Odessa Addison

The effects of exercise on balance in persons with Parkinson's disease: a systematic review across the disability spectrum

Background and Purpose:Parkinsons disease is a progressive neurodegenerative disorder that affects neurophysiologic function, movement abilities, and quality of life (QOL). Research examining the effects of exercise has suggested benefits related to a variety of outcomes; however, no reviews have synthesized research findings across the spectrum of disability. This project sought to systematically review studies that examined the impact of exercise interventions on balance outcomes for people with Parkinsons disease, within the categories defined by the World Health Organization in the International Classification of Functioning, Disability, and Health (ICF) model. Methods:A systematic review of medical literature databases was performed using keywords Parkinsons disease and exercise. Studies were eligible if the intervention included exercise and examined variables within one of the three ICF categories. Following the ICF model, outcomes regarding Body Structure and Function, Activity, and Participation were measured, respectively, in terms of postural instability, balance task performance, and QOL and fall events. Results:Within the Body Structure and Function category, there was moderate evidence that exercise resulted in improvements in postural instability. Within the Activity category, there was moderate evidence that exercise was effective for improving balance task performance. In contrast, within the Participation category, there was limited evidence that exercise resulted in improvements in QOL measures or fall events. Discussion and Conclusions:Regardless of the strength of the evidence, the studies reviewed all report that exercise resulted in improvements in postural stability and balance task performance. Despite these improvements, the number and quality of the studies and the outcomes used were limited. There is a need for longer term follow-up to establish trajectory of change and to determine if any gains are retained long term. The optimal delivery and content of exercise interventions (dosing, component exercises) at different stages of the disease are not clear.

Intermuscular Fat: A Review of the Consequences and Causes

Muscles structural composition is an important factor underlying muscle strength and physical function in older adults. There is an increasing amount of research to support the clear disassociation between the loss of muscle lean tissue mass and strength with aging. This disassociation implies that factors in addition to lean muscle mass are responsible for the decreases in strength and function seen with aging. Intermuscular adipose tissue (IMAT) is a significant predictor of both muscle function and mobility function in older adults and across a wide variety of comorbid conditions such as stroke, spinal cord injury, diabetes, and COPD. IMAT is also implicated in metabolic dysfunction such as insulin resistance. The purpose of this narrative review is to provide a review of the implications of increased IMAT levels in metabolic, muscle, and mobility function. Potential treatment options to mitigate increasing levels of IMAT will also be discussed.

Intramuscular adipose tissue, sarcopenia, and mobility function in older individuals.

Objective. Intramuscular adipose tissue (IMAT) and sarcopenia may adversely impact mobility function and physical activity. This study determined the association of locomotor muscle structure and function with mobility function in older adults. Method. 109 older adults with a variety of comorbid disease conditions were examined for thigh muscle composition via MRI, knee extensor strength via isometric dynamometry, and mobility function. The contribution of strength, quadriceps lean tissue, and IMAT to explaining the variability in mobility function was examined using multivariate linear regression models. Results. The predictors as a group contributed 27–45% of the variance in all outcome measures; however, IMAT contributed between 8–15% of the variance in all four mobility variables, while lean explained only 5% variance in only one mobility measure. Conclusions. Thigh IMAT, a newly identified muscle impairment appears to be a potent muscle variable related to the ability of older adults to move about in their community.

Comparison of combined aerobic and high-force eccentric resistance exercise with aerobic exercise only for people with type 2 diabetes mellitus.

