Boxing with and without Kicking Techniques for People with Parkinson’s Disease: An Explorative Pilot Randomized Controlled Trial (2024)

Procedures

Participants were contacted through posters and flyers in a local hospital and a local physiotherapy practice. Twenty-nine participants volunteered and were, after screening for eligibility and baseline testing, randomly assigned to group-based boxing training with addition of kicking techniques (BK) or group-based boxing alone training (BO). An independent researcher performed the randomization in a 1 : 1 ratio using the data management system Castor (Electronic Data Capture, The Netherlands). Both groups trained once a week, one-hour per session, for a period of 10 weeks. No blinding was applied for the trainers and participants. The measurements were performed by a blinded researcher of the Radboudumc at baseline (T0), and after ten weeks (T1).

Intervention

Training sessions for both groups were led by one physiotherapist specialized in PD (part of the nationwide Dutch ParkinsonNet) [31] and one boxing trainer to guarantee safety and assure appropriate training. Participants trained together in their respective groups with the same instructors. For the first group (BO), each session consisted of training punching movements and progressively adding in dual task challenges (i.e., going through a variety of punching combinations). The intensity and variety of exercises were increased according to the patient’s capacity every week. The second group (BK) received 10 sessions of group-based boxing training comparable to the previous group, but with added kicking techniques, weight shifting exercises and multidirectional stepping. A complete overview of the training sessions can be found in Supplementary Table1.

Outcome measurements

We collected demographic information on age, sex, and years of education. Additionally, we registered years since diagnosis, dopaminergic medication use, and most affected side. We assessed feasibility (adherence to training, satisfaction, perceived benefits, recommend to others) and safety (adverse events) using a self-administered questionnaire assessing participants experiences with the training. The complete questionnaire used can be found in the Supplementary Material.

We also assessed effectiveness of the trainings. The primary outcome measure was balance as measured by the Mini-Balance Evaluation Systems Test (Mini-BESTest), which assesses four balance subdomains (anticipatory postural adjustments, postural responses, sensory orientation, and stability in gait) [32]. The maximum score is 28 points, and each item is scored from 0 (unable or requiring help) to 2 (normal). As secondary outcomes, we measured fear of falling with the Falls Efficacy Scale International FES-I [33] and the Activities Balance Confidence Scale (ABC-scale) [34]. The ABC is a 16-item questionnaire designed to measure balance confidence in various everyday activities. For each item the score ranges from 0 to 10 points (total score will range from 0–160 points). The FES-I is a self-efficacy and balance confidence questionnaire, with 16 items. The score ranges from minimum 16 (no concern about falling) to maximum 64 (severe concern about falling). These were collected by sending out e-mails by the certified data management system castor EDC (electronically) when possible and on paper/pencil when participants preferred.

For walking ability, we used the 6-minute walk distance (6MWD) [35] and the Timed-Up-Go [36]. We also assessed health status and quality of life using the Parkinson’s Disease Questionnaire (PDQ-39). We selected all measurement instruments according to recommendations in the European Physiotherapy Guideline for Parkinson’s disease [9].

Data analysis

We used the intention-to-treat principle in all analyses. The analysis was performed using IBM SPSS statistics version 26 (IBM, New York, United States). Shapiro-Wilk test was used to determine whether the data were normally distributed. Since the data were not normally distributed (p < 0.05), we used non-parametric tests for further analysis. Mann Whitney U tests was used to test the difference between the two groups concerning balance, walking ability, and fear of falling, follow-up (T1). Secondarily, we used the Wilcoxon Signed-rank test to evaluate differences within groups. The level of significance was set to p < 0.05. To measure the effect-size, we calculated Cohen’s d. The effect size can be either small (0.20), medium (0.50), or large (0.80) [37]. We used descriptive statistics and analysis of content to evaluate the narrative of participants collected via the qualitative questionnaires.

Participants

Twenty-nine people with PD (median age 64 (8.8) years; median disease duration 5 (4.3) years, time from first symptoms 7.5 (5.2) years) participated in this pilot explorative randomized controlled trial.

Both groups were comparable at baseline (p > 0.05; Table1). Fourteen individuals participated in the boxing with kicking (BK), and thirteen in the boxing-alone (BO). From those, twelve participants in the BK and eleven in the BO group had a complete dataset (Fig.1).

Safety and feasibility

The trainings were completed by 85% of the participants. During the trial, only four dropouts occurred, all for reasons unrelated to the program. There were no fall incidents or other adverse effects events reported during training in both groups.

