Archives of Physical Medicine and Rehabilitation

journal homepage: www.archives-pmr.org

Archives of Physical Medicine and Rehabilitation 2018;99:826-33

ORIGINAL RESEARCH

The Effects of Functional Training, Bicycle Exercise,

and Exergaming on Walking Capacity of Elderly
Patients With Parkinson Disease: A Pilot Randomized
Controlled Single-blinded Trial
Daniel Dominguez Ferraz, MSc,a Karen Valadares Trippo, MSc,a Gabriel Pereira Duarte, PT,a
Mansueto Gomes Neto, PhD,a Kionna Oliveira Bernardes Santos, PhD,a
Jamary Oliveira Filho, PhDb
From the Departments of aPhysical Therapy and bBiomorphology, Federal University of Bahia, Salvador, Brazil.

Abstract
Objectives: To compare the effects of functional training, bicycle exercise, and exergaming on walking capacity of elderly with Parkinson disease
(PD).
Design: A pilot randomized, controlled, single-blinded trial.
Setting: A state reference health care center for elderly, a public reference outpatient clinic for the elderly.
Participants: Elderly individuals (
60 years of age; NZ62) with idiopathic PD (stage 2 to 3 of modified Hoehn and Yahr staging scale)
according to the London Brain Bank.
Intervention: The participants were randomly assigned to three groups. Group 1 (G1) participated in functional training (nZ22); group 2 (G2)
performed bicycle exercise (nZ20), and group 3 (G3) trained with Kinect Adventures (Microsoft, Redmond, WA) exergames (nZ20).
Main Outcome Measures: The primary outcome measure was the 6-minute walk test (6MWT); secondary outcome measures were the 10-m walk
test (10MWT), sitting-rising test (SRT), body mass index, Parkinson Disease Questionnaire-39, World Health Organization Disability Assessment
Schedule 2.0 (WHODAS 2.0), and 15-item Geriatric Depression Scale.
Results: All groups showed significant improvements in 6MWT (G1 PZ.008; G2 PZ.001; G3 PZ.005), SRT (G1 P<.001; G2 PZ.001; G3
PZ.003), and WHODAS 2.0 (G1 PZ.018; G2 PZ.019; G3 PZ.041). Only G3 improved gait speed in 10MWT (PZ.11). G1 (PZ.014) and
G3 (PZ.004) improved quality of life. No difference was found between groups.
Conclusions: Eight weeks of exergaming can improve the walking capacity of elderly patients with PD. Exergame training had similar outcomes
compared with functional training and bicycle exercise. The three physical exercise modalities presented significant improvements on walking
capacity, ability to stand up and sit, and functionality of the participants.
Archives of Physical Medicine and Rehabilitation 2018;99:826-33
ª 2018 by the American Congress of Rehabilitation Medicine

Parkinson disease (PD) is a brain disorder characterized by loss of
dopaminergic neurons in the substantia nigra of the midbrain.1 It
is the second most prevalent chronic neurodegenerative disorder,
The study was conducted at the State Reference Health Care Centre for Elderly (SRHCCE), a
public reference outpatient clinic for the elderly in Salvador, Bahia, Brazil, between June 1, 2015
and March 27, 2017.
Clinical Trial Register No. ClinicalTrials.gov (clinical trial identifier: NCT02622737).
Disclosures: none.
affecting 1.5% to 2% of the elderly population in the United
States.2 Individuals with PD present classical neurologic symp-
toms such as resting tremor, rigidity, and bradykinesia.3 These PD
symptoms, associated with the effects of aging, impair walking
capacity, physical endurance,4 balance, and functional indepen-
dence for basic activities of daily living,5 leading to progressive
disability.
Because of these limitations, patients with PD are one-third
less active than those without PD of the same age.6 Patients with

