Gait variability in Parkinson's disease: levodopa and walking direction.

BACKGROUND: Levodopa treatment has been shown to improve gait spatio-temporal characteristics in both forward and backward walking. However, effect of levodopa on gait variability during backward walking compared with forward walking has not been reported. AIMS OF STUDY: To study the effects of levodopa on gait variability of forward and backward walking in individuals with Parkinson's disease (PD). METHODS: Forty individuals with PD were studied. Their mean age was 68.70 ± 7.46 year. The average time since diagnosis was 9.41 ± 5.72 year. Gait variability was studied while 'OFF' and 'ON' levodopa when the participants walked forward and backward at their usual speed. Variability in step time, swing time, stride length, double support time, and stride velocity were compared between medication condition and walking direction. RESULTS: Variability of step time, swing time, stride length, and stride velocity decreased significantly during forward and backward walks (P < 0.001; P < 0.001; P = 0.003, P = 0.001, respectively) after levodopa administration. Variability of double support time was not changed after levodopa administration (P = 0.054). CONCLUSIONS: Levodopa had positive effects on gait variability of forward and backward walking in individuals with PD. However, variability in double support time was not affected by the levodopa.

The relation of falls to fatigue, depression and daytime sleepiness in Parkinson's disease.

OBJECTIVE: To characterize non-motor symptoms in individuals with Parkinson's disease (PD) who experience falls compared to those who do not fall. METHODS: Fifty-four individuals with PD were studied. Thirty-six were fallers and 18 were non-fallers. Fatigue was assessed by the Iowa Fatigue Scale. Excessive daytime sleepiness was assessed by the Epworth Sleepiness Scale, and depressive symptomatology was assessed by the short-form Center for Epidemiologic Studies Depression Scale. RESULTS: Compared to non-fallers, fallers had more severe disability, greater general physical fatigue (p = 0.024), lower energy levels (p = 0.042) and less productivity (p = 0.007). Fallers had more depressive symptomatology than the non-fallers (p = 0.01). Excessive daytime sleepiness was not different between the two groups (p = 0.695). CONCLUSIONS: Individuals with PD who fell had more severe motor and non-motor symptoms than those who did not fall. These non-motor symptoms included physical fatigue, energy, productivity and depressive symptomatology.

Effects of levodopa on forward and backward gait patterns in persons with Parkinson's disease.

INTRODUCTION: Backward walking is difficult for persons with Parkinson's disease (PD). It is unknown how levodopa influences backward gait patterns, especially when compared to forward gait patterns. PURPOSE: Investigate the effects of levodopa on forward and backward gait patterns in individuals with PD. DESIGN: A repeated measures design was used. METHODS: The sample consisted of 21 individuals with PD (15 males, 6 females). Their mean age was 70.24 ± 8.69 yr. The average time since diagnosis was 11.81 ± 5.49 years. The median of the Hoehn and Yahr stage while 'ON' medication was 2.57. Gait patterns during forward and backward walking at a self-selected comfortable speed were recorded before and after taking levodopa on the same day. RESULTS: Levodopa significantly increased gait speed and stride length and decreased the percent of the gait cycle (%GC) spent in double support. Gait speed and stride length were greater and the %GC spent in double support was less during forward walking compared with backward walking. Cadence was not changed by levodopa or walking direction. CONCLUSIONS: Levodopa improved gait characteristics during backward walking in a manner similar to that during forward walking in persons with PD.

An investigation of two interventions for micrographia in individuals with Parkinson's disease.

OBJECTIVE: This pilot study was designed to compare a change in micrographia between using grid lines and parallel horizontal lines as visual cues in individuals with Parkinson's disease. DESIGN: Single group pre- and post-test. SETTING: Research lab. PARTICIPANTS: Eleven males with Parkinson's disease. INTERVENTIONS: Practice writing words with parallel and grid lines. The sequence of practising was randomized. MAIN OUTCOME MEASURES: Length of words. RESULTS: The length of the words after practising with parallel lines was longer than in the initial free writing condition (17.83 ± 3.93 cm vs. 23.36 ± 5.82 cm, P =0.008). The length of the words after practising with grid lines was also longer than during free writing (17.83 ± 3.93 cm vs. 22.65 ± 4.04 cm, P =0.003). The length of the words after practising with parallel lines was not different from that after practising with grid lines. CONCLUSION: Improvements in letter size after practising with horizontal parallel lines and grid lines were not different. The addition of vertical lines to form a grid did not appear to improve the writing more than horizontal lines alone in persons with Parkinson's disease who experienced micrographia.

An evaluation of self-administration of auditory cueing to improve gait in people with Parkinson's disease.

