The Effects of Treadmill or Overground Walking Training Program on Gait in Parkinson's Disease

[Abstract] Background. Gait impairment in Parkinson's disease (PD) patients is characterized by the inability to generate appropriate stride length. Treadmill training has been proposed as a therapeutic tool for PD patients. However, it remains unknown whether treadmill training effects are different from overground walking training. Thus, our goal was to explore the effects of two training programs, walking on a treadmill and walking overground, in PD patients. Methods. 22 PD patients were randomly assigned to a treadmill or overground training group. The training program consisted of 5 weeks (3 sessions/week). Before and after the program we evaluated gait kinematics during walking at preferred and maximal speed; Timed Up and Go (TUG); static posturography and knee extensors strength. Gait parameters were reevaluated in the treadmill training group one month after the cessation of the training. Results. Preferred speed walking improved in both groups after the training program. The treadmill training program, but not the overground, led to an improvement in the stride length at the preferred and maximal walking speed in the PD patients. In addition, the treadmill training group showed improvement of the TUG and static posturography tests. The improvement in gait parameters was maintained one month after the cessation of the treadmill training. Conclusions. This study provides evidence of a specific therapeutic effect of treadmill training on Parkinsonian gait and balance. Walking on a treadmill may be used as an easy, effective and accessible way to improve the stride length and balance in PD patients. Background. Gait impairment in Parkinson's disease (PD) patients is characterized by the inability to generate appropriate stride length. Treadmill training has been proposed as a therapeutic tool for PD patients. However, it remains unknown whether treadmill training effects are different from overground walking training. Thus, our goal was to explore the effects of two training programs, walking on a treadmill and walking overground, in PD patients. Methods. 22 PD patients were randomly assigned to a treadmill or overground training group. The training program consisted of 5 weeks (3 sessions/week). Before and after the program we evaluated gait kinematics during walking at preferred and maximal speed; Timed Up and Go (TUG); static posturography and knee extensors strength. Gait parameters were reevaluated in the treadmill training group one month after the cessation of the training. Results. Preferred speed walking improved in both groups after the training program. The treadmill training program, but not the overground, led to an improvement in the stride length at the preferred and maximal walking speed in the PD patients. In addition, the treadmill training group showed improvement of the TUG and static posturography tests. The improvement in gait parameters was maintained one month after the cessation of the treadmill training. Conclusions. This study provides evidence of a specific therapeutic effect of treadmill training on Parkinsonian gait and balance. Walking on a treadmill may be used as an easy, effective and accessible way to improve the stride length and balance in PD patients.Ministerio de Ciencia e Innovación;DEP-2011-2246

Home-based risk of falling assessment test using a closed-loop balance model

The aim of this study is to improve and facilitate the methods used to assess risk of falling at home among older people through the computation of a risk of falling in real time in daily activities. In order to increase a real time computation of the risk of falling, a closed-loop balance model is proposed and compared with One-Leg Standing Test (OLST). This balance model allows studying the postural response of a person having an unpredictable perturbation. Twenty-nine volunteers participated in this study for evaluating the effectiveness of the proposed system which includes seventeen elder participants: ten healthy elderly (68.4 ± 5.5 years), seven Parkinson’s disease (PD) subjects (66.28 ± 8.9 years), and twelve healthy young adults (28.27 ± 3.74 years). Our work suggests that there is a relationship between OLST score and the risk of falling based on center of pressure (COP) measurement with four low cost force sensors located inside an instrumented insole, which could be predicted using our suggested closed-loop balance model. For long term monitoring at home, this system could be included in a medical electronic record and could be useful as a diagnostic aid tool

Treadmill walking in Parkinson's disease patients: adaptation and generalization effect

