Matthew P. Ford

Barriers to Exercise in People With Parkinson Disease

Background Exercise is known to reduce disability and improve quality of life in people with Parkinson disease (PD). Although barriers to exercise have been studied in older adults, barriers in people with chronic progressive neurological diseases, such as PD, are not well defined. Objective The purpose of this study was to identify perceived barriers to exercise in people with PD. Design The study had a cross-sectional design. Methods People who had PD, dwelled in the community, and were at stage 2.4 on the Hoehn and Yahr scale participated in this cross-sectional study (N=260; mean age=67.7 years). Participants were divided into an exercise group (n=164) and a nonexercise group (n=96). Participants self-administered the barriers subscale of the Physical Fitness and Exercise Activity Levels of Older Adults Scale, endorsing or denying specific barriers to exercise participation. Multivariate logistic regression analysis was used to examine the contribution of each barrier to exercise behavior, and odds ratios were reported. Results Three barriers were retained in the multivariate regression model. The nonexercise group had significantly greater odds of endorsing low outcome expectation (ie, the participants did not expect to derive benefit from exercise) (odds ratio [OR]=3.93, 95% confidence interval [CI]=2.08–7.42), lack of time (OR=3.36, 95% CI=1.55–7.29), and fear of falling (OR=2.35, 95% CI=1.17–4.71) than the exercise group. Limitations The cross-sectional nature of this study limited the ability to make causal inferences. Conclusions Low outcome expectation from exercise, lack of time to exercise, and fear of falling appear to be important perceived barriers to engaging in exercise in people who have PD, are ambulatory, and dwell in the community. These may be important issues for physical therapists to target in people who have PD and do not exercise regularly. The efficacy of intervention strategies to facilitate exercise adherence in people with PD requires further investigation.

Factors Associated With Exercise Behavior in People With Parkinson Disease

Background The benefits of exercise for reducing disability in people with Parkinson disease (PD) are becoming more evident. Optimal benefit, however, requires regular and sustained participation. Factors associated with engaging in regular exercise have received little scientific scrutiny in people with PD. Objective The purpose of this study was to explore factors associated with exercise behavior in patients with PD using the International Classification of Functioning, Disability and Health (ICF) as a guiding framework. Design This was a cross-sectional study. Methods The participants in this study were 260 patients with PD from 4 institutions. Participants were designated as “exercisers” or “nonexercisers” based on responses to the Stages of Readiness to Exercise Questionnaire. Exercise status was validated using the Physical Activity Scale for the Elderly and an activity monitor. Factors potentially associated with exercise behavior included measures of body structure and function, activity, participation, environmental factors, and personal factors. Their relative contributions were analyzed using logistic regression and quantified with odds ratios. Results One hundred sixty-four participants (63%) were designated as exercisers. Participants with high self-efficacy were more than twice as likely to engage in regular exercise than those with low self-efficacy (adjusted odds ratio=2.34, 95% confidence interval=1.30–4.23). College educated and older participants also were more likely to exercise. Disabling influences of impairments, activity limitations, and participation restrictions were not associated with exercise behavior. Limitations The cross-sectional nature of the study limited the ability to make causal inferences. Conclusions Self-efficacy, rather than disability, appears to be strongly associated with whether ambulatory, community-dwelling people with PD exercise regularly. The results of this study suggest that physical therapists should include strategies to increase exercise self-efficacy when designing patient intervention programs for patients with PD.

Accuracy of Fall Prediction in Parkinson Disease: Six-Month and 12-Month Prospective Analyses