OBJECTIVE: To evaluate a self-administration of auditory cueing on gait difficulties in people with Parkinson's disease over a one-week period. DESIGN: Single group pre and post test. SETTING: Research lab, community. PARTICIPANTS: Twenty-one individuals with Parkinson's disease. INTERVENTIONS: Self-application of an auditory pacer set at a rate 25% faster than preferred cadence. MAIN OUTCOME MEASURES: Self-selected gait speed, cadence, stride length, and double support time with and without the pacer at the initial visit and after one week of pacer use. RESULTS: During the initial visit, the auditory pacer improved gait speed (79.57 (18.13) cm/s vs. 94.02 (22.61) cm/s, P<0.0005), cadence (102.88 (11.34) step/min vs. 109.22 (10.23) steps/min, P=0.036) and stride length (94.33 (21.31) cm vs. 103.5 (22.65) cm, P =0.012). After one week, preferred gait speed was faster than the initial preferred speed (79.57 (18.13) vs. 95.20 (22.23) cm/s, P<0.0005). Stride length was significantly increased (94.33 (21.31) vs. 107.67 (20.01) cm, P =0.001). Double support time was decreased from 21.73 (5.23) to 18.94 (3.59)% gait cycle, P =0.016. CONCLUSION: Gait performance in people with Parkinson's disease improved significantly after walking with the auditory pacer for one week.

Effects of visual and auditory cues on gait in individuals with Parkinson's disease.

The purpose of this study was to determine if combining visual and auditory cues has a greater effect on the gait pattern of patients with Parkinson's disease (PD) than the cues applied individually. Twenty-four individuals with idiopathic PD were recruited. Patients, while off antiparkinsonian medications, were measured on a 7.62-m walkway during two trials for each of four conditions performed in random order: without cues, with a visual cue, with an auditory cue and with both cues simultaneously. The auditory cue consisted of a metronome beat 25% faster than the subject's fastest gait speed. Brightly colored parallel lines placed along the walkway at intervals equal to 40% of a subject's height served as the visual cue. Average gait speed, cadence and stride length were calculated for each condition. Gait velocity, cadence and stride length significantly improved (p<005) when cues were used. Visual and auditory cues improved gait performance in patients with PD, but they did so in different ways. Auditory cueing significantly improved cadence, but visual cueing improved stride length. The simultaneous use of auditory and visual cues did not improve gait significantly more than each cue alone.

A comparison of regular rehabilitation and regular rehabilitation with supported treadmill ambulation training for acute stroke patients.

The purpose of this pilot study was to compare differences in motor recovery between regular rehabilitation (REG), and regular rehabilitation with supported treadmill ambulation training (STAT) using the performance on a bicycle exercise test and the locomotor scale of the Functional Independence Measure (FIM-L). Twelve patients with acute strokes were randomly assigned to either REG or STAT for 2 to 3 weeks. The STAT group received daily gait training utilizing a treadmill with partial support of body weight. After intervention, the STAT group had higher oxygen consumption (11.34+/-0.88 vs 8.32+/-0.88 ml/kg/min, p=0.039), total workload (58.75+/-7.09 vs 45.42+/-7.09 watts, p=ns), and total time pedaling the bike (288.91+/-30.61 vs 211.42+/-30.61 s, p=ns) compared to the REG group. The FIM-L scores were not different for the two groups. This pilot study suggests that the STAT intervention is a promising technique for acute stroke rehabilitation, and that future studies with larger sample sizes are warranted to establish the effectiveness of this intervention.

Supported treadmill ambulation training after spinal cord injury: a pilot study.

OBJECTIVES: To conduct a pilot study of weight-supported ambulation training after incomplete spinal cord injury (SCI), and to assess its safety. DESIGN: Quasiexperimental, repeated measures, single group. SETTING: Veterans Affairs medical center. PATIENTS: Three subjects with incomplete, chronic, thoracic SCIs; 2 classified as D on the American Spinal Injury Association (ASIA) impairment scale and 1 as ASIA impairment scale C. INTERVENTION: Subjects participated in 12 weeks of training assisted by 2 physical therapists. The training consisted of walking on a treadmill while supported by a harness and a pneumatic suspension device. Support started at 40% of body weight and a treadmill speed of.16kmph, and progressed by reducing support and increasing treadmill speed and continuous treadmill walking time up to 20 minutes. Training was conducted for 1 hour per day, 5 days per week for 3 months. Treadmill walking occurred for 20 minutes during the sessions. MAIN OUTCOME MEASURES: Gait function (speed, endurance, walking status, use of assistive device and orthotics); oxygen costs of walking; brain motor control assessment; self-report indices; ASIA classification; muscle function test; and safety. RESULTS: All 3 subjects increased gait speed (.118m/s initially to.318m/s after training 12wk), and gait endurance (20.3m/5min initially to 63.5m/5min). The oxygen costs decreased from 1.96 to 1.33mL x kg(-1) x m(-1) after 12 weeks of training. CONCLUSIONS: This pilot study suggests that supported treadmill ambulation training can improve gait for individuals with incomplete SCIs by using objective gait measures. The self-report indices used have promise as patient-centered outcome measures of this new form of gait training. A larger, controlled study of this technique is warranted.

