Effects and parameters of community-based exercise on motor symptoms in Parkinson's disease: a meta-analysis

doi:10.21203/rs.3.rs-2074383/v1

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Effects and parameters of community-based exercise on motor symptoms in Parkinson's disease: a meta-analysis

https://doi.org/10.21203/rs.3.rs-2074383/v1

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published 29 Dec, 2022

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Background

Community-based exercise is a continuation and supplement of Parkinson's hospital rehabilitation and is a type of unsupervised exercise. The effects, parameters, and forms of each study were diverse. The effect is affected by many factors. In this paper, a Meta-analysis was conducted to determine the effect and the best parameters for improving motor symptoms and explore the possible factors affecting the effect.

Methods

We conducted a comprehensive search of six databases: PEDro, PubMed, CENTRAL, Scopus, Embase, and WOS. Studies comparing community-based exercise with usual care were included. The intervention mainly included dance, Chinese martial arts, Nordic walking, and home-based exercise. The primary outcome measure was the Unified Parkinson’s Disease Rating Scale part III (UPDRS-III). Mean difference (95% CI) was used to calculate treatment outcomes of continuous outcome variables, and I² was used to estimate the heterogeneity of the statistical analysis. We conducted subgroup analysis and meta-regression analysis to determine the optimal parameters and the most important influencing factors of exercise effect. We previously registered the proposal of the meta-analysis on the PROSPERO website (NO. CRD42022327162) and strictly reported it according to PRISMA's stated terms.

Results

Twenty-two studies enrolling a total of 809 subjects were included in the analysis. Exercise had a positive effect on UPDRS-III (MD= -5.83; 95% CI, -8.29 to -3.37), Timed Up and Go Test (MD= -2.22; 95% CI -3.02 to -1.42), UPDRS ((MD= -7.80; 95% CI -10.98 to -6.42), 6-Minute Walk Test (MD = 68.81; 95% CI, 32.14 to 105.48), and Berg Balance Scale (MD = 4.52; 95% CI, 2.72 to 5.78). However, the heterogeneity of each study included was obvious. Weekly frequency, age, and location are all factors potentially affecting the effect.

Conclusions

This meta-analysis suggests that community-based exercise may benefit motor function in patients with PD. The most commonly used modalities of exercise are Tango and Tai Chi, and The most common prescription is 60 minutes twice a week. Future studies should consider the influence of age, region, and weekly frequency on the effect.

PROSPERO trial registration number CRD42022327162.

Data synthesis

Exercise

Movement

Parkinson’s disease

Prescription

Review

Parkinson's disease (PD) is a progressive neurodegenerative disorder with both motor and non-motor symptoms, defined by the accumulation of misfolded alpha-synuclein and the loss of dopaminergic neurons[1–5]. The number of individuals with PD increased rapidly by approximately 6.1 million in 2016 and has grown by 2.5 times over the past three decades[6, 7]. By 2040, with aging and industrialization, the number of patients with PD is expected to reach a staggering 12.9 to 14.2 million[8]. This will increase patient care and economic burden, seriously affecting patients’ quality of life. The current treatment for PD is mainly drug therapy based on levodopa, but there are certain side effects, such as movement fluctuation, nausea, and psychosis[9, 10]. Comprehensive management of PD involves pharmacology, deep brain stimulation, nursing, and rehabilitation[11, 12]. Rehabilitation has been paid more and more attention as an adjunctive therapy to improve motor function. After the improvement of motor symptoms, the patient's other symptoms and self-care ability will be greatly improved[13]. Rehabilitation can begin at the time of initial diagnosis and continue throughout the disease[12]. Physical therapy is an important and effective technique in rehabilitation medicine[14]. Physical therapy is the key to improving motor functions such as gait and balance that cannot be improved by drugs, so doctors should recommend it to all patients[14–17].

However, many studies are based on hospitals, devices, doctors, and physical therapists. The World Health Organization declared a novel coronavirus pandemic worldwide in March 2020. It has had a major impact on our health, especially for groups with underlying diseases. Although there is no evidence that PD patients are more likely to contract COVID-19 or have increased mortality[18, 19]. However, motor and non-motor symptoms worsen in PD[19–22]. Many patients and others cannot continue to go to rehabilitation facilities due to the lockdown[23]. Even in the absence of an epidemic, people with Parkinson's disease may not be able to get to a hospital, clinic, or rehabilitation center because of transportation or financial reasons. Physical therapy equipment is not available at all venues. How to continue therapy after the therapist's instruction is one of our concerns. In 2014, 19 physiotherapists and Parkinson's patients collaborated to develop the European Guidelines for physiotherapy for PD, which described in detail the form of physical therapy[24]. The guidelines provide physical exercise for doctors and PD patients. However, among the many ways to exercise, Parkinson's patients and even doctors are very confused.

