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\def\RunningAuthor{Sarumathi S et al.}
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\articleType{Original Article}
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\title{Effect of endurance exercise on attention and depression in Parkinson's disease patients - A new approach}
\author{Sujatha~B,  
            Sarumathi~S\textsuperscript{*}, 
            Tinu~Priya~R~\\[5pt]{Saveetha College of Physiotherapy, Thandalaam, Chennai-602105, Tamil Nadu, India}}

\begin{abstract}
Aim of the study is to determine the effects of endurance exercise on depression and attention deficiency in people with Parkinson's disease patients. The methodology of the study is,15 participants with Parkinson's disease were selected both male and female from the neurological rehabilitation centre, Chennai. The purpose and procedure of the study were completely explained to the participants, and informed consent was obtained from all the participants. Depression scale and the digit-symbol task was evaluated before starting the exercise program and participants were randomized into two groups (Group A and Group B). This study compared the effect of endurance exercise to stretch-balance training. The exercise program was given for a duration of 12 weeks. After 12 weeks, Hospital anxiety \& depression scale and digit-symbol task were used to check for the progress. The result we determine from the statistical analysis, it has been revealed that depression symptoms decreased with endurance exercise and stretch-balance training but didn't show any significant improvement on attention with endurance exercise while with stretch-balance training it shows minimal improvement. Hence, we conclude that endurance exercise is a viable intervention in PD that can be used as a protective technique against depression symptoms and can also be used for improving attention in people with Parkinson's.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Parkinson's disease,\newline Endurance exercise,\newline Stretch-balance training,\newline Digit-symbol task,\newline Hospital anxiety,\newline Depression scale
\end{keywords}
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\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Sarumathi~S~\\ Phone:\ +91-7397446315~\\  Email:\ sarumathis01@gmail.com
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\section{Introduction}
Parkinson's disease (PD) is a progressive neuro- logic disease affecting over a million Americans and over ten million people worldwide \unskip~\citep{1580849:26388607,1580849:26388600}. Tremor, bradykinesia and rigidity are the main sources of discomfort reported by Parkinson's disease patients. In addition to the motor symptoms that affect activities of daily living (ADL) and the quality of communications and eating, PD has other symptoms. Cognitive changes occur, in most cases, in the more advanced stages of the dis- ease, preceded by psychiatric signs, such as hallucinations and psychosis. Other symptoms, such as depression, may be present from the early stages of PD \unskip~\citep{1580849:26388603}. More than 90\% of people with PD suffer from depressive symptoms, and it is the predator that affects the quality of life. There is a loss of neurons (nerve cells) in certain areas of the brain, including a region called the substantia nigra. The neurons in this region (which appear dark under a microscope) produce a neurotransmitter (a chemical messenger that allows neurons to communicate) calleddopamine.As the number of cells in the substantia nigra decreases, there is less dopamine available in the brain. Dopamine is important to maintain normal movement patterns \unskip~\citep{1580849:26388607}. Numerous studies have shown that regular exercise decreases the risk of PD \unskip~\citep{1580849:26388601}. The risk of developing the disease reduces with regular exercise for people between the age of 30 and 40 that practice it longer than four years \unskip~\citep{1580849:26388606}. The exercise program usually includes stretching, strengthening, aerobic activities and balancing exercises. There are many useful programs for building stamina, improving balance and mobility \unskip~\citep{1580849:26388597,1580849:26388602}. Some of the exercises are based on traditional training concepts but applied in an alternative way, which includes. Nordic walking, tango (dance), tai chi, qi gong and boxing, all of these have been proven to improve balance, mobility as well as the psychological aspect of life.

The current study tests whether endurance exercise may be an effective treatment for depression and attention deficiency in people with PD. Studies have documented that aerobic exercise can improve memory and executive dysfunction and reduce the severity of depression in older adults En- durance exercise training can be defined as an exercise that improves cardiorespiratory power and cardiorespiratory endurance. Cardiorespiratory power is measured in terms of maximal oxygen uptake or VO2 max. Endurance training is expected to improve cardiorespiratory endurance if the person is training at 40\% to 85\% of VO2 max. Endurance is associated with exercise intensity, which is frequently measured with absolute heart rate (HR), relative HR expressed as a \% of maximum (\%HR max), or metabolic equivalents (METs) \unskip~\citep{1580849:26388605}.

In this study, we will focus on 2 non-motor out- comes of PD depression and attention deficiency through endurance exercise and measuring it by hospital anxiety \& depression scale and digit-symbol test, respectively.
    
