Measures of functional performance were collected every 2 months after initial entry into the program. Data collection began in 2003 and continued through 2004. Data were collected by a team of 3 physical therapists experienced in administering the tests. The same therapist collected the same outcome measures every 2 months. One therapist who collected the Unified Parkinson Disease Rating Scale (UPDRS), medication, and fall data was also involved in supervising the exercise group at the YMCA. Testing order was counterbalanced between sessions among the 3 testers. Data were always collected in a standardized time window to minimize the impact of medication fluctuations that could influence testing results. Demographic data for each participant were collected at the beginning of their first measurement session (date of birth, medications, medical history, and medical diagnoses). Therapists testing the client did not have previous data available to them at the time of data collection. Clients missed some data collection dates because of weather or their own vacation schedule, so data were not collected for all clients on all dates (see Table 2).
Data were collected in 3 general categories: functional movement, ADL, and mentation and mood. To do this, functional performance assessments were administered in the areas of ambulation endurance, walking speed, balance, functional mobility, the UPDRS, and the Hoehn and Yahr (H&Y) scale. The UPDRS and the H&Y scale are ordinal scales that measure the progression of symptoms in PD.24 Data collection typically took about 1 hour.
This project assessed participants' ambulation endurance, walking speed, balance, and functional mobility using 5 performance measures commonly used in the physical therapy clinic and supported by research evidence. Walking (ambulation) endurance was evaluated using the Six-Minute Walk Test (6MWT) in which the participant walks continuously for 6 minutes and total distance is measured. Test-retest reliability for the 6MWT in a group of people with PD was ICC(2,1) = 0.95, with an MDC95 of 86 m.20 Self-selected walking speed and fast walking speed was measured over 6-m course, with an additional 2 m for start-up and 2 m for cooldown. Test-retest reliability for self-selected walking speed in people with PD is ICC(2,1) = 0.96, with an MDC95 of 0.18 m/s. Test-retest reliability for fast walking speed in people with PD is ICC(2,1) = 0.97, with an MDC95 of 0.25 m/s.20 Balance was measured using the BBS. Test-retest reliability for the BBS in people with PD was ICC(2,1) = 0.94 with an MDC95 of 5.20 Finally, functional mobility was tested using the TUG, which records the number of seconds it takes for a participant to rise from a seated position, walk forward a distance of 3 m, turn, walk back to the chair, and return to sitting position. Test-retest for the TUG in people with PD has been demonstrated as ICC(2,1) = 0.85, with an MDC95 of 11 seconds.20
These outcome measures were chosen because they were commonly used in the clinic by physical therapists when the study was conducted. Participants were allowed to use assistive devices as needed for ambulation tests. Two trials of self-selected walking speed, fast walking speed, and TUG tests were averaged for use in data analysis.20
In addition to the functional movement assessments, we used 2 overall measures of PD: the UPDRS and the H&Y scale.24 These assessments were administered at each measurement session to measure any potential changes in the disease process; all testers were previously trained in administration of the tests. The original UPDRS has 3 subscales:
- Mentation, Behavior, and Mood (including 4 questions on intellectual impairment, thought disorder, depression, and motivation/initiative);
- activities of Daily Living, including 13 questions regarding speech, salivation, swallowing, cutting food, handwriting, turning in bed, tremor, walking, and freezing when walking; and
- motor Skills: 14 questions regarding speech, facial expression, rigidity, finger taps, hand movements, transition movements, tremor, bradykinesia, posture, and walking.
In the original UPDRS, all subscales can be summed for a total score. The H&Y scale24 measures movement in people with PD and is often used as a measure of disease progression.