A systematic analysis of the short-term efficacy of physical therapy for PD has shown that although there are various physical therapy techniques, there is little difference in efficacy[25, 26]. People with PD have fewer activities of daily living and exercise than their normal peers. They need exercise to continue to consolidate the benefits. Studies have also found that exercise reduces the risk of falls in older adults[27]. Animal studies have also found significant benefits in the post-training PD model. Exercise induces the regulation of different brain regions, reduces cell death pathways, enhances neurotrophic factors and mitochondrial function, increases neurogenesis, and improves synaptic plasticity[28, 29]. Many studies have reported the benefits of exercise at home for people with PD[30]. The effects of exercise can last from 3 to 12 months[31]. A growing body of evidence suggests that exercise at home is necessary for Parkinson's disease[32]. European physical therapy guidelines for Parkinson's also recommend increasing the proportion of unsupervised exercise. We found that many community-based exercises are an economical and convenient form of physical therapy and a continuation for PD patients after hospital treatment to maintain effects.

Community-based exercise is receiving increasing attention as an economical and convenient form of rehabilitation. Community-based exercise doesn't require a physical therapist, it doesn't require a trip to rehab, and it costs less. It allows patients to continue treatment after discharge or after leaving a rehabilitation center. The main exercises include dancing, Chinese martial arts, Nordic walking, and home-based exercises. It is an important adjunctive means in the rehabilitation of PD. However, different studies have shown inconsistent results. The parameters vary from study to study. In previous meta-analyses, the control group was not rigorous, and the optimal parameters of exercise were rarely analyzed. People with PD are confused about the form, intensity, and frequency of exercise. The heterogeneity of each study in the previous meta-analysis was high, so this study also conducted a multivariate analysis to try to find out the main factors. We summarized the effects of community-based exercise on Parkinson's motor symptoms without the help of a physical therapist or device and analyzed the appropriate parameters to provide a reference for Parkinson's patients. This meta-analysis was conducted following the Preferred Reporting of Systematic Reviews and Meta-Analyses (PRISMA) statement [33] and was registered on the PROSPERO platform under the number CRD42022327162.

2.1 Search strategies

We performed a systematic search of literature including studies issued from initial to April 2022 in the following databases: PubMed, Physiotherapy Evidence, CENTRAL, Scopus, Embase, and Web of Science. The combination of subject words and free words was adopted. The following Medical Subject Heading terms were included: “Parkinson’s Disease,” exercise,” “sports,” “rehabilitation,” and “Physical Therapy Modalities.” The search clauses are listed in Supplementary Appendix S1. The language is limited to English. Additionally, we manually searched the reference list and Google Academic searched to include more articles that met the criteria.

2.2 Inclusion and exclusion criteria

The criteria included randomized controlled trials (RCTs) or crossover trials comparing exercise intervention with usual care for PD, regardless of disease stage and severity. The exercise intervention clinical trials we chose did not require the assistance of physical therapists and expensive equipment. These types of exercise are very economical and convenient for patients and families. The inclusion criteria are shown in Table 1.

Table 1

Inclusion criteria
Item	Criteria
Design	Randomized controlled trials or crossover trials
Participants	Individuals with Parkinson’s Disease
Intervention	dance, martial arts, Nordic walking, home-based exercises
Comparisons	usual care
Outcome measures	Outcomes related to motor function

Excluded studies were as follows: 1) studies on patients enrolled in other neurological conditions except for PD; 2) with a physiotherapist involved; 3) the control group received exercise-related therapy, including stretching or walking; and 4) the mean and standard deviation was not reported.

