Rhythmic auditory stimulation in gait training for Parkinson's disease patients. Effectiveness of physiotherapy in Parkinson's disease: the feasibility of a randomised controlled trial. The effects of incremental speed-dependent treadmill training on postural instability and fear of falling in Parkinson's disease. Cued task-specific training is better than exercise in improving sit-to-stand in patients with Parkinson's disease: A randomized controlled trial. Cueing training in the home improves gait-related mobility in Parkinson's disease: the RESCUE trial. Qigong exercise for the symptoms of Parkinson's disease: a randomized, controlled pilot study. Health-related quality of life and alternative forms of exercise in Parkinson disease. Does treadmill training improve lower-extremity tasks in Parkinson disease? A randomized controlled trial. A randomised controlled trial of a home based exercise programme to reduce the risk of falling among people with Parkinson's disease. The effects of an exercise program on fall risk factors in people with Parkinson's disease: a randomized controlled trial. [The effect of the complex rehabilitation on posture and gait in Parkinson disease]. Gait and step training to reduce falls in Parkinson's disease. Exercise to improve spinal flexibility and function for people with Parkinson's disease: a randomized, controlled trial. The effect of exercise training in improving motor performance and corticomotor excitability in people with early Parkinson's disease. Symptom and gait changes after sensory attention focused exercise vs aerobic training in Parkinson's disease. Efficacy of a physical therapy program in patients with Parkinson's disease: a randomized controlled trial. Training with verbal instructional cues results in near-term improvement of gait in people with Parkinson disease.
Rhythmic auditory stimulation (RAS) was used as a pacemaker during a 3-week home-based gait-training program for Parkinson's disease (PD) patients (n = 15). Electromyogram (EMG) patterns and stride parameters were assessed before and after the test without RAS to evaluate changes in gait patterns. Data were compared with those of two control groups (n = 11), who either did not participate in any gait training or who participated in an internally self-paced training program. RAS consisted of audiotapes with metronome-pulse patterns embedded into the on/off beat structure of rhythmically accentuated instrumental music. Patients who trained with RAS significantly (p < 0.05) improved their gait velocity by 25%, stride length by 12%, and step cadence by 10% more than self-paced subjects who improved their velocity by 7% and no-training subjects whose velocity decreased by 7%. In the RAS-group, timing of EMG patterns changed significantly (p < 0.05) in the anterior tibialis and vastus lateralis muscles. Evidence for rhythmic entrainment of gait patterns was shown by the ability of the RAS group to reproduce the speed of the last training tape within a 2% margin of error without RAS. To study the feasibility of a large randomised controlled trial (RCT) evaluating the effectiveness of physiotherapy in Parkinson's disease (PD), 173 patients were asked to participate in a study with random allocation to best practice physiotherapy, or to no physiotherapy. The primary outcome measures were the Parkinson's disease questionnaire-39, the Parkinson activity scale, and a patient preference outcome scale (PPOS). Only 14% of the patients could be included in the study. The PPOS showed the largest effect size (0.74) with a significant group effect (p<0.05). Specific alterations to the study design to ensure successful RCTs in this field are recommended. To detect the effectiveness of incremental speed-dependent treadmill training on postural instability, dynamic balance and fear of falling in patients with idiopathic Parkinson's disease.
                Randomized controlled trial.
                Ankara Education and Research Hospital, 2nd PM&R Clinic, Cardiopulmonary Rehabilitation Unit.
                Fifty-four patients with idiopathic Parkinson's disease in stage 2 or 3 of the Hoehn Yahr staging entered, and 31 patients (21 training, 10 control) had outcome data.
                Postural instability of patients with Parkinson's disease was assessed using the motor component of the Unified Parkinson's Disease Rating Scale (UPDRS), Berg Balance Test, Dynamic Gait Index and Falls Efficacy Scale. Twenty-one patients with Parkinson's disease participated in an eight-week exercise programme using incremental speed-dependent treadmill training. Before and after the training programme, balance, gait, fear of falling and walking distance and speed on treadmill were assessed in both Parkinson's disease groups.