[Abstract] We examined the adaptation and generalization effect of one familiarization treadmill walking session on gait in patients with Parkinson's disease (PD) with different degrees of disease severity. Eight moderate PD patients (Hoehn and Yahr stage 2–2.5), eight advanced PD patients (Hoehn and Yahr 3), and eight matched control subjects participated in this study. Subjects first walked overground on a 10-m walkway at a self-selected speed (pretreadmill). They then performed a 20-min treadmill training session, followed by three trials of overground walking (Post1, Post2, Post3). Cadence, step length, speed, and coefficient of variation of stride time (CV) were recorded. During the treadmill session the advanced PD patients significantly decreased their cadence (t = 3.9, P ≤ 0.01) and increased their step length (t = 4.27, P ≤ 0.01) compared with pretreadmill walking. After the treadmill, all subjects walked overground significantly faster (F = 16.51 P ≤ 0.001) and with a larger step length (F = 13.03 P ≤ 0.01) than pretreadmill walking. The present study shows a specific adaptation to walk over the treadmill for the advanced PD patients. Moreover, this confirms the potential therapeutic use of the treadmill for PD gait rehabilitation since a single familiarization session lead to an increase in the step length and thus to the improvement of the main gait impairment in PD. © 2008 Movement Disorder Societ

The efficacy of exercise interventions for people with Parkinson´s disease : a systematic review and meta-analysis