2.3 Outcome Measures AND Data extraction

Studies assessing the effectiveness of the intervention on motor symptoms were included. The primary outcome was the Unified Parkinson’s Disease Rating Scale part III (UPDRS-III), which was revised to test motor function in individuals with PD in 2008[34]. The secondary outcomes were as follows: 1) the Timed Up and Go test (TUG); 2) the Unified Parkinson’s Disease Rating Scale (UPDRS); 3) the Berg Balance Scale (BBS); and 4)the 6-Minute Walk Test (6MWT)[24].

Endnote X20 is used to manage the literature. Data were independently extracted from eligible studies by two authors (YCL and HJP). Extracted data were compared, and any discrepancies were resolved through discussion with the third author (TYC). Relevant data, such as study time, sample size, duration of the follow-up process, duration of exercise, and type of exercise, were extracted from all included papers. Data were collected using standard spreadsheets (Excel). If any information was unclear, we contacted the author to provide more detailed data.

2.4 Methodological quality and Data Synthesis

Meta-analysis was performed using the Software Review Manager (v.5.4, Nordic Cochrane Center, Copenhagen, Denmark) provided by the Cochrane Collaboration. Two reviewers (YCL and HJP) independently assessed the methodological quality. If the two reviewers had different opinions, we called all the participants for discussion, and finally, Professor QY made the decision. The quality of the method was assessed using the Cochrane Collaboration risk-of-bias method quality assessment tools[33]. The variables we selected were all continuous data. We extracted the mean and standard deviation of the post-intervention results into a pre-designed Excel table. Mean difference (MD) was used as the effective value. All studies pooled effects, together with corresponding 95% CI, to present the results of the meta-analysis. If I² < 50%, we used the fixed effect model, otherwise, we used the random effect model. We also performed subgroup analysis on the time of each treatment, frequency of treatment per week, total time of exercise per week, and duration of follow-up to analyze the optimal parameters for exercise to improve Parkinson's motor symptoms. Finally, we also did a meta-regression analysis to identify the factors affecting the efficacy.

3.1 Study Characteristics

The process of literature selection is shown in Figure 1. A total of 151 trials that might meet the requirements were found by reading titles and abstracts; 130 trials were excluded through intensive reading and comparison of inclusion criteria. Studies were excluded for various reasons, mainly due to the involvement of physiotherapists, incomplete data, or the use of other equipment and techniques. Two papers were published in duplicate, and we chose one of them. One was found to meet the inclusion criteria through reference. A total of 22 full-text studies were included in the analysis[35-56]. There are a variety of forms of physical exercise, most of which are dance and Tai chi. Exercise interventions ranged from 4 weeks to 12 months, with 12 weeks being the dominant treatment. The frequency of training was 1-5 times per week, but 2-3 times was the majority. Each session lasted 50, 60, or even 90 minutes. The research information of all included studies is shown in Table 2.

3.2 Methodological Quality

The quality assessment of methods for risk of bias in the Cochrane Collaboration showed that the methodological quality of the included trials varied widely. This is unlikely to be possible with subject blindness, and exercise outside the intervention cannot be controlled. Twenty-five studies (92.59%) did better with assignment hiding, but only 18 studies (66.67%) reported the generation of random sequences. Evaluator blindness was not reported in 9 trials (33.33%), and patients could not be blinded due to the nature of the exercise intervention. Most trials reported data loss and subjects dropping out. The risk of publication bias and other biases was low. The overall risks included in the studies and the risk assessment for each study are shown in Figures 2 and 3.

3.3 Effects of exercise

3.3.1 Outcome of UPDRS-III

The results of UPDRS-III were reported in 18 of the 27 included studies. Figure 4a shows that the pooled effect estimates show that exercise has a positive effect on UPDRS-III scores (MD= -5.83; 95% CI, -8.29 to -3.37; P <0.00001). However, high heterogeneity was observed in the analysis (P < 0.00001; I² = 93%). We did not find that eliminating one or more studies significantly changed overall heterogeneity. Two studies showed no improvement in scores, one[56] in which the exercise group scored worse than the control group before intervention and one[36] in which the scores were not statistically significant. However, there is no good reason to exclude these two studies from the analysis. From the funnel plot (Figure 5a), eight items fell outside the 95% confidence interval. We would attempt to further analyze it in subgroup analysis.

