Aerobic Exercise in Parkinson's Disease (LTAE-PD)

Long Term Aerobic Exercise to Slow Progression in Parkinson's Disease

Parkinson's disease (PD) is an incurable brain illness that afflicts more than one million Americans, including many aging Veterans. PD places an unbearable burden on the individual due to progressive impairment of movement and mental function. As a result, patients lose critical abilities such as driving and can become isolated. Although drugs and surgery help movement problems, their benefits are temporary and may cause side effects. Drugs provide limited and temporary benefit for cognition and do not prevent dementia. Animal and preliminary human studies on aerobic exercise show promising results in helping a broad spectrum of symptoms. However, due to limited and inconsistent research results, the long term effects of aerobic exercise on brain health and clinical features in PD is unknown. The investigators will conduct a clinical trial to test the long term effects of aerobic exercise on the brain tissue, movement, mental functions, and driving in PD. If effective, aerobic exercise can be implemented immediately as a low cost, easily accessible treatment in PD.

Study Overview

• Status: Active, not recruiting
• Conditions: Parkinson's Disease
• Intervention / Treatment: Behavioral: Aerobic walking; Behavioral: Usual care with PD specific health education

Detailed Description

Parkinson's disease (PD) culminates in dementia, immobility, and death at a huge societal cost. Even early in the course, motor and cognitive dysfunction impairs instrumental activities of daily living (IADL). Non-motor symptoms due to fatigue, mood, sleep, and autonomic disorders further reduce quality of life (QoL). DTI shows progressive decline in brain tissue integrity. Usual care of PD centers on medical and surgical treatments relieve motor symptoms, but these cause side effects and lose efficacy over time. Usual treatment for non motor manifestations with pharmaceuticals (e.g., antidepressants) is symptomatic and not specific for PD. Acetylcholine esterase inhibitors exert modest symptomatic benefits on dementia, but there is no approved treatment for mild cognitive impairment. Physical Therapy is usually prescribed in later stages when mobility impairment ensues. There is no approved standard exercise regimen for PD. There is no cure or disease modifying treatment. Thus, there is a critical need for treatments that provide broad spectrum of benefits and slow PD.

Preliminary research suggests that aerobic exercise has potential to meet this need. However, aerobic exercise is demanding and carries some risks. It is unknown if aerobic exercise is more beneficial than usual care in PD in long term due to gaps in the investigators knowledge about the effects of cardiorespiratory fitness (CRF) on brain tissue integrity, motor function, cognition, IADL, QoL, and disease progression. Limitations of current studies include short duration, small sample size, lack or inadequacy of controls, lack of outcome measures for cognition and IADL, and lack of biological markers to measure progression. The objective in this application is to fill the translational gap by determining the biological, clinical, and functional effects of long term aerobic exercise (LTAE) in PD.

The overall hypothesis is that LTAE improves brain tissue integrity and slows down PD. The FIRST AIM is to determine the effects of LTAE on clinical features and functional abilities in PD. The investigators' prior 6-month, uncontrolled trial showed preliminary evidence that aerobic exercise improves aspects of motor function, cognition, and QoL in PD, but long term outcomes and implication for functional abilities are unknown. The investigators hypothesize that LTAE will provide sustained improvement in motor function, cognition, and non-motor symptoms with translation of benefits to QoL and IADL. The investigators will test this with a one-year randomized controlled trial (RCT) that compares the effects of moderate aerobic exercise vs usual care. The investigators will use driving as the outcome for IADL. Driving represents an important symbol for independence, and depends on integrity of cognitive and motor systems. The SECOND AIM is to determine the mechanism of LTAE effects in PD. CRF reflects complex improvements in vascular, cardiac, and metabolic health from aerobic exercise. There is preliminary evidence that higher CRF is associated with better brain health and motor/cognitive function, and that aerobic exercise improves these outcomes. For example, the investigators' preliminary study showed improvement of microtissue integrity in the striatum and white matter on DTI, but it is unclear how these changes counteract PD progression over long term. The hypotheses are: 1) LTAE will improve brain tissue integrity as indexed by DTI, 2) LTAE effects on motor and cognitive function are mediated by changes in brain tissue integrity on DTI, and 3) physiological processes leading to improved CRF from AE are critical to the benefits on the brain tissue integrity and motor/cognitive function. The investigators will test these hypotheses determining the effects of LTAE on CRF and DTI, and the association between individual differences in training related changes in motor and cognitive function, DTI, and CRF.