Usefulness of an individualized balance and gait intervention programme based on the problem-oriented assessment of mobility in nursing home residents.

PURPOSE: To examine the usefulness of an individualized balance and gait training proramme according to the specific problems identified from the problem-oriented assessment of mobility (POAM) in residents of a nursing home. METHOD: The clinical records of 74 NH residents (49 female, 25 male) who were consecutively referred to physical therapy for problems related to poor balance or gait or a recent fall in a 2 year period were reviewed retrospectively for the study. According to the medical charts, patients had received a four week (20 sessions) problem-oriented exercise programme that specifically targeted balance and gait deficits identified from the POAM and the retest had been done after four weeks of training. RESULTS: The mean initial and final balance scores were 8.47+/-3.80. and 10.77+ /-3.37. respectively, and the mean gait scores were 6.73+/-2.30 initially and 7.71+/-1.95 finally. A Wilcoxon signed-rank comparison of the initial and final POAM indicated that significant improvement occurred in the balance scores (Z = 5.345, p < 0.0001) and the gait scale (Z = 3.589, p < 0.0001) in this group. Item analysis demonstrated the number of patients who improved or did not change on individual items. CONCLUSIONS: Both balance and gait were significantly improved after a four-week intervention programme based on the deficits identified by POAM. The POAM is a useful tool to guide the clinician to target specific balance and gait deficits for individual nursing home elders.

Equipment specifications for supported treadmill ambulation training.

Supported Treadmill Ambulation Training (STAT) is a mode of therapy for gait retraining for patients with spinal cord injuries or other upper motor neuron dysfunction. The STAT program involves simultaneously supporting a portion of the patient's weight while gait training on a treadmill. STAT has been successful in improving the gait of many research subjects, but has not been widely applied in clinical practice. The goal of this study was to acquire practical, clinically useful information regarding this therapeutic intervention in order to remove barriers to its use. This manuscript enumerates equipment specifications for the treadmill, body weight support (BWS) system, and harness. The ergonomics of the work space are also considered, since the therapist(s) will need access to the patient's legs during therapy. The specific recommendations were determined through prior clinical experience, consultation of anthropometric tables, and application of engineering principles. The guidelines listed are intended to facilitate safe and effective application of the therapy at minimum hardware cost.

Sensitivity of a clinical scale of balance and gait in frail nursing home residents.

PURPOSE: The purpose of this paper was to describe this application, and to assess the sensitivity of the application when evaluating clinical interventions for improving balance and gait. METHODS: The records of fifteen consecutive patients referred to physical therapy for mobility problems or recent falls were reviewed for this study. The subjects were evaluated upon initial referral to physical therapy and after 30 days of treatment. Treatment was developed around the problems noted on initial evaluation and applied 5 days/week for 20 sessions. RESULTS: A Wilcoxon signed-rank comparison of the initial and 30 day re-evaluation of the balance and the gait assessment indicated that significant improvement had occurred in the balance scores (Z = -3.20, p = 0.001) and the gait scores (Z = -2.82, p = 0.005) in this group. CONCLUSION: These assessments are sensitive to clinical improvements in mobility among frail elders.

Exercise performance in those having Parkinson's disease and healthy normals.