Participants acceptability and perceived benefits

A total of 18 participants (n = 10 BK group and n = 8 BO group) replied to the qualitative questionnaire (Table3). The majority (n = 8, 80%) of participants in the BK group reported satisfaction with the training and that they had improved their balance after training. These subjective improvements in both balance and exercise capacity were reported as a motivating factor to keep practicing boxing by 60% (n = 6) of the participants. When asked what the benefits of kicking techniques would be, most participants (60%, n = 6) replied that they expected that BK would improve their balance more than conventional boxing. All participants in the BK group (100%, n = 10) would recommend BK training to other people with PD.

Participants in the BO group reported similar improvements. Satisfaction and balance improvements were reported by 75% (n = 6) of participants in the BO group. Motivations to attend BO training were either improvements in balance and exercise capacity (50%, n = 4) or social contact (50%, n = 4). The two most mentioned benefits of BO training were: improvement in exercise capacity (37%, n = 3) and improvement in mobility (25%, n = 2). All responders (n = 8) in the BO group would recommend BO to other people with PD.

Balance

We did not find any additional benefits of kicking techniques (betewen group differences, BK 25.33 (2.64) and BO 25.80 (2.39) p = 0.53).

The within-group comparison showed that balance improved in both groups after the intervention (BK 22.60 (2.7) to 25.33 (2.64) p = 0.02; BO 23.09 (3.44) to 25.80 (2.39); p = 0.01 on the Mini BEST test) (Table2). The effect size of both types of boxing modalities was large, 1.02 for BK and 0.91 for BO for the Mini-BESTest. Results showed that four people in the BK group and 4 in the BO group improved at least four points in the Mini-Best score, which has been reported as the Minimally Clinical Important Difference) [38].

Fear of falling

Fear of falling, as measured by the FES-I, did not show a significant between group difference after the intervention (BK 27.36 (6.56) and BO 24.00 (3.97) p = 0.34).

Within group comparison showed that fear of falling FES-I did not change in either group (BK 27.54 (7.47) to 27.36 (6.56) p = 0.81; and for BO 24.50 (8.24) to 24.00 (3.97) p = 0.06). Similarly, the ABC-scale score for fear of falling showed no significant improvement between (BK 126.18 (26.83) and BO 126.60 (35.92) p = 0.86) or within the groups (BK 126.72 (19.23) to 126.18 (26.83) p = 0.47; BO 143.66 (19.54) to 126.60 (35.92) p = 0.22) (Table2).

Walking ability

Overall, no significant improvement of walking ability was found between groups (BK 464.36 m (78.07) and BO 458.40 m (67.87) p = 0.70 or within (BK 467.91 m (76.91) to 464.36 m (78.07) p = 0.64; BO 461.09 m (73.63) to 458.40 m (67.87) p = 0.54), as measured with the 6MWD. We also found no significant between group difference for the Timed Up & Go score. However, we did see a tendency towards a decline in TUG score (longer time –worsening of function) within the BK group (8.03 s (3.05) to 9.14 s (2.28) p = 0.06). In the BO group (7.74s (2.21) to 8.86 s (2.36) p = 0.007) there was a significant decline in TUG score.

Health status and quality of life

No significant differences related to quality of life was found between groups (p = 0.46) after the intervention, measured with the PDQ-39. However, the BO group showed a significant within group improvement (decrease) (26.26 (18.08) to 19.01 (10.62) p = 0.04) in PDQ-39.

Conclusions

Here, we assessed the feasibility, safety, and potential effectiveness of a 10-week boxing training intervention with kicking techniques compared with an equivalent dose of boxing alone in people with PD. Our results show that both interventions were feasible and safe and showed a potential improvement in balance in people with PD. Also, both boxing with kicking techniques does not lead to additional benefits over boxing training without kicking techniques. Nevertheless, incorporating kicking techniques may be a valuable addition to the exercise therapy repertoire, by creating greater versatility and thereby assisting in long-term adherence to exercise.

The trainings were completed by 85% of the participants and most reported to be satisfied with boxing, both with and without kicking techniques. There were also no fall incidents or other adverse events during both trainings. During the trial, only four dropouts occurred for reasons unrelated to the program. Compliance and sustained adherence to prolonged exercise programs remains a critical challenge in PD [47–49]. Previous studies have shown that boxing is an engaging activity that can be sustained over the long term with additional benefits of social interaction during group trainings [18, 22, 50]. Our results add to the body of evidence showing that boxing is a feasible and pleasant exercise activity for people with PD. Using kicking techniques may be a valuable addition to the growing and versatile menu of evidence-based interventions in the field of community exercise. Personal preferences will obviously vary across individual patients and are an important motivator for exercise. Expanding the number of options may therefore assist in long-term adherence to exercise.