\section{Methodology}
This study is based on an experimental study design. 12 participants were selected in the geriatric population from neurological rehabilitation center near Anna Nagar. Both male and female were included, and participants with cardiovascular dis- eases and other orthopedic conditions were ex- cluded. The purpose and procedure of the study were explained completely to all the participants in the patient's language, and informed consent was obtained from all participants. Pre-treatment program (Depression scale and digit-symbol task) was evaluated before starting the exercise program for which 2 participants didn't co-operate, and their data was incomplete for analysis. Hence they were excluded from the study. The study proceeded with 10 participants; they were randomized into 2 groups (i.e. Group A and Group B). Group A participants were assigned endurance exercise, and Group B participants were asked to perform the stretch-balance exercise. Both exercise programs were given for 12 weeks' duration with 3 times a week. The program initially started with 20 minutes per session, and towards the end of the program, it reached a maximum of 45 minutes per session. The endurance exercise program includes exercise such as low-intensity walking, stationary bicycle, marching to music \& low-intensity dance and stretch-balance training program includes exercises such as rise to toe, modified squat, sitting to standing \& wall push-ups for arms. Using the hospital anxiety \& depression scale, depression symptoms of the participants in both groups were monitored periodically and digit-symbol task was assigned to all participants, participants during initial assessment faced some problem and then again the task was completely explained to the patient who was also monitored periodically to check for the improvement in attention of the participant.
    
\section{Results }

\begin{table}[!htbp]
\caption{\boldmath {Endurance exercise for depression} }
\label{tw-d71c27032bcb}
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\tbltoprule \rowcolor{kwdboxcolor}HADS-D & Endurance exercise mean (SD) & p value \\
\tblmidrule 
Pre-test   &
  16 (1) &
  \multicolumn{1}{p{\dimexpr(.34\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{p {\textless}0.0001}}\\
Post-test  &
  18.2(0.8) &
  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table}
The data from the above table shows the pre-test and post-test values of the hospital anxiety and depression scale (HADS-D) for the endurance exercise group. The pre-test mean value of is 16 (SD is 1) and the post-test mean value is 18.2 (SD is 0.8) then with P-value ({\textless}0.0001) extremely statistically significant


\begin{table}[!htbp]
\caption{\boldmath {Stretch-balance exercise for depression} }
\label{tw-2b6ed330b6e8}
\def\arraystretch{1.1}
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\tbltoprule \rowcolor{kwdboxcolor}HADS-D & Stretch-balance exercise mean (SD) & p-value\\
\tblmidrule 
Pre-test   &
  15.4 (1) &
  \multicolumn{1}{p{\dimexpr(.30270000000000003\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{p {\textless}0.0001}}\\
Post-test  &
  16.8 (0.8) &
  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table}
The data from the above table shows the pre-test and post-test values of the hospital anxiety and depression scale (HADS-D) for the stretch-balance exercise group. The pre-test mean value of is 15.4 (SD is 1) and the post-test mean value is 16.8 (SD is 0.8) then with P-value ({\textless}0.0001) extremely statistically significant.

From the statistical analysis, it has been revealed that there is a significant decrease in depression symptoms with Endurance exercise than with Stretch-balance exercise, but no significant improvement for attention can be seen Figure~\ref{f-6d2b5edcde22}. In the Hospital anxiety and depression scale (HADS-D) for En- durance Exercise Group, the pre-test mean is 16, with the standard deviation being 1 and the post- test mean being 18.2 with a standard deviation of 0.8, a p-value less than 0.0001. In the Digit-symbol task for Endurance Exercise Group, the pre-test mean is 36.2 with a standard deviation of 0.8 and the post-test mean is 39 with a standard deviation of 1 with a p-value less than 0.0001. The results are given in (Tables~\ref{tw-d71c27032bcb} and~\ref{tw-05e2ac95662e}).


\begin{table}[!htbp]
\caption{\boldmath {Endurance exercise for attention deficiency} }
\label{tw-05e2ac95662e}
\def\arraystretch{1.1}
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\tbltoprule \rowcolor{kwdboxcolor}Digit-symbol task & Endurance exercise mean (SD) & p value\\
\tblmidrule 
Pre test &
  36.2 (0.8) &
  \multicolumn{1}{p{\dimexpr(.19679999999999996\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{p {\textless}0.0001}}\\
Post test &
  39 (1) &
  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table}
The data from Table~\ref{tw-05e2ac95662e} shows the pre-test and post-test values of the digit-symbol task for the endurance exercise groupFigure~\ref{f-7a279808f564}. The pre-test mean value of is 36.2 (SD is 0.8) and the post-test mean value is 39 (SD is 1) then with P-value ({\textless}0.0001) extremely statistically significant.