                Walking distance and speed on treadmill, UPDRS, Berg Balance Test, Dynamic Gait Index and Falls Efficacy Scale.
                Initial total walking distance of the training group on treadmill was 266.45 +/- 82.14 m and this was progressively increased to 726.36 +/- 93.1 m after 16 training session (P < 0.001). Tolerated maximum speed of the training group on treadmill at baseline was 1.9 +/- 0.75 km/h and improved to 2.61 +/- 0.77 km/h (P < 0.001). Berg Balance Test, Dynamic Gait Index and Falls Efficacy Scale scores of the training group were improved significantly after the training programme (P < 0.01). There was no significant improvement in any of the outcome measurements in the control group (P > 0.05).
                Specific exercise programmes using incremental speed-dependent treadmill training may improve mobility, reduce postural instability and fear of falling in patients with Parkinson's disease. We examined whether 4 weeks of audio-visual (AV) cued task-specific training could enhance sit-to-stand (STS) and whether the treatment effects could outlast the treatment period by 2 weeks. Fifty-two subjects with PD completed the study. They were randomly allocated to receive 4 weeks of AV cued task-specific training, conventional exercise (Ex), or no treatment (control). Each subject was assessed before, at the end of 2 and 4 weeks of treatment, and 2 weeks after treatment ended. After 2 weeks of training, the AV group significantly increased the peak horizontal velocity (by 13%, P<0.01) when compared with the Ex group. After 4 weeks of training, AV group increased both peak horizontal and vertical velocities, respectively by 18% and 51%, and reduced the time taken to complete STS by 25%. These improvements were greater than those of the Ex group, who showed 8% (nonsignificant between-group) and 20% (P<0.05 between-group) increases respectively for peak horizontal and vertical velocities, and 10% decrease in movement time (P<0.05). Worth-noting is the improvements in AV group could be carried over to 2 weeks after treatment ended. These findings provided concrete evidence for the use of AV cued task-specific training to reeducate STS in patients with PD.
                (c) 2007 Movement Disorder Society. Gait and mobility problems are difficult to treat in people with Parkinson's disease. The Rehabilitation in Parkinson's Disease: Strategies for Cueing (RESCUE) trial investigated the effects of a home physiotherapy programme based on rhythmical cueing on gait and gait-related activity.
                A single-blind randomised crossover trial was set up, including 153 patients with Parkinson's disease aged between 41 and 80 years and in Hoehn and Yahr stage II-IV. Subjects allocated to early intervention (n = 76) received a 3-week home cueing programme using a prototype cueing device, followed by 3 weeks without training. Patients allocated to late intervention (n = 77) underwent the same intervention and control period in reverse order. After the initial 6 weeks, both groups had a 6-week follow-up without training. Posture and gait scores (PG scores) measured at 3, 6 and 12 weeks by blinded testers were the primary outcome measure. Secondary outcomes included specific measures on gait, freezing and balance, functional activities, quality of life and carer strain.
                Small but significant improvements were found after intervention of 4.2% on the PG scores (p = 0.005). Severity of freezing was reduced by 5.5% in freezers only (p = 0.007). Gait speed (p = 0.005), step length (p<0.001) and timed balance tests (p = 0.003) improved in the full cohort. Other than a greater confidence to carry out functional activities (Falls Efficacy Scale, p = 0.04), no carry-over effects were observed in functional and quality of life domains. Effects of intervention had reduced considerably at 6-week follow-up.
