Treadmill exercise tests in persons with Parkinson's disease: responses and disease severity.

BACKGROUND AND AIMS: There is a paucity of information on cardiovascular responses with regard to the disease stage of Parkinson's disease (PD) when using an exercise test. Our purpose was to examine whether cardiovascular responses to the treadmill exercise test differed among persons with PD who have different disease severity. METHODS: Forty-five subjects with PD were studied (34 men and 11 women). The subjects underwent a treadmill exercise test using a modified Bruce protocol. Resting heart rate (HR), resting blood pressure (BP), maximal HR, maximal BP, exercise duration, maximum percentage HR and METs achieved after the treadmill exercise test were studied. RESULTS: Seventeen subjects were in Hoehn and Yahr Staging Scale (HY) 2, 16 were in HY 2.5, and 12 were in HY 3. HR increased significantly in all three stages. Systolic BP increased significantly in the HY 2 and 2.5, but not the HY 3. Diastolic BP did not change in any stage. Resting HR was lower in the HY 2 compared to the HY 3 and resting systolic BP was higher in HY 2 compared to the HY 2.5. The three HY stages were not different in exercise duration, HR and BP responses, maximum percentage HR achieved, and METs achieved. Fatigue was a primary reason to discontinue the test. There were no fall incidents in any of the tests. CONCLUSIONS: Cardiovascular responses to the treadmill exercise test did not vary with disease severity. Treadmill exercise tests were safe to perform in persons with PD.

Relationship of falls and fear of falling to activity limitations and physical inactivity in Parkinson's disease.

AIM: To investigate the relationships between falls, fear of falling, and activity limitations in individuals with Parkinson's disease (PD). DESIGN/METHODS: Cross-sectional study of individuals with mild to moderate PD (N = 83). Associations among demographic data, fall frequency, disease severity, motor impairment, ability to perform activities of daily living (ADL), Activities Balance Confidence Scale, Iowa Fatigue Scale, Comorbidity Index, and Physical Activity Scale for Elders were studied. RESULTS: Frequent fallers had more ADL limitations than nonfallers (p < .001) and rare fallers (p = .004). Frequent fallers reported a lower percentage of ability to perform ADL than nonfallers (p = .003). Frequent fallers and rare fallers were less physically active than nonfallers (p = .015 and p = .040, respectively). Frequent fallers and rare fallers reported a higher level of fear of falling than nonfallers (p = .031 and p = .009, respectively). CONCLUSIONS: Falls and fear of falling were associated with more ADL limitations and less physical activity after adjusting for physical impairments.

Determinants of use of a walking device in persons with Parkinson's disease.

OBJECTIVE: To identify determinants for the use of a walking device in persons with Parkinson's disease (PD). DESIGN: Cross-sectional study of participants with PD. SETTING: Laboratory. PARTICIPANTS: Persons with PD (N=85; 60 men) were studied. Their mean age was 69.4±8.9 years. The average time since diagnosis was 7.9±5.3 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Age, sex, disease duration, disease severity, and motor impairment were recorded. Participants were asked whether they usually used any walking device (eg, cane or walker) and were categorized as either an "independent walker" or a "device walker." Clinical balance measures including functional reach, turn duration, 5-meter timed Up and Go (5m-TUG) test, and Activities-specific Balance Confidence (ABC) scale were investigated for their contribution to the prediction of walking with a device. RESULTS: Thirty-one participants (36.5%) reported that they usually used a walking device. Classification and regression tree analysis determined that the 5m-TUG test and the ABC scale were important factors in differentiating participants who used a walking device from those who did not. Critical thresholds included 13 seconds for the 5m-TUG test and a score of 75 for the ABC scale in determining device walking. Using only these 2 determinants, the classification and regression tree model correctly classified 81% of the patients as either independent or needing a walking device. CONCLUSION: The 5m-TUG test and the ABC scale may be useful in clinical assessments of the need for a walking device in persons with PD.

Evidence of reduced health-related quality of life in older Mexican Americans with arthritis.

