Impaired economy of gait and decreased six-minute walk distance in Parkinson's disease

Pushing the limit to reach meaningful change: the impact of intensity-driven exercise on clinical outcomes for individuals with Parkinson's disease. A single-subject design

PURPOSE

Parkinson's disease creates an inability to perform previous learned autonomic tasks, such as walking, which worsens with disease progression. Recommendations to incorporate exercise at moderate to high intensities for this population has been established but there is limited knowledge about its impact on clinical based outcomes. The purpose of this research is to investigate the effectiveness of a 6-week intensity-driven walking program on clinical-based outcomes in individuals with PD.

MATERIALS/METHODS

Five individuals with PD were recruited for this single-subject withdrawal design (A-B-A-B) study. 6-minute walk performance and other core neurological measures of gait were collected. Intervention phases incorporated a 30-minute individualized intensity-driven treadmill walking program practiced at 65% or more of ones maximum heart rate. Increased treadmill speed, incline, and resistance were manipulated to reach the target heart rate zone.

RESULTS

6-minute walk test within condition visual analysis demonstrated a therapeutic change during intervention phases and a countertherapeutic change during withdraw periods for all 5 individuals. An abrupt therapeutic effect was demonstrated for all individuals between conditions with the percent of nonoverlapping data ranging from 70-90%. Band method analysis revealed a range of 9-19 sessions two standard deviations above baseline mean performances for all individuals.

CONCLUSION

To achieve sufficient walking performance, gait practiced at higher intensity levels may provide the optimal solution as an adjunct to standard care for individuals with PD who want to improve their walking.

Teleneurorehabilitation and Motor and Nonmotor Symptoms and Quality of Life in Parkinson Disease: The TELEPARK Randomized Clinical Trial

Importance

To our knowledge, no randomized clinical trials have compared the efficacy and safety of teleneurorehabilitation (TNR) with in-person rehabilitation in Parkinson disease (PD) during the COVID-19 pandemic lockdown.

Objective

To assess the efficacy and safety of TNR among patients with PD during the COVID-19 lockdown.

Design, Setting, and Participants

The TELEPARK single-center, assessor-blinded, randomized clinical trial was conducted over 11 months from September 2020 to July 2021, with follow-up after 12 weeks. Final data could be analyzed on July 1, 2024. Patients aged 18 years or older diagnosed with idiopathic PD with Hoehn and Yahr stage 1 to 2.5, Mini-Mental State Examination score of 24 or higher, and who possessed a smartphone allowing videocalling were eligible for inclusion and randomized to in-person or TNR therapy.

Intervention

The in-person group received physiotherapy, aerobic, and breathing exercises for 30 minutes in person once a week for 4 weeks and then once every 2 weeks for 8 weeks. The TNR group received in-person sessions on day 1, followed by supervised sessions via videocalling once a week for the first 4 weeks, then once every 2 weeks for 8 weeks.

Main Outcome and Measures

The primary outcome was mean change in the Movement Disorder Society-Unified Parkinson's Disease Rating Scale III (MDS-UPDRS III) postintervention score from baseline. Mean changes in postintervention MDS-UPDRS II and III, Non-Motor Symptom Scale (NMSS), Parkinson's Disease Questionnaire-8 Summary Index (PDQ8-SI), 6-minute walk test (6MWT), and functional reach test (FRT) scores from baseline between groups was assessed using unpaired t tests.

Results

A total of 63 participants (28 in-person and 35 TNR) were analyzed. Mean (SD) ages in the in-person and TNR groups were 60.50 (7.08) years and 62.80 (12.46) years, respectively. Twelve of 28 patients in the in-person group (42.9%) and 16 of 35 patients in the TNR group (45.7%) were female. Mean (SD) MDS-UPDRS III scores were significantly lower following TNR (pre-TNR: 35.17 [17.72] vs post-TNR: 28.6 [19.7]; P = .001). Mean (SD) change in postintervention MDS-UPDRS III scores was not significantly different between the 2 groups (TNR: -6.74 [11.07] vs in-person: -7.54 [10.52]; P = .39). Median changes in NMSS and PDQ8-SI scores were similar between the groups.