                Cueing training in the home has specific effects on gait, freezing and balance. The decline in effectiveness of intervention effects underscores the need for permanent cueing devices and follow-up treatment. Cueing training may be a useful therapeutic adjunct to the overall management of gait disturbance in Parkinson's disease. Irrespective of limited evidence, not only traditional physiotherapy, but also a wide array of complementary methods are applied by patients with Parkinson's disease (PD). We evaluated the immediate and sustained effects of Qigong on motor and nonmotor symptoms of PD, using an add-on design. Fifty-six patients with different levels of disease severity (mean age/standard deviation [SD], 63.8/7.5 years; disease duration 5.8/4.2 years; 43 men [76%]) were recruited from the outpatient movement disorder clinic of the Department of Neurology, University of Bonn. We compared the progression of motor symptoms assessed by Unified Parkinson's Disease Rating Scale motor part (UPDRS-III) in the Qigong treatment group (n = 32) and a control group receiving no additional intervention (n = 24). Qigong exercises were applied as 90-minute weekly group instructions for 2 months, followed by a 2 months pause and a second 2-month treatment period. Assessments were carried out at baseline, 3, 6, and 12 months. More patients improved in the Qigong group than in the control group at 3 and 6 months (P = 0.0080 at 3 months and P = 0.0503 at 6 months; Fisher's exact test). At 12 months, there was a sustained difference between groups only when changes in UPDRS-III were related to baseline. Depression scores decreased in both groups, whereas the incidence of several nonmotor symptoms decreased in the treatment group only.
                Copyright 2005 Movement Disorder Society. Parkinson disease (PD) reduces health-related quality of life (HRQoL), but exercise may improve HRQoL. This pilot study compared the effects of Tango, Waltz/Foxtrot, Tai Chi and No Intervention on HRQoL in individuals with PD. Seventy-five persons with PD (Hoehn and Yahr I-III) were assigned to 20 lessons of Tango, Waltz/Foxtrot, Tai Chi, or an untreated No Intervention group. Participants completed the PDQ-39 before and after participation in 20 classes or within 13 weeks in the case of the No Intervention group. Two-way repeated measures ANOVAs determined differences between interventions. Tango significantly improved on mobility (p=0.03), social support (p=0.05) and the PDQ-39 SI (p<0.01) at post-testing. No significant changes in HRQoL were noted in the Waltz/Foxtrot, Tai Chi or No Intervention. Tango may be helpful for improving HRQoL in PD because it addresses balance and gait deficits in the context of a social interaction that requires working closely with a partner. To investigate whether gait training with treadmill improves functional tasks of lower extremities in patients with Parkinson disease (PD).
                Randomized controlled trial including two groups, the treadmill training group and the nonintervention group.
                University hospital.
                Thirty consecutive patients diagnosed with idiopathic PD, who were on stable regimens of antiparkinsonian medication, able to walk independently, and had not participated in a rehabilitation program in the previous 3 months. Patients with severe cognitive impairments or severe musculoskeletal, cardiopulmonary, neurologic, or other systemic disorders were excluded. Twenty-four patients completed the study.
                Group I attended a training program on a treadmill for 6 weeks, and group II served as the control group. Both groups were instructed in home mobility exercises.
                The primary study outcome measures were timed functional lower-extremity tasks (walking at a corridor, U-turn, turning around a chair, stairs, standing on one foot, standing from a chair), and secondary outcome measures were exercise test and patient's global assessment. Assessments were performed at baseline and at the end of the study.
                There were significant improvements in functional lower-extremity tests, exercise test parameters, and patients' global assessment in group I, whereas no significant improvements were observed in group II.
                Even though long-term effects remain unknown and the study sample was small, it was concluded that treadmill training in PD patients led to improvements in lower-extremity tasks, thus improving patients' physical well-being in daily life. To evaluate the effectiveness of a personalised home programme of exercises and strategies for repeat fallers with Parkinson's disease (PD).
                Patients with a confirmed diagnosis of idiopathic PD, independently mobile, living at home in the community, experiencing more than one fall in the previous 12 months and with intact gross cognitive function were invited to participate in this randomised controlled trial. Usual care was compared with a personalised 6 week, home based exercise and strategy programme. The primary outcomes were rates of falling at 8 weeks and 6 months. Whether participants had repeat fallen, nearly fallen or experienced injurious falls were also examined. Functional Reach, the Berg Balance Test, PD Self-assessment Scale and the Euro Quol were rated by a blinded assessor.