0003-9993/18/$36 - see front matter ª 2018 by the American Congress of Rehabilitation Medicine
https://doi.org/10.1016/j.apmr.2017.12.014
Parkinson disease and video games
PD who participate in exercise programs have a better perception
of quality of life and a superior walking ability, postural balance,
strength level, flexibility, and fitness capacity compared with
physically inactive patients.7
Conventional physiotherapy is a series of techniques focusing
on transfers, posture, upper limb function, balance (and falls), gait,
physical capacity and (in)activity using cueing strategies, cogni-
tive movement strategies and exercise to optimize the patient’s
independence, safety, and well-being, thereby enhancing quality
of life.8 In addition, whole-body vibration, massage of trigger
points, cueing, dance, aerobic exercises, and Tai Chi are being
used in rehabilitation for PD.6,9 Although a wide range of reha-
bilitation interventions have been successful in treating PD, there
is no robust trial evidence to support any one approach
over another.8
Exergames are exercise-based computer games that have
recently been used to treat patients with PD and other neurologic
disorders.10 These games provide a natural, easy, and fun-to-use
interface; they promote dynamic corporal adaptation using envi-
ronments that seek a patient’s attention, participation, motivation
and retention, thereby seamlessly integrating recreation and dis-
ease management.11 The Xbox 360 video game with Kinecta
should be a friendly exergame for elderly with PD, because it
replaces handheld remote controls through the use of whole-body
motion capture technology.12,13
Thus the purpose of this study was to compare the effects of 3
treatment modalities (functional training, bicycle exercise, and
exergaming) on walking capacity of elderly patients with PD. We
hypothesized that elderly patients with PD who used the Xbox 360
video game with Kinect would present similar efficacy on
improving walking capacity compared with functional training
and bicycle exercise.
Methods
The study was conducted in a public reference outpatient clinic for
the elderly. Data were collected in the period between June 2015
and March/2017. The trial design followed the recommendations
of the Consolidated Standards of Reporting Trials.14 The study
was carried out in accordance with the Declaration of Helsinki and
approved by the Human Research Ethics Committee (approval
number 1.016.971). All participants provided voluntary written
informed consent.
Elderly patients (
60 years of age) with idiopathic PD ac-
cording to the London Brain Bank criteria15 participated in the
study. All participants complied with the inclusion and exclusion
criteria. The inclusion criteria were regular use of medication for
PD and modified Hoehn and Yahr stages 2, 2.5, or 316 (the in-
terventions were developed for patients with bilateral disease
involvement without severe disability) without walking devices.
The exclusion criteria were visual or hearing impairment;
List of abbreviations:
PD Parkinson disease
6MWT 6-minute walk test
10MWT 10-m walk test
SRT sitting-rising test
WHODAS 2.0 World Health Organization Disability
Assessment Schedule 2.0
PDQ-39 Parkinson’s Disease Questionnaire-39
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827
parkinsonian syndromes other than PD; bone, joint, or muscle
diseases that limit the practice of physical activity; chronic un-
controlled diseases (hypertension, diabetes mellitus, chronic pain);
unstable cardiovascular disease (acute heart failure, recent
myocardial infarction, unstable angina, and arrhythmias uncon-
trolled); current alcohol and other toxic substance use; contrain-
dications for performing physical exercise according to the
American College of Sports Medicine17; practicing any physical
exercise program in the past 6 months, or participating in regular
resistance training in the previous 12 months. The participants
were advised to continue their routine physical activity while
participating in the study.
Sample and randomization
Sixty-two participants, 37 (59.7%) men and 25 (40.3%) women
who were 69 (5) years old, weighing 67.05 (12.46) kg, 1.61
(0.09) m in height, and with 6 (4) years of illness duration
were randomly assigned to 3 intervention groups. An independent
physiotherapist performed the method of sequence generation
using True Random Number Service (www.random.org), a
computerized random number generator to generate a randomized
sequence of 3 different numbers. Each number was saved indi-
vidually in different sealed red opaque envelopes. Another
researcher invited the volunteers by telephone for a first individual
evaluation to verify if they complied with the inclusion and
exclusion criteria. After each subject was admitted to the study,
each envelope was opened sequentially, which determined the
group allocation.
Twenty-two patients (6 women and 16 men) participated in
group 1 (G1); 20 patients (9 women and 11 men) participated in
group 2 (G2); and 20 patients (10 women and 10 men) partici-
pated in group 3 (G3). G1 participants performed functional
training, G2 performed bicycle exercise, and G3 trained with
exergames. The sessions performed in all groups lasted 8 weeks
with a frequency of three 50-minute sessions per week, based on
similar protocols from other groups.6,8 Each session consisted of
10 minutes of stretching, 5 minutes of calisthenics, 30 minutes of
intervention, and 5 minutes of breathing exercises to slow down.
All interventions have achieved individual perception of tiring
exercisedthat is, 15 points of Borg scale.18 Participants who
missed more than once a week or more than 4 absences during the
8-weeks of training for any reason were considered lost to follow
up and not analyzed further.
Interventions
Functional training was based on Canning et al19 and consisted of
10 activities lasting 3 minutes each one (table 1).
The G2 participants performed aerobic training on a stationary
bicycle. In the first week, training was titrated to 50% of
maximum heart rate, increasing progressively to 75% in the eighth
week. In the first week, we used 50% of maximum heart rate, in
the second and third week 55%, in the fourth and fifth weeks 65%,
in the sixth and seventh weeks 70%, and in the eighth week 75%.
The Karvonen formula20 was used to determine heart rate training
goals for each session. During all exercise sessions the heart rate
was verified with a heart rate monitor and patients were encour-
aged to achieve the heart rate training.
Patients in G3 trained using Xbox 360 video game with Kinect
(fig 1). The Kinect Adventures games were used. These exer-
games use full-body motion to allow the player to engage in a
828 D.D. Ferraz et al