Tese de mestrado, Neurociências, Universidade de Lisboa, Faculdade de Medicina, 2019Background Parkinson Disease (PD) is the second most common neurodegenerative disorder characterized bymotor and non-motor symptoms that frequently affect patients’ physical activity. Recent studies showed that PD patients spend 75% of all awake time in sedentary behaviors and are 30% less physically active than age-matched comparison subjects. Exercise may improve PD symptomatic control, and perhaps even modify diseases progression. Even though several studies have been published, in the last years, a robust evidence of exercise efficacy in PD is still missing. This study intends to investigate the efficacy of exercise, described as a structured and planned physical activity, associated with an energy expenditure, with the aim of improving physiological and motor function, as a therapeutic intervention in PD. Based on this, assumptions for PD clinical practice and research are made. Methods It was performed a systematic review of published randomized clinical trials assessing exercise interventions in Parkinson Disease. Studies were identified using MEDLINE, PubMed,PEDro andCochraneLibrary(from its inception to February2017). A mixed methods approach was undertaken using narrative and random effects meta-analysis methods. The methodological characteristics and quality of reporting were assessed using Cochrane Risk of Bias tool. Results Fifty-two studies were included. The most frequently used type of exercise was aerobic exercise (32.6% of the included studies). It is also important to highlight that 34.6% of the included studies assessed the effect of the exercise on motor impairment/disability. Exercise appears to be efficacious improving UPDRS III score, falls frequency and gait measured through the 6-minutes walking test. However, due to the reduced number of studies, conclusions cannot be drawn about the relevance of the improvement. Exercise has not shown to contribute to a significant improvement in the quality of life and balance of Parkinson's disease patients. Conclusions Data, from the included studies, suggests that exercise has a potential positive effect in falls frequency, PD patients’ motor impairment and gait parameters. However, the number of studies was small and to better conclude about exercise efficacy on PD additional studies with larger samples, using the recommended outcomes tools for PD and a placebo or sham-intervention comparator should be performed. The role of exercise as disease modifying intervention, the best type of exercise, intensity and frequency of exercise for each disease stage and therapeutic purpose are still unanswered questions.Contextualização A doença de Parkinson é a segunda doença neurodegenerativa mais comum. Um conjunto de sintomas motores e não motores conduzem a uma progressiva dependência nas atividades da vida diária e consequente perda de qualidade de vida para estes doentes. Os primeiros sintomas e a sua progressão não são lineares, existindo uma grande variabilidade no decurso da doença. Habitualmente, no início, a doença de Parkinson é unilateral e o tratamento farmacológico permite o controlo sintomático. Contudo após dois a cinco anos, a maioria dos pacientes desenvolve complicações motoras associadas à Levodopa. Estudos recentes mostraram que os doentes com Parkinson gastam 75% do seu tempo em atividades sedentárias e que, em comparação com adultos da mesma idade, são 30% menos ativos, diferença que se acentua com a progressão da doença. O exercício tem sido cada vez mais recomendado como intervenção coadjuvante às intervenções farmacológica e cirúrgica. Por isso, torna-se cada vez mais relevante investigar que efeitos tem o exercício e como atua nos sintomas e nos mecanismos neurofisiológicos da doença de Parkinson. Estudos prévios em animais realçaram o seu potencial benefício na neuroplasticidade, uma vez que, com o exercício ocorre um aumento da síntese e libertação de dopamina e um aumento dos seus níveis no estriado. Esta revisão sistemática da literatura é especialmente relevante para investigar a eficácia do exercício na DP e para definir diretrizes para novos ensaios clínicos e para o seu uso enquanto potencial ferramenta terapêutica, quer como coadjuvante, quer como potencial modificador da progressão da doença. Objetivos Este estudo visa investigar a eficácia do exercício cujo objetivo é a melhoria da função fisiológica e motora como intervenção terapêutica na DP, descrito como uma atividade física estruturada e planeada, associada a um gasto energético, e cujo objetivo é a melhoria da função fisiológica e motora. Com base nos resultados, procuraremos delinear recomendações para a prática clínica e investigação na área da DP. Métodos Foi realizada uma pesquisa eletrónica de ensaios clínicos que investigassem o efeito do exercício na doença de Parkinson nas seguintes bases de dados: MEDLINE, PubMed, PEDro and Cochrane Library, desde o início do estudo até Fevereiro de 2017. Na seleção de artigos foram considerados os seguintes critérios de inclusão: 1) estudos clínicos randomizados e controlados 2) a população incluída nos estudos ser composta por doentes deParkinsonem qualquer estádiodadoença3) estudos queavaliem eficácia terapêutica do exercício, entendido como uma atividade física planeada e estruturada, à qual está associado um gasto de energia e cujo objetivo é a melhoria da função fisiológica e motora 4) estudos com uma das seguintes intervenções como