It has been over six months since my last post. Six months of discovery. It turns out the problem with the repeated dislocation of my knee had to be addressed surgically. On Sept 15 the surgeon worked on my meniscus. So, since June 6 until now I have been trying to rehab both the toe joint that was replaced the knee surgery. The PT has not always been compatible. The bottom line is that i was not able to ride my bike consistently for all that time. What did I notice? Movement: much stiffer body, compromised balance resulting in two falls (I had had none prior), difficulty getting off the floor, general weakness. Executive functions: difficulty following directions (cooking and driving), reading recall, preparing and giving presentations. Cognitive: apathy, getting cognitive mixed up with exec functions, understanding computer instructions, speaking in coherent sentences. (No-one complained, but i could feel the difference. My leg muscles atrophied significantly as did my endurance. For three days in a row I've been back in the bike saddle again, much to my relief. Although I'm certainly not where i was in June, it feels like the ship is turning, even if just a bit.

"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:​
Results from the Randomized Controlled Trial Cyclical Lower Extremity Exercise (CYCLE) Trial for Parkinson’s disease: 1543 Board #4 May 31 1

Trial record for The Cyclical Lower-extremity Exercise for Parkinson's Trial (CYCLE):
The Cyclical Lower-extremity Exercise for Parkinson's Trial - Full Text View - ClinicalTrials.gov

At first glance, the results of the CYCLE trial seem to say that there is nothing "special" about high-cadence cycling (i.e. it is not about the bike or the pedaling, it is about the aerobic exercise!). Or maybe the results are saying that there is a fundamental difference between the use of a powered bicycle and the use of a tandem bicycle?

Meanwhile, research on (dynamic) high-cadence cycling continues at KSU (Angela Ridgel et al.).

"Individuals (N=17) completed three sessions of high cadence cycling, on a custom motorized stationary cycle, consisting of a 5-minute warm-up at 50 revolutions per minute (rpm), 30 minutes of high cadence cycling between 75-85 rpm, and a 5-minute cool down."

The Effects Of High-Cadence Cycling On Emotional Recognition In Individuals With Parkinson’s Disease:
The Effects Of High-Cadence Cycling On Emotional Recognition In Individuals With Parkinson’S Disease: 48 Board #249 May 3 11

I've also seen Ridgel et al. use the term "dynamic cycling at a high cadence" to refer to their version of "forced exercise". [1]

[1] The Efficacy of Dynamic Cycling in an Individual with ALS: A Pilot Study:
The Efficacy of Dynamic Cycling in an Individual with ALS: A Pilot Study

I'm very glad to see that there may be no difference between forced and voluntary cycling. After starting on a motor assist bike that my husband rigged up, I became too good for it. So I started on a regular stationary bike and contacted Dr. Alberts' office to see what was the best approach. They suggested continuing without the motor assist, staying down at 80 to 90 rpm, keeping my heart rate up by increasing the resistance,and cycling every second day. Which I've done for over a year now.

RecentlyI've been watching Grey's Anatomy while I pedal and a couple of times have gotten so into it that I pedal longer. It seemed to help more, so now I'm thinking that more than 45 minutes with a 5 minute warm-up and cool-down might be even better. Anyone have any experience with longer times or maybe more frequent times?

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.

wendy s said:

"They suggested continuing without the motor assist, staying down at 80 to 90 rpm, keeping my heart rate up by increasing the resistance, and cycling every second day."

When Dr. Alberts' office said to keep your heart rate "up", I presume they meant up above 60% of HRmax, as per their original protocol.

Given the results of the SPARX trial, and the preliminary results of the CYCLE trial, I am now keeping my heart rate in the range 80 to 85 percent of HRmax.

I'll look at this again when/if the full results of the CYCLE trial are finally published.

Eight Weeks of Aerobic Interval Training Improves Psychomotor Function in Patients with Parkinson’s Disease—Randomized Controlled Trial, Jaroslaw Marusiak et al., Int. J. Environ. Res. Public Health 2019, 16(5), 880.

"... the current study is the first randomized controlled study to present a positive generalized effect with a moderate intensity aerobic interval training (AIT) regimen on a cycle ergometer."

"Previous studies have established that interval training is more enjoyable and effective than continuous exercise programs for non-PD populations."

"... other studies have shown that the BDNF increase following interval training is greater than that following continuous regimen training."

IJERPH | Free Full-Text | Eight Weeks of Aerobic Interval Training Improves Psychomotor Function in Patients with Parkinson’s Disease—Randomized Controlled Trial | HTML

(hat tip to easilly at HU for the link)

"This pilot project will involve a randomized trial of 30 individuals with PD comparing the effects of HIIT [High-Intensity Interval Training] and CMIT [Continuous Moderate Intensity Training]."

"Participants will include men and women between 50-85 years of age, who are able to stand unsupported for 1 min, walk 18m without use of an aid, and mount a stationary bike."

"Participants will be randomized to either HIIT (10, 1-minute cycling intervals at 90% of peak power output, each separated by 1-min at 10% peak power output) or CMIT (30-50min cycling at 60% of peak power output)."

"Training will be completed thrice weekly for 10 weeks."

So the members of the HIIT group do 1 minute of cycling at 90% of peak power output, "rest" for 1 minute, then do that 9 more times back to back. Given the rather loose eligibility criteria, I think the 90% figure is probably a little ambitious!

Physiological Benefits of High-intensity Interval Training for Individuals With Parkinson's Disease - Full Text View - ClinicalTrials.gov

(hat tip to iqbaliqbal at HU for the link)

Jay Alberts has just received $3M for a CYCLE Trial Mark 2!

"Cleveland Clinic and University of Utah will recruit 250 Parkinson’s patients who will be randomized to a high-intensity home exercise or usual and customary care (UCC) group. [The high-intensity home exercise group will follow the protocol from the CYCLE trial, and will] utilize indoor cycling bikes from fitness technology company Peloton. Participants will be instructed to exercise 3x/week for 12 months; the UCC group will be instructed to engage in their normal activities."

Cleveland Clinic Awarded $3 Million NIH Grant to Determine Disease-Modifying Effects of Exercise in Parkinson’s Patients – Cleveland Clinic Newsroom

The Clinical Trials website has a trial record for the new "Pragmatic CYCLE" trial. My guess is that they have added the word "pragmatic" because the Peloton bikes they will be using are normal spin bikes (i.e. no motor). PwPs in the high-intensity home exercise group will be given an aerobic-intensity target range of 60-80 percent of heart rate reserve, and a cadence target range of 80-90 RPM.

Estimated Study Completion Date: September 1, 2024

Pragmatic Cyclical Lower Extremity Exercise Trial for Parkinson's Disease - Full Text View - ClinicalTrials.gov