Table 1 Description of functional training used in group 1

Game Description
Gait with obstacles Hula hoops, rubber cones, plastic sticks, wood steps, and mattresses were used
to perform this exercise.
Going up and down stairs and ramp The patient went up and down 3 steps and 1 ramp until completing 3 minutes.
Sitting and standing exercises Manual resistances, dumbbell, and unstable bases (Swiss ball) were used to
increase the level of difficulty.
Side gears The patient performed side gait according to the physiotherapist’s commands.
Balance exercise in proprioceptive platform Inflatable balance disks, jumping beds, and proprioceptive tables were used.
Activities with balls The exercise consisted of kicking balls of different sizes and weights, alternating
each foot.
Step exercises The exercise consisted of going up and down steps with the right or left foot
according to cognitive commands.
Foot tip exercises The patient performed foot tip exercises on flat and sloped surface with 2 or 2
foot maintaining sural triceps contraction for 5 seconds.
Graded reaching activities The reach exercises were performed standing and sitting. Dual task activities
were performed.
Gait training The patient walked around the gym following verbal commands of stop and
changing direction. Gait re-education consisted of working scapular and pelvic
girdle dissociation.
NOTE. The intensity evolution was performed progressively with barbells and manual resistance.

variety of mini-games, all of which feature jump-in, jump-out power were evaluated through the sitting-rising Test (SRT),26 and
multiplayer play (table 2). Each mini-game lasts about 3 minutes. the body fat composition was evaluated by the body mass index
To complete 30 minutes of training, the same 1 or 2 mini-games and abdominal circumference.
were repeated in different levels of intensity in each session. The World Health Organization Disability Assessment
All treatments were carried out under the supervision of a Schedule 2.0 (WHODAS 2.0) questionnaire was used to evaluate
physiotherapist who motivated the patients to use correct posture the perception of functional capacity (activities and participa-
and promote the best exercise performance. The same physio- tion).27 Quality of life was assessed through Parkinson’s Disease
therapist conducted G1 and G2 and another one conducted G3. Questionnaire-39 (PDQ-39)28 and EuroQol-5D questionnaires,29
All patients should be in the “on” period (the period of greatest and the emotional state was evaluated through the Geriatric
effectiveness of levodopa or equivalent medication), and hyper- Depression Scale.30
tensive participants were advised to take their regular antihyper-
tensive medications.
Statistical analysis
Primary outcome Categorical variables were expressed as absolute numbers and
proportions. The Kolmogorov-Smirnov test was used to assess
We chose the 6-minute walk test (6MWT) as the primary outcome normality of continuous variables. Five descriptive variables (age,
in this study as a measure of walking capacity. It is a simple, valid education, Hoehn and Yahr stage, illness duration, Mini-Mental
tool for testing walking capacity used widely in elderly pop-
ulations and for those with various diseases.21 Disease-specific
characteristics, balance, and mobility impairments can also in-
fluence 6MWT.22
We estimated the sample size using 6MWT means and stan-
dard deviations.23 A confidence interval (2-sided) of 95% was
considered, a power of 80%, and a ratio of sample size (group 2/
group 1) of 1, leading to an estimated sample size of 34þ34þ34
patients. An interim analysis was planned when half the patients
were recruited. Owing to slow recruitment, we decided to halt the
trial after the first interim analysis.
The evaluations were performed by a single blinded researcher,
following recommendations of the American Thoracic Society
guidelines.24 All patients performed the 6MWT, during the “on”
period, 1 week before and 1 week after training.

