ghanta, M. K., Nuthalapati, P., Natesh, N. S., Tang, J., & Bhaskar, L. V. (2025) · Life · doi:10.3390/life15081255 · Cited by 9
Zou, Y., Tan, J., Li, N., Yang, J., Yu, B.-C., Yu, J., Zhao, Y., & Wang, L. (2015) · Neuropsychiatric Disease and Treatment · doi:10.2147/ndt.s79707 · Cited by 8
“…nerve cell regeneration 42–44 and improving neural cell plasticity; 45,46 physical exercise can improve the motor symptoms of PD, and cycling 47 and Tai Chi exercise 48 have been shown to improve gait disorders and disequilibrium in patients with PD, underscoring the ability of physical…”
BackgroundRigby, B. R., & Davis, R. W. (2018) · Frontiers in Physiology · doi:10.3389/fphys.2018.01040 · Cited by 8
“A combination of stretching and resistance exercise can improve muscle strength and gait speed in this population (Shulman et al., 2013).”
BackgroundClinical and Genetic Analysis of Costa Rican Patients With Parkinson's Disease
Acosta, G. T., Yu, E., Lobo-Prada, T., Ruiz‐Martínez, J., Pagola, A. G., Gan‐Or, Z., Carazo-Céspedes, K., Trempe, J.-F., Mata, I. F., & Trías, J. F. (2021) · Frontiers in Neurology · doi:10.3389/fneur.2021.656342 · Cited by 8
“Although exercise has not been proven to slow the progression of akinesia, rigidity, and gait disturbances, it promotes a feeling of physical and mental well-being, and at the same time, it can alleviate rigidity-related pain and improve patients’ motor (77) and non-motor symptoms (78).”
BackgroundDağ, F., Çımen, Ö. B., & Doğu, O. (2021) · Irish Journal of Medical Science (1971 -) · doi:10.1007/s11845-021-02772-3 · Cited by 9
Berger, A. A., Winnick, A. A., Izygon, J. J., Jacob, B. M., Kaye, J. S., Kaye, R. J., Neuchat, E. E., Kaye, A. M., Alpaugh, E. S., Cornett, E. M., et al. (2022) · Health Psychology Research · doi:10.52965/001c.36074 · Cited by 10
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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