OBJECTIVE: This study assessed and compared the cardiopulmonary function of individuals with Parkinson's disease (PD) with that of healthy normals (HN) in order to provide health professionals with more thorough information about the problems associated with PD. METHODS: 20 men (PD = 13, HN = 7; mean age 64 and 64, respectively) and 23 women (PD = 7, HN = 16; mean age 65 and 66, respectively) were recruited from the Houston metropolitan area. Maximal oxygen consumption (VO2max mL x kg(-1) x min(-1)) and time to maximal exercise in minutes (time(max)) were measured. Exercise was performed on a stationary bicycle using an incremental exercise protocol. Because the assumption of homogeneity of variance was not met for the dependent variable VO2max in women, the nonparametric Wilcoxon-Mann-Whitney-U analysis was used (alpha < or = 0.025). All other group comparisons were analyzed using an independent t-test (alpha < or = 0.025). RESULTS: For men and women, there were no significant differences in VO2max between those having PD and the HN (men: PD = 23.52 vs HN = 25.46 mL x kg(-1) x min(-1), P = 0.50; women: PD = 20.10 vs HN = 16.20 mL x kg(-1) x min(-1), P = 0.35). Likewise, there was no significant differences in time(max) between women (PD = 5.2 vs HN = 5.4 min, P = 0.20). Comparison of time(max) between men did show a significant difference (PD = 9.5 vs HN = 13.10 min, P = 0.02). CONCLUSIONS: Although there were no significant differences in VO2max between the men, the comparison of time(max) indicates those with PD were unable to exercise as long before reaching VO2max, indicating that individuals with PD may be less efficient during exercise and therefore unable to exercise as long before reaching VO2max. Although women with PD had a higher VO2max, comparisons of VO2max and time(max) between those with PD and HN resulted in no significant differences.

Considerations related to disability and exercise in elderly women with congestive heart failure.

Congestive heart failure is one of the most common diagnoses in older women. This article reviews physiologic and pathophysiologic factors that contribute to disability in older women with normal left ejection fraction congestive heart failure; the possibility that aerobic exercise training may be an effective means to reduce the disability experienced by these women is examined. Most literature has dealt with low-output ejection fraction congestive heart failure. Comparisons between low-output ejection fraction congestive heart failure and normal left ejection fraction congestive heart failure can help to clarify beneficial interventions. A physiologic model is proposed that includes peripheral and cardiac factors caused by heart disease, and factors caused by aging, that may account for increasing the disabling consequences and reducing exercise tolerance of older women with normal left ejection fraction congestive heart failure. The potential impact of exercise training on these factors is discussed. Directions for practice and further research are included.

Cardiovascular and metabolic responses to upper- and lower-extremity exercise in men with idiopathic Parkinson's disease.

BACKGROUND AND PURPOSE: The aerobic capacity of individuals with Parkinson's disease (PD) has not been characterized. This study (1) compared maximal exercise performance in individuals with and without PD, (2) compared exercise performance during upper- and lower-extremity exercise, and (3) described submaximal exercise responses. SUBJECTS: Eight men with PD (PD group) and 7 men without PD (control group) participated. METHODS: Subjects performed a lower-extremity ergometer test (LE test) and an arm-cranking ergometer test (AC test). Peak oxygen consumption, heart rate, respiratory exchange ratio, and power, as well as submaximal values of oxygen consumption and heart rate for each power level, were recorded. RESULTS: No differences were found between the groups for either test. Peak power was less for the PD group than for the control group for both tests. Submaximal heart rate and oxygen consumption were higher for the PD group than for the control group. CONCLUSION AND DISCUSSION: We conclude that individuals with mild to moderate PD can be tested with both exercise protocols to a peak exercise capacity and that there are differences in upper- and lower-extremity peak power and submaximal responses between persons with and without PD.

Comparison of peak isometric knee extensor torque in children with and without juvenile rheumatoid arthritis.

This study compared peak isometric knee extensor torque in children with juvenile rheumatoid arthritis (JRA) and healthy children. A secondary purpose was to determine the relationship between measures of articular disease severity and peak isometric knee extensor torque. Peak torque was measured with a computerized dynamometer. Twenty-eight children with JRA and 28 children without JRA were matched for age, sex, and body surface area. Peak isometric knee extensor torque was significantly lower among the children with JRA than their respective control (P < 0.05, paired Student's t-test, one-tailed). There was no relationship between peak torque and measures of articular disease severity among the children with JRA. Subjects complained of quadriceps muscle discomfort as a result of the isometric muscle test. One child with JRA complained of increased knee pain and swelling. Peak isometric knee extensor torque appears to be a useful variable for characterizing muscle function deficits in children with JRA. Isometric muscle performance did not correlate with articular disease severity. The results suggest that isometric strengthening programs are indicated for this patient population. We recommend that clinicians monitor patients for joint and muscle symptoms during exercise training sessions.

Exercise response in children with and without juvenile rheumatoid arthritis: a case-comparison study.