Secondary outcomes
The 10MWT was used to assess the gait speed, following the Fig 1 Elderly patient with Parkinson disease playing Xbox 360 video
criteria described by Salbach et al.25 Lower limb strength and game with Kinect.

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Parkinson disease and video games
Table 2 Description of Kinect Adventures exergames used in
group 3
Game Description
River Rush The player’s avatar stands in a raft and
works to pick up the adventure pins
scattered throughout the winding
rapids. The raft is controlled by
stepping left or right to steer, and by
jumping to make the raft jump.
Reflex Ridge The player’s avatar is on a moving
platform in an environment similar to a
wooden R or mine cart. One or 2 players
race on a platform, jump over hurdles,
lean away from obstacles, and limbo to
avoid hitting their heads on low beams.
Jumping in place makes the platform
move faster along its rail.
20,000 Leaks The player’s avatar is in a glass cube under
water. The player positions his or her
limbs and head to plug cracks as crabs,
fish, and “bosses” such as sharks and
swordfish cause cracks and holes in the
cube. As difficulty increases, up to 5
leaks must be plugged at a time to earn
Adventure pins.
NOTE. The intensity evolution was performed progressively with
different game levels of difficulty. Physical components involved in
those games included strength and muscular endurance, cardiorespi-
ratory fitness, postural balance, and executive function.
Test) and 3 secondary outcomes (15-item Geriatric Depression
Scale, EuroQol-5D, SRT) were not normally distributed. These
variables were expressed as median and interquartile range and
compared with Kruskal-Wallis and Wilcoxon signed-rank tests.
All others variables were normally distributed, expressed as mean
and standard deviation, and compared with analysis of variance
and t test. The significance level was set at 5%. All analyses were
performed using SPSS 22.0 software.b
Assessed for eligibility (n=76)
Randomized (n=72)
Functional Group (n=25) Bike training Group (n=25)
Lost to follow-up (n=3) Lost to follow-up (n=5)
1 nonadherent 2 nonadherent
1 humeral head fracture 1 ankle fracture
1 hypertension 1 hypertension
1 hospitalization for respiratory infection
Analyzed (n=22) Analyzed (n=20)
Fig 2 Flow diagram of the progress through the phases of a parallel randomized trial of 3 intervention groups in Salvador, Brazil, 2017.
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829
Results
During the recruitment process, 76 elderly individuals were
invited, of whom 4 candidates declined to participate, and 72
volunteers were evaluated and randomly divided into 3 groups:
functional group (G1), bicycle exercise group (G2), and exer-
gaming group (G3). Ten participants (13.8%) were lost to follow-
up: 4 abandoned the study, 1 had an ankle fracture after a fall at
home, 1 had a humeral head fracture, 3 presented with hyper-
tension at the initial treatment session, and 1 had an acute respi-
ratory infection requiring hospitalization (fig 2).
All groups presented similar demographic and clinical char-
acteristics, anthropometric measurements, education level,
cognitive status, and PD disease stage (table 3). Table 4 provides a
summary result for each study group (G1, G2, and G3).
All groups showed significant improvements in 6MWT, SRT,
and WHODAS 2.0. Only G3 demonstrated significant improve-
ment on gait speed performed in 10MWT. G1 and G3 improved
the perception of quality of life (EuroQol-5D and PDQ-39) and no
groups decreased body mass index significantly. Only G2 and G3
obtained a significant difference in reducing abdominal circum-
ference. No significant differences were found among the 3 groups
in any of the prespecified outcomes (table 5).
Discussion
The results supported our hypothesis. The G3 group as well as the
G2 and G3 groups had similar improvements on walking capacity,
ability to stand up and sit, and functionality of elderly persons
with PD Hoehn and Yahr stages 2 to 3. There were no significant
differences among these 3 exercise modalities. However, only G3
participants significantly improved gait speed. G1 and G3 showed
significant improvements in quality of life, and significant re-
ductions in abdominal circumference were found in patients in G2
and G3.
The 3 exercise modalities used in this study were able to
improve mobility and reduce fall risk of the participants. Clinical
and functional conditions, such as mobility impairment,26 disease
severity, functional balance, walking ability, and energy cost of
Declined to participate (n=4)
Exergaming Group (n=22)
Lost to follow-up (n=2)
1 nonadherent
1 hypertension
Analyzed (n=20)
830 D.D. Ferraz et al