3.3.2 Outcome of TUG

The results of TUG were reported in 17 of the 27 included studies. The TUG scale is one of the scales widely used to assess a patient's ability to transfer. Figure 4b shows that the combined effect estimate suggests that exercise improves the TUG score (MD= -2.22; 95% CI -3.02 to -1.42; P <0.00001). Figure 4b shows that high heterogeneity was observed in the analysis (P < 0.00001; I² = 84%). According to the funnel plot (Figure 5b), many studies fell outside the 95%CI interval, no one or each type of study was found to change the funnel plot, and we would attempt to further analyze it in subgroup analysis.

3.3.3 Outcome of UPDRS

URPDS can reflect the degree of PD. However, the results of UPDRS were reported in only 6 of the 27 included studies. Figure 4c shows that the combined effect estimates indicate that exercise is beneficial in terms of the UPDRS score (MD= -7.80; 95% CI -10.98 to -6.42; P =0.02). Figure 4c shows that high heterogeneity was observed in the analysis (P = 0.02; I² = 60%). From the funnel plot (Figure 5c), there was some bias between all the studies.

3.3.4 Outcome of BBS

The results of BBS were reported in 10 of the 27 included studies. Of course, a few other scales were used to assess balance function. Figure 4d shows that pooled effect estimates indicate the beneficial effects of exercise on balance. There was a helpful effect on the BBS (MD= 4.52; 95% CI, 2.72 to 5.78; P = 0.002). Figure 4d shows that high heterogeneity was observed in the analysis (P = 0.002; I² = 66%). From the funnel plot (Figure 5d), there was some bias between all the studies.

3.3.5 Outcome of 6 MWT

The results of the 6 MWT were reported in 6 of the 27 included studies. Figure 4e shows that the estimated pooling effect indicated improvement at the 6 MWT (MD =68.81; 95% CI, 32.14 to 105.48; P <0.0001). These results confirm that exercise can improve the motor capacity of patients. Figure 4e shows that severe heterogeneity was observed in the analysis (P < 0.0001, I² = 83%). From the funnel plot (Figure 5e), there was some bias between all the studies.

3.4 Optimal parameters of exercise

We performed a subgroup analysis and detailed discussion of outcomes involving more than ten studies. The results of the subgroup analysis of the effects of different exercise intensities on exercise are shown in Table 3.

3.4.1 Training frequency

Subgroup analysis of the frequency of weekly exercise showed a significant difference in the effect of exercise on UPDRS-III scores (P =0.09, I² = 57.6%) and TUG (P<0.00001, I² = 92.4%). Two and three times a week had significant effects with MD of -6.65 (95%CI: -10.19 to -3.11) and -3.21 (95%CI: -5.98 to -0.44) on UPDRS-III scores, respectively. Two and three times a week had significant effects with MD of -0.93(95% CI: -2.53 to 0.66) and -5.70 (95%CI: -6.33 to -4.77) on TUG scores, respectively. Twice a week was the most common and effective frequency of exercise in terms of UPDRS-III scores. There was heterogeneity among subgroups in terms of TUG scores, while heterogeneity was significantly reduced when we removed the four-times-a-week subgroup ( P =0.46, I² = 0%.).

3.4.2 Duration of each session

Each training duration includes 50min, 60mim, and 90min. We divided them into three subgroups. In the comparison between subgroups, we found no significant difference between subgroups in the effect of the duration of each session on UPDRS-III (p=0.6; I²= 0%) for all tests between subgroups. However, a 60-minute exercise session is the most common choice. The time of 60-minute exercise per session had a significant effect (MD = -5.82; 95% CI, -8.75, -2.89). There were no differences among the subgroups in TUG (P = 0.89; I²= 0). The time of 60-minute exercise per session had a significant effect (MD = -1.96; 95% CI, -2.79, -1.13) on TUG scores. The frequency of the week affects motor symptoms and may also be related to the area of evaluation.

3.4.3 Duration of exercise per week

Because of the different training times, the total training time of a week is more grouped. The weekly exercise duration included in the study was divided into 60 minutes, 120 minutes,150 minutes, 180 minutes, and >180 minutes subgroups. The difference between subgroups was not significant on UPDRS-III scores (P =0.24, I² = 29.1%) and TUG (P=0.36, I² = 6.3%). Between 120 and 180 minutes of total exercise time per week was the most selected parameter. We will also analyze the relationship between the total time of one week and efficacy in the subsequent Meta-regression analysis.