In summary, the investigators' proposal leverages the diverse interdisciplinary team, strong preliminary data and past work, and unique infrastructure to determine if LTAE slows down neurodegeneration and clinical disability in PD.

• Study Type: Interventional
• Enrollment (Actual): 57
• Phase: Phase 2; Phase 3

Contacts and Locations

• Study Contact: Name: Ergun Y Uc, MD; Phone Number: (319) 356-4757; Email: ergun-uc@uiowa.edu
• Study Contact Backup: Name: Christina M Weber, BA; Phone Number: (608) 790-7557; Email: christina-weber@uiowa.edu

Study Locations

• United States
  • Iowa
    • Iowa City, Iowa, United States, 52242
      • University of Iowa Hospitals & Clinics
    • Iowa City, Iowa, United States, 52246-2292
      • Iowa City VA Health Care System, Iowa City, IA

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 40 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Men or women aged 40 and older with the diagnosis of idiopathic PD per UK Brain Bank criteria
• Hoehn-Yahr Stage I-III, on stable dopaminergic treatment regimen for equal or greater than 4 weeks prior to baseline.
• Aerobic Fitness: VO2max below "very good" fitness levels for their age and gender at baseline cyle ergometry.

To include subjects who have room to improve their aerobic fitness, the investigators will enroll only those subjects whose VO2max is below "very good" fitness level (about 90% of the population) using age and gender based VO2max norms based review of 62 studies where VO2max was measured directly in healthy adult subjects in the USA, Canada and 7 European countries (Reference: Shvartz, E and Reibold, RC. Aerobic fitness norms for males and females aged 6 to 75 years: a review.

Aviat Space Environ Med. 1990; 61:3-11).

• Cognitive function: No dementia per Movement Disorder Society Level I criteria (Reference: Dubois, B, Burn, D, Goetz, C, et al. Diagnostic procedures for Parkinson's disease dementia: recommendations from the movement disorder society task force. Mov Disord. 2007; 22:2314-2324).
• Current active drivers with a valid driver's license
• Veteran or non-veteran

Exclusion Criteria:

• Subjects unwilling or unable to give informed consent
• Secondary parkinsonism (e.g., drug induced)
• Parkinson-plus syndromes
• History of brain surgery for PD such as deep brain stimulation
• Corrected visual acuity less than 20/50 (due to effect on driving)
• Contraindications to exercise per ACSM criteria for Exercise Testing and Training (Reference: American College of Sports Medicine. Cardiorespiratory Exercise Prescription. In: Ehrman JK, ed. ACSM's Guidelines for Exercise Testing and Prescription.6th ed. Baltimore: Lippincott Williams & Wilkins, 2010:448-462).
• No confounding acute or unstable medical, psychiatric, orthopedic condition. Subjects who have hypertension, diabetes mellitus, depression, or other common age related illness will be included if their disease under control with stable treatment regimen for at least 30 days.
• Clinically significant TBI or PTSD
• Presence of other known medical or psychiatric comorbidity that in the investigator's opinion would compromise participation in the study
• Presence of dementia per Movement Disorder Society Level I criteria
• Subjects with clinically significant depression as determined by a Beck Depression Inventory (BDI) score greater than 15 at the screening visit
• History of exposure to typical or atypical antipsychotics or other dopamine blocking agents within 6 months prior to the baseline visit
• Use of investigational drugs within 30 days before screening
• Subjects have to be on a stable regimen of central nervous system acting medications (benzodiazepines, antidepressants, hypnotics) for 30 days prior to the baseline visit
• Contraindication to having a brain MRI

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Aerobic; Participants randomized to aerobic exercise	Behavioral: Aerobic walking; The investigators will use self-administered continuous walking exercise at a moderate intensity level, defined as 40-59% of heart rate reserve or 64-77% of heart rate at gas exchange threshold (HRGET) by ACSM as in the investigators' preliminary study (PMID: 24991037 PMCID: PMC4132568). The HRGET will be determined as the heart rate at VO2max during graded cycle ergometry. The total duration of the exercises will be 150 min/week per 2008 Physical Activity Guidelines for Americans and American Heart Association recommendations, conducted in three 50 min sessions. The aerobic walking intervention will take place outdoors (e.g., trails, sidewalks, parks) or indoors (e.g., track in a local gym or a mall) depending on the preferences of the subject and weather. Session duration will be 20 min the first week and will be advanced by 5 min per week over 6 weeks.
Other: Control; Participants randomized to usual care with PD specific health education	Behavioral: Usual care with PD specific health education; In this study, patients will receive their usual medical treatment for motor and non-motor symptoms from their primary neurologist. The investigators will use a streamlined form of PD specific health education prepared by the VA: My Parkinson's Story, which consists of a series of short videos prepared by the VA PADRECCs addressing various aspects of PD. These 6-12 minutes long videos are freely available on YouTube. The investigators can also provide them on a CD if subjects desire. They start with a patient testimony about the topic of the episode, followed by comments of experts in the field. The title of the episodes are: Early Parkinson's, Medications, Exercise, Memory, Visual Disturbances, Depression, Sleep, Speech and Swallowing, Impulsive Behaviors, Driving, Pain, Dyskinesias, Deep Brain Stimulation, Advanced Parkinson's Disease, Falls, The Caregiver, Hospitalization, Genetics, Environmental Exposure, Atypical Parkinsonism