Table 3 Baseline experimental group characteristics in individuals with Parkinson disease

G1 (nZ22) G2 (nZ20) G3 (nZ20)
n (%) n (%) n (%)
Variable Median (IR)/Mean (SD) Median (IR)/Mean (SD) Median (IR)/Mean (SD) P Value
Sex (female) 6 (27.3) 9 (45.0) 10 (50.0) .358
Fallers 10 (45.5) 9 (45.0) 10 (50.0) .861
Weight (kg) 68.57 (9.92) 64.66 (13.10) 67.76 (14.45) .577
Height (m) 1.61 (0.09) 1.62 (0.09) 1.60 (0.09) .630
BMI (kg/m2) 26.62 (4.17) 24.36 (3.97) 26.61 (5.83) .222
UPDRS 29.86 (12.95) 28.65 (12.86) 32.30 (15.48) .696
AC (cm) 94.70 (11.76) 90.62 (19.04) 95.27 (13.07) .559
Age (y) 71 (66e75) 67 (64e71) 67 (66e68) .063
Illness duration (y) 4 (3e7) 6 (4e9) 4 (4e7) .461
Mini-Mental Test 27.00 (24.75e28.00) 27.00 (25.00e29.00) 27.00 (25.00e28.00) .723
Hoehn and Yahr stage 2.50 (2.50e3.00) 2.50 (2.00e3.00) 2.50 (2.00e2.50) .108
Education (y) 8.00 (4.75e11.00) 9.50 (5.00e11.00) 8.00 (4.00e11.00) .457
NOTE. Variables with not normal distribution were expressed as median and interquartile range and compared with Kruskal Wallis test; Variables with
normal distribution was expressed as mean and standard deviation and compared with ANOVA test.
Abbreviations: AC, abdominal circumference; BMI, body mass index; G, group; IR, interquartile range; n, number of participants; UPDRS, Unified
Parkinson’s Disease Rating Scale.

walking, may influence the 6MWT distance in patients with
moderate PD.21 Thus in these patients there is a convergent val-
idity of the 6MWT in relation to functional balance or mobility as
a test of walking capacity.21 Improvements on SRT may already
be related to the increase of muscle strength of lower limbs.
Moreover, performance on the SRT in PD is most related to
balance and bradykinesia, and it can be useful as a quick means of
assessing gross fall risk of these individuals.26
Additionally, our results with the 6MWT seem clinically mean-
ingful. Bohannon and Crouch31 suggested that changes in 6MWT
distance between 14.0 m and 30.5 m can be a reasonable standard for
setting goals and concluded that a real change in 6MWT distance has