This project assessed participants' ambulation endurance, walking speed, balance, and functional mobility using 5 performance measures. Data were also collected on age, years since diagnosis, daily levodopa (L-DOPA) dose, falls, overall disease progression as measured by the H&Y scale and total UPDRS scores, as well as specific measures of mentation, behavior, and mood, ADL, and motor performance garnered from the UPDRS. The UPDRS and the BBS are ordinal measures; all other measures are ratio measures. All variables had normal distribution except the TUG test that demonstrated variability. SPSS (version 17.0) and Excel (2007) were used to analyze and graph the data. Wilcoxon tests were used to compare significant differences on 10 clients, with complete data sets between the initial data collection and the 10-month follow-up. Wilcoxon tests were used because the sample size was small and because the UPDRS and the BBS provided ordinal data. Table 1 reports the percentage of change for the measures of the people who completed 10 months of the program. Longitudinal data for the exercise group were graphed (simple linear regression lines) to incorporate lines of best fit for differential scores over time (Figure). Time is the independent variable (x-axis) and outcome measures are the predictors (y-axis). Table 2 shows participant attendance throughout the program. All 15 participants were tested at the first 3 data collection time points. Ten of the 15 participants were available for testing at month 10. This occurred because some of the clients began the program later, and data collection had concluded.
Aggregate data are presented in Table 1 (part A). Levodopa was tracked on 6 participants. During this time, 3 people decreased L-DOPA use by a total of 750 mg per day whereas 3 people increased its use by a total of 400 mg daily. This total change was not significant. Table 1 compares the initial evaluation and the final (10-month) evaluation. Participants as a group demonstrated improvements in ambulation endurance that averaged 35 m (11%). Although this is significant, it does not equal the MDC95 for the 6MWT (86 m). Mentation, behavior, and mood as measured by the UPDRS also improved, with a mean change of −1.2 (38%). The MDC95 for this test would be −2, or a 62% change.20 Group scores for all other measures showed neither improvement nor decline, indicating that walking speed, balance, and mobility were maintained throughout the 10-month period. However, we do not know whether the change between the group participants who exercised and the control group participants who did not exercise equaled the MDC95 for a test such as the 6MWT.
The mean number of falls in the 6 months before the beginning of the study averaged 1.67 falls per participant. While participants were involved in the study, they were asked how many falls had occurred in the past 2 months. After 8 months of participation, there was 1 fall among the 11 people, and after 10 months, 4 falls were reported. These data showed no significant change over time.
Data on individual participant attendance are presented in Table 2. As shown, not all participants were involved for the entire 10-month period and not all participants attended each measurement session. The number of months attended ranged from 4 to 10 months, whereas the average number of sessions attended per month was 5, with a range of 3 to 8 sessions. Table 2 presents data allowing for correlations of individual attendance (number of months attended and average number of sessions attended per month) with scores on the 6MWT. There was no correlational improvement in the 6MWT associated with increased attendance. Most participants (10/15) showed improvement in ambulation endurance, and some either showed no change (3/15) or demonstrated a decline in endurance (2/15). Although there was a small practice effect for people with PD for the 6MWT, no other tests have demonstrated a practice effect in this population.20 The ability to improve ambulation endurance while maintaining initial walking speed would mean that the person can endure that walking speed over longer distances. This implies that community ambulation should have improved; however, community ambulation was not specifically assessed.
Participants demonstrated improvements in ambulation endurance over the 10-month course of this study. All other measures of motor function remained stable including falls. Larger studies may help determine whether an exercise program can reduce falls in people with PD. Because PD is progressive, a decline in these values over a 10-month period without exercise might be expected.25 However, Carne et al26 followed a group of clients with PD who received a multidisciplinary treatment approach including support groups and a home exercise program. Their results showed that a majority of participants maintained or improved motor function over the 1-year course of the study. These authors did not quantify adherence to the home exercise program. Dibble et al27 have begun a longitudinal cohort study to characterize the trajectory of disablement in a large cohort of people with PD that will include data on exercise habits and physical activity.
The program produced improvements in ambulation endurance, and walking speed was maintained despite the progressive nature of PD. The authors suspect that the mechanism for these improvements was the treadmill-walking component of the program. It is not clear whether adding the backward walking component to the protocol helped produce any positive effect on speed or endurance independent of forward walking. Hackney and Earhart28 investigated backward walking in people with mild to moderate PD who have impaired forward and backward walking. Differences between those with and without PD were more pronounced in backward walking. The authors concluded that backward walking impairments might be related to the propensity for backward falls. They state that backward walking could be a rehabilitative component.28 In addition, any positive effect of the strengthening and stretching exercises may have enhanced the outcome of treadmill walking both forward and backward. Further studies aimed at distinguishing among the effects of each component of the exercise program need to be conducted.
