Parkinson's disease: an investigation of exercise capacity, respiratory function, and gait

Effectiveness of tai chi for Parkinson's disease: a critical review

The objective of this review is to assess the effectiveness of tai chi as a treatment option for Parkinson's disease (PD). We have searched the literature using 21 databases from their inceptions to January 2008, without language restrictions. We included all types of clinical studies regardless of their design. Their methodological quality was assessed using the modified Jadad score. Of the seven studies included, one randomised clinical trial (RCT) found tai chi to be superior to conventional exercise in terms of the Unified PD Rating Scale (UPDRS) and prevention of falls. Another RCT found no effects of tai chi on locomotor ability compared with qigong. The third RCT failed to show effects of tai chi on the UPDRS and the PD Questionnaires compared with wait list control. The remaining studies were either non-randomised (n=1) or uncontrolled clinical trials (n=3). Collectively these data show that RCTs of the tai chi for PD are feasible but scarce. Most investigations suffer from methodological flaws such as inadequate study design, poor reporting of results, small sample size, and publication without appropriate peer review process. In conclusion, the evidence is insufficient to suggest tai chi is an effective intervention for PD. Further research is required to investigate whether there are specific benefits of tai chi for people with PD, such as its potential effect on balance and on the frequency of falls.

Endurance exercise training to improve economy of movement of people with Parkinson disease: three case reports

BACKGROUND AND PURPOSE

Even early in Parkinson disease (PD), individuals have reduced economy of movement. In this case report, the effects of endurance exercise training are examined on walking economy and other measures for 3 individuals in early and middle stages of PD.

PATIENTS

The patients were 1 woman and 2 men with PD, aged 52 to 72 years, classified at Hoehn and Yahr stages 2 to 2.5.

INTERVENTION

Each patient completed 4 months of supervised endurance exercise training and 12 months of home exercise, with monthly clinic follow-up sessions. Strategies were included to enhance adherence to exercise.

OUTCOMES

The main outcome measure was economy of movement (rate of oxygen consumption during gait) measured at 4 treadmill speeds. Secondary outcome measures included the Unified Parkinson's Disease Rating Scale (UPDRS), Continuous-Scale Physical Functional Performance Test (CS-PFP), Functional Reach Test (FRT), and Functional Axial Rotation Test (FAR). Economy of movement improved for all 3 patients after 4 months of supervised exercise and remained above baseline at 16 months. Two patients also had scores that were above baseline for UPDRS total score, CS-PFP, FRT, and FAR, even at 16 months.

DISCUSSION AND CONCLUSION

: Evidence from these 3 individuals suggests that gains may occur with a treadmill training program that is coupled with specific strategies to enhance adherence to exercise.

Tai Chi–Based Exercise for Older Adults with Parkinson’s Disease: A Pilot-Program Evaluation

The primary objective of this study was to provide preliminary evaluation of the feasibility, safety, and efficacy of a newly developed Tai Chi-based exercise program for older adults with Parkinson’s disease (PD). Using a one-group pretest-posttest design, 17 community-dwelling adults (mean age 71.51 years) with mild to moderate idiopathic PD (Stage I, II, or III on the Hoehn and Yahr scale) and stable medication use completed a 5-day, 90-min/day Tai Chi exercise-evaluation program. Outcome measures included face-to-face exit interviews on appropriateness and safety and physical performance (i.e., 50-ft speed walk, up-and-go, functional reach). At the end of this brief intervention, exercise adherence was 100% and the program was shown to be safe. Exit interviews indicated that the program was well received by all participants with respect to program appropriateness, participant satisfaction and enjoyment, and intentions to continue. Furthermore, a significant pretest-to-posttest change was observed at the end of the 5-day program in all three physical-performance measures (p< .05). The results of this pilot evaluation suggest that Tai Chi is an appropriate physical activity for older adults with PD and might also be useful as a therapeutic exercise modality for improving and maintaining physical function. These preliminary findings warrant further investigation.

Locomotor training in people with Parkinson disease

The purpose of this article is to consider the role of the physical therapist in locomotor training for people with Parkinson disease. The ways in which disease progression, medication status, environmental conditions, individual factors, and the goals of locomotor tasks contribute to clinical decision making are explored. Using the International Classification of Functioning, Disability and Health, gait training will be considered in relation to impairments of body structure and function, activity limitations, and participation restrictions in people who are newly diagnosed through to those with end-stage disease. Based on the principles of neural adaptation and clinical research findings, practical suggestions are made on how to provide the most efficient and effective physical therapy services at different stages of Parkinson disease.