Introduction. We analyzed the ability of four balance assessments to predict falls in people with Parkinson Disease (PD) prospectively over six and 12 months. Materials and Methods. The BESTest, Mini-BESTest, Functional Gait Assessment (FGA), and Berg Balance Scale (BBS) were administered to 80 participants with idiopathic PD at baseline. Falls were then tracked for 12 months. Ability of each test to predict falls at six and 12 months was assessed using ROC curves and likelihood ratios (LR). Results. Twenty-seven percent of the sample had fallen at six months, and 32% of the sample had fallen at 12 months. At six months, areas under the ROC curve (AUC) for the tests ranged from 0.8 (FGA) to 0.89 (BESTest) with LR+ of 3.4 (FGA) to 5.8 (BESTest). At 12 months, AUCs ranged from 0.68 (BESTest, BBS) to 0.77 (Mini-BESTest) with LR+ of 1.8 (BESTest) to 2.4 (BBS, FGA). Discussion. The various balance tests were effective in predicting falls at six months. All tests were relatively ineffective at 12 months. Conclusion. This pilot study suggests that people with PD should be assessed biannually for fall risk.

Capturing ambulatory activity decline in Parkinson's disease.

Background and Purpose: Relatively little is known about the natural evolution of physical activity–related participation restrictions associated with Parkinsons disease (PD). We examined this issue prospectively, using continuous monitoring technology to capture the free-living ambulatory activity of persons with PD engaging in life situations. We specifically sought (1) to explore natural, long-term changes in daily ambulatory activity and (2) to compare the responsiveness of ambulatory activity parameters to clinical measures of gait and disease severity. Methods: Thirty-three persons with PD participated (Hoehn and Yahr range of 1–3). Participants wore a step activity monitor for up to 7 days at baseline and again at 1-year follow-up. Mean daily values were calculated for parameters indicative of amount, intensity, frequency, and duration of ambulatory activity. Clinical measures included the Unified Parkinson Disease Rating Scale, the 6-Minute Walk, and Maximal Gait Speed. Parametric tests for paired samples were used to investigate changes in ambulatory activity parameters and clinical measures. Results: Participants had significant declines in the amount and intensity of daily ambulatory activity but not in its frequency and duration (P < 0.007). Declines occurred in the absence of changes in clinical measures of gait or disease severity. The greatest 1-year decline occurred in the number of daily minutes participants spent engaging in at least moderate-intensity ambulatory activity. Conclusion: Continuous monitoring of ambulatory activity beyond mere step counts may serve as a distinct and important means of quantifying declining ambulatory behavior associated with disease progression or improved ambulatory behavior resulting from rehabilitation and medical and/or surgical interventions in persons with PD.

Comparative Utility of the BESTest, Mini-BESTest, and Brief-BESTest for Predicting Falls in Individuals With Parkinson Disease: A Cohort Study

Background The newly developed Brief–Balance Evaluation System Test (Brief-BESTest) may be useful for measuring balance and predicting falls in individuals with Parkinson disease (PD). Objectives The purposes of this study were: (1) to describe the balance performance of those with PD using the Brief-BESTest, (2) to determine the relationships among the scores derived from the 3 versions of the BESTest (ie, full BESTest, Mini-BESTest, and Brief-BESTest), and (3) to compare the accuracy of the Brief-BESTest with that of the Mini-BESTest and BESTest in identifying recurrent fallers among people with PD. Design This was a prospective cohort study. Methods Eighty participants with PD completed a baseline balance assessment. All participants reported a fall history during the previous 6 months. Fall history was again collected 6 months (n=51) and 12 months (n=40) later. Results At baseline, participants had varying levels of balance impairment, and Brief-BESTest scores were significantly correlated with Mini-BESTest (r=.94, P<.001) and BESTest (r=.95, P<.001) scores. Six-month retrospective fall prediction accuracy of the Brief-BESTest was moderately high (area under the curve [AUC]=0.82, sensitivity=0.76, and specificity=0.84). Prospective fall prediction accuracy over 6 months was similarly accurate (AUC=0.88, sensitivity=0.71, and specificity=0.87), but was less sensitive over 12 months (AUC=0.76, sensitivity=0.53, and specificity=0.93). Limitations The sample included primarily individuals with mild to moderate PD. Also, there was a moderate dropout rate at 6 and 12 months. Conclusions All versions of the BESTest were reasonably accurate in identifying future recurrent fallers, especially during the 6 months following assessment. Clinicians can reasonably rely on the Brief-BESTest for predicting falls, particularly when time and equipment constraints are of concern.