Recently, a wider variety of exercise options, including balance programs,29 treadmill training,13 tango dancing,30 Nordic walking,21 and an axial mobility program,31 have been explored for people with PD. Some participants in the present study expressed interest in weight/strength training activities. Such exercises might include strengthening of spinal and upper and lower extremity extensors as a possible means of countering the flexed posture often seen in people with PD. A published review demonstrated that strength training protocols reported in the literature are of relatively short duration (16–36 training bouts) and frequency (2–3 d/wk).32 Well-controlled trials of high-intensity resistance training in people with PD with emphasis on musculoskeletal and neural adaptations are needed.
Many of the exercises described in the Appendix cannot be done by clients on their own. For example, hip extension in the prone position with the arm in full flexion is difficult for many people with PD, and some people cannot safely do the upright balance activities alone. From our perspective, most clients with PD should be supervised for backward ambulation on the treadmill. Safety is always a concern, although we had no adverse outcomes in our program.
The small size of this study limits the ability to generalize results to all people with PD. Further data are needed to evaluate the effects of a long-term group exercise program on a larger population of people with PD. It would be beneficial to assess time frames longer than 10 months: financial constraints prohibited longer data collection in this project. In addition, there may be barriers to exercise for some people with PD that could have prevented them from participating in the program, including working, financial resources, and transportation issues. Ene et al33 reported barriers to exercise in people with PD that included transportation, time conflicts, and comorbidities. Further exploration of these and other possible barriers is needed.
It could not be determined whether the program's benefits were solely due to exercise or the group format, or resulted from the combination of exercise and social support. The group format may serve as a source of social and emotional support for people with PD.21,34 Further research is needed to determine whether the physical or social aspects of the group exercise program (or a combination) were most efficacious.
Participants in the study demonstrated improvements in mentation, behavior, and mood (as measured by the UPDRS). This was an unexpected finding and needs to be replicated in future studies using community programming. In addition, it would be valuable to quantify participants' perceptions of the program in future studies.
The program presented here demonstrates that accessible community exercise programs for people with PD can be developed and maintained and that at least some people with PD will participate over the long term. Currently, there are 13 programs in Wisconsin following the basic exercise protocol described in this study. All are designed to be easily accessible by community members with PD because of low cost and location. Programs are directed and lead by a physical therapist trained to deal with the symptoms of PD who can effectively and safely monitor a number of participants and implement individual program progression. It appears that participation in the group exercise program produced positive physical and mental changes or prevented negative change for the participants. This is an exciting outcome that needs to be studied further.
This study initiated a long-term community exercise program for people with PD in the state of Wisconsin. The program has expanded to 13 locations since it was initiated. Program participants improved ambulation endurance and maintained walking speed, balance, and mobility. Access to exercise directed by a therapist may help prevent one complication of PD—immobility.
1. Stacy M, Jankovic J. Current approaches in the treatment of Parkinson's disease. Ann Rev Med. 1993;44:431–440.
2. Schenkman M, Donovan J, Tsubota J, Kluss M, Stebbins P, Butler RB. Management of individuals with Parkinson's disease: rationale and case studies. Phys Ther. 1989;69:944–955.
3. Komitova M, Johansson B, Eriksson P. On neural plasticity, new neurons and the postischemic milieu: an integrated view on experimental rehabilitation. Exp Neurol. 2006;199:42–55.
4. Carreras I, Yuruker S, Aytan N, Hosain L, Choi J, Jenkins B. Moderate exercise delays the motor performance decline in a transgenic model of ALS. Brain Res. 2010;1313:192–201.
5. Moore J, Roth E, Killian C, Hornby T. Locomotor training improves daily stepping activity and gait efficiency in individuals poststroke who have reached a “plateau” in recovery. Stroke. 2010;41:129–135.
6. Dunlop S. Activity-dependent plasticity: implications for recovery after spinal cord injury. Trends Neurosci. 2008;31:410–418.