                Participants were randomised to the exercise (n = 70) and control (n = 72) groups. There was a consistent trend towards lower fall rates in the exercise group at both 8 weeks and 6 months and lower rates of injurious falls needing medical attention at 6 months. Lower rates of repeat near falling were evident for the exercise group at 8 weeks (p = 0.004) and 6 months (p = 0.007). There was a positive effect of exercises at 6 months on Functional Reach (p = 0.009) and quality of life (p = 0.033). No significant differences were found on other secondary outcomes measures.
                There was a trend towards a reduction in fall events and injurious falls with a positive effect of exercises on near falls and quality of life. This randomized controlled trial with blinded assessment aimed to determine the effect of a 6-month minimally supervised exercise program on fall risk factors in people with Parkinson's disease (PD). Forty-eight participants with PD who had fallen or were at risk of falling were randomized into exercise or control groups. The exercise group attended a monthly exercise class and exercised at home three times weekly. The intervention targeted leg muscle strength, balance, and freezing. The primary outcome measure was a PD falls risk score. The exercise group had no major adverse events and showed a greater improvement than the control group in the falls risk score, which was not statistically significant (between group mean difference = -7%, 95% CI -20 to 5, P = 0.26). There were statistically significant improvements in the exercise group compared with the control group for two secondary outcomes: Freezing of Gait Questionnaire (P = 0.03) and timed sit-to-stand (P = 0.03). There were statistically nonsignificant trends toward greater improvements in the exercise group for measures of muscle strength, walking, and fear of falling, but not for the measures of standing balance. Further investigation of the impact of exercise on falls in people with PD is warranted. Rehabilitation plays an important role in treatment of Parkinson's disease (PD). The influence of rehabilitation on balance and gait in PD hasn't been widely investigated. There is general agreement about positive influence of rehabilitation on postural instability and prevention of falls, but therapeutic program prevention of falls hasn't been worked out. Ambiguous results of studies indicate necessity of further investigations.
                61 patient were included (H&Y 1, 5-3) and randomly assigned to two groups with and without rehabilitation. The balance test battery included: Functional Reach Test, Balance Performance-Oriented Mobility Assessment (Tinetti), assessment on force platform of quiet standing and active standing with Rhythmic Weight Shifts Test and dynamic task (reaction time, number of hitted targets). Gait was assessed with: timed Up&Go test, 10 m walk, locomotion test and 360 degrees turn. Patients were assessed 3 times, at month intervals. Between 1 and 2 assessment, exercising group took part in 1 month complex rehabilitation, consist of the 28 therapeutic sessions.
                The group, which took part in rehabilitation significantly improved in quiet standing with closed eyes after rehabilitation in comparison with initial status. All of the rest variables significantly improved in exercising group after rehabilitation both in comparison between evaluations and in comparison with the nonexercising group.
                Rehabilitation significantly influences balance and gait of patients with PD. Frequent falls and risk of injury are evident in individuals with Parkinson's disease (PD) as the disease progresses. There have been no reports of any interventions that reduce the incidence of falls in idiopathic PD.
                Assess the benefit of gait and step perturbation training in individuals with PD.
                Randomized, controlled trial.
                Outpatient research, education and clinical center in a tertiary care Veterans Affairs Medical Center.
                Gait parameters, 5-step test, report of falls.
                Eighteen men with idiopathic PD in stage 2 or 3 of the Hoehn and Yahr staging.
                Subjects were randomly assigned to a trained or control group. They were asked about any falls 2 weeks prior to and after an 8 week period. Gait speed, cadence, and step length were tested on an instrumented walkway. Subjects were timed while stepping onto and back down from an 8.8 cm step for 5 consecutive steps. Gait training consisted of walking on a treadmill at a speed greater than over ground walking speed while walking in 4 directions and while supported in a harness for safety. Step training consisted of suddenly turning the treadmill on and off while the subject stood in the safety harness facing either forwards, backwards, or sideways. Training occurred 1 hour per day, three times per week for 8 weeks. A two-factor (time and group) analysis of variance with repeated measures was used to compare the groups.
