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

Differentiating Parkinson Disease Subtypes Using Clinical Balance Measures

BACKGROUND AND PURPOSE

People with Parkinson disease (PD) present phenotypes that are characterized as tremor-dominant (TD) or postural instability/gait difficulty (PIGD) subtypes. Differentiation of subtypes allows clinicians to predict disease course and adjust treatment. We examined whether brief mobility and balance measures can discriminate PIGD from TD phenotypes.

METHODS

We performed a cross-sectional study with individuals with PD (n = 104). Blinded raters assessed participants with the Unified Parkinson's Disease Rating Scale (UPDRS) or Movement Disorders Society revision (MDS-UPDRS), and balance assessments: 360° turn test, one-leg stance, a reactive postural control test, and tandem walk. Participants were classified as PIGD or TD based on the UPDRS or MDS-UPDRS assessment results. Differences in balance variables between subtypes were assessed with univariate analyses. Receiver operating characteristic (ROC) curve analyses were performed to investigate the ability of balance variables to differentiate PD subtypes.

RESULTS

No differences between subtypes were observed for tandem walk or reactive postural control. Participants with PIGD performed worse on number of steps and time to complete the 360° turn test and on one-leg stance time. ROC curves showed only the 360° turn test discriminated PIGD from TD with high specificity (0.84). Post hoc analyses revealed that the 360° turn test is the most discriminatory for classifying PD subtypes in early stages of the disease. ROC analyses based on combined models including both the 360° test and tandem walk test performance increased the specificity to 0.97.

DISCUSSION AND CONCLUSIONS

The 360° turn test requires minimal time to administer and may be useful in mild-moderate PD for distinguishing PIGD from TD subtypes.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A295).

The Association of Balance, Fear of Falling, and Daily Activities With Drug Phases and Severity of Disease in Patients With Parkinson

Introduction:

In the elderly, functional balance, fear of falling, and independence in daily living activities are interrelated; however, this relationship may change under the influence of drug phase and the severity of disease in individuals with idiopathic Parkinson disease. This study aimed to investigate the association of functional balance, fear of falling, and independence in the Activities of Daily Living (ADL) with the drug on- and drug off-phases.

Methods:

A total of 140 patients with Parkinson disease (age: Mean±SD; 60.51±12.32 y) were evaluated in terms of their functional balance, fear of falling, and independence in their daily activities by the Berg Balance Scale (BBS), Fall Efficacy Scale-International (FES-I), and Unified Parkinson Disease Rating Scale-ADL (UPDRS-ADL), respectively, in drug on- and drug off-phases. The Hoehn and Yahr scale recorded global disease rating. The Spearman coefficient, Kruskal-Wallis, and Mann-Whitney tests were used to find out whether the distribution of scale scores differs with regard to functional balance or disease severity.

Results:

A strong correlation was found between the functional balance, fear of falling, and independence in ADL with both drug phases. The results also showed the significant difference in the distribution of the FES-I and UPDRS-ADL scores with regard to functional balance (except independence in ADL in drug off-phase). Also, the distribution of the scores of BBS, FES-I, and UPDRS-ADL showed significant differences with regard to disease severity.

Conclusion:

The study showed a strong correlation between functional balance, fear of falling, and independence in ADL that can be affected by the drug phase and severity of the disease. However, more studies are needed to understand this relationship precisely.

The effect of the rehabilitation program on balance, gait, physical performance and trunk rotation in Parkinson's disease

BACKGROUND

Parkinson's disease (PD) is a progressive, neurodegenerative disease which leads to postural and gait disorders, limitation in mobility, activities of daily living and disability.

AIMS

The aim of the study is to assess the effects of the rehabilitation program on balance, gait, motor performance and trunk rotations in PD patients.

METHODS

Sixty-four patients with 1.5-3.0 stage PD in the Hoehn and Yahr scale were randomly allocated to rehabilitation and control groups. Sixty-one patients completed the study. Patients were assessed three times, at month intervals. Between the first and second assessments, the rehabilitation group participated in a rehabilitation training program focused on mobility, balance and gait exercises, consisting of 28 sessions. Balance was assessed with tandem stance and the Pastor test (shoulder tug). Gait was assessed with a 10 m walk at preferred speed and 360° turn. Motor performance was evaluated by means of the Physical Performance Test (PPT) and timed motor activities. The trunk rotations were measured in the lumbar and thoraco-lumbar spine with a tape measure.