grupo de controlo: não intervenção, cuidados habituais, placebo, sham-intervention ou outro tipo de exercício 5) incluir pelo menos um dos seguintes outcomes: marcha, qualidade de vida, incapacidade, capacidade aeróbia, amplitudes articulares, força muscular ou cognitivo. Foi construída uma grelha de recolha de dados dos artigos selecionados, na qual cinco domínios foram tidos em conta: informação geral (título, nome e país do autor de correspondência, língua de publicação, ano e jornal de publicação, tipo de intervenção, aprovação ética e consentimento informado), métodos (critérios de elegibilidade, tipo de desenho doestudo, método derandomização, presençadeocultação daaleatorização, tipo de ocultação e duração do follow-up, número total de doentes e de doentes por grupo), intervenção (tipo, duração e timming da intervenção), análise dos dados (tipo de análise, métodos estatísticos utilizados, objetivos, desistências, cálculo do tamanho da amostra, outcomes pré-definidos, instrumentos de avaliação e comparabilidade dos grupos) e resultados. A qualidade metodológica dos estudos foi avaliada com recurso à ferramenta da Cochrane para avaliar o risco de viés – Cochrane tool Cochrane Risk of bias. Todos os estudos foram classificados de acordo com o risco de viés. Foi realizada uma análise estatística descritiva dos resultados. A meta-análise foi conduzida recorrendo ao RevMan 5.3.5 software. Para que se pudesse avaliar a eficácia, apenas os estudos que tinham como intervenção no grupo de controlo o não exercício, foram incluídos nameta-análise. Os estudos foram analisados de acordo com os outcomes e incluídos na meta-análise se o outcome e a respetiva ferramenta de avaliação fossem usados em pelo menos outros dois estudos. Foi conduzida uma análise por subgrupos tendo por base o tipo de exercício (exercício aeróbio vs multimodal), para o único outcome que tinham dados suficientes para comparar dois tipos de exercícios diferentes e outra com base na progressão da intensidade ao longo do estudo (intensidade mantida versus aumento progressivo da intensidade ao longo do estudo). Resultados A pesquisa eletrónica identificou 368 citações, das quais 159 potencialmente elegíveis. A aplicação dos critérios de inclusão resultou na exclusão de 107 estudos. As principais razões de exclusão foram: não serem ensaios clínicos randomizados (n=32), não avaliarem a eficácia do exercício (n=48), o grupo de controlo ser constituído por participantes sem doença de Parkinson (n=18), tipo de outcomes (n=2), estudos duplicados (n=6) e a língua de publicação (n=1). A intervenção mais frequentemente utilizada nos estudos incluídos foi o exercício aeróbio (32.6% dos estudos) e os doentes foram, na sua grande maioria avaliados sob o efeito da medicação. O outcome primário mais utilizado foi o comprometimento motor/incapacidade e os outcomes secundários mais avaliados foram a marcha e a qualidade de vida. Na meta-analise avaliámos o efeito do exercício nos seguintes outcomes: comprometimento motor/incapacidade, equilíbrio, parâmetros de marcha, frequência de quedas e qualidade de vida. O exercício poderá ter benefícios no comprometimento motor (UPDRS, parte III), na diminuição da frequência de quedas e na marcha avaliada através do teste dos 6 minutos de marcha, no entanto, em nenhuma das análises a melhoria foi significativa. Na análise de subgrupos, foram comparados o exercício multimodal com o aeróbio, sendo mais benéfico o exercício multimodal para a melhoria na UPDRS parte III, no entanto, mais uma vez os resultados não foram estatisticamente significativos. Na análise de subgrupos, na qual comparámos estudos com intensidade mantida com estudos com aumento progressivo da intensidade, não se registaram diferenças significativas, embora o aumento progressivo da intensidade tenha melhorias superiores na UPDRS parte III. A maioria dos estudos não reporta efeitos adversos da intervenção, apresenta baixo risco de víeis e só têm ocultação do avaliador. Conclusões A revisão sistemática sugere que o exercício poderá ter um impacto positivo nos sintomas motores da doença de Parkinson, com especial impacto no comprometimento motor/incapacidade, avaliado pelo UPDRS parte III, na frequência de quedas e nalguns parâmetros da marcha. No entanto, as melhorias encontradas não são estatisticamente significativas. Nos estudos incluídos, nesta revisão sistemática da literatura, não foram encontrados benefícios significativos do exercício para a qualidade de vida ou para a melhoria do equilíbrio na DP. Este estudo observou que, na maioria dos estudos incluídos, a intensidade e frequência do exercício seguem as indicações definidas pelas ACSM relativas à prescrição do exercício para o adulto idoso. O número reduzido de estudos, o tamanho reduzido da amostra, a diversidade de outcomes entre os estudos limitam as conclusões sobre os benefícios do exercício em doentes de Parkinson, que podem ser retiradas com esta revisão sistemática. Estudos futuros são necessários para perceber os efeitos do exercício noutros parâmetros de saúde e para avaliar a correlação entre o exercício e os benefícios alcançados porque só assim será possível que os profissionais de saúde escolham o programa mais eficaz para os doentes de Parkinson. Outro aspeto importante passa pela avaliação da eficácia em estádios mais avançados da patologia, assim como o estudo do impacto do recurso ao exercício em fases precoces da doente e do seu potencial papel como modificador da progressão da doença