Conclusions and Relevance

TNR is safe and effective in improving motor and nonmotor symptoms and quality of life among Indian patients with PD.

Tango and physiotherapy interventions in Parkinson's disease: a pilot study on efficacy outcomes on motor and cognitive skills

Pharmacological treatments in Parkinson's disease (PD), albeit effective in alleviating many motor symptoms, have limited effects in non-motor signatures as cognitive impairment, as well as in other aspects included postural instability. Consequently, complementary interventions are nowadays a prerogative of clinical practice managing PD symptomatology. In this pilot longitudinal study, we recruited twenty-four PD patients participating in one of two interventions: adapted Argentine Tango or group-based physiotherapy. Participants underwent a motor and neuropsychological evaluation before and after four months of activities, carried out twice a week. We found a general stabilization of motor and cognitive abilities, with significant improvements in several motor skills, mainly pertaining to static and dynamic balance, similarly in both groups. At cognitive level, we measured a significant improvement in both groups in the Action Naming task. Interestingly, only PD patients in the Tango group improved their performance in the test measuring facial emotion recognition. These findings highlight the crucial role that physical activities have in the stabilization and slowdown of disease's progression in PD. They further highlight the beneficial effects of a group-based physical intervention, which, especially in the case of Tango, could lead to behavioral ameliorations in domains other than the motor, such as emotion recognition.

THE RELATIONSHIP BETWEEN TRUNK MUSCLE STRENGTH AND PELVIC OSCILLATION IN HEALTHY ADULTS

Purpose: Pelvis and trunk structure are body segments that are integrated with each other. Collaboration between pelvic mobility and trunk muscles plays a significant role in walking and energy consumption. The aim of this study is to investigate the relationship between trunk muscle strength and pelvic oscillations. Methods: Twenty-eight healthy individuals volunteered for the study (16 women, 12 man; mean age 24.46 ± 2.97 yrs., height 172.03 ± 9.41cm, weight 67.78 ± 16.31 kg). Gait characteristics and pelvic oscillation were measured by using wireless tri-axial accelerometer. Trunk muscle strength were evaluated with Isokinetic Dynamometer (Cybex Humac Norm Testing & Rehabilitation System, USA). The trunk extensors and flexors were tested concentrically at 60°s. Statistically, the direction and level of the relationship were examined by using Spearman Correlation Analysis. Results: Correlation analysis showed significant relationships between concentric strength of trunk flexion and anterior-posterior pelvic tilt (r=-0.419), lateral pelvic tilt (r=-0.768) and hip rotation (r=-0.382). A statistically significant relationship was not observed between concentric strength of trunk extension and anterior-posterior pelvic tilt, hip rotation (p>0.05). Conclusion: The current study reports that trunk muscle strength is associated with pelvic oscillations. Also, these results suggest that maintaining optimal levels of trunk muscle strength prepares a healthful basis for the pelvis during walking. Therefore, it contributes to the prevention of possible pathologies related to lower extremity. Although trunk muscle strength and pelvic mobility are important determinants of gait, these factors are insufficient to evaluate the whole gait cycle and energy expenditure of individuals.

Exercise capacity in people with Parkinson's disease: which clinical characteristics are important?

BACKGROUND

People with Parkinson's (PwP) are suffering from reduced exercise capacity. However, little information is known about clinical correlates of exercise capacity in this population.

OBJECTIVE

This study aimed to evaluate correlations between motor and non-motor symptoms with exercise capacity in PwP.

METHODS

A total of 50 individuals with Parkinson's disease participated in the study. Exercise capacity was measured by 6 minutes' walk test (6MWT). Besides, the Movement Disorder Society-Unified Parkinson's Disease Rating Scale-Part III used to evaluate disease motor severity, Berg Balance Scale to assess balance, Montréal Cognitive Assessment to evaluate cognitive status, hospital anxiety and depression scale to assess depression and anxiety, Modified Fatigue Impact scale to evaluate fatigue, and the Pittsburgh Sleep Quality Index to evaluate sleep quality.

RESULTS

The results showed that exercise capacity, when measured by the 6MWT, can be significantly predicted by balance, disease motor severity, anxiety, and age (R² = 0.61 P < .0001).

