Cheryl M. Petersen

Long-Term Locomotor Training for Gait and Balance in a Patient With Mixed Progressive Supranuclear Palsy and Corticobasal Degeneration

Background and Purpose: Progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD) are slowly progressive tauopathies characterized by impaired balance, disturbances in gait, and frequent falls, among other features. Wheelchair dependence is an inevitable outcome in people with these disorders. Insufficient evidence exists regarding the effectiveness of exercise in the management of people with these disorders. This case report describes a program of exercise and long-term locomotor training, using a treadmill (both with and without body-weight support), to reduce falls and improve the balance and walking ability of a patient with mixed PSP and CBD features. Case Description: Six years after diagnosis with mixed PSP and CBD features, the client, a 72-year-old dentist, was seen for physical therapy for asymmetric limb apraxia, markedly impaired balance, and frequent falls during transitional movements. Intervention: Over a 2.5-year period, intervention included routine participation in an exercise group for people with Parkinson disease (mat exercise and treadmill training) and intermittent participation in individual locomotor training on a treadmill. The exercise group met for 1 hour, twice weekly. The individual treadmill sessions lasted 1 hour, once weekly, for two 14-week periods during the follow-up period. Outcomes: Over the 2.5-year period, fall frequency decreased, and tests of functional balance showed improved limits of stability (functional reach tests) and maintained balance function (Berg Balance Scale). Tests of walking performance showed only slight declines. A 4-wheeled walker was introduced and accepted by the client early in the intervention period. The client, with supervision, remained ambulatory with this wheeled walker in the community. Discussion: In this case report of a person with mixed PSP and CBD features, a physical therapy intervention, which included locomotor training using a treadmill and a long-term exercise program of stretching and strengthening, appears to have improved some dimensions of balance, slowed the rate of gait decline, prevented progression to wheelchair dependence, and decreased falls. Contrary to the expected decline in function, this client maintained independent mobility over a 2.5-year period. An ongoing, intensive program of exercise and locomotor training may help people with PSP and CBD maintain upright balance, decrease falls, and decrease the rate of decline of ambulation.

Upper Limb Neurodynamic Test of the Radial Nerve: A Study of Responses in Symptomatic and Asymptomatic Subjects

STUDY DESIGN Clinical measurement. INTRODUCTION Nonspecific cervical pain is a common clinical presentation. The role of upper limb neurodynamic tests (ULNT), for evaluation and treatment intervention, is not well defined for this population. PURPOSE OF THE STUDY This studys purpose was to determine if the radial-biased (RB)-ULNT discriminates any response differences between symptomatic subjects with a positive (+) RB-ULNT (n=36), symptomatic subjects with a negative (-) RB-ULNT (n=24), and asymptomatic subjects (n=60). METHODS Sixty asymptomatic and 60 subjects presenting with nonspecific cervical and/or unilateral upper extremity pain were compared using the RB-ULNT. Symptomatic subjects were further divided in (+) and (-) RB-ULNT groups due to their response to the RB-ULNT. Within the symptomatic population, a positive response to the RB-ULNT was defined by the symptomatic subject reporting their sensations were increased with contralateral cervical lateral flexion and decreased with ipsilateral cervical lateral flexion. Sensation provocation and location were evaluated using the RB-ULNT in all the subjects during each stage of the testing. RESULTS Significant differences on stage of reproduction and type of sensations were identified between 1) the (+) RB-ULNT symptomatic subjects, 2) the (-) RB-ULNT symptomatic subjects, and 3) the asymptomatic subjects. The (+) RB-ULNT group showed significantly increased pain responses during the first stage of the RB-ULNT compared with the (-) RB-ULNT group and the asymptomatic subjects. The (+) RB-ULNT also showed significantly decreased glenohumeral abduction passive range of motion when compared with the asymptomatic group. CONCLUSION Clinically, the differences found between the groups in their response to the RB-ULNT suggest heightened mechanosensitivity in the (+) RB-ULNT group. LEVEL OF EVIDENCE 3a.

Long-Term Exercise Training for an Individual With Mixed Corticobasal Degeneration and Progressive Supranuclear Palsy Features: 10-Year Case Report Follow-up

