Margaret Schenkman

Striding Out With Parkinson Disease: Evidence-Based Physical Therapy for Gait Disorders

Although Parkinson disease (PD) is common throughout the world, the evidence for physical therapy interventions that enable long-term improvement in walking is still emerging. This article critiques the major physical therapy approaches related to gait rehabilitation in people with PD: compensatory strategies, motor skill learning, management of secondary sequelae, and education to optimize physical activity and reduce falls. The emphasis of this review is on gait specifically, although balance and falls are of direct importance to gait and are addressed in that context. Although the researchers who have provided the evidence for these approaches grounded their studies on different theoretical paradigms, each approach is argued to have a valid place in the comprehensive management of PD generally and of gait in particular. The optimal mix of interventions for each individual varies according to the stage of disease progression and the patients preferred form of exercise, capacity for learning, and age.

Effects of Vestibular Rehabilitation on Multiple Sclerosis–Related Fatigue and Upright Postural Control: A Randomized Controlled Trial

Background Fatigue and impaired upright postural control (balance) are the 2 most common findings in people with multiple sclerosis (MS), with treatment approaches varying greatly in effectiveness. Objectives The aim of this study was to investigate the benefits of implementing a vestibular rehabilitation program for the purpose of decreasing fatigue and improving balance in patients with MS. Design The study was a 14-week, single-blinded, stratified blocked randomized controlled trial. Setting Measurements were conducted in an outpatient clinical setting, and interventions were performed in a human performance laboratory. Patients Thirty-eight patients with MS were randomly assigned to an experimental group, an exercise control group, or a wait-listed control group. Intervention The experimental group underwent vestibular rehabilitation, the exercise control group underwent bicycle endurance and stretching exercises, and the wait-listed control group received usual medical care. Measurements Primary measures were a measure of fatigue (Modified Fatigue Impact Scale), a measure of balance (posturography), and a measure of walking (Six-Minute Walk Test). Secondary measures were a measure of disability due to dizziness or disequilibrium (Dizziness Handicap Inventory) and a measure of depression (Beck Depression Inventory–II). Results Following intervention, the experimental group had greater improvements in fatigue, balance, and disability due to dizziness or disequilibrium compared with the exercise control group and the wait-listed control group. These results changed minimally at the 4-week follow-up. Limitations The study was limited by the small sample size. Further investigations are needed to determine the underlying mechanisms associated with the changes in the outcome measures due to the vestibular rehabilitation program. Conclusion A 6-week vestibular rehabilitation program demonstrated both statistically significant and clinically relevant change in fatigue, impaired balance, and disability due to dizziness or disequilibrium in patients with MS.

Exercise for People in Early- or Mid-Stage Parkinson Disease: A 16-Month Randomized Controlled Trial

Background Exercise confers short-term benefits for individuals with Parkinson disease (PD). Objective The purpose of the study was to compare short- and long-term responses among 2 supervised exercise programs and a home-based control exercise program. Design The 16-month randomized controlled exercise intervention investigated 3 exercise approaches: flexibility/balance/function exercise (FBF), supervised aerobic exercise (AE), and home-based exercise (control). Setting This study was conducted in outpatient clinics. Patients The participants were 121 individuals with PD (Hoehn & Yahr stages 1–3). Interventions The FBF program (individualized spinal and extremity flexibility exercises followed by group balance/functional training) was supervised by a physical therapist. The AE program (using a treadmill, bike, or elliptical trainer) was supervised by an exercise trainer. Supervision was provided 3 days per week for 4 months, and then monthly (16 months total). The control group participants exercised at home using the National Parkinson Foundation Fitness Counts program, with 1 supervised, clinic-based group session per month. Measurements Outcomes, obtained by blinded assessors, were determined at 4, 10, and 16 months. The primary outcome measures were overall physical function (Continuous Scale—Physical Functional Performance [CS-PFP]), balance (Functional Reach Test [FRT]), and walking economy (oxygen uptake [mL/kg/min]). Secondary outcome measures were symptom severity (Unified Parkinsons Disease Rating Scale [UPDRS] activities of daily living [ADL] and motor subscales) and quality of life (39-item Parkinsons Disease Quality of Life Scale [PDQ-39]). Results Of the 121 participants, 86.8%, 82.6%, and 79.3% completed 4, 10, and 16 months, respectively, of the intervention. At 4 months, improvement in CS-PFP scores was greater in the FBF group than in the control group (mean difference=4.3, 95% confidence interval [CI]=1.2 to 7.3) and the AE group (mean difference=3.1, 95% CI=0.0 to 6.2). Balance was not different among groups at any time point. Walking economy improved in the AE group compared with the FBF group at 4 months (mean difference=−1.2, 95% CI=−1.9 to −0.5), 10 months (mean difference=−1.2, 95% CI=−1.9 to −0.5), and 16 months (mean difference=−1.7, 95% CI=−2.5 to −1.0). The only secondary outcome that showed significant differences was UPDRS ADL subscale scores: the FBF group performed better than the control group at 4 months (mean difference=−1.47, 95% CI=−2.79 to −0.15) and 16 months (mean difference=−1.95, 95% CI=−3.84 to −0.08). Limitations Absence of a non-exercise control group was a limitation of the study. Conclusions Findings demonstrated overall functional benefits at 4 months in the FBF group and improved walking economy (up to 16 months) in the AE group.