Timed Gait test: normative data for the assessment of the AIDS dementia complex

The Timed Gait test is a standardized procedure assessing motor dysfunction of lower extremities and gait abnormalities associated with AIDS dementia complex. Heretofore, interpretations of Timed Gait results have been hampered by the lack of normative data. We provide results on this test derived from 1,549 subjects (HIV-seronegatives (HIV-) and seropositives (HIV+) classified according to ADC stage). Timed Gait was found to be a useful screening and assessment tool for evaluating ADC and correlated with clinical ADC staging as well as more extensive structured neurological and neuropsychological evaluations. Analysis of covariance results (with age and education as covariates) revealed symptomatic HIV+(SX) and AIDS groups having significantly slower Timed Gait scores than those in the HIV- and asymptomatic HIV+(ASX) groups. The SX group obtained significantly slower timed gait scores than those in the AIDS group. There was a significant increase in Timed Gait scores with each increase in dementia staging with the HIV- subjects having the fastest mean Timed Gait scores and the HIV+ dementia stage 2+ having the slowest. These normative data should prove useful in both recognition of ADC and treatment response. Given its minimal training requirements, the Timed Gait would have utility in resource limited settings.

Walking Capacity in Mild to Moderate Parkinson’s Disease

OBJECTIVES

To examine walking capacity in people with mild to moderate Parkinson's disease (PD), specifically, to determine whether spatiotemporal abnormalities observed when people with PD walk over short distances are exacerbated over longer distances and whether these and other motor impairments affect walking capacity.

DESIGN

Descriptive study comparing participants with PD and healthy participants.

SETTING

University laboratory.

PARTICIPANTS

Sixteen participants (mean age, 65y) with mild to moderate PD (stages 1-3 of the Hoehn and Yahr rating scale) were tested "on" medication. Twenty-two healthy participants (mean age, 66y) formed a control group.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Walking capacity was quantified as the distance walked in the 6-minute walk test (6MWT), hypokinesia during walking was quantified as "fast-as-possible" velocity over 8m, hypokinesia during turning was quantified as the time taken to complete a 360 degrees turn in standing, automaticity was quantified as velocity during dual-task walking expressed as a percentage of velocity during single-task walking over 8m, and muscle strength was quantified as peak isometric knee extensor torque.

RESULTS

The PD group covered less distance (P=.01) in the 6MWT than the control group. Although both groups recorded similar fast-as-possible walking velocities, the PD group walked at only 76% of their fast-as-possible velocity during the 6MWT compared with 84% for the control group (P=.002). In the PD group, 94% of the variance in walking capacity was accounted for by hypokinesia during walking and turning as well as strength (P<.001).

CONCLUSIONS

Even when people with PD are capable of walking at velocities comparable to healthy controls, they do not sustain this velocity over longer distances. Training that targets high velocities warrants investigation as a remediation technique.

Impact of an exercise program on physical, emotional, and social aspects of quality of life of individuals with Parkinson's disease

We evaluated changes in different domains of quality of life (QL) for persons with Parkinson's disease after a program of physical activity. Twenty subjects with a diagnosis of Parkinson's disease classified as Stages 1 to 3 on the Hoehn and Yahr scale and with a mean age of 61.5 +/- 9.8 years participated in 36 group sessions of a combined group program of aerobic conditioning and muscular strengthening. QL was investigated by the Nottingham Health Profile, a generic questionnaire composed of six domains. Student's paired t tests indicated significant gains associated with the program (P < 0.05) on the total score and those related to emotional reactions (ER), social interactions (SI), and physical ability (PA). SI was the domain that showed the greatest program gains (41.4%). The program of physical activity performed with persons with Parkinson's disease at light to moderate stages resulted in improvements in their perception of QL, mainly in the domains of ER, SI, and PA.

Effects of Respiratory Muscle Weakness on Daily Living Function, Quality of Life, Activity Levels, and Exercise Capacity in Mild to Moderate Parkinsonʼs Disease

OBJECTIVE

To investigate respiratory muscle strength in mild to moderate Parkinson's disease in comparison with prediction equations and age-matched controls. To identify correlations between respiratory muscle strength and daily living function, activity levels, quality of life, and exercise capacity.