Background and Purpose: The purpose of this study was to compare the outcomes between a diabetes exercise training program using combined aerobic and high-force eccentric resistance exercise and a program of aerobic exercise only. Subjects and Methods: Fifteen participants with type 2 diabetes mellitus (T2DM) participated in a 16-week supervised exercise training program: 7 (mean age=50.7 years, SD=6.9) in a combined aerobic and eccentric resistance exercise program (AE/RE group) and 8 (mean age=58.5 years, SD=6.2) in a program of aerobic exercise only (AE group). Outcome measures included thigh lean tissue and intramuscular fat (IMF), glycosylated hemoglobin, body mass index (BMI), and 6-minute walk distance. Results: Both groups experienced decreases in mean glycosylated hemoglobin after training (AE/RE group: −0.59% [95% confidence interval (CI)=−1.5 to 0.28]; AE group: −0.31% [95% CI=−0.60 to −0.03]), with no significant between-group differences. There was an interaction between group and time with respect to change in thigh lean tissue cross-sectional area, with the AE/RE group gaining more lean tissue (AE/RE group: 15.1 cm2 [95% CI=7.6 to 22.5]; AE group: −5.6 cm2 [95% CI=−10.4 to 0.76]). Both groups experienced decreases in mean thigh IMF cross-sectional area (AE/RE group: −1.2 cm2 [95% CI=−2.6 to 0.26]; AE group: −2.2 cm2 [95% CI=−3.5 to −0.84]) and increases in 6-minute walk distance (AE/RE group: 45.5 m [95% CI=7.5 to 83.6]; AE group: 29.9 m [95% CI=−7.7 to 67.5]) after training, with no between-group differences. There was an interaction between group and time with respect to change in BMI, with the AE/RE group experiencing a greater decrease in BMI. Discussion and Conclusion: Significant improvements in long-term glycemic control, thigh composition, and physical performance were demonstrated in both groups after participating in a 16-week exercise program. Subjects in the AE/RE group demonstrated additional improvements in thigh lean tissue and BMI. Improvements in thigh lean tissue may be important in this population as a means to increase resting metabolic rate, protein reserve, exercise tolerance, and functional mobility.

Testing balance and fall risk in persons with Parkinson disease, an argument for ecologically valid testing

INTRODUCTION Despite clear deficits in postural control, most clinical examination tools lack accuracy in identifying persons with Parkinson disease (PD) who have fallen or are at risk for falls. We assert that this is in part due to the lack of ecological validity of the testing. METHODS To test this assertion, we examined the responsiveness and predictive validity of the Functional Gait Assessment (FGA), the Pull test, and the Timed up and Go (TUG) during clinically defined ON and OFF medication states. To address responsiveness, ON/OFF medication performance was compared. To address predictive validity, areas under the curve (AUC) of receiver operating characteristic (ROC) curves were compared. Comparisons were made using separate non-parametric tests. RESULTS Thirty-six persons (24 male, 12 female) with PD (22 fallers, 14 non-fallers) participated. Only the FGA was able to detect differences between fallers and non-fallers for both ON/OFF medication testing. The predictive validity of the FGA and the TUG for fall identification was higher during OFF medication compared to ON medication testing. The predictive validity of the FGA was higher than the TUG and the Pull test during ON and OFF medication testing. DISCUSSION In order to most accurately identify fallers, clinicians should test persons with PD in ecologically relevant conditions and tasks. In this study, interpretation of the OFF medication performance and use of the FGA provided more accurate prediction of those who would fall.

Downregulation of E3 Ubiquitin Ligases and Mitophagy-Related Genes in Skeletal Muscle of Physically Inactive, Frail Older Women: A Cross-Sectional Comparison

