Home-Based Vigorous Tele-Exercise in People with Parkinson’s Disease: Feasibility Beyond Complexity

The COVID-19 pandemic has drastically changed our way of life. Lockdown was established as the most secure method to prevent the spread of the virus and protect health, especially in older people and those with chronic conditions. This situation, which is still recommended to safeguard vulnerable population, implies a reduction of mobility and may restrict assistance to certain places, including rehabilitation centres. Despite this circumstance could cause an abandonment of rehabilitation programs by people with neurologic diseases, the experts have exposed several alternatives to maintain physical exercise regimens at home without the risk of being exposed directly to COVID-19 [1]. According to the American College of Sports Medicine, online training leads the ranking of fitness trends for 2021 (it was at the 26 position in 2020), revealing the transcendence of the pandemic [2].

A recent study published in The Lancet Neurology by van der Kolk et al has shown that home-based tele-exercise may be feasible and effective in people with Parkinson’s disease, provided it is supervised by a healthcare professional [3]. This well-designed study analysed the effects of a 6-month cycling-based vigorous-intensity exercise protocol performed during 30– 54 minutes at least three times per week, finding significant improvements in motor function (1.3 points in the Movement Disorders Society-Unified Parkinson’s Disease Rating Scale [MDS-UPDRS] motor section) and VO₂max (1.5 mL/kg min-1) in comparison with a control group which performed stretching exercises.

In our opinion, this study has two factors that made it complex. First, patients with Parkinson’s disease were able to performed vigorous-intensity exercise; and second, they could perform the exercise protocol alone, monitoring the intensity. Additionally, training was accompanied by an exergaming environment that consisted of a virtual reality software and real-life videos.

Vigorous exercise offers similar or even greater health benefits than moderate exercise in patients with chronic diseases [4]. This argument supports the application of high intensity sessions (>77% VO₂max) in the medical management plan for people with Parkinson’s disease and, indeed, van der Kolk found no exacerbation of Parkinson’s symptoms following this program. The study achieved a good adherence, with only 10 losses among the 65 participants. Nevertheless, these authors have reported exercise-related adverse events in seven (11%) subjects in the exercise group, such as arthralgia, back pain and palpitations, which highlights the importance of a correct and constant exercise monitoring, either face-to-face or virtual. As regards training design, these authors have incorporated a cycling protocol, which is more practical in a home-based exercise program. Cycling seems to be a good alternative for patients in advanced phases of the disease, since it is well preserved than walking/running in people with Parkinson’s disease, regardless the stage and even in those with severe walking impairments and postural instability [5].

Interestingly, this study has described a significant reduction in motor symptoms severity following vigorous training in the off phase (when the effects of drugs “wear off” or diminish), but not in the on phase, suggesting that medication may have a stronger effect on dopaminergic transmission than exercise and would override its effects [3]. In parallel, dopaminergic system seems not to be solely responsible of gait and postural dysfunctions, and current investigations are focusing on degeneration of cholinergic neurons of the pedunculopontine nucleus as a possible switch of these impairments [6]. This perspective highlights the complex brain networks implicated in Parkinson’s disease and could also explain the L-dopa resistance deficits showed in the advanced stages. Therefore, researchers and physicians are encouraged to decipher the interactions between vigorous exercise and brain (cortical excitation/inhibition balance, neuroplasticity and neurotransmission) in order to enrich and maximize the effects on clinical practice.

Based on the results from this study, we can con-clude that home-based tele-exercise is feasible, beneficial and a safe alternative in this patients even when they must track intensity and operate virtual reality devices. In parallel, vigorous intensity was well-tolerated by the participants, opening a new window for further research on this topic. Bearing in mind the current pandemic situation and also considering the future post-COVID-19, these results support that rehabilitation and physical exercise programs can be carried out at home in people with Parkinson’s disease.