DESIGN

A total of 66 participants with Parkinson's disease and 32 age-matched, healthy controls participated. Respiratory mouth pressures (representing respiratory muscle strength) were compared with predicted values. A comparison was also made between participants with Parkinson's disease and age-matched controls. Respiratory mouth pressures were correlated with results of the Barthel index (daily living function), a modified Baecke activity questionnaire (activity levels), the Parkinson's disease questionnaire (quality of life in Parkinson's disease), peak heart rate, peak oxygen consumption, blood lactate thresholds, and the number of stages completed during an incremental cycle ergometer test (representing exercise capacity).

RESULTS

Respiratory mouth pressures were significantly lower (P < 0.05) in the Parkinson's disease group, but this did not influence the measures of daily living function, activity levels, and quality of life. Respiratory mouth pressures correlated with lactate thresholds (r = 0.308, P < 0.01) and the number of completed stages of the cycle ergometer test (r = 0.490, P < 0.01).

CONCLUSIONS

In mild to moderate Parkinson's disease, there is a significant weakness of the respiratory muscles. This can affect the individual during exercise but has no apparent effect on activities that do not require a large effort of the respiratory muscles.

Exercise capacity, disability and leisure physical activity of subjects with multiple sclerosis

The purpose of the present study was to examine exercise capacity and its relationship to neurological disability as measured using the Expanded Disability Status Scale (EDSS) and to leisure physical activity in subjects with multiple sclerosis (MS). Thirty-four men and 61 women (mean age 44 +/- 6.7 years, mean disease duration 5.7 +/- 6.4 years) with mild to moderate disability (EDSS range 1.0-5.5) participated. They underwent an incremental exercise test on a leg cycling ergometer. Leisure physical activity was measured using a questionnaire. Peak oxygen uptake (VO2peak) in men was 27.0 +/- 5.2 mL/kg/min, and in women 21.7 +/- 5.5 mL/kg/min. The disability correlated inversely with the VO2peak both in men (r = - 0.50, P = 0.004) and in women (r = - 0.25, P = 0.05). No correlation between disease duration and VO2peak was found. In a multivariate regression analysis, neurological disability was confirmed as a predictor of VO2peak. No evidence of a relationship between leisure physical activity and VO2peak was found. A main finding was that disability and exercise capacity are inter-related, even in subjects who are not severely handicapped (84% had an EDSS of < 4.0). The level of disability should be taken into account in the planning of aerobic exercise programs for fully ambulatory MS subjects.

Muscle activation and force production in Parkinson's patients during sit to stand transfers

OBJECTIVE

The purpose of this study was to compare the kinematics, muscle activation, and force production between Parkinson's patients and healthy, age-matched participants during sit-to-stand transfers.

DESIGN

This cross-sectional study employed a 2x2x3 multivariate analysis of variance to test for significant differences between and within groups.

BACKGROUND

The underlying mechanisms that predispose an individual to lose strength during the clinical progression of Parkinson's disease have proved to be elusive, especially during performance of functional tasks such as the sit to stand transfer.

METHODS

Twenty-four men (mean age: 71.5 years) categorized as Parkinson's patients (n = 13) and healthy adults (n = 11) participated in this study. Two force platforms measured antero-posterior and vertical force components as well as peak torque. Muscle activation was measured by a six channel, bilateral electromyography system. A lower-body kinematic assessment was conducted utilizing a high-speed motion analysis system.

RESULTS

No statistically significant differences were found between groups for the outcome variables measured. However, Parkinson's patients did exhibit significant within-group bilateral differences for the variables of knee angle at seat-off, peak vertical force and peak torque.

CONCLUSION

Data from this study reveal that persons with mild to moderate Parkinson's disease exhibit moderately altered bilateral mechanics when performing a sit to stand transfer compared to their healthy peers.

RELEVANCE

The inability to produce constant equilateral force when performing functional tasks could be an indicator for the increased propensity of falls or other instabilities in this population.

Prediction of outcome of physiotherapy in advanced Parkinson's disease

OBJECTIVE

Prediction of the effect of a home physiotherapy intervention on the basis of four clinical characteristics of patients with advanced Parkinson's disease.

DESIGN

A repeated measures design comparing six weeks without treatment with six weeks of physiotherapy and a follow-up of 12 weeks.

SUBJECTS

Persons with Parkinson's disease without dementia and suffering from considerable functional disability.

INTERVENTION

Community physiotherapists treated patients in the home situation three times a week teaching cueing and conscious movement control for walking and carrying out transfers in and out of beds and chairs.