Although we expected that kicking techniques would further challenge the balance system, both interventions appear to be equally effective for balance outcomes. The average scores showed an increase in Mini-BESTest score of around 2-3 points for all participants, which is not clinically relevant. However, 4 people in both groups did reach a clinical relevant increase in Mini-BESTest scores of at least 4 points [38]. These results may be a reflection of the complex interplay between the many different factors that are related to balance control in PD, and we presume that balance interventions for PD will most likely need to take a multiple systems approach [25, 39–41]. Additionally, typically boxing trainings incorporate multimodal exercises including different agility, strength, and aerobic activities [17–21] that would challenge balance. Even the boxing drills, shadow boxing and speedbag drills will ultimately require dynamic weight shifting and balance tasks. Another possible factor that could have benefited balance improvements in both groups was the dual task training component of both boxing interventions. Even though, we did not see improvements in the TUG cog in both groups, the ability to perform a motor task while simultaneously engaging in a cognitively demanding task (dual-task) is critical for balance control in PD. Several studies have shown that dual task activities result in reduced balance, gait performance, and falls [39, 42, 43]. Training dual task performance has been shown to improve balance and gait outcomes [44, 45]. Finally, the training dosage of once per week for 10 weeks alongside the small sample size also potentially play a role in the limited results. Ultimately, many factors can interplay and justify why both groups improved their balance and adding kicking did not bring greater improvements.

Additionally, despite the small improvements in balance in both groups, fear of falling did not improve significantly. Improvement of balance may not directly lead to a diminished fear of falling because fear of falling is not only based on balance performance [46].

Walking ability did not show improvement in both groups. These results are not consistent with previous boxing research that showed an overall improvement on stride length and walking ability [19]. This can potentially be explained by the shorter duration and lower frequency of the intervention (10 weeks –1 time per week in this study, versus twice-a-week for 12 weeks in earlier work [18]).

We need to mention several limitations of the present study. First, the small sample size may have hampered finding statistically significant differences between groups. It was our aim to perform an exploratory pilot study aimed at evaluating the experiences/feasibility safety, and potential effects of two variants of boxing. Definitive results can therefore not be drawn. Additionally, given the type of training in group formats, the size of the groups could not be too big to assure safety.

However, the lack of a trend towards significant between group balance difference indicates that a bigger sample size would probably not have led to different results. A second limitation is that we do not have UPDRS and HY scores for our population that would better characterize the groups. We used duration since symptom onset and diagnosis as a proxy for disease severity, indicating mild to moderate disease stages in both groups. In principle, randomization should warrant an equal distribution between groups, which is a strength of the current study. We did not find any significant differences between the groups at baseline in the demographics and outcomes that we measured (Table1), which makes us confident that both groups were comparable at baseline. Third, we did not measure the long-term effects, and consequently, no predictions can be made about any lasting effects on balance improvements for each intervention. Fourth, the frequency of training in future studies should be at least twice a week. Here, we chose a once per week frequency for feasibility reasons. Even though we believe though this dose may replicate real world access as many people with PD program different exercises each week, in the study this may limit the beneficial effects (which would be expected to be larger with a more frequent training program). Some studies that have looked at dosing effects suggest that more intense exercises come with greater benefits for people with PD [51, 52]. These limitations must be considered in future large randomized controlled trials on boxing in PD.

Ultimately, while we did not find additional benefits of kicking techniques, both boxing with and without kick techniques led to small balance improvements in people with PD. Importantly, participants were satisfied with the training, adherence was good, and no safety issues were reported. Boxing interventions have the potential to keep people with PD engaged and motivated in exercise activities over the long-term.

Supplementary Material:

The supplementary material is available in the electronic version of this article: https://dx.doi.org/10.3233/JPD-223447.