Table 4 Primary and secondary outcome measures comparing before and after intervention for each study group in patients with Parkinson
disease
G1 (nZ22) G2 (nZ20) G3 (nZ20)
Baseline median (IR) Baseline median (IR) Baseline median (IR)
Baseline mean (SD) Baseline mean (SD) Baseline mean (SD)
8 weeks median (IR) 8 weeks median (IR) 8 weeks median (IR)
Variable 8 weeks mean (SD) P Value 8 weeks mean (SD) P Value 8 weeks mean (SD) P Value
6MWT (m) 354.9 (98.9) .008 405.2 (97.3) .001 365.4 (81.1) .005
391.7 (107.5) 440.2 (90.2) 401.2 (77.9)
10MWT (s) 1.3 (0.3) .068 1.3 (0.3) .101 1.2 (0.3) .011
1.4 (0.4) 1.4 (0.3) 1.4 (0.3)
PDQ39 47.0 (25.1) .069 38.1 (19.8) .185 44.7 (26.7) .004
41.7 (21.7) 32.9 (19.1) 33.9 (25.2)
BMI (kg/m2) 26.6 (4.2) .562 24.4 (4.0) .105 26.6 (5.8) .126
26.5 (4.1) 24.1 (3.8) 26.3 (5.7)
AC (cm) 95.0 (11.8) .691 90.6 (19.0) .069 95.3 (13.1) .011
94.4 (11.5) 88.4 (15.6) 92.9 (13.5)
WHODAS 2.0 73.3 (22.0) .018 66.2 (17.7) .019 70.75 (19.6) .041
63.91 (14.0) 61.9 (16.2) 64.3 (19.2)
SRT (s) 16.6 (12.0e21.3) <.001 13.2 (11.4e17.1) .001 14.5 (11.4e16.1) .003
11.8 (9.6e15.9) 11.1 (9.8e13.7) 10.5 (7.4e13.4)
EuroQol-5D 7.0 (6.0e9.0) .014 6.0 (5.0e7.0) .399 6.5 (5.0e7.0) .311
6.0 (5.0e7.0) 5.0 (5.0e6.8) 6.0 (5.0e7.0)
GDS-15 5.0 (3.8e7.3) .099 3.0 (2.0e6.0) .962 5.0 (3.0-7.8) .115
5.0 (1.8e7.0) 4.0 (2.0e5.0) 3.5 (2.8e8.3)
NOTE. P values refer to the Wilcoxon signed-rank test or t test. Variables with not normal distribution were expressed as median (interquartile range)
and compared with Wilcoxon signed-rank test. Variables with normal distribution were expressed as mean  SD and compared with t test.
Abbreviations: AC, abdominal circumference, BMI, body mass index; IR, interquartile range; n, number of participants, 6MWT: 6-minute walk test;
PDQ39, Parkinson Disease Questionnaire-39; SRT, sitting-rising test; 10MWT, 10-m walk test; WHODAS 2.0, World Health Organization Disability
Assessment Schedule 2.0; GDS-15, 15-item Geriatric Depression Scale.

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Parkinson disease and video games 831