Comparison of Self-Reported Knee Injury and Osteoarthritis Outcome Score to Performance Measures in Patients After Total Knee Arthroplasty

To characterize patient outcomes after total knee arthroplasty (TKA) by (1) examining changes in self‐report measures (Knee Injury and Osteoarthritis Outcome Score [KOOS]) and performance measures over the first 6 months after TKA, (2) evaluating correlations between changes in KOOS self‐report function (activities of daily living [ADL] subscale) and functional performance (6‐minute walk [6MW]), and (3) exploring how changes in pain correlate with KOOS ADL and 6MW outcomes.

Walking economy in people with Parkinson's disease.

Gait dysfunction is an early problem identified by patients with Parkinsons disease (PD). Alterations in gait may result in an increase in the energy cost of walking (i.e., walking economy). The purpose of this study was to determine whether walking economy is atypical in patients with PD when compared with healthy controls. A secondary purpose was to evaluate the associations of age, sex, and level of disease severity with walking economy in patients with PD. The rate of oxygen consumption (V̇O2) and other responses to treadmill walking were compared in 90 patients (64.4 ± 10.3 years) and 44 controls (64.6 ± 7.3 years) at several walking speeds. Pearson correlation coefficients (r) were calculated to determine relationships of age, sex, and disease state with walking economy in PD patients. Walking economy was significantly worse in PD patients than in controls at all speeds above 1.0 mph. Across all speeds, V̇O2 was 6 to 10% higher in PD patients. Heart rate, minute ventilation, respiratory exchange ratio, and rating of perceived exertion were correspondingly elevated. No significant relationship of age, sex, or UPDRS score with V̇O2 was found for patients with PD. The findings suggest that the physiologic stress of daily physical activities is increased in patients with early to mid‐stage PD, and this may contribute to the elevated level of fatigue that is characteristic of PD.

Kinematic characterization of standing reach: comparison of younger vs. older subjects

OBJECTIVE To characterize typical spinal motions that occur during standing reach and to describe differences in spinal motions and center of pressure displacements during reach between younger and older healthy adults. DESIGN Exploratory, cross sectional investigation utilizing video motion and biomechanics force platform analysis. BACKGROUND Standing reach provides a means for assessing both arm function and balance control in the context of a common functional activity. The interaction between age-related declines in spinal mobility and the spinal motion occurring during reach is poorly understood. The characterization of spinal motions during task performance for healthy subjects of different age groups is an important first step for understanding the relationship between impairments and physical performance in disabled populations. METHODS Thirty-four subjects ages 20-36 and 33 subjects ages 60-76 participated. Video motion and force plate analysis were used to characterize spinal motion and center of pressure displacements during the functional reach test for younger and older subjects. RESULTS Spinal motion during standing reach was characterized by forward trunk flexion, lateral trunk flexion, thoracolumbar rotation, and lower body rotation. Younger and older subjects differed (P = 0.05) in the amount of forward trunk flexion and thoracolumbar rotation which occurred but not lower body rotation. Younger subjects displaced their center of pressure further forward (P = 0.0001) and through a greater percentage of their initial base of support (P = 0.0001) than older subjects. CONCLUSION This study provides the first multiplanar characterization of spinal motion used during standing reach. Significant differences for a number of variables existed between younger and older subjects.