7. Tajiri N, Yasuhara T, Shingo T, et al. Exercise exerts neuroprotective effects on Parkinson's disease model of rats. Brain Res. 2010;1310:200–207.
8. Petzinger GM, Walsh JP, Akopian G, et al. Effects of treadmill exercise on dopaminergic transmission in the 1-methyl-4-phenyl-1, 2,3,6-tetrahydropyridine-lesioned mouse model of basal ganglia injury. J Neurosci. 2007;27:5291–5300.
9. Fisher B, Wu A, Salem G, et al. The effect exercise training in improving motor performance and corticomotor excitability in people with early Parkinson's disease. Arch Phys Med Rehabil. 2008;89:1221–1229.
10. Schenkman M, Cutson TM, Kuchibhatla M, et al. Exercise to improve spinal flexibility and function for people with Parkinson's disease: a randomized, controlled study. J Am Geriatr Soc. 1998;46:1207–1216.
11. Goodwin VA, Richards SH, Taylor RS, Taylor AH, Campbell J. The effectiveness of exercise interventions for people with Parkinson's disease: a systematic review and meta-analysis. Mov Disord. 2008;23:631–640.
12. Allen N, Sherrington C, Paul S, Canning C. Balance and falls in Parkinson's disease: a meta-analysis of the effect of exercise and motor training. Mov Disorders. 2011;26:1605–1615.
13. Mehrholz J, Friis R, Kugler J, Twork S, Storch A, Pohl M. Treadmill training for patients with Parkinson's disease. Cochrane Database Syst Rev. 2010;(1):CD007830. doi:10.1002/14651858.CD007830.pub2.
14. Miyai I, Fujimoto Y, Yamamoto H, et al. Long-term effect of body weight-supported treadmill training in Parkinson's disease: a randomized controlled trial. Arch Phys Med Rehabil. 2002;83:1370–1373.
15. Filippin N, Lobo da Costa P, Mattioli R. Effects of treadmill-walking training with additional body load on quality of life in subjects with Parkinson's disease. Rev Bras Fisioter. 2010;14:344–350.
16. Herman T, Giladi N, Gruendlinger L, Hausdorff JM. Six weeks of intensive treadmill training improves gait and quality of life inpatients with Parkinson's disease: a pilot study. Arch Phys Med Rehabil. 2007;88:1154–1158.
17. Pohl M, Rockstroh G, Ruckriem S, Mrass G, Mehrholz J. Immediate effects of speed-dependent treadmill training on gait parameters in early Parkinson's disease. Arch Phys Med Rehabil. 2003;84:1760–1766.
18. Toole T, Maitland CG, Warren E, Hubmann MF, Panton L. The effects of loading and unloading treadmill walking on balance, gait, fall risk, and daily function in parkinsonism. NeuroRehabil. 2005;20:307–372.
19. Gobbi L, Oliveira-Ferreira M, Caetano J, et al. Exercise programs improve mobility and balance in people with Parkinson's disease. Parkinsonism Rel Disord. 2009;15S3:S49–S52.
20. Steffen T, Seney M. Test-retest reliability and minimal detectable change on balance and ambulation tests, the 36-Item Short Form Health Survey, and the Unified Parkinson Disease Rating Scale in people with Parkinsonism. Phys Ther. 2008;88:733–746.
21. Reuter I, Mehnert S, Leone P, Kaps M, Oechsner M, Engelhardt M. Effects of a flexibility and relaxation programme, walking, and Nordic walking on Parkinson's disease. J Aging Res. 2011;2011:232473.
22. Quinn L, Busse M, Khalil H, Richardson S, Rosser A, Morris H. Client and therapist views on exercise programmes for early-mid stage Parkinson's disease and Huntington's disease. Disabil Rehabil. 2010;32:917–928.
23. Jette M, Sidney K, Blumchen G. Metabolic equivalents (METs) in exercise testing, exercise prescription, and evaluation of functional capacity. Clin Cardiol. 1990;13:555–565.
24. Hoehn M, Yahr M. Parkinsonism: onset, progression, and mortality. Neurology. 1967;17:427–442.
25. Toole T, Hirsch M, Forkink A, Lehman D, Maitland C. The effects of a balance and strength training program on equilibrium in Parkinsonism: a preliminary study. NeuroRehabil. 2000;14:165–174.