CONCLUSION

These results suggest that exercise capacity in PwP is multifactorial and can potentially be predicted by balance, motor severity, anxiety, and age.

How groove in music affects gait

Rhythmic auditory stimulation (RAS) is a gait intervention in which gait-disordered patients synchronise footsteps to music or metronome cues. Musical 'groove', the tendency of music to induce movement, has previously been shown to be associated with faster gait, however, why groove affects gait remains unclear. One mechanism by which groove may affect gait is that of beat salience: music that is higher in groove has more salient musical beats, and higher beat salience might reduce the cognitive demands of perceiving the beat and synchronizing footsteps to it. If groove's effects on gait are driven primarily by the impact of beat salience on cognitive demands, then groove's effects might only be present in contexts in which it is relevant to reduce cognitive demands. Such contexts could include task parameters that increase cognitive demands (such as the requirement to synchronise to the beat), or individual differences that may make synchronisation more cognitively demanding. Here, we examined whether high beat salience can account for the effects of high-groove music on gait. First, we increased the beat salience of low-groove music to be similar to that of high-groove music by embedding metronome beats in low and high-groove music. We examined whether low-groove music with high beat salience elicited similar effects on gait as high-groove music. Second, we examined the effect of removing the requirement to synchronise footsteps to the beat (i.e., allowing participants to walk freely with the music), which is thought to remove the cognitive demand of synchronizing movements to the beat. We tested two populations thought to be sensitive to the cognitive demands of synchronisation, weak beat-perceivers and older adults. We found that increasing the beat salience of low-groove music increased stride velocity, but strides were still slower than with high-groove music. Similarly, removing the requirement to synchronise elicited faster, less variable gait, and reduced bias for stability, but high-groove music still elicited faster strides than low-groove music. These findings suggest that beat salience contributes to groove's effect on gait, but it does not fully account for it. Despite reducing task difficulty by equalizing beat salience and removing the requirement to synchronise, high-groove music still elicited faster, less variable gait. Therefore, other properties of groove also appear to play a role in groove's effect on gait.

Fatigability and Cardiorespiratory Impairments in Parkinson's Disease: Potential Non-Motor Barriers to Activity Performance

Parkinson's disease (PD) is the second most common neurodegenerative condition after Alzheimer's disease, affecting an estimated 160 per 100,000 people 65 years of age or older. Fatigue is a debilitating non-motor symptom frequently reported in PD, often manifesting prior to disease diagnosis, persisting over time, and negatively affecting quality of life. Fatigability, on the other hand, is distinct from fatigue and describes the magnitude or rate of change over time in the performance of activity (i.e., performance fatigability) and sensations regulating the integrity of the performer (i.e., perceived fatigability). While fatigability has been relatively understudied in PD as compared to fatigue, it has been hypothesized that the presence of elevated levels of fatigability in PD results from the interactions of homeostatic, psychological, and central factors. Evidence from exercise studies supports the premise that greater disturbances in metabolic homeostasis may underly elevated levels of fatigability in people with PD when engaging in physical activity. Cardiorespiratory impairments constraining oxygen delivery and utilization may contribute to the metabolic alterations and excessive fatigability experienced in individuals with PD. Cardiorespiratory fitness is often reduced in people with PD, likely due to the combined effects of biological aging and impairments specific to the disease. Decreases in oxygen delivery (e.g., reduced cardiac output and impaired blood pressure responses) and oxygen utilization (e.g., reduced skeletal muscle oxidative capacity) compromise skeletal muscle respiration, forcing increased reliance on anaerobic metabolism. Thus, the assessment of fatigability in people with PD may provide valuable information regarding the functional status of people with PD not obtained with measures of fatigue. Moreover, interventions that target cardiorespiratory fitness may improve fatigability, movement performance, and health outcomes in this patient population.

Accuracy and Precision of Three Consumer-Grade Motion Sensors During Overground and Treadmill Walking in People With Parkinson Disease: Cross-Sectional Comparative Study

BACKGROUND

Wearable motion sensors are gaining popularity for monitoring free-living physical activity among people with Parkinson disease (PD), but more evidence supporting the accuracy and precision of motion sensors for capturing step counts is required in people with PD.