Endurance Exercise Training to Improve Economy of Movement of People With Parkinson Disease: Three Case Reports

Background and Purpose: Even early in Parkinson disease (PD), individuals have reduced economy of movement. In this case report, the effects of endurance exercise training are examined on walking economy and other measures for 3 individuals in early and middle stages of PD. Patients: The patients were 1 woman and 2 men with PD, aged 52 to 72 years, classified at Hoehn and Yahr stages 2 to 2.5. Intervention: Each patient completed 4 months of supervised endurance exercise training and 12 months of home exercise, with monthly clinic follow-up sessions. Strategies were included to enhance adherence to exercise. Outcomes: The main outcome measure was economy of movement (rate of oxygen consumption during gait) measured at 4 treadmill speeds. Secondary outcome measures included the Unified Parkinsons Disease Rating Scale (UPDRS), Continuous-Scale Physical Functional Performance Test (CS-PFP), Functional Reach Test (FRT), and Functional Axial Rotation Test (FAR). Economy of movement improved for all 3 patients after 4 months of supervised exercise and remained above baseline at 16 months. Two patients also had scores that were above baseline for UPDRS total score, CS-PFP, FRT, and FAR, even at 16 months. Discussion and Conclusions: Evidence from these 3 individuals suggests that gains may occur with a treadmill training program that is coupled with specific strategies to enhance adherence to exercise.

Relative Contributions of Adiposity and Muscularity to Physical Function in Community‐dwelling Older Adults

Objective: To determine the relative contributions of adiposity and muscularity to multi‐dimensional performance‐based and perceived physical function in older adults living independently.

Relationship Between Intensity of Quadriceps Muscle Neuromuscular Electrical Stimulation and Strength Recovery After Total Knee Arthroplasty

Background Neuromuscular electrical stimulation (NMES) can facilitate the recovery of quadriceps muscle strength after total knee arthroplasty (TKA), yet the optimal intensity (dosage) of NMES and its effect on strength after TKA have yet to be determined. Objective The primary objective of this study was to determine whether the intensity of NMES application was related to the recovery of quadriceps muscle strength early after TKA. A secondary objective was to quantify quadriceps muscle fatigue and activation immediately after NMES to guide decisions about the timing of NMES during rehabilitation sessions. Design This study was an observational experimental investigation. Methods Data were collected from 30 people who were 50 to 85 years of age and who received NMES after TKA. These people participated in a randomized controlled trial in which they received either standard rehabilitation or standard rehabilitation plus NMES to the quadriceps muscle to mitigate strength loss. For the NMES intervention group, NMES was applied 2 times per day at the maximal tolerable intensity for 15 contractions beginning 48 hours after surgery over the first 6 weeks after TKA. Neuromuscular electrical stimulation training intensity and quadriceps muscle strength and activation were assessed before surgery and 3.5 and 6.5 weeks after TKA. Results At 3.5 weeks, there was a significant association between NMES training intensity and a change in quadriceps muscle strength (R2=.68) and activation (R2=.22). At 6.5 weeks, NMES training intensity was related to a change in strength (R2=.25) but not to a change in activation (R2=.00). Furthermore, quadriceps muscle fatigue occurred during NMES sessions at 3.5 and 6.5 weeks, whereas quadriceps muscle activation did not change. Limitations Some participants reached the maximal stimulator output during at least 1 treatment session and might have tolerated more stimulation. Conclusions Higher NMES training intensities were associated with greater quadriceps muscle strength and activation after TKA.

An Integrated Framework for Decision Making in Neurologic Physical Therapist Practice

Decision-making frameworks are used by clinicians to guide patient management, communicate with other health care providers, and educate patients and their families. A number of frameworks have been applied to guide clinical practice, but none are comprehensive in terms of patient management. This article proposes a unifying framework for application to decision making in the management of individuals who have neurologic dysfunction. The framework integrates both enablement and disablement perspectives. The framework has the following attributes: (1) it is patient-centered, (2) it is anchored by the patient/client management model from the Guide for Physical Therapist Practice, (3) it incorporates the Hypothesis-Oriented Algorithm for Clinicians (HOAC) at every step, and (4) it proposes a systematic approach to task analysis for interpretation of movement dysfunction. This framework provides a mechanism for making clinical decisions, developing clinical hypotheses, and formulating a plan of care. Application of the framework is illustrated with a case example of an individual with neurologic dysfunction.