This podcast discusses preliminary evidence about the effects of karate on quality of life and several measures of gait, balance, and mobility in patients with PD.
Heidi Moawad, MD interviews Jori Fleisher, MD, MSCE, who provides preliminary evidence about the effect of karate on patients with PD.
The idea for a pilot study by Principal Investigator Jori E. Fleisher, MD at Rush University Medical Center1came directly from one of her patients who had a Parkinson disease (PD) diagnosis. As someone who has done a number of different aerobic forms of exercise, Pilates, yoga, and resistance training, the patient wanted to know whether anyone had studied karate for PD, as this discipline seem to pull together so many of the other activities that have shown benefit.
There is little research on karate for PD in the literature. The small, 10-week long pilot study investigated the feasibility and patient-centered outcomes of twice-weekly karate classes and individuals with early- to mid-stage PD.1 We measured retention in the program, adherence (attendance at classes), quality of life using a PD-specific instrument (PDQ-39), and several measures of gait, balance, and mobility. We also conducted pre- and post-intervention focus groups to explore expectations and concerns about karate before the classes began, and then to better understand the subjective benefits the participants appreciated post-intervention. From these focus groups, our qualitative data reflect a theme of camaraderie amongst the participants that was nearly universal, quite surprising, and very beneficial.
Based on the promising results from a pilot study, we designed a more rigorous, randomized controlled trial to better understand this intervention.2 In phase 2, subjects all attended a group baseline study visit, during which time we assessed their baseline physical activity, depression, anxiety, and quality of life. We administered several cognitive tests, the Unified Parkinson's Disease Rating Scale, the Hoehn and Yahr stage, and then measured several gait and balance parameters using wearable sensors through a collaboration with Dr Joan Ann O'Keefe. At that baseline group visit, we also provided participants with an update on the state of the science regarding exercise for PD delivered by an outstanding colleague, Joellyn Fox, DPT. Then, armed with a number of options for improving their baseline exercise routines, participants were randomized into either immediate-start-six months of twice weekly karate-or delayed-start-six months of being on the waiting list. After six months, we will repeat the baseline evaluations for all participants, and then the delayed-start arm will enter active karate classes twice weekly for the following six months. The immediate-start participants will have the option to continue their participation in classes, however, they will have to pay for classes on their own after this for six months. This gives us a chance to examine the real-world efficacy of this intervention as well.
Safety concerns. Our fantastic karate instructors understood that some of our participants might have balance impairments, and so we made sure that the teacher-to-student ratio was sufficient to provide individualized attention. The instructors were also aware of our participants' fear of falling, and they addressed it head-on. Rather than avoid the topic of falls, the instructors taught our participants HOW to fall safely, and then how to get up off the ground. This was something that came up over and over again in the post-intervention focus groups that participants found so helpful.
Feasibility. A total of 15 out of 19 participants completed the study and our adherence rate was quite high at 87%. Of those 15 who completed the study, 100% indicated that the intended to continue and that they would recommend it to a friend. Additionally, we found a clinically and statistically significant improvement in quality of life, as measured by the PDQ-39. On the self-reported global impression of change, more than three quarters of participants rated themselves as moderately or significantly better. We also found a trend towards reduction in falls, and in post intervention focus groups, participants highlighted the camaraderie aspect of this intervention. What is very exciting is that when we followed up with those 15 completers six months later, more than half indicated that they were continuing to participate in karate in some form, and five out of 15 had gone on to compete in citywide competitions and had earned their yellow belts.
There is a great evidence to support the benefit of so many forms of exercise and PD. It really seems that the best exercise, however, is the one that a person will stick with. We know that moderate intensity aerobic exercise, particularly for at least 150 minutes/week, shows great benefit in the short-term and may slow down the progression of PD in the long-term. This includes things like treadmill exercise, biking, swimming, jogging, etc. There is also good evidence that progressive resistance training, weight training, various forms of dance, and non-contact boxing also offer benefits to people with PD. Finally, lower-impact forms such as tai chi, Pilates, and yoga also have been demonstrated to be effective and beneficial, particularly for balance and core strength.
Karate is beneficial for PD because it incorporates some of the aerobic benefits of other forms of exercise, along with large-amplitude movements that are the cornerstone of effective physical therapy for PD. It builds in balance and core strength, and there is a symmetry to the discipline, so that the patterns of movement done on one side of the body are then done with the other. For our people with PD, who frequently have a “worse” side that they might favor, this forces them to use that side again, and feel stronger doing so. There is mindfulness built into the practice, which may be helping with the non-motor symptoms of anxiety and depression, though that requires further investigation. Finally, the sense of camaraderie and achievement that participants had is something that may set karate apart. Rather than sitting in a support group, our participants felt that they could shed their PD stigma at the door, that they were in a safe space, and they shared their pride in watching their classmates improve. I think this was a big motivator for those who stuck with it during our six-month follow-up, and who continue to do so today. We are eager to see which of these benefits persist in our Phase 2 study, when we will have one year of follow-up.
1. Fleisher JE. Rush University Medical Center. Karate Intervention to Change Kinematic Outcomes in Parkinson's Disease. ClinicalTrials.gov. https://ichgcp.net/clinical-trials-registry/NCT03555695. Accessed June 18, 2019.
2. Fleisher JE. Rush University Medical Center. Karate Intervention to Change Kinematic Outcomes in Parkinson's Disease. KICK OUT 2: A Phase Two, Randomized Trial of a Karate Intervention. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT03882879. Accessed June 18, 2019.