Music for physical rehabilitation (1987-1996): a literature review and analysis

1998 Spring.Includes bibliographical references.A comprehensive literature review and analysis was conducted on the use of music for physical rehabilitation from 1987-1996. An earlier literature review and analysis of music for physical rehabilitation was published by Staum (1988), which covered the literature from 1950 -1986. The purpose of the current study was to provide music therapists with an updated and comprehensive resource to aid them in choosing effective treatment strategies for clients in need of physical rehabilitation. Pertinent music therapy sources, such as the Journal of Music Therapy, and pertinent non-music sources, specifically electronic bibliographic databases such as Medline, were consulted. Relevant sources were discussed in two chapters; Chapter 4 - An Overview of the Use of Music in the Treatment of Physical Rehabilitation, and Chapter 5- Clinical Implications for the Use of Music in Physical Rehabilitation . Tables containing frequency data supplement the discussion of the findings on treatment modalities, research settings, clinical population, musical applications, and literature sources. An overview of the methodology of all experimental and single-subject studies is provided in Table 8

The Effect of Moderate Parkinson's Disease on the Biomechanics of Compensatory Backwards Stepping

Postural instability leading to falls is one of the major unmet needs in the treatment of Parkinson's disease (PD). The progression of postural instability is not well understood, and a better understanding of the biomechanics underlying the progression of postural instability may be instrumental in the development of more sensitive clinical measures of postural instability and fall risk in PD. The biomechanical analysis of the response to a balance perturbation provides an opportunity to better understand postural instability in PD. This study examined the compensatory stepping response to a backwards pull in participants with moderate PD compared to age-range matched healthy controls. The first study investigated the overall response to a balance disturbance in moderate PD, and found that patients with moderate PD utilized more steps to regain balance, had a longer weight shift time, and used a base-width neutral step as a strategy to regain balance, compared to controls. The second study further investigated the compensatory response by focusing on the preparation phase and found that participants with moderate PD used multiple anticipatory postural adjustments (APAs), resulting in longer liftoff times and significantly different movement in the center of pressure prior to liftoff compared to healthy controls. The third study investigated the effects of PD and step strategy (single step, multiple steps, and a base-width neutral step) on balance recovery and found that participants with moderate PD took significantly longer to recover balance, and that the type of strategy used to respond to the disturbance significantly impacted recovery time. Additionally, the use of a base-width neutral step as the first step in the response emerged as a strategy that has not been previously documented and significantly delays balance recovery. These results suggest that moderate PD significantly impairs the compensatory response to a backwards pull. Furthermore, this impairment could be attributed to a delay in the preparation phase of the step response. This delay was associated with the use of multiple anticipatory postural adjustments and/or the use of a base-width neutral step as the first step in the response. Further study should examine the progression of impairment in these compensatory responses across PD severity levels, and the correlation with fall risk