[1] Allen NE, Sherrington C, Canning CG, Fung VS (2010) Reduced muscle power is associated with slower walking velocity and falls in people with Parkinson’s disease. Parkinsonism Relat Disord16, 261–264. [PubMed] [Google Scholar]

[2] Kim SD, Allen NE, Canning CG, Fung VS (2013) Postural instability in patients with Parkinson’s disease. Epidemiology, pathophysiology and management. . CNS Drugs27, 97–112. [PubMed] [Google Scholar]

[3] van Nimwegen M, Speelman AD, Hofman-van Rossum EJ, Overeem S, Deeg DJ, Borm GF, van der Horst MH, Bloem BR, Munneke M (2011) Physical inactivity in Parkinson’s disease. . J Neurol258, 2214–2221. [PMC free article] [PubMed] [Google Scholar]

[4] Dontje ML, de Greef MH, Speelman AD, van Nimwegen M, Krijnen WP, Stolk RP, Kamsma YP, Bloem BR, Munneke M, van der Schans CP (2013) Quantifying daily physical activity and determinants in stary patients with Parkinson’s disease. . Parkinsonism Relat Disord19, 878–882eden. [PubMed] [Google Scholar]

[5] Benka Wallen M, Franzen E, Nero H, Hagstromer M (2015) Levels and patterns of physical activity and sedentary behavior in elderly people with mild to moderate Parkinson disease. Phys Ther95, 1135–1141. [PubMed] [Google Scholar]

[6] Kim DW, Hassett LM, Nguy V, Allen NE (2019) A comon of activity monitor data from devices worn parison the wrist and the waist in people with Parkinson’s disease. . Mov Disord Clin Pract6, 693–699. [PMC free article] [PubMed] [Google Scholar]

[7] Goodwin VA, Richards SH, Taylor RS, Taylor AH, Campbell JL (2008) The effectiveness of exercise interventions for people with Parkinson’s disease: a systematic review and meta-analysis. . Mov Disord23, 631–640. [PubMed] [Google Scholar]

[8] van der Kolk NM, King LA (2013) Effects of exercise on mobility in people with Parkinson’s disease. . Mov Disord28, 1587–1596. [PubMed] [Google Scholar]

[9] Keus SHJ, Munneke M, Graziano M, Paltamaa J, Pelosin E, Domingos J, Bruhlmann S, Ramaswamy B, Prins J, Struiksma C, Rochester L, Nieuwboer A, Bloem BR(2014) European Physiotherapy Guideline for Parkinson‚s disease. KNGF/ParkinsonNet, the Netherlands.

[10] Bloem BR, de Vries NM, Ebersbach G (2015) Nonpharmacological treatments for patients with Parkinson’s disease. Mov Disord30, 1504–1520. [PubMed] [Google Scholar]

[11] Radder DLM, Ligia Silva de Lima A, Domingos J, Keus SHJ, van Nimwegen M, Bloem BR, de Vries NM (2020) Physiotherapy in Parkinson’s disease: a meta-analysis of present treatment modalities. . Neurorehabil Neural Repair34, 871–880. [PMC free article] [PubMed] [Google Scholar]

[12] Duncan RP, Earhart GM (2012) Randomized controlled trial of community-based dancing to modify disease progression in Parkinson disease. . Neurorehabil Neural Repair26, 132–143. [PubMed] [Google Scholar]

[13] Choi HJ (2016) Effects of therapeutic Tai chi on functional fitness and activities of daily living in patients with Parkinson disease. . J Exerc Rehabil12, 499–503. [PMC free article] [PubMed] [Google Scholar]

[14] Monteiro EP, Franzoni LT, Cubillos DM, de Oliveira fa*gundes A, Carvalho AR, Oliveira HB, Pantoja PD, Schuch FB, Rieder CR, Martinez FG, Peyre-Tartaruga LA (2017) Effects of Nordic walking training on functional parameters in Parkinson’s disease: a randomized controlled clinical trial. . Scand J Med Sci Sports27, 351–358. [PubMed] [Google Scholar]

[15] Cheema BS, Davies TB, Stewart M, Papalia S, Atlantis E (2015) Thefeasibility and effectiveness of high-intensity boxing trainingversus moderate-intensity brisk walking in adults with abdominalobesity: a pilot study. . BMC Sports Sci Med Rehabil7, 3. [PMC free article] [PubMed] [Google Scholar]

[16] Park J, Gong J, Yim J (2017) Effects of a sitting boxing program on upper limb function, balance, gait, and quality of life in stroke patients. . NeuroRehabilitation40, 77–86. [PubMed] [Google Scholar]

[17] Alves Da Rocha P, McClelland J, Morris ME (2015) Complementary physical therapies for movement disorders in Parkinson’s disease: a systematic review. . Eur J Phys Rehabil Med51, 693–704. [PubMed] [Google Scholar]

[18] Combs SA, Diehl MD, Staples WH, Conn L, Davis K, Lewis N, SchanemanK (2011) Boxing training for patients with Parkinson disease: a caseseries. . Phys Ther91, 132–142. [PubMed] [Google Scholar]

