Cardiovascular,perceived exertion and affective responses during aerobic exercise performed with imposed and a self-selected intensity in patients with Parkinson’s disease

Abstract

BACKGROUND:

Exercise with self-selected intensity (SSI) has emerged as a new strategy for exercise prescription aiming to increase exercise adherence in Parkinson’s disease (PD).

OBJECTIVE:

We compared the cardiovascular, perceived exertion and affective responses during traditional aerobic exercise and with SSI in PD.

METHODS:

Twenty patients with PD performed two aerobic exercise sessions in random order with an interval of at least 72 h between them: Traditional session (cycle ergometer, 25 min, 50 rpm) with imposed intensity (II) (60–80% maximum heart rate [HR]) and SSI: (cycle ergometer, 25 min, 50 rpm) with SSI. The HR (Polar V800 monitor), systolic blood pressure (auscultatory method), rating of perceived exertion (Borg scale 6–20) and affective responses (feeling scale) were assessed during the exercise at 8th and 18th minute. The Generalized Estimating Equation Model was used for comparison between both sessions (P < 0.05).

RESULTS:

The exercise intensity was not significantly different between both exercise sessions (8th minute: II –76.3±1.0 vs. SSI –76.5±1.3 % of maximal HR; 18th minute: II –78.9±0.9 vs. SSI –79.1±1.3 % of maximal HR, p = 0.93). Blood pressure, perceived exertion and affective responses were also not significantly different between both sessions (P > 0.05).

CONCLUSIONS:

Cardiovascular and psychophysiological responses were not different during aerobic exercise performed with II and with SSI in patients with PD.

Keywords

Parkinsonism cardiovascular system aerobic exercise pleasure adherence

1 Introduction

Parkinson’s disease (PD) is a progressive neurodegenerative disease characterized by motor impairment, involving resting tremor, rigidity, bradykinesia, and postural instability (Dickson, 2018). Patients with PD frequently present cardiovascular dysfunction, leading to orthostatic hypotension and alterations on circadian blood pressure rhythm (Goldstein et al., 2003; Kanegusuku et al., 2017; Fanciulli et al., 2020), which may contribute to the mortality in this population (Fereshtehnejad et al., 2015).

Exercise training is recommended for patients with PD and aimed to improve motor and cardiovascular function (Feito, 2009; Kim et al., 2019; Alberts & Rosenfeldt, 2020). However, most patients do not have access to supervised exercise prescription, limiting the number of practitioners. Exercise with self-selected intensity (SSI) has emerged as a new strategy to improve adherence to physical training programs of people with similar conditions. Interestingly, it has been observed that SSI generally chosen by healthy and subjects with chronic degenerative diseases (e.g. heart disease, obesity) are within the intensity recommended by the American College of Sports Medicine (Ekkekakis, 2009). Furthermore, the SSI of exercise has shown to promote positive emotions during exercise (Hamlyn-Williams, Freeman & Parfitt, 2014; Costa et al., 2019; Sócrates et al., 2020), which can also improve adherence to physical training programs for this population. However, whether similar responses are observed in patients with PD has not yet been studied.

Thus, the aim of the study was to evaluate cardiovascular, rating of perceived exertion (RPE) and affective emotional responses during an aerobic exercise session performed with an imposed intensity (II) (following the guideline prescription) and with a SSI in patients with PD. We hypothesized that the cardiovascular and RPE responses would not be significantly different between both exercise sessions and greater promote positive emotions would be observed during aerobic exercise with SSI compared to traditional aerobic exercise.

2 Methods

2.1 Participants

This is a randomized controlled crossover trial which included patients with PD recruited from the Brazil Parkinson Association, São Paulo, Brazil. The inclusion criteria were 1) diagnosis of PD by a specialized physician; 2) aged ≥50 years; 3) 1–3 of the modified Hoehn and Yahr stages (Goetz et al., 2004); 4) no other neurological disorder or any diagnosed cardiac disease; 5) not taking medications that could directly affect the autonomic regulation (e.g. beta-blockers), except for those used for the treatment of PD; 6)≥26 points in the Montreal Cognitive Assessment (Nasreddine et al., 2005); 7) no health problem that restrains exercise. The study was approved by the Universidade Nove de Julho’ Ethics Committee (CAAE: 95350718.6.0000.5511), and written informed consent was obtained from all patients. Considering a power of 80%, an alpha error of 0.05 and an effect size of 0.5 for 2 experimental sessions, the necessary sample size was calculated at 19 patients.