                Substantial reduction occurred in falls in the trained group, but not in the control group. Gait speed increased in the trained group from 1.28+/-0.33 meters/sec to 1.45+/-0.37 meters/sec, but not in the control group (from 1.26 to 1.27 m/s). The cadence increased for both groups: from 112.8 to 120.3 steps/min for the trained group and 117.7 to 124.3 steps/min for the control group. Stride lengths increased for the trained group, but not the control group. The 5-step test speed increased in the trained group from 0.40+/-0.08 steps/sec to 0.51+/-0.12 steps/sec, and in the control group (0.36+/-0.11 steps/sec to 0.42+/-0.11 steps/sec).
                Gait and step perturbation training resulted in a reduction in falls and improvements in gait and dynamic balance. This is a promising approach to reduce falls for patients with PD. The effectiveness of an exercise intervention for people in early and midstage Parkinson's disease (stages 2 and 3 of Hoehn and Yahr) in improving spinal flexibility and physical performance in a sample of community-dwelling older people is described.
                Fifty-one men and women, aged 55-84 years, identified through advertisement, local support groups, and local neurologists were enrolled into a randomized, controlled trial. Subjects were assigned randomly to an intervention or a usual care arm (i.e., no specific exercise). Of the original 51 participants, 46 completed the randomized, controlled trial. Participants in the exercise arm (n = 23) received individual instruction three times per week for 10 weeks. Participants in the usual care arm (n = 23) were "wait listed" for intervention.
                Changes over 10 weeks in spinal flexibility (i.e., functional axial rotation) and physical performance (i.e., functional reach, timed supine to stand) were the primary outcome measures.
                MANOVA conducted for the three primary outcome variables demonstrated significant differences (P < or = .05) between the two groups. Further analysis using ANOVA demonstrated significant differences between groups in functional axial rotation and functional reach for the intervention compared with the control group. There was no significant difference in supine to sit time.
                Study results demonstrate that improvements in axial mobility and physical performance can be achieved with a 10-week exercise program for people in the early and midstages of PD. To obtain preliminary data on the effects of high-intensity exercise on functional performance in people with Parkinson's disease (PD) relative to exercise at low and no intensity and to determine whether improved performance is accompanied by alterations in corticomotor excitability as measured through transcranial magnetic stimulation (TMS).
                Cohort (prospective), randomized controlled trial.
                University-based clinical and research facilities.
                Thirty people with PD, within 3 years of diagnosis with Hoehn and Yahr stage 1 or 2.
                Subjects were randomized to high-intensity exercise using body weight-supported treadmill training, low-intensity exercise, or a zero-intensity education group. Subjects in the 2 exercise groups completed 24 exercise sessions over 8 weeks. Subjects in the zero-intensity group completed 6 education classes over 8 weeks.
                Unified Parkinson's Disease Rating Scales (UPDRS), biomechanic analysis of self-selected and fast walking and sit-to-stand tasks; corticomotor excitability was assessed with cortical silent period (CSP) durations in response to single-pulse TMS.
                A small improvement in total and motor UPDRS was observed in all groups. High-intensity group subjects showed postexercise increases in gait speed, step and stride length, and hip and ankle joint excursion during self-selected and fast gait and improved weight distribution during sit-to-stand tasks. Improvements in gait and sit-to-stand measures were not consistently observed in low- and zero-intensity groups. The high-intensity group showed lengthening in CSP.
                The findings suggest the dose-dependent benefits of exercise and that high-intensity exercise can normalize corticomotor excitability in early PD. The current study compared lower-limb aerobic training and sensory attention focused exercise (PD SAFEx) to a non-exercise control group with the overall objective of determining which strategy would have a greater benefit for Parkinson's disease (PD) symptoms and gait. PD SAFEx was developed to focus on sensorimotor deficits identified in PD with the aim of increasing sensory feedback and body awareness, while the lower-limb aerobic training utilized a specially designed semi-recumbent elliptical device. Intervention groups (PD SAFEx, n = 18; aerobic, n = 13) exercised three times/week for 10-12 weeks, while nonexercise control participants (n = 15) maintained their regular activity level for 12 weeks. Outcome measures included the Unified Parkinson's disease rating scale motor section (UPDRS) administered by a blinded clinician; a posture and gait (PG) score (total of UPDRS items 27-31); the Timed-Up-and-Go (TUG); and spatiotemporal aspects of self-paced gait. PD SAFEx resulted in an improved UPDRS, PG score, and TUG (reached significance when participants with poor attendance were excluded) but not self-paced gait. The lower-limb aerobic training led to increased step length and velocity but had no change to disease severity. Since gait improvements were not combined with symptomatic changes, lower-limb aerobic exercise may not be optimal for individuals with PD. Conversely, sensory-based exercise (PD SAFEx) was beneficial, and led to improvement in symptoms and functional movement control.