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
OFF period MDS-UPDRS Motor Subscale score	Motor function. MDS-UPDRS motor examination subscale (Part III) score in the "practically defined OFF state", i.e., after overnight (~12 hours) withdrawal of PD medications. Higher scores worse. Range: 0-132.	Change from Baseline OFF period MDS-UPDRS Motor Subscale score at 1 year
Percent Increase Score (PIS) on Eriksen's flanker task	Cognitive function. Due to its sensitivity to changes in aerobic fitness (including in the investigators' preliminary study), the investigators chose change in Percent Increase Score (PIS) on Eriksen's flanker task, which measures the cost of conflict resolution between the incongruent and congruent stimuli. Higher scores worse.	Change from Baseline Percent Increase Score (PIS) on Eriksen's flanker task at 1 year
total number of driving safety errors on road test	Driving. The video of a standardized experimental drive in an instrumented vehicle will be scored for safety errors by a certified driving instructor. Higher scores worse.	Change from Baseline total number of driving safety errors on road test at 1 year
regional DTI (diffusion tensor imaging)	Brain tissue integrity. The investigators will analyze differences in regional rD (radial diffusivity) changes between the aerobic exercise and usual care control groups in primary outcome regions of interest (Putamen, Cingulum, Superior Longitudinal Fasciculus). Higher scores worse.	Change from Baseline regional DTI at 1 year
MDS-UPDRS Non-motor Experiences of Daily Living subscale (Part I) score	Non-motor symptoms. Higher scores worse. Range: 0-48	Change from Baseline MDS-UPDRS Non-motor Experiences of Daily Living subscale (Part I) score at 1 year
Summary index of the Parkinson's Disease Questionnaire-39 (PDQ-39)	Quality of life	Change from Baseline PDQ-39 Summary Index at 1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
ON Period MDS-UPDRS motor examination subscale score	Motor function. Higher scores worse. Range: 0-132.	Change from Baseline ON Period MDS-UPDRS motor examination subscale score at 1 year
Dexterity (time on 9-hole peg board) test of NIH Toolbox motor battery	Motor function. Dexterity	Change from Baseline 9-hole peg board test performance at 1 year
COGSTAT score	Cognitive function. COGSTAT, a composite measure of cognition, calculated by assigning and summing standard T-scores (mean=50, SD=10) to eight tests from the cognitive test battery the investigators used in the driving studies, will be the main secondary outcome measure. This cognitive battery will enable us to probe multiple domains: Complex Figure Test-Copy (CFT-Copy) Version, Block Design for visuospatial construction; Trail-making Test (B-A), a measure of set shifting and Controlled Oral Word Association Test (also tests language) for executive functions; Rey Auditory Verbal Learning Test (anterograde verbal memory), CFT-Recall is administered 30 minutes after the CFT-Copy (visual memory), Benton Visual Retention Test errors for memory; Judgment of Line Orientation for visual perception. Higher scores worse.	Change from Baseline COGSTAT score at 1 year
Radial Diffusivity (rD) on Diffusion imaging tractography	Brain tissue integrity. Motor: Substantia nigra <-> putamen (nigrostriatal tract) and putamen <-> premotor cortex Cognitive: Dorsal lateral prefrontal cortex (DLPFC) <-> caudate and the parietal cortex <-> prefrontal cortex. Higher scores worse.	Change from Baseline Diffusion imaging tractography at 1 year
Geriatric Depression Scale (GDS) score	Severity of depression. Higher scores worse. Range: 0-15	Change from Baseline GDS score at 1 year
Motor experiences of daily living score	Motor function. Higher scores worse. Range:0-52.	Change from Baseline motor experiences of daily living score at 1 year
Beck Anxiety Inventory (BAI) score	Anxiety severity. Higher scores worse. Range: 0-63	Change from Baseline BAI score at 1 year
Parkinson's Disease Sleep Scale version 2 (PDSS-2)	Sleep quality. Higher scores worse. Range: 0-60	Change from Baseline PDSS-2 score at 1 year
Fatigue Severity Scale (FSS)	Severity of fatigue. Higher scores worse. Range: 9-63	Change from Baseline FSS score at 1 year
Locomotion (time on 25-f walk test for gait speed) test	Motor function. Locomotion.	Change from Baseline Locomotion (time on 25-f walk test for gait speed) test performance at 1 year
Locomotion (time on 4-m walk test for gait speed) test of NIH Toolbox motor battery	Motor function. Locomotion	Change from Baseline Locomotion (time on 4-m walk test for gait speed) test performance at 1 year
Finger Tapping test	Average between two trials of oscillating finger tapping for both hands.	Change from Baseline average performance for right and left finger tapping at 1 year
Endurance (distance on 6-minute walk) test	Motor function. Endurance (6-minute walk).	Change from Baseline Endurance (distance on 6-minute walk) test performance at 1 year
Schwab and England Activities of Daily Living Scale	Changes of ability to complete activities of daily living. Lower percentage of ability worse. Range: 0-100%	Change from Baseline score at 1 year
Mini-Mental Status Examination (MMSE)	Cognitive and memory. Lower scores worse. Range: 0-30	Change from Baseline MMSE score at 1 year
Montreal Cognitive Assessment (MOCA)	Cognitive and memory. Lower scores worse. Range: 0-30	Change from Baseline MOCA score at 1 year
Pelli-Robson Contrast Sensitivity	Vision. Sensitivity to contrast changes of letters. Range: 0.00 - 2.25	Change from Baseline score at 1 year
Early Treatment Diabetic Retinopathy Study (ETDRS)	Visual acuity test. Changes of ETDRS Acuity Log Score.	Change from Baseline score at 1 year
EEG	Various EEG metrics.	Change from Baseline metrics at 1 year