Table 5 Primary and secondary outcome measures compared among the 3 experimental groups
G1 (nZ22) G2 (nZ20) G3 (nZ20) G1 vs G2 G1 vs G3
Median (IQR) Median (IQR) Median (IQR)
Variable Mean (SD) Mean (SD) Mean (SD) Mean Difference (95% CI)
6MWT (m) 36.73 (59.15) 34.98 (38.71) 35.77 (49.84) 1.7 (29.8 to 33.3) 1.0 (33.3 to 35.3)
10MWT (s) 0.12 (0.30) 0.07 (0.19) 0.12 (0.20) 0.0 (0.1 to 0.2) 0.0 (0.2 to 0.1)
PDQ39 5.36 (13.13) 5.15 (16.74) 10.85 (14.67) 0.2 (9.1 to 9.5) 5.5 (14.2 to 3.2)
BMI (kg/m2) 0.09 (0.69) 0.26 (0.69) 0.34 (0.94) 0.2 (0.6 to 0.3) 0.3 (0.8 to 0.3)
AC (cm) 0.34 (4.00) 2.20 (5.10) 2.40 (3.82) 1.9 (4.7 to 1.0) 2.1 (4.5 to 0.4)
WHODAS 2.0 9.36 (17.11) 4.30 (7.52) 6.45 (13.18) 5.1 (3.3 to 13.5) 3.0 (6.7 to 12.5)
SRT (s) 2.95 (1.03-7.72) 2.11 (0.34e3.53) 4.48 (0.61e6.27) 1.8 (1.2 to 4.8) 1.1 (2.0 to 4.1)
EuroQol-5D 1.00 (0.00e2.00) 0.00 (0.00e1.00) 0.00 (1.00 to 1.75) 0.6 (0.3 to 1.5) 0.5 (0.6 to 1.5)
GDS-15 0.50 (0.25 to 1.25) 0.00 (1.75 to 1.75) 1.00 (0.00e2.00) 0.6 (0.8 to 1.9) 0.1 (1.3 to 1.5)
NOTE. Variables with nonnormal distribution were expressed as median (interquartile range). Variables with normal distribution were expressed as
mean  SD.
Abbreviations: AC, abdominal circumference; BMI, body mass index; GDS-15, 15-item Geriatric Depression Scale; IQR, interquartile range; n, number of
participants; 6MWT, 6-minute walk test; PDQ39, Parkinson Disease Questionnaire-39; SRT, sitting-rising test; 10MWT, 10-m walk test; WHODAS 2.0,
World Health Organization Disability Assessment Schedule 2.0.

been accomplished. Our 3 exercise groups exceeded 30.5 m in
6MWT comparing the performance before and after training.
The motor disturbance related to the neurologic symptoms of
PD and age biomechanical changes can contribute to impaired
balance and limited mobility. The intrinsic factors are often the
primary contributors to the fall risk,32 There is a significant
relation between the individual’s fall risk and his or her muscle
strength, aerobic endurance, agility, and dynamic balance.32 In
patients with PD the increasing age, PD dementia, motor
disability, postural instability, and gait difficulties probably
explain the more than 3-fold increased risk of falls.33 Recurrent
falls are a common consequence of these clinical and functional
PD conditions and will probably have a major impact on the
health care system in the future.33
The mechanisms for the functional benefits observed in this
study are probably multiple and complex. Studies suggest that
physiological use of exercise can be an important component of
neuroplastic changes in human PD brain and support the central
hypothesis that self-produced activity is important in slowing,
halting, or reversing human PD.34 Therefore it is possible that
these types of nonpharmacologic interventions could preserve or
help restore motor and cognitive effectiveness in PD.35
Aerobic exercise is a modality of training widely used in assisting
pharmacologic treatments of PD. Endurance exercise training also
improves physical condition in patients with PD.36 However, there is
not sufficient evidence to include endurance exercise training as a
specific treatment for individuals with PD.36 A meta-analysis sug-
gested that aerobic exercise improves motor action, balance, gait
velocity, step length, and walking capacity of patients with PD.36
Almost 80% of aerobic exercises used high intensities.
Although intensive aerobic exercise showed superior effects in
improving motor action, balance, and gait of patients with PD, the
evidence is not conclusive.36 We have used 50%-75% of maximal
heart rate for participants in G2, and this intensity is in line with
the American College of Sports Medicine and American Heart
Association suggestion of moderate intensity physical activity to
generate multiple health benefits.37 However, future research
should further investigate intensity level of aerobic exercise to
check and monitor its effectiveness based on maximal heart rate or
metabolic equivalents.
We used a stationary bicycle as a modality of aerobic exercise.
Arcolin et al38 recommend the bicycle ergometer as a valid
endurance exercise alternative to treadmill for improving gait over
the short term for patients with PD. In their pilot study elderly
patients with PD performed bicycle ergometer training for 3
weeks, 1 h/d.38 Our results are in line with this study which re-
ported significant improvements in 6MWT.38
Physical rehabilitation of elderly people with PD is a long
process. Physiotherapists might face patients with complicated
health conditions during the neurorehabilitation program, such as
poor motivation, limited time to perform rehabilitation exercises,
financial issues, and difficulties reaching the therapy location.39
Although the physical exercise programs seem to work well in
people with PD, they should motivate the patient and aim to
reduce disease progression.39 Therefore the exergaming may be an
alternative exercise modality for patients with PD, because it in-
duces patient movements to solve cognitive tasks. The exergame
provides competitive elements, immersion in different situations
without risk, and allows home training.10 This technology can
deliver multisensory exercises that have been used in the reha-
bilitation process of neurologic disorders.10 The ludic aspects are
another important characteristic that may help patients to be more
motivated during the exercise.10 However, the adherence level in
our 3 exercise groups was similar, and there are no studies that
have compared the motivation of patients with PD treated with
exergaming and other therapies.
A variety of exergame strategies have been tested in PD with
heterogeneous protocols. Xbox 360 video game with Kinect
sensor does not use specific controls or platforms, which could
limit the movement performance or interfere on transmission and
capture of the gesture by the sensors in patients with motor dis-
orders. However, 9 of 10 studies included in a meta-analysis used
the video game Nintendo Wiic and only one used Xbox 360 video
game with Kinect to treat patients with PD.39
Randomized clinical trials showed results similar to those
found in this study. A single-blinded, stratified, randomized
controlled trial40 has compared patients treated with Nintendo Wii
exercises, conventional therapy, and a normative group. The
exergaming group and conventional therapy exhibited significant
improvements in movement velocity and sensory organization