MAIN OUTCOME MEASURES

Mental status, disease severity, age and mood were included as predictor variables. A new functional scale developed as part of a previous study was used as the dependent variable administered in both the hospital and the home to determine whether the outcome generalized from the learning to a different environment.

RESULTS

Only disease severity was a negative predictor of treatment outcome at home. In the hospital setting none of the factors predicted the immediate effect of treatment but cognitive ability and age were determinants of whether the treatment effects were maintained in the long term.

CONCLUSIONS

Using cueing and cognitive strategies benefited younger and older patients with Parkinson's disease alike. However, the findings indicate targeting of treatment at patients with milder disease severity and providing follow-up treatment for older and cognitively less able patients.

The effect of COMT inhibition with entacapone on cardiorespiratory responses to exercise in patients with Parkinson's disease

The inhibition of catechol-O-methyltransferase (COMT) may impair catecholamine clearance resulting in unwanted cardiac and hemodynamic events. We therefore studied the effects of entacapone, an inhibitor of peripheral COMT, on cardiorespiratory and plasma noradrenaline (NA) responses to exercise and on respiratory muscle strength in l-dopa treated patients with Parkinson's disease (PD). A randomized, double-blind, cross-over study with two 1week treatment periods was performed in 15 PD patients. The test battery included analysis of hemodynamics, gas exchange parameters and plasma NA during a maximal exercise test, assessment of maximal static airway pressures and pre- and post-exercise motor scores of the Unified Parkinson's Disease Rating Scale (UPDRS). The first test was done after withholding l-dopa overnight ('run-in' test, off-phase). The second and third tests were done in on-phase after 1week treatment with either entacapone 200mg or placebo given with each dose of l-dopa. No differences in maximal work load, plasma NA, or in cardiorespiratory responses to either maximal or work rate standardized submaximal exercise were observed between entacapone and placebo, except for O(2) pulse, which was slightly lower (p < 0.05) after entacapone at submaximal exercise level. Maximal airway pressures were similar between the study treatments and run-in. Exercise had no effect on motor UPDRS after either study treatment or during the run-in test. No serious adverse events were observed. The results of this study suggest that entacapone does not change the work capacity, work efficiency or respiratory muscle strength in l-dopa treated PD patients with mild to moderate disease severity, and that its use with l-dopa seems to be safe in conditions of maximal physical effort. However, data from the long-term use of COMT inhibitors are needed to confirm these findings.

[Analysis of breathing function in Parkinson's disease]

We studied 40 parkinsonian patients (P), mean age 50-80 years, with Hoehn and Yahr stages I-III and 40 no parkinsonian patients (NP), with similar characteristics. The results of the thoracic amplitude was 1,8+/-0,8cm of P that showed a reduction to 4,3+/-1,0 cm of NP (p=0,00001), the vital capacity and forced vital capacity, 66,8+/-20,3% and 69,6+/-22,2% of P was decreased that 82,3+/-15,7% and 82,7+/-16,6% of NP (p=0,00001 and p=0,0023). There was not difference among the maximal inspiratory and expiratory mouth pressures, 33,5+/-12,7 cmH2O and 36,3+/-17,8 cmH2O of P and 37,0+/-12,2 cmH2O and 43,1+/-16,6 cmH2O of NP (p=0,1753 and p=0,0398), the forced expiratory volume in 1 second, 71,3+/-25,6% of P and 80,6+/-23,6% of NP (p=0,0899), and the forced expiratory volume in 1 second/ forced vital capacity, 104,5+/-19,9% of P and 97,4+/-22,8% of NP (p=0,1234). The parkinsonian patients present restrictive pulmonary dysfunction, low chest wall compliance and the respiratory muscle strength do not decreased.

The effect of a home physiotherapy program for persons with Parkinson's disease

The purpose of this study was to evaluate the effect of a home physiotherapy program for persons with Parkinson's disease. Thirty-three patients took part in the study using a within-subject controlled design. Functional activities including walking and carrying out transfers were measured at home and in the hospital before and after a 6-week baseline period, after 6 weeks home physiotherapy and after 3 months follow-up. Spatiotemporal and plantar force variables of gait were determined with video and pododynography. Treatment provided by community physiotherapists consisted of teaching cueing and conscious movement control 3 times a week. The study revealed that patients had significantly higher scores on a functional activity scale after treatment in the home setting and to a lesser degree in hospital, a result, which was partly sustained at follow-up. However, duration of the transfer movements, spatiotemporal and plantar force variables were not significantly improved except for stride length. The results support application and development of the treatment concept and highlight that physiotherapy aimed at improving function in Parkinson's disease is best provided in the home situation.