The 9-hole PEG test of upper extremity function: Average values, test-retest reliability, and factors contributing to performance in people with Parkinson disease

Background and Purpose: Pegboard tests of hand dexterity are commonly used in clinical settings to assess upper extremity function in various populations. For individuals with Parkinson disease (PD), the clinical utility of pegboard tests has not been fully evaluated. Our purpose was to examine the commercially available 9-Hole Peg Test (9HPT) using a large sample of individuals with PD to determine average values, test-retest reliability, and factors predictive of 9HPT performance. Methods: A total of 262 participants with PD (67% men, Hoehn & Yahr stage = 2.3 ± 0.7) completed the 9HPT along with a battery of other tests including the Movement Disorder Society Unified PD Rating Scale—Motor Subscale III and Freezing of Gait Questionnaire. Results: Average time to complete the 9HPT was 31.4 ± 15.7 s with the dominant and 32.2 ± 12.4 s with the nondominant hand. Test-retest reliability of 2 trials performed with the same hand was high (dominant ICC2,1 = 0.88, nondominant ICC2,1 = 0.91). Women performed the test significantly faster than men, and nonfreezers significantly faster than freezers. For either hand, age, bradykinesia, and freezing of gait scores individually predicted significant portions of the variance in 9HPT time. Sex also was a significant predictor, but for the nondominant hand only. Tremor and rigidity did not predict performance. Discussion and Conclusions: The 9HPT appears to be a clinically useful measure for assessing upper extremity function in individuals with PD. The 9HPT has advantages over previously used methods including standardization, known normative values for healthy controls, commercial availability, transportability, and ease of administration.

Gait Training With Progressive External Auditory Cueing in Persons With Parkinson's Disease

OBJECTIVE To investigate the progressively increasing external auditory cues during mobility training with persons with Parkinsons disease (PD). DESIGN Experimental. SETTING General community. PARTICIPANTS Convenience sample of persons with PD (N=12) who walked independently. INTERVENTIONS Gait training to external auditory cues was based on a participants comfortable walking pace. Training external auditory cues rates were increased if patients were able to maintain or increase stride length with increasing external auditory cues rate. Movement synchronization was not monitored during training. Participants trained for 30min/session, 3 sessions/wk, for 8 weeks. MAIN OUTCOME MEASURES Walking velocity, stride length, and cadence. RESULTS Participants trained at a mean maximal rate of 157bpm. They showed a significant (P<.01) increase in walking velocity, stride length, and cadence after 8 weeks of training. CONCLUSIONS Walking velocity, stride length, and cadence can significantly improve when community-dwelling persons with PD participate in progressive mobility training.

Charting the progression of disability in parkinson disease: study protocol for a prospective longitudinal cohort study

BackgroundPeople with Parkinson disease (PD), even in the presence of symptomatic relief from medical, surgical, and rehabilitative interventions, face a persistent worsening of disability. This disability is characterized by diminished quality of life, reduced functional mobility, declining performance in activities of daily living and worsening neurological impairments. While evidence has emerged supporting the clinically meaningful benefits of short-term exercise programs on these underlying factors, assertions regarding the effects of sustained programs of exercise and physical activity on the trajectory of disablement in PD are made in the absence of direct evidence. Indeed, the natural decline in quality of life and functional mobility in people diagnosed with PD is poorly understood. Moreover, outcome measures commonly used in clinical exercise trials typically do not capture the full spectrum of disability as defined by the World Health Organization (WHO).Methods/DesignThe objective of this multicenter prospective study will be to examine the 2-year trajectory of disablement in a cohort of persons with PD. Two hundred sixty participants will be recruited to produce an expected final sample size of 150 individuals. Participants will be included if they are greater than 40 years of age, have a neurologist confirmed diagnosis of idiopathic PD, and are at Hoehn and Yahr stages 1 through 4. Data will be collected every 6 months during the study period. Primary outcome measures reflecting a broad spectrum of disablement will include, but will not be limited to, MDS-UPDRS, Timed Up and Go, Berg Balance Test, Nine Hole Peg Test, PDQ-39, and directly monitored ambulatory activity. Self-reported exercise and physical activity data also will be recorded. Statistical analyses will be used to characterize the trajectory of disablement and examine the influence of its underlying contributing factors.DiscussionTertiary prevention is an important component of contemporary healthcare for individuals living with degenerative disease. For individuals with PD, there is growing recognition that exercise and/or physical activity efforts to slow the rate of functional mobility decline, in particular, may be critical for optimizing quality of life. By describing the natural trajectory of disablement, exercise habits, and physical activity in a cohort of persons with PD, this investigation will establish an important foundation for future intervention research. Specifically, through the evaluation of the influence of sustained exercise and physical activity on disablement, the study will serve as a preliminary step toward developing a randomized controlled trial of long-term exercise in persons with PD.

