Jay Alberts is the guru when it comes to FE and PD.
at about 16:00 in his video he addresses a critical issue re: using a motorized bike. He explains that the PwP MUST contribute to the pedaling stroke effort (it is critical to understand this distinction) to obtain any benefit, but his hypothesis probably also applies to those Pwp who use the typical motorized treadmills.
In sum, The PwP must actively contribute to gain a benefit; he/she gains no benefit by not contributing (simply pedaling or running passively).
My questions to Alberts are....Is the real issue all about high RPM (80-90) vs a much slower RPM (50-60)? and secondly, is it a function of significance of time (up to several hours at a time in some cases)? and thirdly, is it simply an improvement in smell?
My question to Alberts would be : For your latest trial (i.e. CYCLE II), why have you dropped the term "forced exercise", and replaced it with the term "high-intensity aerobic exercise"?
It was never "forced exercise" anyway, but rather "forced cadence".
I have not watched all of the video but the remarks in the OP relating to treadmills would be somewhat in contrast to the Schenkman trials, no? (SPARX)
I would disagree with your comment about apples/oranges. It is all about any type of forced exercise which is passive in nature. Does it reduce your motor symptoms is the issue.
I agree that you can pedal passively on a motorized bicycle, but how could you run passively on a motorized treadmill? Wouldn't you very quickly end up on your a###?
"It was never 'forced exercise' anyway, but rather 'forced cadence'."
December 2023 update:
In a recent paper they have replaced the term "forced exercise" with the term "forced-rate aerobic cycling" (in the title) and the more-general term "forced-rate aerobic exercise (FE)" in the abstract.
Hooray!
Forced-rate aerobic cycling enhances motor recovery in persons with chronic stroke: A randomized clinical trial.
Interested to know if powered treadmills are really no use. I actually have a manual treadmill and I HATE IT. It makes me work (therefore I don't use it).
Great webinar on exercise: Webinar – Exercise and Parkinson’s
This webinar discusses recent publications around the theme of exercise in Parkinson’s. The panel is chaired by Van Andel Institute’s Professor Patrik Brundin who is joined by Professor Bas Bloem (Radboud University Medical Centre, Netherlands), Dr Jakowec (University of Southern California) with patient views from Professor Karen Raphael, an epidemiological research scientist.
Actually, my (revised) question to Alberts would be : For your latest trial (i.e. CYCLE II), why have you dropped the motor? (and consequently, replaced the term "forced exercise" with the term "high-intensity aerobic exercise")
I think the answer to that question is buried within the results of the original CYCLE trial.
"There were no significant differences between the VE [voluntary exercise] and FE [forced exercise] groups."
Wow!
Results from the Randomized Controlled Trial Cyclical Lower Extremity Exercise (CYCLE) Trial for Parkinson’s disease:
I didn't say or imply THE VIDEO was current; you made the false assumption.
I simply stated his hypothesis as he expressed it in this specific video, and in his early study, which I referenced. I thought the distinction was important regardless of the age of the video. I still do.
You have taken his CYCLE-II study completely out of context. Re-read the methodology AND THE OBJECTIVES.
He used VE and FE in his 1st trial, but as you point out, results were very comparable. Again, is it all about high RPMs as I suggested it might be? Perhaps; perhaps not.
He dropped the motor because CYCLE-II is not a replay of CYCLE. Re-read both studies.
In this thread you are basically arguing that the "forced exercise" hypothesis is correct, and reminding us that the hypothesis specifies that the PwP must put in some effort in order to get the "forced exercise" extra benefit.
I am basically arguing that the "forced exercise" hypothesis seems to be incorrect (based on the results of the CYCLE trial).
I debated this about 5 years ago on the forum. I concluded that heart rate was probably more important than rpm and failing this......just make sure that you sweat!
Perhaps the results of the Sparx trial give us a hint as to what might have gone wrong in the CYCLE trial.
In the Sparx trial [1] participants were assigned to one of three groups: control, moderate-intensity treadmill exercise (60 to 65 percent maximum heart rate) or high-intensity treadmill exercise (80 to 85 percent maximum heart rate). After six months researchers found that the motor symptoms of only the high-intensity group had not progressed.
In the CYCLE trial [2] and the earlier (smaller) trial [3], both the VE and the FE groups were instructed to maintain their heart rates within the range of 60 - 80 percent of HRmax.
Hypothesis: Perhaps in the CYCLE trial the average heart rate for both groups was up near 80. Perhaps in the earlier trial the average heart rate for only the FE group was up near 80 while the average heart rate for the VE group was down near 60.
Unfortunately, references [2] and [3] do not contain the data needed to test this hypothesis.
Bottom line: We now know (from the results of the Sparx trial) that a heart-rate range of 60 - 80 percent of HRmax is just too large.
[1] Effect of High-Intensity Treadmill Exercise on Motor Symptoms in Patients With De Novo Parkinson Disease: A Phase 2 Randomized Clinical Trial, Margaret Schenkman et al., JAMA Neurology: 75(2) 2018.
[2] Results from the Randomized Controlled Trial Cyclical Lower Extremity Exercise (CYCLE) Trial for Parkinson’s disease, Jay Alberts et al., Medicine & Science in Sports & Exercise: May 2018.
[3] Forced, Not Voluntary, Exercise Improves Motor Function in Parkinson's Disease Patients, Angela Ridgel et al., Neurorehabilitation and Neural Repair: 23(6) 2009
"60 - 80 percent of HRmax is just too large." Specifically too wide a range for such a small sample although it isn't definitive. Also, Sparx had low compliance and used motorized treadmills which are to some degree "passive".