3.4.4 Exercise types

In the primary outcome measure URPDS-III, we found mainly tango and Tai chi. We selected studies with 2-3month intervention and divided them into tango and Tai Chi subgroups, including 4 and 6 studies, respectively. Figure 6 showed that there was no significant difference in the subgroup analysis (P =0.39, I²= 0%).

3.5 Meta-regression analysis

After we performed subgroup analysis, there was high heterogeneity among subgroup classes. We continued to perform univariate and multivariate regression analyses to determine the factors of heterogeneity (Table 4). We selected the average age, exercise modality (dance, Chinese martial arts, others), the number of exercises per week, the time of each exercise, the total time of the week, the length of the intervention, and the region of the participants (divided into eastern and Western countries) as covariates. Univariate meta-regression showed that the average age of participants could affect the score of UPDRS-III (β =1.242; 95% CI, -2.27, -0.206; p=0.022). After multiple regression analysis, it was found that age had no significant effect (β =-0.962; 95% CI, -2.053, 0.128; p=0.078), but region might be the influencing factor (β =-9.406; 95% CI, -17.423, -1.389; p=0.026).

The European guidelines for Parkinson's Physical Therapy recommend continued physical therapy and increased rates of unsupervised exercise in patients with Parkinson's disease. We selected exercises that were not supervised by a physical therapist and performed in the community for analysis. We systematically and comprehensively studied the effect of exercise on motor function and optimal exercise prescription in patients with PD. Subgroup and regression analyses were also performed. The key findings of this study are as follows: 1) exercise at home has effects on improving motor symptoms; (2)in the current study, the most common exercise parameters were 60min each time, twice a week, Tango and Tai chi are the most common movement modalities;3) the frequency of weekly exercise, age, and region of participants may be important factors affecting the results; 4) no significant heterogeneity was found in subgroup analysis, univariate analysis, or multivariate regression analysis for Tango, Tai Chi, or other exercise methods.

Heterogeneity was so significant that even if we performed a subgroup analysis or tried to exclude a single study, the heterogeneity could not be significantly changed. The higher heterogeneity is consistent with the results of other exercise interventions[57]. This suggests that the improvement of motor symptoms in PD by exercise is affected by multiple factors. The clinical manifestations of PD vary widely, even in motor symptoms[58]. PD is not just a motor disease; there are many non-motor symptoms, such as salivary glands, visual disturbances, constipation, anxiety, and depression[4, 58]. These non-motor symptoms can also lead to a reduced willingness to exercise in PD. People with PD often fall, making them sedentary and reluctant to exercise.[59] Complications other than Parkinson's motor disease may affect treatment outcomes. The incidence is higher in men than women at every age[60], but women have a higher mortality rate and progress faster[61, 62]. And the optimal parameters for exercise are different for men and women. Gender is also one of the factors affecting exercise in PD. The proportion of women is also a factor in the effect. The same form of exercise still not homogenous, such as Tai Chi, dance, and Tango groups. However, the heterogeneity between different exercise groups was not obvious. Therefore, our Parkinson's patients do not need to be confused about the form of exercise, and the effects of different exercise forms may be a little different. That's good news for people who can't get to rehabilitation centers because of the economy and transportation. Geography creates heterogeneity that may be related to race and lifestyle. Parkinson's disease is a progressive disease of the nervous system, which may be the reason why age is an important factor. The duration of treatment should be studied for three or six months in the future to increase the homogeneity of the study. The treatment course is too short, and the patient may learn various motor skills, which may exaggerate the curative effect; It is too long, and since PD is a progressive disease[32], it is not comparable to other training cycles. Long-term exercise training has not been found to have adverse results in older adults and PD patients[27, 63]. For patients, weekly and lifelong training is recommended. A more standardized, rigorous scientific design is also needed to explore the best exercise prescription.

But our study also has some shortcomings: 1)Due to the large heterogeneity, we did not conduct evidence-level classification; 2) We were unable to include studies with the same movement parameters, and more studies on parameters and movement forms are needed in the future; 3) We did not account for changes in other parameters in the subgroup analysis; 4)Some studies did not report the number of men and women, and the sex ratio was not considered as one of the multifactor factors in the meta-regression analysis.