OBJECTIVE

This study aimed to examine the accuracy and precision of 3 common consumer-grade motion sensors for measuring actual steps taken during prolonged periods of overground and treadmill walking in people with PD.

METHODS

A total of 31 ambulatory participants with PD underwent 6-min bouts of overground and treadmill walking at a comfortable speed. Participants wore 3 devices (Garmin Vivosmart 3, Fitbit One, and Fitbit Charge 2 HR), and a single researcher manually counted the actual steps taken. Accuracy and precision were based on absolute and relative metrics, including intraclass correlation coefficients (ICCs) and Bland-Altman plots.

RESULTS

Participants walked 628 steps over ground based on manual counting, and Garmin Vivosmart, Fitbit One, and Fitbit Charge 2 HR devices had absolute (relative) error values of 6 (6/628, 1.0%), 8 (8/628, 1.3%), and 30 (30/628, 4.8%) steps, respectively. ICC values demonstrated excellent agreement between manually counted steps and steps counted by both Garmin Vivosmart (0.97) and Fitbit One (0.98) but poor agreement for Fitbit Charge 2 HR (0.47). The absolute (relative) precision values for Garmin Vivosmart, Fitbit One, and Fitbit Charge 2 HR were 11.1 (11.1/625, 1.8%), 14.7 (14.7/620, 2.4%), and 74.4 (74.4/598, 12.4%) steps, respectively. ICC confidence intervals demonstrated low variability for Garmin Vivosmart (0.96 to 0.99) and Fitbit One (0.93 to 0.99) but high variability for Fitbit Charge 2 HR (-0.57 to 0.74). The Fitbit One device maintained high accuracy and precision values for treadmill walking, but both Garmin Vivosmart and Fitbit Charge 2 HR (the wrist-worn devices) had worse accuracy and precision for treadmill walking.

CONCLUSIONS

The waist-worn sensor (Fitbit One) was accurate and precise in measuring steps with overground and treadmill walking. The wrist-worn sensors were accurate and precise only during overground walking. Similar research should inform the application of these devices in clinical research and practice involving patients with PD.

Feasibility of a mobile feedback system for gait retraining in people with lower limb loss-A technical note

Gait retraining in people with musculoskeletal and/or neurological impairments requires sustained dedicated efforts by the patient and the rehabilitation therapist. Various technical approaches have been proposed and utilized to improve the effectiveness of training interventions. Among the most promising approaches is the provision of real-time feedback information to the patient, which has been used with success on treadmill-based interventions in the past. We are describing a mobile visual feedback system that is intended to work in the user's everyday-life environment. The data are captured by a small mobile load cell, processed in a wearable computer, and displayed to the user via smart-glasses. Preliminary testing of the initially selected feedback variable stance/step ratio (i.e., the duration of a step's stance phase in relation to the overall step's duration) confirmed that data quality is sufficient for purposes of generating feedback information and that the chosen variable is responsive to changes in gait symmetry. The presented work may inform future studies and developments on the topic of mobile visual feedback for gait rehabilitation.

Rethinking energy in parkinsonian motor symptoms: a potential role for neural metabolic deficits

Parkinson’s disease (PD) is characterized as a chronic and progressive neurodegenerative disorder that results in a variety of debilitating symptoms, including bradykinesia, resting tremor, rigidity, and postural instability. Research spanning several decades has emphasized basal ganglia dysfunction, predominantly resulting from dopaminergic (DA) cell loss, as the primarily cause of the aforementioned parkinsonian features. But, why those particular features manifest themselves remains an enigma. The goal of this paper is to develop a theoretical framework that parkinsonian motor features are behavioral consequence of a long-term adaptation to their inability (inflexibility or lack of capacity) to meet energetic demands, due to neural metabolic deficits arising from mitochondrial dysfunction associated with PD. Here, we discuss neurophysiological changes that are generally associated with PD, such as selective degeneration of DA neurons in the substantia nigra pars compacta (SNc), in conjunction with metabolic and mitochondrial dysfunction. We then characterize the cardinal motor symptoms of PD, bradykinesia, resting tremor, rigidity and gait disturbance, reviewing literature to demonstrate how these motor patterns are actually energy efficient from a metabolic perspective. We will also develop three testable hypotheses: (1) neural metabolic deficits precede the increased rate of neurodegeneration and onset of behavioral symptoms in PD; (2) motor behavior of persons with PD are more sensitive to changes in metabolic/bioenergetic state; and (3) improvement of metabolic function could lead to better motor performance in persons with PD. These hypotheses are designed to introduce a novel viewpoint that can elucidate the connections between metabolic, neural and motor function in PD.