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
VO2max on cycle ergometry	Cardiorespiratory fitness as an index of aerobic exercise intervention delivery. Higher scores better.	Change from Baseline VO2max on cycle ergometry at 1 year

Collaborators and Investigators

• Sponsor: VA Office of Research and Development
• Collaborators: University of Iowa
• Investigators: Principal Investigator: Ergun Y. Uc, MD, Iowa City VA Health Care System, Iowa City, IA

Publications and helpful links

General Publications

• Uc EY, Doerschug KC, Magnotta V, Dawson JD, Thomsen TR, Kline JN, Rizzo M, Newman SR, Mehta S, Grabowski TJ, Bruss J, Blanchette DR, Anderson SW, Voss MW, Kramer AF, Darling WG. Phase I/II randomized trial of aerobic exercise in Parkinson disease in a community setting. Neurology. 2014 Jul 29;83(5):413-25. doi: 10.1212/WNL.0000000000000644. Epub 2014 Jul 2.

Study record dates

Study Major Dates

• Study Start (Actual): July 1, 2019
• Primary Completion (Estimated): June 30, 2024
• Study Completion (Estimated): June 30, 2024

Study Registration Dates

• First Submitted: January 7, 2019
• First Submitted That Met QC Criteria: January 14, 2019
• First Posted (Actual): January 17, 2019

Study Record Updates

• Last Update Posted (Actual): August 14, 2023
• Last Update Submitted That Met QC Criteria: August 9, 2023
• Last Verified: August 1, 2023

More Information

Terms related to this study

• Keywords: MRI; Depression; Exercise; Aerobic exercise; Quality of life; Driving; Cognition; Parkinson's disease; Health education; DTI; Diffusion tensor imaging; Cardiorespiratory Fitness; Executive functions
• Additional Relevant MeSH Terms: Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Parkinsonian Disorders; Basal Ganglia Diseases; Movement Disorders; Synucleinopathies; Neurodegenerative Diseases; Parkinson Disease
• Other Study ID Numbers: E2987-R; 1I01RX002987-01A1 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES

IPD Plan Description

Final datasets underlying all publications resulting from the proposed research will be shared outside VA.

Final data sets underlying publications resulting from this research will be shared upon written request and through ClinicalTrials.gov and databank/repository if specified by the VA.

Individuals can download the data and analyze the results using methods described in the investigators' articles or alternative methods as necessary.

• IPD Sharing Time Frame: As per VA specifications.
• IPD Sharing Access Criteria: As per VA specifications.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No