It is important to note that by 2020, WHO recommends 150–300 minutes of moderate-intensity physical activity per week for all adults, also for people over 65 years of age, and people with disabilities[64]. PD mostly affects people over 60 years of age, and the age of onset of the disease is usually 65 to 70 years[65]. A study in northern Sweden showed that the average age of PD was 70.6 years[66]. Moderate-intensity training was beneficial in all older adults over the age of 85, and there was no significant increase in adverse events[67]. Studies have shown no difference in 5-year mortality between moderate-intensity and high-intensity exercise interventions but a downward trend compared with the control group[68]. Studies have shown that exercise stem is safe and effective in reversing functional decline caused by acute hospitalization in elderly patients (mean age: 87.3 range, 75–101)[69]. Therefore, we believe that the WHO recommendations also apply to PD patients. People with PD have reduced activities of daily living and exercise less per week than healthy elderly people. Studies have shown that intensive exercise therapy can be beneficial for PD patients[70]. Surveys show a global trend of inactivity[71, 72]. PD may not have gotten enough exercise intensity in the current study. We should appropriately increase the exercise time of patients in future studies.

This meta-analysis suggests that community-based exercise may benefit motor function in patients with PD. This is stronger evidence for physicians and patients to increase the proportion of unsupervised exercise and to continue exercise at home. The most commonly used modalities of exercise are Tango and Tai Chi, and The most common prescription is 60 minutes twice a week. However, more direct studies comparing these parameters should be conducted in the future. Age, region, and weekly frequency were important factors affecting the effect. Future studies should consider the influence of age, region, and weekly frequency on the effect.

PD: Parkinson's disease;

UPDRS-III: the Unified Parkinson’s Disease Rating Scale part III;

MD: Mean difference;

TUG: the Timed Up and Go test

UPDRS: the Unified Parkinson’s Disease Rating Scale;

BBS: the Berg Balance Scale;

6MWT: the 6-Minute Walk Test;

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of data and materials

All data generated or analyzed in this work are included in the published version.

Competing interests

All authors declare that they have no competing interests.

Funding

This work was supported Ministry of Science and by Technology of the People's Republic of China, Grant numbers: National Key R&D Plan/2017YFC1308504；

Science and Technology Department of Sichuan Province, Grant numbers: Project of Science and Technology Department of Sichuan Province/2021YJ0184.

Acknowledgments

We thank all the people who performed the trials that contributed to this meta-analysis and systematic analysis.

Author Contributions

For this present update, YCL and QY designed and implemented the searches. TYC, HJP, and WTT selected the studies. YCL, TYC, and HJP undertook data extraction and assessment of the risk of bias. YCL and TYC performed the data analysis. CY, QCH, CY, and ZZQ contributed to the writing of the paper. All authors were involved in the interpretation of the review.

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Table 1. Inclusion criteria
Item	Criteria
Design	Randomized controlled trials or crossover trials
Participants	Individuals with Parkinson’s Disease
Intervention	dance, martial arts, Nordic walking, home-based exercises
Comparisons	usual care
Outcome measures	Outcomes related to motor function

Table 2. characteristic of the study

Author

Year Location

intervention

Sample

(N)

Frequency

(Per week)

Time

(min)

Total time of the week (min)

Duration

Gender

（M/F）

Age

Outcome Measures

Hackney

2009 American

Waltz

17 (E)

17 (C)

2 times

120

13 weeks

11/6 (E)

12/5 (C)

66.8 ± 2.4 (E)

66.5 ± 2.8 (C)

UPDRS, BBS, TUG, 6 MWT

Hackney

2009 American

Tango

14 (E)

17 (C)

2 times

120

13 weeks

11/3 (E)

12/5 (C)

68.2 ± 1.4 (E)

66.5 ± 2.8 (C)

UPDRS, BBS, TUG, 6 MWT

Duncan

2012 American

Tango

26 (E)

26 (C)

2 times

120

12 weeks

15/11 (E)

15/11 C)

69.3 ± 1.9 (E)

69.0 ± 1.5 (C)

UPDRS-III, FOG-Q, 6 MWT,

Choi

2013 S. Korea

Tai Chi

11 (E)

9 (C)

3 times

180

12 weeks

----

60.81 ± 7.6(E)

65.4 ± 6.8(C)

UPDRS-III, PDQ, BBS, BDI

S.-M. Cheon

2013 Korea

Tai Chi

9 (E)

7 (C)

3 times

180

8 weeks

-----

65.6 ± 7.9 (E)

64.9 ± 7.2 (C)