As you correctly point out, we don't really know the specifics from #2 and #3.
I have stumbled upon some evidence that supports Sharon's "RPM" hypothesis.
It turns out that Alberts et al. conducted a number of separate investigations in parallel with the CYCLE trial, one of which involved a subset of 59 of the CYCLE trial's 100 PwPs [4]. I can't get the paper itself as it is behind a paywall, but I've come across another paper [5] that makes reference to it.
"One recent study did demonstrate gains in both forced and voluntary groups, but it was noted that the voluntary group self-selected to pedal at a cadence near the target achieved by the forced group [4]."
I may just have to raid my piggy bank to find out what else they "noted".
[4] Miller Koop, M., Rosenfeldt, A. B., & Alberts, J. L. (2019). Mobility improves after high intensity aerobic exercise in individuals with Parkinson's disease.
[5] Kathleen E. McKee et al. (2021). Implementation of high-cadence cycling for Parkinson’s disease in the community setting: A pragmatic feasibility study.
So is Alberts saying it is all about RPMs? Or is he saying high RPMs using "forced active pedaling"to achieve those high RPMs?
I would assume the nod goes to the latter protocol plus significant time spent pedaling. He seems to forget the latter variable since very few could or would comply. Yet it was clearly critical back in 2013 when he started.
The results of the CYCLE trial were published as a half-page "poster" in May 2018 [2]. I'm still hoping to one day see a full research paper containing a solid "discussion" section.
Meanwhile, they have published a couple of research papers covering investigations they ran in parallel with the CYCLE trial.{4], [6]
It seems that your questions (and mine) will just have to wait a bit longer.
[6] Anson B. Rosenfeldt, Mandy Miller Koop, Hubert H. Fernandez, Jay L. Alberts (2021). High intensity aerobic exercise improves information processing and motor performance in individuals with Parkinson's disease.
"Data from these and other studies provide the basis to include aerobic exercise as an integral component in treating PD. Based on positive clinical findings and trials, it is advised that PwPD perform aerobic exercise in the following dose: 3x/week, 30-40-minute main exercise set, 60-80% of heart rate reserve or 70-85% of heart rate max. In lieu of heart rate, individuals can achieve an intensity of 14-17 on a 20-point RPE scale. "
Unrealistic goal for most Pwps > 65 in my 11-12 years of working with PwPs, particularly those > 75. (Without use of a stimulant.)
HR max = roughly 110 (70%) to 135 (85%) FOR 65 YEAR OLD.
heart rate reserve (resting HR - Max HR) is not heart rate max. Using HRR makes no sense to me here with old people. I don't get it.
Although they seem to have given up on "forced exercise" for PD, Alberts et al. have had some success with it fairly recently, in the field of rehabilitation after stroke [7].
" ... both groups exercised at similar aerobic intensities: 60% HRR for the FE group and 59% HRR for the VE group. Furthermore, power produced for both groups was similar at 32.4 and 33.9 W for the FE and VE groups, respectively, as was exercise duration. The only training variable that differed between the 2 groups was cadence ..."
[7] Linder SM, Rosenfeldt AB, Davidson S, Zimmerman N, Penko A, Lee J, Clark C, Alberts JL (2019). Forced, Not Voluntary, Aerobic Exercise Enhances Motor Recovery in Persons With Chronic Stroke.
I have talked to Jay several times over the years going back to 2013. I don't think he could convince me that using HRR is particularly useful given they took the RHR 5 minutes after cessation of exercise to measure it and that it is best used in younger male cohorts than found in PwP.
Specifically, when looking at PwP by age cohort (>65), it is probably not as useful as he thinks.
I've come across another recent paper [8] that includes some thoughts from Alberts et al. on why the CYCLE trial produced the (unexpected) results that it did.
"Unlike the human powered tandem cycle used in the previous study, the current cycle cadence was controlled via a motor and control algorithm. To our knowledge, this was the first application of this type of exercise in humans; thus, the IRB [Institutional Review Board] limited the maximum cadence the motor could be set to 90 RPMs for safety reasons. A limit in the maximum cadence resulted in some patients in the VE group actually pedaling faster than those in the FE group. Similarly, a fixed 30% increase in cadence, based on CPX [cardiopulmonary exercise] testing for the FE group, rather than a fixed cadence range (80–90 RPMs) was used; again resulting in some FE participants pedaling at lower rates than those in the VE group. Participants in the initial study were more severely affected based on clinical ratings (~14 points higher in initial study); hence the earlier participants had greater room for improvement. In the current trial, those patients in the VE group pedaled nearly 30% faster than patients in the original study. A substantial increase in the voluntary pedaling rates of those in the VE group suggest our initial study along with others were likely impactful in changing the perception that PD patients should not or could not complete high intensity exercise."
"Ongoing and future projects are aimed at the following: 1) determine the relationship between changes in aerobic fitness and improvements in clinical and biomechanical evaluation of motor symptoms, 2) determine if higher percentage of HRR in conjunction with preferred RPM is optimal method of improving outcomes, and 3) determine the phenotype that may be most suitable to perform VE (e.g. if a participant can pedal at a high RPM and a high percentage of HRR) or FE (e.g. more advanced PD patient who is unable to voluntarily achieve a cadence greater than 70)."
[8] A Elizabeth Jansen, Mandy Miller Koop, Anson B Rosenfeldt, Jay L Alberts (2021). High intensity aerobic exercise improves bimanual coordination of grasping forces in Parkinson’s disease.
My take on the focus of "ongoing and future projects" is that they are still grappling with some basic questions regarding the definition and the role of "high-intensity aerobic exercise" and "forced exercise", in the treatment of PD.
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