\begin{table}[!htbp]
\caption{\boldmath {Stretch-balance exercise for attention deficiency} }
\label{tw-c6897cd3bb89}
\def\arraystretch{1.1}
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\tbltoprule 
Digit-symbol task  &
  Stretch-balance exercise mean (SD)  &
  P value \\
Pre-test &
  36.2 (0.8) &
  \multicolumn{1}{p{\dimexpr(.1989\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{p {\textless}0.0001}}\\
Post-test &
  37.6 (0.5) &
  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table}
The data from Table~\ref{tw-c6897cd3bb89} shows the pre-test and post-test values of the digit-symbol task for the stretch-balance exercise groupFigure~\ref{f-bb3bba35c0a8}. The pre-test mean value of is 36.2 (SD is 0.8) and the post-test mean value is 37.6 (SD is 0.5) then with P-value ({\textless}0.0001) extremely statistically significant.


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\caption{\boldmath {Depression score for endurance exercise}}
\label{f-6d2b5edcde22}
\end{figure}
\egroup

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\caption{\boldmath {Depression score for the stretch-balance exercise}}
\label{f-7a279808f564}
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\caption{\boldmath {Digit-symbol task for endurance exercise}}
\label{f-bb3bba35c0a8}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/7f646580-da24-4be7-9b5a-eb02755609ed-upicture4.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/7f646580-da24-4be7-9b5a-eb02755609ed-upicture4.png}{\includegraphics{images/7f646580-da24-4be7-9b5a-eb02755609ed-upicture4.png}}{}
\makeatother 
\caption{\boldmath {Digit-symbol task for stretch-balance exercise}}
\label{f-5b68884eef99}
\end{figure}
\egroup
In the Hospital anxiety and depression scale (HADS-D) for Stretch-balance exercise Group, the pre-test mean is 15.4, with the standard deviation being 1 and post-test mean being 16.8, with the standard deviation being 0.8, a p-value less than 0.0001. In Digit-symbol task for Stretch-balance exercise Group, the pre-test mean is 36.2, with the standard deviation of 0.8 and the post-test mean is 37.2, with the standard deviation being 0.5, a p- value less than 0.0001. The results are given in (Tables~\ref{tw-2b6ed330b6e8} and~\ref{tw-c6897cd3bb89} ).
    
\section{Discussion}
In another study, \unskip~\cite{1580849:26388599} reported the effects of a 12-week treadmill exercise intervention in one individual with PD, which yielded improvements in verbal fluency and the Stroop task. Therefore, despite several differences, the previous studies and the current one has observed improvements in executive function tasks in individuals with PD following aerobic exercise interventions. Consistent with, the current study adds to the accumulating evidence that aerobic exercise training can be protective against the increasing incidence of depressive symptoms in people with PDFigure~\ref{f-5b68884eef99}. Mood disorders are common in PD and can be traced to both progressive neurophysiological changes in the limbic system and to the everyday burden of the disease \unskip~\citep{1580849:26388598,1580849:26388604}. In the previous study done by Gretchen O. Reynolds et al., On the therapeutic potentials of exercise that compared the aerobic exercise to resisted exercise in improving cognition, depression and sleep in people with Parkinson's disease.

In my study, a significant decrease in the symptoms of depression was recorded with endurance exercise group than with the stretch-balance training group but no significant improvement in case of attention with the endurance group. The samples involved previously untrained until undertaking this study. However, the samples were made to engage in endurance and stretch-balance training for 20 minutes to 45 minutes, thrice a week for 12 weeks' duration.

One of the major limitations of my study was a randomized grouping of the participants. Therefore, group differed somewhat in age, and another limitation was a small sample size and the risk of falling and becoming fatigued while performing the exercise. Future researches would include a number of exercises other than endurance exercise and stretch-balance training.
    
\section{Conclusion}
The current study compared the effects of endurance exercise on depression and attention deficiency in PD patients on the effects of the stretch- balance training group. Group A (endurance exercise) participants had a significant decrease in depression episodes when compared to Group B (stretch-balance) participants. But endurance exercise didn't show any significant change in attention deficiency while on an exercise program.
    

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