BIOMECHANICAL MARKERS AS INDICATORS OF POSTURAL INSTABILITY PROGRESSION IN PARKINSON'S DISEASE

The long term objective of this research is to identify quantitative biomechanical parameters of postural instability in patients with Parkinson’s disease (PD) that can in turn be used to assess fall risk. Currently, clinical assessments in PD are not sufficiently sensitive to predict fall risk, making a history of falls to be the best predictor of a future fall. Identifying biomechanical measures to predict risk of falls in PD would provide a quantitative justification to implement fall-reducing therapies prior to a first fall and help prevent the associated debilitating fractures or even morbidity. While past biomechanical studies have shown the presence of balance deficits in PD patients, which often include a broad spectrum of disease stages, compared to healthy controls (HC), no studies have assessed whether such parameters can distinguish the onset of postural instability prior to clinical presentation, and if such parameters persist following clinical presentation of postural instability. Toward this end this study had three goals: • Determine if biomechanical assessment of a quasi-static task, postural sway, could provide preclinical indication of postural instability in PD. • Define a mathematical model (based on principal component analysis, PCA) with biomechanical and clinical measures as inputs to quantitatively score earlier postural instability presence and progression in PD. • Investigate if biomechanical assessment of a dynamic task, gait initiation, could provide preclinical indication of postural instability in PD. Specific Aim 1 determined that some biomechanical postural sway variables showed evidence of preclinical postural instability and increased with PD progression. This aim distinguished mild PD (Hoehn and Yahr stage (H&Y) 2, without postural deficits) compared to HC suggesting preclinical indication of postural instability, and confirmed these parameters persisted in moderate PD (H&Y 3, with postural deficits). Specifically, trajectory, variation, and peak measures of the center of pressure (COP) during postural sway showed significant differences (p < .05) in mild PD compared to healthy controls, and these differences persisted in moderate PD. Schwab and England clinical score best correlated with the COP biomechanical measures. These results suggest that postural sway COP measures may provide preclinical indication of balance deficits in PD and increase with clinical PD progression. Specific Aim 2 defined a PCA model based on biomechanical measures of postural sway and clinical measures in mild PD, moderate PD, and HC. PCA modeling based on a correlation matrix structure identified both biomechanical and clinical measures as the primary drivers of variation in the data set. Further, a PCA model based on these selected parameters was able to significantly differentiate (p < .05) all 3 groups, suggesting PCA scores may help with preclinical indication of postural instability (mild PD versus HC) and could be sensitive to clinical disease progression (mild PD versus moderate PD and moderate PD versus HC). AP sway path length and a velocity parameter were the 2 primary measures that explained the variability in the data set, suggesting further investigation of these parameters and mathematical models for scoring postural instability progression is warranted. Specific Aim 3 determined that a velocity measure from biomechanical assessment of gait initiation (peak COP velocity towards the swing foot during locomotion) showed evidence of preclinical postural instability in PD. Because balance is a complex task, having a better understanding of both quasi-static (postural sway) and dynamic (gait initiation) tasks can provide further insight about balance deficits resulting from PD. Several temporal and kinematic parameters changed with increasing disease progression, with significant difference in moderate PD versus HC, but missed significance in mild PD compared to HC. Total Unified Parkinson’s Disease Rating Scale (UPDRS) and Pull Test clinical scores best correlated with the biomechanical measures of the gait initiation response. These results suggest dynamic biomechanical assessment may provide additional information in quantifying preclinical postural instability and progression in PD. In summary, reducing fall risk in PD is a high priority effort to maintain quality of life by allowing continued independence and safe mobility. Since no effective screening method exists to measure fall risk, our team is developing a multi-factorial method to detect postural instability through clinical balance assessment, and in doing so, provide the justification for implementing fall reducing therapies before potentially debilitating falls begin

Effectiveness of the LSVT BIG™ Exercise Protocol on Measures of Balance, Gait, and Cardiovascular Fitness in Two Persons with Parkinson’s Disease

Case Background and Purpose. Parkinson’s disease (PD) is a progressive neurological pathology which leads to a decrease in functional capabilities. Non-pharmacologic treatment programs do exist which can enable people to function better while living with this disease. The purpose of this study was to assess the effect of the LSVT BIG™ exercise protocol on measures of balance, gait, and cardiovascular fitness in two subjects with PD. Case Description. The case study was an A-B design. Two individuals with PD consented to perform the outcome measures weekly for four weeks followed by four weeks of the LSVT BIG™ treatment protocol plus weekly testing. The outcome measures included Multi-directional Reach Test (MDRT), the GAITRite™ gait analysis system, electromyography (EMG), postural stability and limits of stability tests on Biodex™ Balance SD (BBSD), Functional Gait Assessment (FGA), Brief Balance Evaluation Systems Test (Brief BESTest), Five Times Sit to Stand (FTSTS), Six Minute Walk Test (6MWT), heart rate, blood pressure, and pulse oximetry. Outcome. The two participants demonstrated significant benefits in the outcome measures used. However, the number of changed measures for each subject was not equal, due to differences in PD signs. PD05 was a better candidate as his primary signs were bradykinesia and rigidity. Conclusion. Results of this study suggest LSVT BIG™ protocol may be used by patients with bradykinesia and rigidity as their primary motor signs of PD to help improve aspects of balance and gait. Further research is needed to solidify the results including more selective sample, larger sample size, and monitoring results of outcome measures post intervention period