UPDRS, UPDRS-III,

functional fitness

Amano

2013 USA

Tai Chi

15 (E)

9 (C)

3 times

180

16 weeks

7/8 (E)

7/2 (C)

66 ± 11 (E)

65 ± 7 (c)

UPDRS, GI, Gait

Gao

2014 China

Tai Chi

37 (E)

39 (C)

3 times

180

12 weeks

23/14 (E)

27/12 (C)

69.54 ± 7.32 (E)

68.28 ± 8.53 (C)

BBS, UPDRS-III, TUG

Cugusi

2015 Italy

Nordic Walking

10 (E)

10 (C)

2 times

120

12 weeks

2/8 (E)

2/8(C)

68.1 ± 8.7 (E)

66.6±7.3 (C)

UPDRS-III, 6MWT, BBS, HY scale, BDI-II, TUG,

Rios Romenets

2015 Canada

Tango

18 (E)

15 (C)

2 times

120

12 weeks

12/6 (E)

7/8 (C)

63.2 ± 9.9(E)

64.3 ± 8.1(C)

UPDRS-III, TUG, PDQ39

Hashimoto

2015 Japan

Dance

15 (E)

14 (C)

1 time

12 weeks

3/12 (E)

7/7 (C)

67.9 ± 7.0 (E)

69.7 ± 4.0 (C)

UPDRS, BBS, TUG, SDS

Liu

2016 China

Qigong

28 (E)

26 (C)

5 times

300

10 weeks

11/17 (E)

14/12 (C)

65.84 ± 5.45 (E)

62.5 ± 3.13 (C)

TUG

Vergara-Diaz

2018 American

Tai Chi

16 (E)

16 (C)

3 times

180

3 months

6 months

9/7 (E)

7/9 (C)

65.7 ± 3.86 (E)

62 ± 7.77(C)

UPDRS-III, TUG, PDQ39

Michels

2018 USA

Dance

9 (E)

4 (C)

---

10 weeks

------

66.44 (E)

75.50 (C)

UPDRS-III, BBS, TUG, PDQ-39

Kunkel

2018UK

Dance

31 (E)

15 (C)

2 times

120

10 weeks

19/17 (E)

6/9 (C)

71.3±7.7(E)

69.7±6.0(C)

TUG, 6 MWT, BBS

Van Puymbroeck

2018 USA

Yoga

15 (E)

12 (C)

2 times

8 weeks

10/5(E)

7/5 (C)

65.3 ± 6.09(E)

70.5 ± 4.44(C)

UPDRS, MINI, FGA, FOG

Cheung

2018 USA

Yoga

10 (E)

10 (C)

2 times

120

12 weeks

----

63.5 ± 8.5(E)

65.8 ± 6.6(C)

UPDRS-III,

Oxidative status

H.J. Lee

2018 S. Korea

Qi Dance

15 (E)

16 (C)

2 times

120

8 weeks

10/5 (E)

7/9 (C)

65.8 ± 7.2(E)

65.7± 6.4C)

UPDRS, PDQ, BBS, BDI

Wroblewska

2019 UK

Nordic Walking

20 (E)

20 (C)

2 times

120

12 weeks

8/12(E)

9/11(C)

72.1 ±7.5 (E)

67.6±6.6(C)

FOG-Q, TUG

P. Solla

2019 Italy

Sardinian

Folk Dance

10 (E)

10 (C)

2 times

180

12 weeks

6/4 (E)

7/3 (C)

67.8 ± 5.9(E)

67.1 ± 6.3(C)

UPDRS-III, 6MWT, BBS, TUG

Kalyani

2020 Australia

Dance

17 (E)

16 (C)

2 times

120

12 weeks

3/14 (E)

10/6 (C)

65.24 ± 11.88 (E)

66.50 ± 7.70 (C)

UPDRS III, TUG, BBS, FOG

P. L. Wu

2021 China

home-based exercise

49 (E)

49 (C)

3 times

150

4/8 weeks

26/23 (E)

30/19 (C)

65.12 ± 7.54(E)

63.65 ± 6.02(C)

UPDRS-III

Wan

2021 China

Qigong

20 (E)

20 (C)

4 times

240

12 weeks

8/12 (E)

11/9 (C)

64.95 ± 7.83(E)

67.03 ± 7.47(C)

TUG

2022 China

Qigong

15 (E)