www.archives-pmr.org
832
testing compared with the normative group after the exercise
program at 1-month of follow-up. In agreement with our study, no
significant differences were found between the Nintendo Wii and
conventional therapy group, and both showed improvements in
quality of life. Anther recent pilot randomized clinical trial also
showed similar outcomes using Nintendo Wii exergames to treat
patients with PD.23 These patients improved balance and reduced
fatigue after 12 weeks of treatment, but this benefit was not sus-
tained after 60 days of follow-up.23 Pompeu et al41 also found
improvements in cardiopulmonary endurance, balance, gait, and
quality of life using Kinect Adventures exergames to treat patients
with PD. In this study, the physiotherapist did not participate in
making proprioceptive and verbal stimulus in all sessions and only
14 sessions were performed.41 It is possible that the lack of
physiotherapist support in the study by Pompeu et al41 combined
with a low number of participants, may have influenced the
nonsignificant result on 6MWT.
The main limitations of the study were the small sample size
and the losses to follow-up. However, losses were minimal
(13.8%) and not expected to change the overall results. Only the
participants who performed bicycle exercise had controlled car-
diac performance (heart rate) during all training sessions, because
they needed this feedback to correctly intensify the exercise pro-
gram. Therefore for future studies, we suggest controlling cardiac
performance during all proposed interventions for elderly patients
with PD to precisely regulate training intensity. To make definite
clinical recommendations possible, further research should focus
on randomized trials with larger sample sizes and sufficient
follow-up periods after completing the intervention. Further
studies may also reveal the effects of different modalities of ex-
ercise program on such important outcome measures as physical
fitness and mobility, quality of life, activities of daily living, cost-
effectiveness, fall risk, and muscle strength.
Conclusions
Functional training, bicycle exercise, and Kinect Adventures
exergames were safe and improved the walking capacity of elderly
participants with PD. We recommend any of these 3 exercise
programs that most motivate patients to promote regular practice
of physical exercise and mobility benefits.
Suppliers
a. Kinect Adventures; Microsoft, Redmond, WA.
b. SPSS 22.0; SPSS.
c. Nintendo Wii Fit; Nintendo of America Inc. Redmond, WA.
Keywords
Aged; Parkinson disease; Physical Therapy Modalities; Video
Games; Virtual Reality Exposure Therapy
Corresponding author
Daniel Dominguez Ferraz, MSc, Universidade Federal da Bahia,
Instituto de Ciências da Saúde, Departamento de Fisioterapia, Av.
Reitor Miguel Calmon, Número: s/n. Bairro: Vale do Canela.
D.D. Ferraz et al
CEP: 40110-902, Salvador, Bahia, Brazil. E-mail address:
danieldf@ufba.br.
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