Background and Purpose This case report describes the effects of long-term (10-year) participation in a community exercise program for a client with mixed features of corticobasal degeneration (CBD) and progressive supranuclear palsy (PSP). The effects of exercise participation on both functional status and brain volume are described. Case Description A 60-year-old male dentist initially reported changes in gait and limb coordination. He received a diagnosis of atypical CBD at age 66 years; PSP was added at age 72 years. At age 70 years, the client began a therapist-led community group exercise program for people with Parkinson disease (PD). The program included trunk and lower extremity stretching and strengthening, upright balance and strengthening, and both forward and backward treadmill walking. The client participated twice weekly for 1 hour for 10 years and was reassessed in years 9 to 10. Outcomes Falls (self-reported weekly over the 10-year period of the study by the client and his wife) decreased from 1.9 falls per month in year 1 to 0.3 falls per month in year 10. Balance, walking endurance, and general mobility declined slightly. Gait speed (both comfortable and fast) declined; the client was unable to vary gait speed. Quantitative brain measurements indicated a slow rate of whole brain volume loss and ventricular expansion compared with clients with autopsy-proven CBD or PSP. Discussion This client has participated consistently in a regular group exercise program for 10 years. He has reduced fall frequency, maintained balance and endurance, and retained community ambulation using a walker. Combined with the slow rate of brain volume loss, this evidence supports the efficacy of a regular exercise program to prolong longevity and maintain function in people with CBD or PSP.

Community-based exercise and wellness program for people diagnosed with Parkinson disease: experiences from a 10-month trial.

Objective:This study considered whether a therapy community could create an infrastructure for developing and maintaining a service delivery model grounded in a clinic-based physiotherapy model. A longitudinal clinical study was conducted to assess the abilities of participants with Parkinson disease in a 10-month community exercise program. Methods:Fifteen individuals averaging stage 3 on the Hoehn and Yahr scale, 6 years since Parkinson disease diagnosis, and 72 years old, participated. Results:Graphical analysis of ambulation endurance demonstrated the strongest improvement over time (11%). Walking speeds, balance, and mobility showed a maintenance effect over the 10 months. The total Unified Parkinson Disease Rating Scale, Activities of Daily Living subscale, and Motor subscale remained statistically unchanged in the study. Scores on the Unified Parkinson Disease Rating Scale Mentation, Behavior, and Mood subscale improved by 38%. None of the scores met or exceeded the minimal detectable change, MDC95 but two scores demonstrated more than 10% change. Conclusion:This clinical study implemented previous short-term research findings into an ongoing community wellness program for individuals with Parkinson disease. No community-based studies have demonstrated an ability to maintain a group for an extended time frame. Group exercise including forward and backward treadmill training, designed and monitored by a physical therapist, may improve or maintain functional outcomes.

A new measurement method for spine reposition sense.

BackgroundA cost effective tool for the measurement of trunk reposition sense is needed clinically. This study evaluates the reliability and validity of a new clinical spine reposition sense device.MethodsThe first part of this three part investigation included 45 asymptomatic subjects examined in the first 20 repeated trials portion assessing spine reposition sense. The second portion, test-retest, examined 57 asymptomatic subjects. Initial testing consisted of subjects sitting on the device and performing 20 trials of a self-determined 2/3 trunk flexion position. The second portion of the study involved 7 trials of trunk flexion performed twice. The angular position for each trial was calculated and the mean reposition error from the initial 2/3 position was determined. For the third portion, the new device was compared to the Skill Technologies 6D (ST6D) Imperial Motion Capture and Analysis System.ResultsICC (3,1) for trials 4–7 was 0.79 and 0.76 for time one and time two, respectively and the test-retest ICC (3,k) was 0.38. Due to the poor test-retest ICC, the Bland Altman method was used to compare test and retest absolute errors. Most measurement differences were small and fell within the 95% confidence interval. Comparable measures between the two methods were found using the Bland Altman method to compare the reposition sense device to the ST6D system.ConclusionThe device may be a cost effective clinical technique for sagittal trunk reposition sense measurement.

Validation of spinal motion with the spine reposition sense device

BackgroundA sagittal plane spine reposition sense device (SRSD) has been developed. Two questions were addressed with this study concerning the new SRSD: 1) whether spine movement was occurring with the methodology, and 2) where movement was taking place.MethodsSixty-five subjects performed seven trials of repositioning to a two-thirds full flexion position in sitting with X and Y displacement measurements taken at the T4 and L3 levels. The thoracolumbar angle between the T4 and the L3 level was computed and compared between the positions tested. A two (vertebral level of thoracic and lumbar) by seven (trials) mixed model repeated measures ANOVA indicated whether significant differences were present between the thoracic (T4) and lumbar (L3) angular measurements.ResultsCalculated thoracolumbar angles between T4 and L3 were significantly different for all positions tested indicating spinal movement was occurring with testing. No interactions were found between the seven trials and the two vertebral levels. No significant findings were found between the seven trials but significant differences were found between the two vertebral levels.ConclusionThis study indicated spine motion was taking place with the SRSD methodology and movement was found specific to the lumbar spine. These findings support utilizing the SRSD to evaluate changes in spine reposition sense during future intervention studies dealing with low back pain.