2.2 Maximal exercise test

Before taking part in the experimental sessions, patients underwent a maximal exercise test as previously described (Kanegusuku et al., 2016). All tests were performed in cycle ergometer (Lode, Corival, Netherlands), with an individualized ramp protocol (i.e. increment between 3 and 15 watts per minute, 50–60 rpm) chosen to cause fatigue within 8 to 12 minutes. During the tests, heart rate (HR) was continuously monitored by a 12-lead echocardiogram (Cardio Perfect, ST 2001, The Netherlands).

In a sub sample (11 patients), ventilatory variables were continuously measured by a metabolic cart (Medical Graphics Corporation, CPX/D, USA). Peak HR was considered as the highest values obtained during the exercise phase (average of 30 s data). Posteriorly, (i.e. anaerobic threshold and respiratory compensation point) were also determined (Skinner & McLellan, 1980; Wasserman, Sue & Whipp, 1994).

2.3 Experimental protocol

Patients performed two exercise sessions in random order with an interval of at least 72 h between them: 1) with II (60–80% maximum HR, following the guideline prescription for the management of PD (Feito, 2009; Kim et al., 2019); and 2) with a SSI (patients choose the intensity that they want to perform exercise). The order in which the patients performed each experimental session was determined using simple randomization (www.randomizer.org). Before sessions, the patients were instructed to eat a light meal 2 h beforehand and to avoid caffeinated beverages on the testing days. Patients performed the sessions at the same time of day and in the “on state” of their medication.

The pre-intervention period started with patients resting in the supine position for 20 minutes followed by assessment of HR and blood pressure (BP) measurements. Then, the patients underwent 25 minutes of exercise on the cycle ergometer at 50 rpm. During the exercise, cardiovascular parameters (i.e. HR and BP), RPE (Borg Scale) and affective responses (positive/negative) were assessed at 8th and 18th minute.

During the experimental sessions, the HR was monitored by Polar V800 (Polar Electro, Finland) and registered as 30 s averages. BP was measured by the auscultatory method using korotkoff sounds with a mercury sphygmomanometer.

The RPE was assessed using the Borg scale (6–20). This scale allows the patient to classify the effort between 6 (“very, very light”) to 20 (“very, very hard”) (Borg, 1982). Affective responses were assessed by the Felling Scale (Hardy, 1989), which ranges between –5 (“very bad”) to + 5 (“very good”), measuring basic or core affective valence (negative/unpleasant and positive/pleasant). Patients were instructed on use of the RPE scale and the Felling Scale on the day of the maximal exercise test and immediately before each experimental session.

2.4 Statistical analysis

The data were stored and analyzed using the Statistical Package for the Social Sciences (version 20.0; SPSS Inc., Chicago, IL, USA). The normality of the data distribution was confirmed by the Shapiro-Wilk test. The variables were expressed as mean±SE and as frequency distribution. Generalized Estimating Equations were used to compare the effects of sessions (II or with a SSI) on cardiovascular, RPE, and affective responses. Post hoc pairwise comparison using the Bonferroni correction for multiple comparisons was employed when necessary. Significance was defined as P < 0.05.

3 Results

A flowchart of the study is provided in Fig. 1. Twenty male patients with PD (65±2 yr, 28.0±1.0 kg/m², 2.1±0.2 modified Hoehn & Yahr) that had a confirmed diagnosis of PD (6.5±0.9 yr) completed the study. Patients were on the following medications for treatment of PD: levodopa (100%), dopamine agonist (40%), amantadine (25%) and selegiline (10%).

Fig. 1

Participant flowchart.

The exercise workloads were not significantly different between exercise session performed with II and with SSI (8th minute: 38.9±5.4 vs. 32.6±3.3 watts; 18th minute: 37.5±5.1 vs. 30.8±2.8 watts, interaction effect p = 0.40, respectively). The percentage of maximal HR was higher during 18th minute compared to 8th minute of the exercise in both sessions (main effect of time p < 0.01). However, it was not significantly different between sessions (8th minute: 76.3±1.0 vs. 76.5±1.3% of maximal HR; 18th minute: 78.9±0.9 vs. 79.1±1.3% of maximal HR, interaction effect p = 0.93, respectively).