16 (C)

5 times

300

12 weeks

5/10 (E)

6/10 (C)

65.87 ± 6.13 (E)

63.25 ± 6.70 (C)

UPDRS-III, TUG

Abbreviations: N=Number, min= minutes, E=Experimental group, C =Control group, H&Y=Hoehn and Yahr, UPDRS-III=Unified Parkinson’s Disease Rating Scale part III, PFS-16=Parkinson’s Fatigue Scale, BDI-II=Beck Depression Inventory-II, NMSS: Non-motor Symptoms Scale FU= Follow Up, FOG_Q =Freezing of Gait Questionnaire, PDQ39= Parkinson’s Disease Questionnaire (QoL), UPDRS=Unified Parkinson’s Disease Rating Scale, PDQL= the Parkinson’s disease Quality of Life questionnaire, BBS=the Berg Balance Scale, BDI=the Beck Depression Inventory, GI =Gait initiation, TUG= Timed Up & Go, MINI = Mini-BESTest, FGA = Functional Gait Assessment, ADL=activities of daily living, SDS=Self-rating Depression Scale

Table 3. Subgroup analysis for different parameters of exercise on each motor performance measure

UPDRS-III

TUG

MD (95%CI)

Frequency of weekly

-15.56 (-29.19, -1.93)

-2.32 (-4.00, -0.65)

-6.65 (-10.19, -3.11)

308

-0.93 (-2.53, 0.66)

222

-3.21 (-5.98, -0.44)

384

-5.70 (-6.63, -4.77)

-0.61 (-1.91, -0.69)

-2.04 (-3.30, -0.78)

Test for subgroup

Chi² = 4.71, df = 2 (P=0.09), I² =57.6%

Chi² = 52.87, df = 4 (P < 0.00001), I² = 92.4%

Duration of each session (min)

-5.03 (-6.40, -3.66)

196

-5.82 (-8.75, -2.89)

490

-1.96 (-2.79, -1.13)

496

-7.85 (-13.67, -2.03)

-1.87 (-2.79, -0.95)

Test for subgroup

Chi² = 1.01, df = 2 (p= 0.60), I² = 0%

Chi² = 0.02, df = 1 (P = 0.89), I² = 0%

Duration of the week (min)

-15.56(-29.19, -1.13)

-1.22(-4.97, 2.53)

120

-7.86 (-11.51, -4.21)

289

-3.65 (-4.18, -3.11)

233

150

-4.90 (-8.57, -1.23)

196

180

-6.60 (-9.06, -4.15)

188

-1.37 (-2.22, -0.52)

167

>180mim

-2.57 (-3.71 -1.44)

112

Test for subgroup

Chi² = 4.23, df = 3 (P=0.24), I² = 29.1%

Chi² = 3.20, df = 4 (P =0.36), I² = 6.3%

Abbreviations: UPDRS-III, the Unified Parkinson’s Disease Rating Scale part III; UPDRS, the Unified Parkinson’s Disease Rating Scale; TUG, the Timed Up and Go test; BBS, the Berg Balance Scale; 6 MWT, the 6-Minute Walk Test; MD, mean difference; S, the number of included studies; N, the total number of participants; NA, not applicable.

Table 4 Univariate and multiple meta-regression for UPDRS-III

	Univariate analysis		Multiple analysis
	Coefficient (95%CI)	P	Coefficient (95%CI)	P
Type of exercise	0.030(-3.668, 3.728)	0.986	-1.087 (-4.815, 2.641)	0.531
Area	-1.107( -7.733, 5.518)	0.728	-9.406 (-17.423, -1.389)	0.026
Age	-1.242 (-2.27, -0.206)	0.022	-0.962 (-2.053, 0.128)	0.078
Frequency of week	4.184(-0.902, 9.271)	0.100	9.536 (-43.410, 62.483)	0.697
Time for session	-0.070(-0.445, 0.304)	0.697	0.013 (-1.908, 1.935)	0.988
Time for week	0.070(-0.021, 0.163)	0.123	-0.038 (-0.918, 0.840)	0.924
Duration of exercise	-0.160(-0.425, 0.104)	0.218	-0.186 (-0.394,0.0221)	0.074

No competing interests reported.

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Effects and parameters of community-based exercise on motor symptoms in Parkinson's disease: a meta-analysis

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