Phase manipulation and walking in stroke.

Purpose: The purpose of this study was to investigate the effects of in- and out-phase arm movement on upper and lower body movement patterns during walking in individuals with stroke. Methods: Eight individuals (ages 14–74 years) who had suffered a cerebrovascular accident and walked independently participated. There were three separate conditions of walking at 0.22, 0.40, and 0.63 m/s: (1) with no upper extremity phase manipulation, (2) instructions to move the arms in-phase at each velocity level, (3) instructions to move the arms out-of-phase at each velocity level. Results: With instruction to the move the arms out-of-phase, the arms moved more reciprocally, back and forth, coinciding with increased arm swing, greater transverse trunk rotation as compared to when subjects were instructed to move the arms in-phase. Instructions to move the arms either in- or out-of-phase led to coordination between arm movement frequency and stride frequency (1:1 frequency coordination). Discussion: Stroke is the leading cause of disability in the United These findings showed that altered arm swing is constrained by an attraction to 1:1 frequency coordination. Arm swing amplitude was not specified; however participants swung their arms at a frequency that synchronized with stride frequency (1:1 coordination). Future study is still needed to examine how paretic arm movement affects intersegmental coordination during walking. Research is needed to assess the effects of imposed upper extremity phasing and whether training with specific phase relations facilitates a relatively permanent change in the intersegmental coordination and therefore walking function in patients who have suffered a stroke.

Novel, high-intensity exercise prescription improves muscle mass, mitochondrial function, and physical capacity in individuals with Parkinson's disease

We conducted, in persons with Parkinsons disease (PD), a thorough assessment of neuromotor function and performance in conjunction with phenotypic analyses of skeletal muscle tissue, and further tested the adaptability of PD muscle to high-intensity exercise training. Fifteen participants with PD (Hoehn and Yahr stage 2-3) completed 16 wk of high-intensity exercise training designed to simultaneously challenge strength, power, endurance, balance, and mobility function. Skeletal muscle adaptations (P < 0.05) to exercise training in PD included myofiber hypertrophy (type I: +14%, type II: +36%), shift to less fatigable myofiber type profile, and increased mitochondrial complex activity in both subsarcolemmal and intermyofibrillar fractions (I: +45-56%, IV: +39-54%). These adaptations were accompanied by a host of functional and clinical improvements (P < 0.05): total body strength (+30-56%); leg power (+42%); single leg balance (+34%); sit-to-stand motor unit activation requirement (-30%); 6-min walk (+43 m), Parkinsons Disease Quality of Life Scale (PDQ-39, -7.8pts); Unified Parkinsons Disease Rating Scale (UPDRS) total (-5.7 pts) and motor (-2.7 pts); and fatigue severity (-17%). Additionally, PD subjects in the pretraining state were compared with a group of matched, non-PD controls (CON; did not exercise). A combined assessment of muscle tissue phenotype and neuromuscular function revealed a higher distribution and larger cross-sectional area of type I myofibers and greater type II myofiber size heterogeneity in PD vs. CON (P < 0.05). In conclusion, persons with moderately advanced PD adapt to high-intensity exercise training with favorable changes in skeletal muscle at the cellular and subcellular levels that are associated with improvements in motor function, physical capacity, and fatigue perception.