Reliability and Minimal Detectable Change for Sit-to-stand Tests and the Functional Gait Assessment for Individuals With Parkinson Disease.

Background and Purpose: This study examined test-retest relative (intraclass correlation coefficient [ICC]) and absolute (minimum detectable change [MDC]) reliabilities for the 5 times sit-to-stand (5×STS), 30-second sit-to-stand (30sSTS), and the functional gait assessment (FGA) tests in people with Parkinson disease (PD). In addition, correlation of these functional tests with a history of falls was examined over a 6-month period, and the internal consistency of the FGA was established. Methods: Twenty-two patients with PD (Hoehn and Yahr stages 1-3) completed 3 functional tests over 2 test-retest periods of 6 to 8 days. Falls were self-reported for the prior 6 months. Results and Discussion: Moderate-to-excellent test-retest ICC(2,2) and MDC95 values were found for the 30sSTS (0.94, 3 times) and ICC(2,1) and MDC95 values were found for the FGA (0.86, 4 points). The 5×STS demonstrated a lower ICC(2,2) and a high MDC95 value (0.74, 10 seconds). A significant correlation was only found between past falls and the FGA test (r =−0.48, P < .05) during session 1. Cronbach &agr; values for the 10-item FGA during session 1 and session 2 were 0.75 and 0.85, respectively. Conclusions: To assess for change over time, we found the 30sSTS and the FGA tests can be used reliably in patients with PD. A lower FGA score was associated with a higher chance of falls, and good internal consistency of the FGA was found.

The Effect of Parkinson Drug Timing on Cardiovascular Response during Treadmill Exercise in a Person with Parkinson Disease and Freezing of Gait

PURPOSE To examine the response of cerebral oxygenation during treadmill walking in a person with Parkinson disease (PD) who experiences freezing of gait (FOG) and to determine whether the oxygen response was related to the timing of his PD medication. Client Description: A 61-year-old man with PD performed two bouts of treadmill testing on the same day, during the on- and off-phases of his PD medication. Measures and Outcome: The client experienced two FOG episodes during the first testing session (on-phase with hypokinetic movement session). Cerebral oxygen response (measured by near-infrared spectroscopy) was stable until the FOG episodes occurred, at which point it decreased until the FOG episode was over. No electrocardiogram (ECG) changes or lightheadedness were noted; blood pressure (BP) remained stable. During the second exercise testing session (off-phase with dyskinetic movement session), the client did not experience any FOG episodes, and his cerebral oxygen response remained stable. Toward the end of the second testing session, he experienced lightheadedness and a drop in BP of approximately 30 mmHg, along with significant ST segment depression on his ECG. IMPLICATIONS Haemodynamic and cerebral oxygen changes occurred that were specific to the timing of the clients PD medication and to his FOG episodes. This case study shows a person with PD demonstrating decreased cerebral oxygenation during FOG, which may be based on his variable response to levodopa medication or may be attributable to as yet unidentified physiologic mechanisms.

The reliability and minimal detectable change of the cardiovascular response and self-selected exercise intensity during forward and backward treadmill exercise in individuals with Parkinson disease

Objective: This study examined test–retest relative (intraclass correlation coefficient) and absolute (minimum detectable change) reliabilities for heart rate, blood pressure, rate of perceived exertion, and the cerebral oxygen response during both forward and backward treadmill walking in clients with Parkinson disease. In addition, the intensity of exercise based on the individual’s heart rate response during forward and backward walking treadmill work was assessed. Design: Test–retest reliability study. Subjects: A total of 22 clients with Parkinson disease (Hoehn and Yahr stages 1–3). Main measures: Outcome measures of heart rate, blood pressure, and cerebral oxygen response were assessed during forward and backward walking on a treadmill for a total of 20 minutes up to an intensity based on the clients’ prior treadmill work and their rate of perceived exertion. Results: Good to excellent 6–8 day test–retest findings for both forward (intraclass correlation coefficient(2,1), 0.89–0.99) and backward (intraclass correlation coefficient(2,1), 0.82–0.99) treadmill walking were found for heart rate, blood pressure, cerebral oxygen response, and the participants’ rate of perceived exertion. Low minimum detectable change (MDC)95 values were found for heart rate (4.9 and 4.8), rate of perceived exertion (1.0 and 1.6), and cerebral oxygen response (1.2 and 0.92), during forward and backward walking, respectively. All treadmill exercise heart rates attained by participants were within an intensity of 54%–87% of the client’s predicted maximal heart rate. Conclusion: Treadmill exercise training can be included in Parkinson disease exercise programs with relative confidence in test–retest reliability of cardiovascular response. It was also demonstrated that individuals with Parkinson disease previously involved with exercise consistently self-select walking speeds which induce heart rates within recommended guidelines for positive cardiovascular adaptation.