The primary purpose of the study was to compare the response to bicycle ergometer exercise in children with and without juvenile rheumatoid arthritis (JRA). Heart rate, exercise duration, highest work load completed, and peak oxygen consumption (peak VO2) were compared. A secondary purpose of the study was to determine the relationship between peak VO2 and articular disease severity. Thirty children with JRA and 30 controls matched for age, sex, and body surface area (BSA) were the subjects. Peak VO2 was determined by an open-circuit computerized gas analysis system. Peak VO2, highest work load completed, exercise duration, and peak heart rate were significantly lower among the children with JRA than their respective controls. Submaximal heart rate was significantly higher for the children with JRA. There was no difference in resting heart rate between the two groups. There was no relationship between peak VO2 and articular disease severity among the children with JRA. The results suggest that aerobic conditioning programs may be indicated soon after diagnosis for patients with JRA, regardless of the severity of their articular disease. One subject with JRA and 2 control subjects reported light-headedness and dizziness, and 1 subject with JRA complained of increased knee swelling. We recommend that physical therapists monitor patients for signs of exercise intolerance and joint symptoms during exercise training sessions. [Jasso Giannini M, Protas EJ. Exercise response in children with and without juvenile rheumatoid arthritis: a case-comparison study.

Aerobic capacity in juvenile rheumatoid arthritis patients and healthy children.

This study compared aerobic capacity and highest work load completed by children with juvenile rheumatoid arthritis (JRA) and healthy children during bicycle ergometer exercise. A secondary purpose was to determine the relationship between measures of disease severity and (a) aerobic capacity and (b) highest work load completed among the JRA patients. Aerobic capacity was measured using an open-circuit computerized gas analysis system. Sixteen patients with JRA and 16 healthy children were matched for age, sex, and body surface area. The healthy children achieved a significantly higher aerobic capacity than their respective control (p < 0.001, paired t test, two-tailed). The healthy children were able to complete higher work loads than their respective control (p < 0.01, Wilcoxon matched-pairs signed-rank test). There was no relationship between measures of articular disease severity and (a) aerobic capacity and (b) highest work load completed among the JRA patients. Results of this study provide specific direction to clinicians to initiate aerobic conditioning programs for children with JRA soon after diagnosis. Additionally, an individual's functional exercise capacity is not directly related to the severity of the articular disease.

Effects of weight lifting on bone mineral density in premenopausal women.

A group of 68 premenopausal women participated in a controlled 12 month exercise program. Two groups were matched according to age, body size (body mass index), and typical activity level. Data collection included bone mineral density (BMD) of the lumbar spine with dual-photon absorptiometry and of the os calcis with single-photon absorptiometry, lean body mass, urinary calcium/creatinine, and urinary gamma-carboxyglutamic acid (Gla). Subjects were given a daily 500 mg supplement of elemental calcium. There was no significant difference between groups in terms of diet, in urinary calcium/creatinine or Gla, or in lean body mass. The weight lifting group had a nonsignificant increase in mean lumbar BMD of 0.81% and the control group exhibited a nonsignificant decrease of 0.5%. However, a paired t-test revealed a significant change in the means in either group or as matched pairs. The relatively small change seen as a result of this modified Nautilus exercise program may prevent moderate weight lifting from being a practical answer for osteoporosis, even in a highly motivated population.

Oxygen consumption during calisthenic exercise in women with coronary artery disease.

The purpose of this study was to compare the oxygen consumption (VO2) during calisthenic exercises in middle-aged women (aged 43-63 years) with and without coronary artery disease (CAD). Indirect calorimetry was used to measure VO2 in 15 healthy women and 15 women with CAD. Four exercises were performed for three minutes each before measurements of VO2 were taken. The exercises were 1) sitting knee extension, 2) standing hip flexion, 3) an upper extremity range-of-motion exercise, and 4) lateral trunk flexion. Using an analysis of covariance, no significant difference was found in VO2 between the two groups; however, there was a significant difference among the four exercises. Oxygen consumption was lowest for both groups during the knee extension and the lateral trunk flexion exercises; both groups demonstrated the highest levels for VO2 during the hip flexion exercise. This study provides evidence that the energy cost of these low-intensity calisthenics is similar for healthy women and women with CAD.

Oxygen consumption and heart rate responses during five active exercises.

Oxygen consumption (VO2) and heart rate (HR) responses during five active exercises from a cardiac rehabilitation program were measured in 12 healthy female subjects aged 20 to 30 years. The VO2 value was determined by collecting expired gases using an open-circuit method. Resting HR and VO2 values were established while the subjects were positioned supine for 10 to 20 minutes. Exercise values were recorded while the subjects performed five different active exercise bouts consisting of various combinations of upper and lower extremity range-of-motion exercises in the supine or semi-Fowler positions. These exercises were adopted from a stage 1 bedside cardiac rehabilitation program. These activities resulted in low cardiovascular responses: an HR increase of less than 8 bpm and a VO2 increase of less than 2.0 mL X kg-1 X min-1.