[19] Combs SA, Diehl MD, Chrzastowski C, Didrick N, McCoin B, Mox N, Staples WH, Wayman J (2013) Community-based group exercise for persons with Parkinson disease: a randomized controlled trial. . Neurorehabilitation32, 117–124. [PubMed] [Google Scholar]

[20] Horbinski C, Zumpf KB, McCortney K, Eoannou D (2021) Longitudinal study of boxing therapy in Parkinson’s disease, including adverse impacts of the COVID-19 lockdown. . BMC Neurol21, 326. [PMC free article] [PubMed] [Google Scholar]

[21] Sangarapillai K, Norman BM, Almeida QJ (2021) Boxing vs sensory exercise for Parkinson’s disease: a double-blinded randomized controlled trial. . Neurorehabil Neural Repair35, 769–777. [PMC free article] [PubMed] [Google Scholar]

[22] Domingos J, Radder D, Riggare S, Godinho C, Dean J, Graziano M, de Vries NM, Ferreira J, Bloem BR (2019) Implementation of a community-based exercise program for Parkinson patients: using boxing as an example. . J Parkinsons Dis9, 615–623. [PMC free article] [PubMed] [Google Scholar]

[23] Morris ME, Ellis TD, Jazayeri D, Heng H, Thomson A, Balasundaram AP, Slade SC (2019) Boxing for Parkinson’s disease: has implementation accelerated beyond current evidence? . Front Neurol10, 1222. [PMC free article] [PubMed] [Google Scholar]

[24] Brunet J, Price J, Wurz A, McDonough M, Nantel J (2022) Boxing with Parkinson’s Disease: findings from a qualitative study using self-determination theory. . Disabil Rehabil44, 3880–3889. [PubMed] [Google Scholar]

[25] Allen NE, Sherrington C, Paul SS, Canning CG (2011) Balance and falls in Parkinson’s disease: a meta-analysis of the effect of exercise and motor training. . Mov Disord26, 1605–1615. [PubMed] [Google Scholar]

[26] Schoneburg B, Mancini M, Horak F, Nutt JG (2013) Framework for understanding balance dysfunction in Parkinson’s disease. . Mov Disord28, 1474–1482. [PMC free article] [PubMed] [Google Scholar]

[27] Bonora G, Mancini M, Carpinella I, Chiari L, Ferrarin M, Nutt JG, Horak FB (2017) Investigation of anticipatory postural adjustments during one-leg stance using inertial sensors: evidence from subjects with Parkinsonism. . Front Neurol8, 361. [PMC free article] [PubMed] [Google Scholar]

[28] Adkin AL, Frank JS, Jog MS (2003) Fear of falling and postural control in Parkinson’s disease. . Mov Disord18, 496–502. [PubMed] [Google Scholar]

[29] Jacobs JV, Horak FB, Tran VK, Nutt JG (2006) Multiple balance tests improve the assessment of postural stability in subjects with Parkinson’s disease. . J Neurol Neurosurg Psychiatry77, 322–326. [PMC free article] [PubMed] [Google Scholar]

[30] Folstein MF, Folstein SE, McHugh PR (1975) “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. . J Psychiatr Res12, 189–198. [PubMed] [Google Scholar]

[31] Bloem BR, Rompen L, Vries NM, Klink A, Munneke M, Jeurissen P (2017) ParkinsonNet: a low-cost health care innovation with a systems approach from the Netherlands. . Health Aff (Millwood)36, 1987–1996. [PubMed] [Google Scholar]

[32] Franchignoni F, Horak F, Godi M, Nardone A, Giordano A (2010) Usingpsychometric techniques to improve the Balance EvaluationSystems Test: the mini-BESTest. . J Rehabil Med42, 323–331. [PMC free article] [PubMed] [Google Scholar]

[33] Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C, Todd C (2005) Development and initial validation of the Falls Efficacy Scale-International (FES-I). . Age Ageing34, 614–619. [PubMed] [Google Scholar]

[34] Powell LE, Myers AM (1995) The Activities-specific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci50A, M28–34. [PubMed] [Google Scholar]

[35] Falvo MJ, Earhart GM (2009) Six-minute walk distance in persons with Parkinson disease: a hierarchical regression model. Arch Phys Med Rehabil90, 1004–1008. [PubMed] [Google Scholar]

[36] Podsiadlo D, Richardson S (1991) The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc39, 142–148. [PubMed] [Google Scholar]