26. Carne W, Cifu D, Marcinko P, et al. Efficacy of a multidisciplinary treatment program on one-year outcomes of individuals with Parkinson's disease. NeuroRehabilitation. 2005;20:161–167.
27. Dibble L, Cavanaugh J, Earhart G, Ellis T, Ford M, Foreman K. Charting the progression of disability in Parkinson disease: study protocol for a prospective longitudinal cohort study. BMC Neurol. 2010;10:1–8.
28. Hackney ME, Earhart GM. Backward walking in Parkinson's disease. Mov Disord. 2009;24:218–223.
29. Horak F, Wrisley D, Frank J. The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits. Phys Ther. 2009;89:484–498.
30. Hackney ME, Kantorovich S, Levin R, Earhart GM. Effects of tango on functional mobility in Parkinson's disease: a preliminary study. J Neurol Phys Ther. 2007;31:173–179.
31. Schenkman M, Keysor J, Chandler J, Cotter Laub K, MacAller H. Axial Mobility Exercise Program: An Exercise Program to Improve Functional Ability. 2nd ed. Durham, NC: Duke University Claude D. Pepper Older Americans Independence Center; 1994.
32. Falvo MJ, Schilling BK, Earhart GM. Parkinson's disease and resistive exercise: rationale, review and recommendations. Mov Disord. 2008;23:1–11.
33. Ene H, McRae C, Schenkman M. Attitudes toward exercise following participation in an exercise intervention study. J Neurol Phys Ther. 2011;35:34–40.
34. de Paula F, Teixeira-Salmela L, de Morais Faria C, de Brito P, Cardoso F. Impact of an exercise program on physical, emotional, and social aspects of quality of life of individuals with Parkinson's disease. Mov Disord. 2006;21:1073–1077.
APPENDIX Exercise Protocol
The initial exercise routine involved 20 min of stretching/strengthening exercises that required each participant to get up and down to a mat on the floor. Some of the participants required the assistance of an individual and/or a chair.
The following exercises were completed:
- Lower trunk rotation in supine (2 sets of 10 repetitions)
- Bridging in supine (hip extension strengthening) (2 sets of 10 repetitions)
- Two joint hamstring stretch in supine with instructor assistance, statically or using contract/relax (1–2 min)
- Rectus femoris and iliopsoas stretch in prone (1–2 min)
- Hip extension in prone (10 repetitions bilaterally)
- Prone on elbows for back extension mobility (1–2 min)
- Four-point position with low back extension and flexion (5–10 repetitions)
- Four-point position with opposite leg and arm lifts (5–10 repetitions)
- Extension of the hips in kneeling (1–2 min)
- Rotation of the trunk to right and left in kneeling (1–2 min)
- Lateral flexion stretch of the trunk in kneeling (1–2 min)
- Half-kneeling position and hip flexor stretch in kneeling (1–2 min)
This was followed by 10 min of activity in standing including:
- Gastrocnemius stretch (1–2 min)
- Active plantar flexion with or without support (2 sets of 10 repetitions)
- With the back against a wall, a latissimus dorsi stretch was performed bilaterally (1 min)
- Ambulation backward up to 20 m
- Tandem walking up to 20 m
Participant then walked down stairs or down a ramp to proceed with 20–30 min of aerobic exercise on the treadmill:
- Backward treadmill walking 10 min at a comfortable speed (the study's range was 0.8–3.1 km/h); participants use hand support while walking backward
- Forward treadmill walking 10 min with minimal use of hand support (the study's range of speeds was 0.8–5.6 km/h)
A few participants then used the weight machine equipment.
Three pieces of equipment were encouraged:
- The back extension machine (erector spinae muscles)
- Overhead flexion-to-extension (trapezius muscles)
- The rowing machine (rhomboid muscles)
Participants were free to use any of the machines, as this part of the program was optional. Not all participants were able to complete the entire program each session.
Keywords:Copyright © 2012 the Section on Geriatrics of the American Physical Therapy Association
balance; community programming; exercise; older adults; Parkinson disease; treadmill training