HR and systolic BP (Fig. 2A and B) were higher during exercise compared to rest and higher during 18th minute compared to 8th minute of the exercise in both sessions (main effect of time p < 0.01). The response of these parameters during exercise were not significantly different between sessions (interaction effect p = 0.99 and p = 0.53, respectively).

Fig. 2

Heart rate (A), systolic blood pressure (B), the rating of perceived exertion (C), and affective responses (D) measured during an aerobic exercise session performed with an intensity imposed and with a self-selected intensity in patients with Parkinson’s disease. Non-normally distributed data: the rating of perceived exertion and affective responses. P < 0.05.

The RPE and affective responses (Fig. 2C and D) were higher during 18th minute compared to 8th minute of the exercise in both sessions (main effect of time p < 0.01). However, the response of these parameters during exercise were not significantly different between sessions (interaction effect p = 0.11 and p = 0.82, respectively).

4 Discussion

The main findings of the current study were: 1) The exercise intensity was not significantly different between the session performed with II and with SSI; 2) The cardiovascular and psychophysiological responses during exercise were not significantly different between sessions.

In the current study, patients with PD performed both exercise sessions with the same relative exercise intensity. The subsample analysis (i.e. 11 patients) also revealed that exercise intensity was above anaerobic threshold in 81.8% of patients in both exercise sessions, a recognized stimulus for improving motor and cardiovascular parameters in patients with PD (Arfa-Fatollahkhani et al., 2019; Marusiak et al., 2019). This result increases the practical applicability of the exercise performed with SSI for management of PD when patients do not have access to more precise exercise prescription via the maximal exercise test.

Cardiovascular responses and RPE were also not significantly different between exercise sessions. An interesting point to be raised is that although HR responses during both exercise sessions corresponded to moderate to vigorous intensity of aerobic exercise, which is in accordance with the exercise prescription in clinical guidelines for management of PD (Feito, 2009; Kim et al., 2019), the RPE reported by patients in most of the time corresponded to a level of effort between “fairly light” to “somewhat hard”, suggesting a disconnexion between physiological and perceptual parameters in both aerobic exercise sessions. Future studies are required to understand the relationship between physiological and perceptual parameters during aerobic exercise in patients with PD.

Patients with PD also did not present difference in affective emotional response during exercise sessions. Sixty five percent of patients reported positive feelings at 18^th minute in II exercise session and 70% in SSI exercise session, which shows great acceptance of exercise modality for these patients. This positive affective response during exercise is similar to others previous studies (Hamlyn-Williams, Freeman & Parfitt, 2014; Costa et al., 2019; Sócrates et al., 2020) conducted in subjects without PD (e.g. healthy subjects, hypertensive) that also demonstrated positive feeling of pleasure during the exercise. These are important aspects for exercise prescription because negative feelings during exercise may to be a barrier for practice of physical exercise. In this context, exercise with SSI may be an interesting option for patients who are unable to carry out supervised training and open new strategies for home-based exercise training for these patients.

This study has some limitations. First, we only include male patients at stages 1–3 of the modified Hoehn & Yahr scale and without cardiac disease. Thus, results cannot be generalized to subjects without these characteristics. Second, our patients were taking different medications and doses for PD treatment, which increases the external validity of the results but precludes the extrapolation to any specific drug regimen. Finally, we only analyze a single session of exercise using SSI and the possible adherence and chronic effects of this prescription should be determinated

5 Conclusion

In conclusion, the cardiovascular, RPE and affective responses were also not significantly different during aerobic exercise performed with II and with a SSI in patients with PD. Therefore, exercise with SSI may be an interesting option to improve adherence to physical training programs of patients who do not have access to supervised exercise prescription.

Footnotes

Acknowledgments

The authors gratefully acknowledge the volunteers and the Brazil Parkinson Association.

Conflict of interest

The authors declare that they have no conflict of interests, financial or otherwise.

Funding

RR received a research productivity fellowship granted by the Brazilian National Council for Scientific and Technological Development and HK received a fellowship granted by the Fundação de Amparo à Pesquisa do Estado de São Paulo –FAPESP (2018/11564-6).

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