The role of the physiotherapist in quantifying movement fluctuations in Parkinson's disease

Although a variety of medications are used in the treatment of Parkinson's disease, all have short term effects. As a result, motor performance varies over time. A key role of the physiotherapist is to measure fluctuations in the severity of movement disorders in relation to the dose and timing of anti-Parkinsonian medication with a view to: (i) optimising motor performance; (ii) targeting therapeutic interventions for times of greatest need; and (iii) communicating findings to the inter-professional team. For an informed approach to the measurement of medication-induced motor fluctuations, clinicians require an understanding of the pathophysiology of Parkinson's disease, the mode of action of medications and the validity of existing methods used to quantify changes in performance resulting from pharmaceuticals and rehabilitation.

The biomechanics and motor control of gait in Parkinson disease

Parkinson disease is a progressive neurological condition characterised by hypokinesia (reduced movement), akinesia (absent movement), tremor, rigidity and postural instability. These movement disorders are associated with a slow short-stepped, shuffling gait pattern. Analysis of the biomechanics of gait in response to medication, visual cues, attentional strategies and neurosurgery provides insight into the nature of the motor control deficit in Parkinson disease and the efficacy of current therapeutic interventions. In this article we supplement a critical evaluation of the Parkinson disease gait literature with two case examples. The first case describes the kinematic gait response of an individual with Parkinson disease to visual cues in the "off" phase of the levodopa medication cycle. The second case investigates the biomechanics and motor control of turning during walking in a patient with Parkinson disease compared with elderly and young control subjects. The results are interpreted in light of the need for gait analysis to investigate complex functional walking tasks rather than confining assessment to straight line walking, which has been the trend to date.

The effects of mountain exercise in Parkinsonian persons - a preliminary study

Persons suffering from Parkinson's disease (PD) show variable motor manifestations such as gait dysfunction and hypokinesia as well as psychosocial manifestations like emotional and social impairment. In order to assess short- and midterm impact on PD persons from a comprehensive training concept, we launched a study with daily walks in the Swedish mountains during 1 summer week. The 3-6 km daily walking tours in hilly terrain were combined with lectures about the disease and self-training, social intercourse and a general encouraging atmosphere brought about by three accompanying leaders. The participants stayed in a mountain pension during the week. Nineteen mild to moderate PD persons volunteered and were assessed before (0 weeks), immediately after (1 week), and 4 months later (18 weeks) by a self-reporting questionnaire containing four subscales. These covered the domains PD symptoms, systemic symptoms, emotional functioning, and social functioning. There was a general improvement in PD scores at 1 week compared to baseline. This was not sustained at the 18-week follow-up. We postulate the results were due to a combination of information, professional guidance, exercise in hilly terrain with environmental visual cues, social interaction, and comparison with the others. Further research should aim at pinpointing the most essential components to achieve short- as well as midterm improvements. We believe there is a need to focus on patients' self-reported health to a greater extent than today in order to complement traditional rehabilitation and training outcome measures.

Movement Disorders in People With Parkinson Disease: A Model for Physical Therapy

People who are diagnosed with idiopathic Parkinson disease (PD) experience movement disorders that, if not managed, can lead to considerable disability. The premise of this perspective is that physical therapy for people with PD relies on clinicians having: (1) up-to-date knowledge of the pathogenesis of movement disorders, (2) the ability to recognize common movement disorders in people with PD, (3) the ability to implement a basic management plan according to a person's stage of disability, and (4) problem-solving skills that enable treatment plans to be tailored to individual needs. This article will present a model of physical therapy management for people with idiopathic PD based on contemporary knowledge of the pathogenesis of movement disorders in basal ganglia disease as well as a review of the evidence for physical therapy interventions. The model advocates a task-specific approach to training, with emphasis on treating people with PD-related movement disorders such as hypokinesia and postural instability within the context of functional tasks of everyday living such as walking, turning over in bed, and manipulating objects. The effects of medication, cognitive impairment, the environment, and coexisting medical conditions are also taken into consideration. An argument is put forward that clinicians need to identify core elements of physical therapy training that apply to all people with PD as well as elements specific to the needs of each individual. A case history is used to illustrate how physical therapy treatment is regularly reviewed and adjusted according to the changing constellation of movement disorders that present as the disease progresses.