BACKGROUND AND OBJECTIVES Reduced lean mass and physical function is a characteristic of frailty. However, it is currently unknown if proteolysis through the E3 ubiquitin ligases and the autophagic lysosomal pathway is dysregulated in inactive frail older women. The purpose of this study was to determine the expression of key markers of ubiquitin-mediated and autophagic lysosomal proteolysis in inactive (N = 7) compared with active (N = 7) older women. METHODS Strength, mobility, leg lean mass, and physical activity assessment were used to characterize activity levels and frailty in older women. Vastus lateralis biopsies were collected after an overnight fast and were assessed for gene and protein targets related to E3 ubiquitin ligases and the autophagic lysosomal system. RESULTS We found that AMP-activated protein kinase alpha (Thr172) was increased (p = .045), and forkhead box O3A (FOXO3A) gene expression (p = .047) was lower in inactive frail older women. Foxo3a (Ser253), Beclin1 (Ser93/96), and class III phosphatidylinositol-3-kinase (VPS34) protein expression were not different between the groups (p > .05). Neural precursor cell-expressed developmentally downregulated protein 4, muscle ring finger 1, muscle atrophy F-box, and the autophagy/mitophagy gene expression markers, Beclin1, autophagy-related-7, BCL2/adenovirus E1B 19 kDa interacting protein 3 (BNIP3), dynamin-related protein 1, and Parkinson protein 2 (PARKIN) were lower in inactive frail older women (p < .05). Autophagy/mitophagy markers were positively correlated with the 6-minute walk and leg lean mass (p < .05). CONCLUSIONS We conclude that physical inactivity in frail older women is associated with a downregulation of ubiquitin-mediated and autophagic lysosomal skeletal muscle gene expression, perhaps related to low muscle mass and poor physical function.

Intramuscular fat and inflammation differ in older adults: The impact of frailty and inactivity

ObjectivesIntramuscular adipose tissue (IMAT) is recognized as a negative predictor of both muscle and mobility function in older adults, however the mechanism by which IMAT may negatively influence muscle and mobility function is currently unknown. The release of pro-inflammatory cytokines from IMAT provides a potential reason for these negative associations. To explore this hypothesis we compared IMAT and muscular inflammation in age-and BMI-matched older non-obese frail and non-frail adults. We also sought to examine the relationship between IMAT and inflammation, and muscle and mobility function in this group of older adults.DesignA case-control sampling was used for this study. Age-and BMI-matched non-obese frail and non-frail individuals (<65 years) were recruited.MeasurementsMRI was used to quantify thigh IMAT and lean tissue. Unilateral muscle biopsies were used to quantify muscular inflammation as represented by interleukin-6 (IL-6) and tumor-necrosis factor alpha (TNF-α). Muscle and mobility function was also measured using a maximal voluntary isometric contraction, six-minute walk, and self-selected gait speed.Participants26 older (80.7 +/− 5.4 years) individuals (8 frail and 18 non-frail) were enrolled.ResultsThe frail-group had increased IMAT (p<0.01) and decreased lean tissue (p<0.01), and elevated IL-6 muscle mRNA (p=0.02) and IL-6 protein content (p=0.02) compared to the non-frail group. IMAT was significantly associated with IL-6 mRNA (r=0.43, p=.04) and protein expression within the muscle (r=0.41, p= 0.045). IL-6 mRNA was significantly associated with six-minute walk (r=−0.63, p<0.01), and gait speed (r=−0.60, p <0.01) and IL-6 protein was significantly associated with muscle force (r=−0.54, p=0.01), six-minute walk (r=−0.66, p<0.01), and gait speed (r=−0.76, p<0.01). No significant relationships were found for any variables with TNF-α.ConclusionNon-obese, older, frail individuals have increased IMAT and muscular inflammation when compared to their non-frail, age- and BMI-matched peers. A significant relationship exists between IMAT and muscle IL-6 expression as well as between IL-6 and muscle and mobility function of these older adults. This IMAT-inflammatory pathway provides a potential link between IMATs and decreased muscle and mobility function.