                (c) 2009 Movement Disorder Society. To investigate the effects of a physical therapy (PT) program in groups of people with Parkinson's disease (PD).
                Randomized controlled trial with a crossover design.
                Two outpatient rehabilitation clinics in Boston and Amsterdam, respectively.
                Sixty-eight subjects diagnosed with typical, idiopathic PD, Hoehn and Yahr stage II or III, and stable medication use.
                Group A received PT and medication therapy (MT) for the first 6 weeks, followed by MT only for the second 6 weeks. Group B received only MT for the first 6 weeks and PT and MT for the second 6 weeks.
                The Sickness Impact Profile (SIP-68), the mobility portion of the SIP-68, the Unified Parkinson's Disease Rating Scale (UPDRS), and comfortable walking speed (CWS) at baseline, 6-week, 12-week, and 3-month follow-up.
                At 6 weeks, differences between groups were significant for the SIP mobility ( P =.015; effect size [ES]=.55), for CWS ( P =.012; ES=.49), for the activities of daily living (ADL) section of the UPDRS ( P =.014; ES=.45), and for the total UPDRS ( P =.007; ES=.56). The total SIP and the mentation and motor sections of the UPDRS did not differ significantly between groups. Significant differences were found at 3 months compared with baseline for CWS, the UPDRS ADL, and total scores.
                People with PD derive benefits in the short term from PT group treatment, in addition to their MT, for quality of life related to mobility, CWS, and ADLs; long-term benefits were found in CWS, UPDRS ADL, and total scores but varied between groups. To assess immediate and near-term effects of an instructional set on select gait parameters in people living with Parkinson disease (PD).
                Five individuals with early stage PD participated in a within subject design in Part One. Eleven individuals with early stage PD were randomly assigned to a treatment group (n = 5) or a control group (n = 6) in Part Two.
                The treatment consisted of a 10-day training program of walking 1800 feet per day and with the instructions to take long steps. Testing occurred before treatment (baseline), immediately after treatment, one week after treatment, and one month after treatment. Measurements of step length, velocity, and cadence were taken without the use of the instructional set.
                There was a significant increase in step length and velocity and a significant decrease in cadence between baseline and all post-test measures for part one. For part 2, step length of the treatment group significantly increased between baseline and all 3 post-tests and there was a significant difference between the treatment group and control group at all posttests for step length.
                The instructional set was effective in improving parameters of gait for at least 4 weeks. These data support the concept that people with Parkinson disease have a potential for motor learning.
Benefit for physiotherapy was found in most outcomes over the short-term (i.e. < three months), but was only significant for velocity, two- or six-minute walk test, step length, Timed Up & Go, Functional Reach Test, Berg Balance Scale and clinician-rated UPDRS. Most of the observed differences between the treatments were small. However, for some outcomes (e.g. velocity, Berg Balance Scale and UPDRS), the differences observed were at, or approaching, what are considered minimally clinical important changes.
The review illustrates that a wide range of approaches are employed by physiotherapists to treat PD. However, there was no evidence of differences in treatment effect between the different types of physiotherapy interventions being used, though this was based on indirect comparisons. There is a need to develop a consensus menu of 'best-practice' physiotherapy, and to perform large well-designed randomised controlled trials to demonstrate the longer-term efficacy and cost-effectiveness of 'best practice' physiotherapy in PD.