[37] Sawilowsky S (2009) New effect size rules of thumb. . J Mod Appl Stat Methods8, 26. [Google Scholar]

[38] Godi M, Arcolin I, Giardini M, Corna S, Schieppati M (2020) Responsiveness and minimal clinically important difference of the Mini-BESTest in patients with Parkinson’s disease. Gait Posture80, 14–19. [PubMed] [Google Scholar]

[39] Bloem BR, Grimbergen YA, van Dijk JG, Munneke M (2006) The “posture second” strategy: a review of wrong priorities in Parkinson’s disease. J Neurol Sci248, 196–204. [PubMed] [Google Scholar]

[40] Bohnen NI, Cham R (2006) Postural control, gait, and dopamine functions in parkinsonian movement disorders. Clin Geriatr Med22, 797–812.vi [PubMed] [Google Scholar]

[41] King LA, Horak FB (2009) Delaying mobility disability in people with Parkinson disease using a sensorimotor agility exercise program. . Phys Ther89, 384–393. [PMC free article] [PubMed] [Google Scholar]

[42] Raffegeau TE, Krehbiel LM, Kang N, Thijs FJ, Altmann LJP, Cauraugh JH, Hass CJ (2019) A meta-analysis: Parkinson’s disease and dual-task walking. Parkinsonism Relat Disord62, 28–35. [PMC free article] [PubMed] [Google Scholar]

[43] Kelly VE, Eusterbrock AJ, Shumway-Cook A (2012) A review of dual-task walking deficits in people with Parkinson’s disease: motor and cognitive contributions, mechanisms, and clinical implications. Parkinsons Dis2012, 918719. [PMC free article] [PubMed] [Google Scholar]

[44] De Freitas Ms PT Tb, Leite PB, Dona PhD PT F, Pompeu Je PhD PT, Swarowsky PhD PT A, Torriani-Pasin PhD PT C (2020) The effects of dual task gait and balance training inParkinson’s disease: a systematic review. . Physiother TheoryPract36, 1088–1096. [PubMed] [Google Scholar]

[45] Strouwen C, Molenaar E, Munks L, Keus SHJ, Zijlmans JCM, Vandenberghe W, Bloem BR, Nieuwboer A (2017) Training dual tasks together or apart in Parkinson’s disease: Results from the DUALITY trial. Mov Disord32, 1201–1210. [PubMed] [Google Scholar]

[46] Dibble LE, Addison O, Papa E (2009) The effects of exercise on balance in persons with Parkinson’s disease: a systematic review across the disability spectrum. J Neurol Phys Ther33, 14–26. [PubMed] [Google Scholar]

[47] Rhodes RE, Martin AD, Taunton JE, Rhodes EC, Donnelly M, Elliot J (1999) Factors associated with exercise adherence among older adults. An individual perspective. Sports Med28, 397–411. [PubMed] [Google Scholar]

[48] Ellis T, Boudreau JK, DeAngelis TR, Brown LE, Cavanaugh JT, Earhart GM, Ford MP, Foreman KB, Dibble LE (2013) Barriers to exercise in people with Parkinson disease. . Phys Ther93, 628–636. [PMC free article] [PubMed] [Google Scholar]

[49] Morris ME, Taylor NF, Watts JJ, Evans A, Horne M, Kempster P, Danoudis M, McGinley J, Martin C, Menz HB (2017) A home program of strength training, movement strategy training and education did not prevent falls in people with Parkinson’s disease: a randomised trial. J Physiother63, 94–100. [PubMed] [Google Scholar]

[50] Claesson IM, Stahle A, Johansson S (2020) Being limited by Parkinson’s disease and struggling to keep up exercising; is the group the glue? Disabil Rehabil42, 1270–1274. [PubMed] [Google Scholar]

[51] Schenkman M, Moore CG, Kohrt WM, Hall DA, Delitto A, Comella CL, Josbeno DA, Christiansen CL, Berman BD, Kluger BM, Melanson EL, Jain S, Robichaud JA, Poon C, Corcos DM (2018) Effect of high-intensity treadmill exercise on motor symptoms in patients with de novo Parkinson disease: a phase 2 randomized clinical trial. JAMA Neurol75, 219–226. [PMC free article] [PubMed] [Google Scholar]

[52] Tsukita K, Sakamaki-Tsukita H, Takahashi R (2022) Long-term effect of regular physical activity and exercise habits in patients with early Parkinson disease. , e859-e. Neurology98, e859–e871. [PMC free article] [PubMed] [Google Scholar]