The impact of a submaximal level of exercise on balance performance in older persons

Objective. The purpose of this study was to determine the impact of a submaximal level of exercise on balance performance under a variety of conditions. Material and Method. Thirteen community-dwelling older persons with intact foot sensation (age = 66.69 ± 8.17 years, BMI = 24.65 ± 4.08 kg/m², female, n = 6) volunteered to participate. Subjects' balance performances were measured using the Modified Clinical Test of Sensory Integration of Balance (mCTSIB) at baseline and after test, under four conditions of stance: (1) eyes-opened firm-surface (EOF), (2) eyes-closed firm-surface (ECF), (3) eyes-opened soft-surface (EOS), and (4) eyes-closed soft-surface (ECS). The 6-minute walk test (6MWT) protocol was used to induce the submaximal level of exercise. Data was analyzed using the Wilcoxon Signed-Rank Test. Results. Balance changes during EOF (z = 0.00, P = 1.00) and ECF (z = −1.342, P = 0.180) were not significant. However, balance changes during EOS (z = −2.314, P = 0.021) and ECS (z = −3.089, P = 0.02) were significantly dropped after the 6MWT. Conclusion. A submaximal level of exercise may influence sensory integration that in turn affects balance performance, particularly on an unstable surface. Rehabilitation should focus on designing intervention that may improve sensory integration among older individuals with balance deterioration in order to encourage functional activities.

The Unified Parkinson's Disease Rating Scale as a predictor of peak aerobic capacity and ambulatory function

The Unified Parkinson's Disease Rating Scale (UPDRS) is a widely applied index of disease severity. Our objective was to assess the utility of UPDRS for predicting peak aerobic capacity (VO2 peak) and ambulatory function. Participants (n = 70) underwent evaluation for UPDRS (Total and Motor ratings), VO2 peak, 6-minute walk distance (6MW), and 30-foot self-selected walking speed (SSWS). Using regression, we determined the extent to which the Total and Motor UPDRS scores predicted each functional capacity measure after adjusting for age and sex. We also tested whether adding the Hoehn and Yahr scale (H-Y) to the model changed predictive power of the UPDRS. Adjusted for age and sex, both the Total UPDRS and Motor UPDRS subscale failed to predict VO2 peak. The Total UPDRS did weakly predict 6MW and SSWS (both p < 0.05), but the Motor UPDRS subscale did not predict these ambulatory function tests. After adding H-Y to the model, Total UPDRS was no longer an independent predictor of 6MW but remained a predictor of SSWS. We conclude that Total and Motor UPDRS rating scales do not predict VO2 peak, but that a weak relationship exists between Total UPDRS and measures of ambulatory function.

Randomized clinical trial of 3 types of physical exercise for patients with Parkinson disease

OBJECTIVE

To compare the efficacy of treadmill exercises and stretching and resistance exercises in improving gait speed, strength, and fitness for patients with Parkinson disease.

DESIGN

A comparative, prospective, randomized, single-blinded clinical trial of 3 types of physical exercise.

SETTING

The Parkinson's Disease and Movement Disorders Center at the University of Maryland and the Baltimore Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center.

PATIENTS

A total of 67 patients with Parkinson disease who had gait impairment were randomly assigned to 1 of 3 arms of the trial. INTERVENTIONS; (1) A higher-intensity treadmill exercise (30 minutes at 70%-80% of heart rate reserve), (2) a lower-intensity treadmill exercise (50 minutes at 40%-50% of heart rate reserve), and (3) stretching and resistance exercises (2 sets of 10 repetitions on each leg on 3 resistance machines [leg press, leg extension, and curl]). These exercises were performed 3 times a week for 3 months.