RESULTS

The rehabilitation group significantly improved (p < 0.05) in balance and gait outcomes, PPT score, timed activities and trunk rotations both in comparison to the control group and baseline results. The positive effects of the exercise program maintained for at least 1 month.

CONCLUSION

The 4-week rehabilitation training program focused on mobility, balance and gait exercises improved balance, gait, physical performance and trunk rotations in patients with PD.

A single-blind cross over study investigating the efficacy of standard and controlled release levodopa in combination with entacapone in the treatment of end-of-dose effect in people with Parkinson's disease

OBJECTIVE

To determine the efficacy of standard levodopa combined with controlled release levodopa and entacapone in controlling end-of-dose symptoms in Parkinson's disease.

METHODS

A single-blind cross over design was used to compare the duration of action for three pharmacological combinations: standard levodopa (L/DDC); standard levodopa combined with entacapone (L/DDC/E); and standard levodopa combined with controlled release levodopa (CR) and entacapone (L/DDC/CR/E). Thirty two participants with wearing-off symptoms and inadequate symptom control with L/DDC/E had their optimum dose of L/DDC determined at base line. Entacapone was added to the optimal L/DDC dose and duration of action determined. Levodopa CR dosage was adjusted to match the optimal L/DDC dose for each participant. All participants were then trialed on L/DDC/CR/E and duration of response calculated. Timed Up and Go (TUG) times and magnitude of extra movements were recorded hourly throughout the day over several days to determine the optimum interval between doses for each combination. The UPDRS (Sections 2 and 3), PDQ39 and fatigue scale, the PDF-16, were recorded at base line and when dosage intervals had stabilized on L/DDC/CR/E.

RESULTS

Duration of response was greatest with L/DDC/CR/E compared to L/DDC/E (p < 0.001) and number of daily doses were less on L/DDC/CR/E compared to L/DDC/E (p < 0.001). UPDRS, PDQ39 and fatigue scores also improved on L/DDC/CR/E compared to L/DDC (p < 0.001). Dyskinesia increased on L/DDC/CR/E (p = 0.001) however magnitude was mild.

CONCLUSION

Combining standard levodopa and levodopa CR preparations with entacapone is an additional treatment strategy to manage motor fluctuations in advanced PD.

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.

Rehabilitation for Parkinson's disease: a systematic review of available evidence

OBJECTIVE

To systematically review the available evidence on the effectiveness of nonpharmacological rehabilitation interventions for people with Parkinson's disease, and identify future research needs.

DESIGN

Electronic searches of four databases (CINAHL, Cochrane Library, MEDLINE, PsychLIT) 1980-2002; examination of reference lists of relevant papers. Controlled trials and observational studies were included. Data extraction and quality assessment of papers by two independent reviewers. A narrative review.

SETTING

Rehabilitation interventions delivered either in subjects' own homes, or in clinical settings as outpatients.

SUBJECTS

Community-living adults with Parkinson's disease.

INTERVENTIONS

Physiotherapy, occupational therapy, speech and language therapy, psychological counselling and support, and education.

MAIN MEASURES

A range of outcomes: mobility, functional status, speech, swallowing, psychological well-being, as determined by the studies included in the review.

RESULTS

Forty-four different studies (reported in 51 papers) were included (25 physiotherapy, 4 occupational therapy, 10 speech and language therapy, 3 psychological counselling, 1 educational, 1 multidisciplinary). All studies, except one, reported improvements on at least one outcome measure.

CONCLUSIONS

Findings may reflect publication bias, but suggest interventions can affect patients' lives for the better in a variety of ways. It is difficult to interpret the clinical importance of statistically significant improvements reported in most studies. There is a need for methodologically more robust research with meaningful follow-up periods, designed in a manner that separates specific and nonspecific effects. Cost-effectiveness evidence is required to provide clear guidance on service extensions.

