Terry Ellis

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.

Self-management rehabilitation and health-related quality of life in Parkinson's disease: a randomized controlled trial.

The purpose of this randomized controlled trial was to determine whether increasing hours of self‐management rehabilitation had increasing benefits for health‐related quality of life (HRQOL) in Parkinsons disease beyond best medical treatment, whether effects persisted at 2 and 6 months of follow‐up, and whether targeted compared with nontargeted HRQOL domains responded more to rehabilitation. Participants on best medication therapy were randomly assigned to one of three conditions for 6 weeks intervention: 0 hours of rehabilitation; 18 hours of clinic group rehabilitation plus 9 hours of attention control social sessions; and 27 hours of rehabilitation, with 18 in clinic group rehabilitation and 9 hours of rehabilitation designed to transfer clinic training into home and community routines. Results (N = 116) showed that at 6 weeks, there was a beneficial effect of increased rehabilitation hours on HRQOL measured with the Parkinsons Disease Questionnaire‐39 summary index (F(1,112) = 6.48, η = 0.23, CI = 0.05–0.40, P = 0.01). Benefits persisted at follow‐up. The difference between 18 and 27 hours was not significant. Clinically relevant improvement occurred at a greater rate for 18 and 27 hours (54% improved) than for 0 hours (18% improved), a significant 36% difference in rates (95% CI = 20–52% difference). Effects were largest in two targeted domains: communication and mobility. More concerns with mobility and activities of daily living at baseline predicted more benefit from rehabilitation.

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.

Effectiveness of an Inpatient Multidisciplinary Rehabilitation Program for People With Parkinson Disease

Background and Purpose: In the outpatient setting, it can be difficult to effectively manage the complex medical and rehabilitation needs of people with Parkinson disease (PD). A multidisciplinary approach in the inpatient rehabilitation environment may be a viable alternative. The purposes of this study were: (1) to investigate the effectiveness of an inpatient rehabilitation program for people with a primary diagnosis of PD, (2) to determine whether gains made were clinically meaningful, and (3) to identify predictors of rehabilitation outcome. Subjects: Sixty-eight subjects with a diagnosis of PD were admitted to an inpatient rehabilitation hospital with a multidisciplinary movement disorders program. Methods: Subjects participated in a rehabilitation program consisting of a combination of physical therapy, occupational therapy, and speech therapy for a total of 3 hours per day, 5 to 7 days per week, in addition to pharmacological adjustments based on data collected daily. A pretest-posttest design was implemented. The differences between admission and discharge scores on the Functional Independence Measure (FIM) (total, motor, and cognitive scores), Timed “Up & Go” Test, 2-Minute Walk Test, and Finger Tapping Test were analyzed. Results: An analysis of data obtained for the 68 subjects admitted with a diagnosis of PD revealed significant improvements across all outcome measures from admission to discharge. Subjects with PD whose medications were not adjusted during their admission (rehabilitation only) (n=10) showed significant improvements in FIM total, motor, and cognitive scores. Improvements exceeded the minimal clinically important difference in 71% of the subjects. Prior level of function at admission accounted for 20% of the variance in the FIM total change score. Discussion and Conclusion: The results suggest that subjects with a diagnosis of PD as a primary condition benefited from an inpatient rehabilitation program designed to improve functional status.

Physical activity behavior change in persons with neurologic disorders: overview and examples from Parkinson disease and multiple sclerosis.

Persons with chronic progressive neurologic diseases such as Parkinson disease (PD) and multiple sclerosis (MS) face significant declines in mobility and activities of daily living, resulting in a loss of independence and compromised health-related quality of life over the course of the disease. Such undesirable outcomes can be attenuated through participation in exercise and physical activity, yet there is profound and prevalent physical inactivity in persons with PD and MS that may initiate a cycle of deconditioning and worsening of disease consequences, independent of latent disease processes. This Special Interest article highlights the accruing evidence revealing the largely sedentary behaviors common among persons living with physically disabling conditions and summarizes the evidence on the benefits of physical activity in persons with PD and MS. We then examine the social cognitive theory as an approach to identifying the primary active ingredients for behavioral change and, hence, the targets of interventions for increasing physical activity levels. The design and efficacies of interventions based on the social cognitive theory for increasing physical activity in persons with PD and MS are discussed. Finally, a rationale for adopting a secondary prevention approach to delivering physical therapy services is presented, with an emphasis on the integration of physical activity behavior change interventions into the care of persons with chronic, progressive disabilities over the course of the disease. Video Abstract available (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A42) for more insights from the authors.

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.

Changes in Walking Activity and Endurance Following Rehabilitation for People With Parkinson Disease

OBJECTIVE To investigate changes in walking activity and endurance after interdisciplinary rehabilitation in people with Parkinson disease (PD). DESIGN Randomized controlled trial. SETTING Clinic, home, and community. PARTICIPANTS Mild to moderate PD (Hoehn and Yahr stage 2-3). INTERVENTIONS Three experimental conditions lasting 6 weeks in duration: (1) no active rehabilitation; (2) 3.0 hours of interdisciplinary rehabilitation a week; or (3) 4.5 hours of interdisciplinary rehabilitation a week. Participants had stable medication regimes during the study. MAIN OUTCOME MEASURES Walking activity was estimated with an activity monitor (AM) (time spent walking and number of 10-second walking periods) in the home and community settings over a 24-hour period. Walking endurance was measured in the clinic with the two-minute walk test (2MWT). Linear contrast analyses were applied to examine changes in walking activity and endurance after higher doses of rehabilitation, and 2-way analysis of variance models with interaction were applied to examine the effect of high and low baseline walking levels on changes. RESULTS The 2MWT was completed by 108 people with PD (mean age, 66.53y; with PD, 6.59y), and AM data were used from 74 of these people (mean age, 66.7y; with PD, 5.8y). Improvement in AM measures and the 2MWT did not significantly change across increasing dosages of interdisciplinary rehabilitation. Higher doses of rehabilitation resulted in significant improvements in the 2MWT for subjects with low baseline walking endurance (P=.001), and in AM measures for subjects with high baseline walking activity (P<.02). CONCLUSIONS Interdisciplinary rehabilitation can improve walking activity and endurance depending on baseline walking levels.