MAIN OUTCOME MEASURES

The primary outcome measures were gait speed (6-minute walk), cardiovascular fitness (peak oxygen consumption per unit time [$$ VO2], and muscle strength (1-repetition maximum strength).

RESULTS

All 3 types of physical exercise improved distance on the 6-minute walk: lower-intensity treadmill exercise (12% increase; P=.001), stretching and resistance exercises (9% increase; P<.02), and higher-intensity treadmill exercise (6% increase; P=.07), with no between-group differences. Both treadmill exercises improved peak $$ VO2 (7%-8% increase; P<.05) more than did the stretching and resistance exercises. Only stretching and resistance improved muscle strength (16% increase; P<.001).

CONCLUSIONS

The effects of exercise were seen across all 3 exercise groups. The lower-intensity treadmill exercise resulted in the greatest improvement in gait speed. Both the higher- and lower-intensity treadmill exercises improved cardiovascular fitness. Only the stretching and resistance exercises improved muscle strength. Therefore, exercise can improve gait speed, muscle strength, and fitness for patients with Parkinson disease. The combination of treadmill and resistance exercises may result in greater benefit and requires further investigation.

Oxygen consumption, oxygen cost, heart rate, and perceived effort during split-belt treadmill walking in young healthy adults

During split-belt treadmill walking the speed of the treadmill under one limb is faster than the belt under the contralateral limb. This unique intervention has shown evidence of acutely improving gait impairments in individuals with neurologic impairment such as stroke and Parkinson's disease. However, oxygen use, heart rate and perceived effort associated with split-belt treadmill walking are unknown and may limit the utility of this locomotor intervention. To better understand the intensity of this new intervention, this study was undertaken to examine the oxygen consumption, oxygen cost, heart rate, and rating of perceived exertion associated with split-belt treadmill walking in young healthy adults. Fifteen participants completed three sessions of treadmill walking: slow speed with belts tied, fast speed with belts tied, and split-belt walking with one leg walking at the fast speed and one leg walking at the slow speed. Oxygen consumption, heart rate, and rating of perceived exertion were collected during each walking condition and oxygen cost was calculated. Results revealed that oxygen consumption, heart rate, and perceived effort associated with split-belt walking were higher than slow treadmill walking, but only oxygen consumption was significantly lower during both split-belt walking than fast treadmill walking. Oxygen cost associated with slow treadmill walking was significantly higher than fast treadmill walking. These findings have implications for using split-belt treadmill walking as a rehabilitation tool as the cost associated with split-belt treadmill walking may not be higher or potentially more detrimental than that associated with previously used treadmill training rehabilitation strategies.

Quantitative normative gait data in a large cohort of ambulatory persons with Parkinson's disease

BACKGROUND

Gait performance is widely evaluated to assess health status in older adult populations. While several investigators have presented normative values for spatiotemporal gait parameters drawn from older adult populations, the literature has been void of large-scale cohort studies, which are needed in order to provide quantitative, normative gait data in persons with Parkinson's disease. The aim of this investigation was to provide reference values for clinically important gait characteristics in a large sample of ambulatory persons with Parkinson's disease to aid both clinicians and researchers in their evaluations and treatments of gait impairment.

METHODOLOGY/PRINCIPAL FINDINGS

Gait performance was collected in 310 individuals with idiopathic Parkinson's disease as they walked across a pressure sensitive walkway. Fourteen quantitative gait parameters were measured and evaluated with respect to Hoehn and Yahr disease staging and gender. Disease duration and age were controlled for in all analyses. Individuals with the greatest Parkinson's disability walked significantly slower with shorter steps and stride lengths than the mild and moderately affected groups. Further, the most affected patients spent more time with both feet on the ground, and walked with a wider base of support than the moderately disabled patients. No differences were detected between the mild and moderate disability groups on any of the gait parameters evaluated.

CONCLUSIONS/SIGNIFICANCE

Reference values for 14 gait parameters in a large cohort of ambulatory patients with Parkinson's disease are provided and these may be highly useful for assessing and interpreting an individual's gait dysfunction. It is important for clinicians and researchers to appreciate the lack of change in quantitative parameters as PD patients move from mild to moderate gait impairment.