The effect of velocity on the strategies used during gait termination

The purpose of this study was to examine the changes that occur in gait termination (GT) as cadence increases. Five healthy volunteers walked at three cadences in time to a metronome under the following conditions: normal walking, planned stopping and unplanned stopping. Electromyography and force plate data were collected at 1000 Hz. Peak posterior ground reaction force (deceleration force) was greatest for the lead limb in unplanned stopping and, in general, deceleration force increased as cadence increased. Duration of muscle activity relative to the time to peak loading was unchanged by cadence and was always longest in the lead limb during planned stopping. As cadence increases, the signal to stop must occur earlier during stance phase if a person is to stop in the subsequent step.

An exploratory study of the consistency of balance control and the mobility of people with Parkinson's disease (PD) between medication doses

OBJECTIVE

To evaluate the consistency of balance control, mobility and perceived difficulties with functional tasks by people on carefully controlled anti-parkinsonian medication programmes, between doses on a single day and across days using standard clinical measures.

DESIGN

Small group prospective study.

SETTING

A hospital outpatient physiotherapy department.

SUBJECTS

Subjects, recruited from a specialist Parkinson's disease (PD) clinic, had to be independently mobile, diagnosed with PD at least five years previously and on a stable drug regime.

METHOD

Assessments (timed up and go, functional reach and a tap test) were completed 30 minutes prior to medication and hourly for 4 hours. They were repeated on a second day within a seven-day period. The self-assessment of functional disability was completed during the worst and best periods of the drug cycle. A general linear model (repeated measures analysis of variance) was used to analyse the data.

RESULTS

Nine subjects (8 males) with PD (grade III Hoehn and Yahr, average duration of symptoms eight years), average age 72 years, were recruited to the study. Four subjects had worse Hoehn and Yahr scores (grade 4) during the worst phase of the L-dopa cycle. Balance and mobility data did not change significantly over the medication cycle. Tests on day 2 were similar to day 1 with only the tap test showing a significant mean difference (p = 0.02) (2.6, 95% confidence interval (CI) 0.5-4.8). Individuals perceived significantly greater difficulty (mean difference = 7.9, 95% CI 3.6-12.2) (p < 0.001) in achieving functional tasks at the end of dose than peak dose of the medication cycle.

CONCLUSION

Measures of balance and mobility remained stable over the cycle. Fluctuations in the perception of difficulties with daily functional tasks were not accompanied by observed fluctuations in performance. The improvement in the mean of the tap test over the days could reflect a learning effect.

How toconduct a dose response trial of Parkinson's disease medication

With the rapid increase in the prevalence of Parkinson's disease in Australia, it is becoming increasingly common for neurologists to refer patients to a physiotherapist for a "dose response trial" (DRT) to determine the short duration response to medication. This article provides a step-by-step guide on how to perform a DRT in the in-patient ward setting.

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.

Gait consistency over a 7-day interval in people with Parkinson's disease

OBJECTIVE

To evaluate the consistency of temporal and spatial parameters of the walking pattern in subjects with idiopathic Parkinson's disease (PD) over a 7-day interval during the "on" phase of the levodopa medication cycle.

SETTING

Walking patterns were measured on a 12-meter walkway at the Kingston Gait Laboratory, Cheltenham, using a computerized stride analyzer.

SUBJECTS

Sixteen subjects (7 women, 9 men) with PD recruited from the Movement Disorders Clinic at Kingston Centre.

MAIN OUTCOME MEASURES

Speed of walking, stride length, cadence, and the percentage of the walking cycle spent in the double limb support phase of gait were measured, together with the level of disability as indexed by the modified Webster scale.

RESULTS AND CONCLUSIONS

Product-moment correlation coefficients and intraclass correlation coefficients (ICC 2,1) for repeat measures over a 7-day interval were high for speed (r = .90; ICC = .93), cadence (r = .90; ICC = .86), and stride length (r = 1.00; ICC = .97) and moderate for double limb support duration after removal of outliers (r = .75; ICC = .73); 95% confidence intervals for the change scores were within clinically acceptable limits for all variables. The mean modified Webster score was 11.4 on the first day and 10.1 7 days later. The gait pattern and level of disability in subjects with PD without severe motor fluctuations remained stable over a 1-week period when optimal medication prevailed.