Intramuscular adipose tissue attenuates gains in muscle quality in older adults at high risk for falling. A brief report

ObjectiveTo examine the influence of intramuscular adipose tissue (IMAT) on muscle quality (MQ) changes in older adults after 12 weeks of exercise training.DesignProspective cohort design.SettingAcademic health science center clinical exercise facility.Participants70 older (mean age 73.4 ± 6.3 years) adults with a history of falls.InterventionResistance, endurance and balance exercise three times weekly for 12 weeks.MeasurementsQuadriceps strength was determined by maximum voluntary isometric contraction. An MRI of the thigh was used to determine cross-sectional area of lean tissue and IMAT. MQ was calculated as the force per unit area of lean tissue. Individuals were stratified into tertiles (Low IMAT, Middle IMAT, High IMAT) based on pre-IMAT levels. Changes in MQ, lean and IMAT were compared across groups.ResultsNo significant changes in lean or IMAT occurred in any group with training. MQ increased only in the Low IMAT group. The Middle and High IMAT groups did not demonstrate a significant change in MQ following 12 weeks of training. Low IMAT, pre = 2.7 [0.6] post= 3.0 [0.6]; Middle IMAT, pre =2.54 [0.8] post =2.75 [0.7]; High IMAT, pre =2.6 [0.6] to post =2.5 [0.6].ConclusionHigh levels of thigh IMAT appear to blunt the adaptive MQ response to training. High levels of thigh IMAT may be a potential reason why some older adults do not change their MQ following training. Future research should confirm these results and determine why IMAT impairs MQ and the adaptive response to training in older adults.

Exercise and Medication Effects on Persons with Parkinson Disease Across the Domains of Disability: A Randomized Clinical Trial

Background and Purpose: Hypokinesia and bradykinesia as movement deficits of Parkinson disease are thought to be mediated by both basal ganglia dysfunction and a loss of muscle mass and strength commensurate with aging and decreased levels of physical activity. For these reasons, we sought to utilize resistance training as a means to increase muscle force and minimize hypokinesia and bradykinesia in persons with Parkinson disease and examine the effects of exercise and medication on Body Structure and Function (muscle force production and muscle cross-sectional area), Activity (mobility), and Participation (Health Status) outcomes. Methods: Forty-two participants were enrolled in a 12-week randomized clinical trial that compared 2 active exercise interventions: a standard care control group (Active Control) and an experimental group that underwent Resistance Exercise via Negative Eccentric Work (RENEW). Results: Participants in both groups improved in muscle force production and mobility as a result of exercise and medication (P < 0.02). There were no significant interaction or between-group differences and no significant changes in muscle cross-sectional area or health status were observed. Effect sizes for exercise and medication combined exceeded the effect sizes of either intervention in isolation. Discussion and Conclusions: Taken together, these results point to the complementary effects of exercise and medication on the Body Structure and Function and Activity outcomes but little effect on Participation outcomes. Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A92).

Inflammation, aging, and adiposity: Implications for physical therapists

Background:Physical therapists treat older individuals, characterized as both a needy and expanding population. Frailty, a predisability condition with links to chronic inflammatory conditions, is estimated to affect 7% of individuals older than 60 years and 40% of people older than 80 years. Chronic inflammation is one of the most important physiologic correlates of the frailty syndrome and high levels of proinflammatory cytokines, related to both aging and increasing adiposity in older individuals are related to an increased risk of mortality, sarcopenia, reduced muscle strength and decreased mobility. Purpose:The purpose of this narrative review is to inform the physical therapist of the effects of aging and increasing adiposity on chronic inflammation and the association of inflammation with muscle loss, strength, and mobility impairments in older adults; and to review the current evidence to provide clinical recommendations on physical activity and exercise regimes that may mitigate chronic inflammation in older adults. Discussion:As physical therapists help manage and treat an increasingly older population, understanding how the inflammatory milieu changes with aging and increasing adiposity and how these changes can be impacted by physical therapists via exercise and physical activity is critical. Conclusion:Exercise is a potent preventive intervention strategy and countermeasure for chronic inflammation and adiposity. Exercise can also benefit the frail older individual by combating the negative effects of chronic inflammation and optimally balancing the production of pro and anti-inflammatory cytokines. In addition to providing an anti-inflammatory environment within muscle to mitigate the effects of chronic inflammation, exercise has the added benefit of improving muscle mass and function and decreasing adiposity in older adults.