OBJECTIVE: To examine the association between self-reported physician-diagnosed arthritis and health-related quality of life among older Mexican Americans. DESIGN: Cross-sectional study involving population-based survey. SETTING: Hispanic Established Population for the Epidemiologic Study of the Elderly (EPESE) survey conducted in Texas, Arizona, New Mexico, Colorado, and California. PARTICIPANTS: 839 non-institutionalized Mexican American older adults (> or = 75 years) participating in Hispanic EPESE. MAIN OUTCOME MEASURES: Self-reported physician-diagnosed arthritis; sociodemographic variables; medical conditions; body mass index; and the physical and mental composite scales from the Medical Outcomes Study Short Form 36 Health Survey (SF-36). RESULTS: 518 (62%) of the subjects reported physician-diagnosed arthritis. Participants with arthritis had significantly lower scores on the physical composite scale (PCS) (mean = 35.3, SD = 11.3) and the mental composite scale (MCS) (mean = 53.5, SD = 10.8) of the SF-36 compared to persons without arthritis (PCS mean = 42.9, SD = 10.9; MCS mean = 57.0, SD = 8.8). Multiple regression showed that arthritis was associated with decreased PCS and MCS (model estimates of -5.74 [SE = .83]; and -3.16 [SE = .64]), respectively, after controlling for sociodemographic and clinical covariates. CONCLUSIONS: Arthritis is a highly prevalent medical condition in Mexican American older adults. Our findings suggest that deficits in both physical health and mental function contribute to reduced quality-of-life in this population.

Relation of chair rising ability to activities of daily living and physical activity in Parkinson's disease.

BACKGROUND: Many persons living with Parkinson's disease (PD) have difficulty rising from a chair. Impaired ability to perform the chair rise may be associated with low physical activity levels and reduced ability to perform activities of daily living (ADL). METHODS: Cross-sectional analysis was performed in 88 persons with PD to study the association of chair rising ability with ADL and physical activity. RESULTS: We found that the participants who pushed themselves up from the chair had more severe PD, higher motor impairment and more comorbidity than those who rose from a chair normally. The Unified Parkinson's Disease Rating Scale ADL (UPDRS-ADL), Schwab and England Activities of Daily Living Scale (SE-ADL) and the Physical Activity Scale for the Elderly (PASE) scores for the participants who pushed themselves up to rise (17.20 ± 7.53; 76.67 ± 13.23; 46.18 ± 52.64, respectively) were significantly poorer than for those who rose normally (10.35 ± 3.79; 87.64 ± 8.30; 112.90 ± 61.40, respectively) (all p < .05). Additionally, PASE scores were significantly poorer for participants who pushed themselves up to rise compared to those who rose slowly (95.21 ± 60.27) (p < .01). Pushing up to rise from a chair was a significant predictor of UPDRS-ADL (ß = .357; p < .001; R2 = .403), SE-ADL (ß = -.266; p = .009; R2 = .257) and PASE (ß = -.250; p = .016; R2 = .162). CONCLUSIONS: Ability to rise from a chair was associated with ADL limitation and physical activity in persons with PD. Poor ability to rise from a chair may prevent persons from living independently and engaging in physical activity.

Predictive ability of functional tests for postural instability and gait difficulty in Parkinson's disease.

The objective of this study is to identify clinical determinants for postural instability and gait difficulty in persons with Parkinson's disease (PD). Ninety-one persons (68 males; 74.7%) with PD were studied. Their mean age was 68.73 ± 8.74 years. The average time since diagnosis was 7.69 ± 5.23 years. The average Hoehn and Yahr stage was 2.43 ± 0.44. Age, gender, disease duration, disease severity and motor impairment were recorded. Participants were asked to perform timed clinical mobility tests that included a 5-step test, turns, forward walk, backward walk, and a sideways walk. The mobility tests were investigated for their contribution to predict the postural instability and gait difficulty (PIGD) score (falling, freezing, walking, gait and postural stability) of the Unified Parkinson Disease Rating Scale (UPDRS). PIGD score was significantly correlated with age, disease duration, Hoehn and Yahr score, comorbidity, UPDRS motor score, gait speed of forward, backward and sideways walks, and time to turn. PIGD score was marginally significantly correlated with timed 5-step test. After controlling for age, disease duration, disease severity, comorbidity, and motor impairment, sideway gait speed (ß = - 0.335; p = 0.024), timed 5-step test (ß = - 0.397; p = 0.003) and time to turn (ß = 0.289; p = 0.028) significantly predicted postural instability and gait difficulty. Walking sideways, 5-step test, and turning are significant predictors of PIGD score. These simple mobility tests can be quickly applied in clinical practice to determine postural instability and gait problems in persons with PD.

Contribution of Axial Motor Impairment to Physical Inactivity in Parkinson Disease.

OBJECTIVE: The objective of this study was to investigate the relationships between motor symptoms of Parkinson disease (PD) and activity limitations in persons with PD. DESIGN/METHODS: This is a cross-sectional study of persons with mild to moderate PD (N = 90). Associations among axial motor features, limb motor signs, the Physical Activity Scale for the Elderly, the ability to perform Activities of Daily Living (ADLs), and level of ADL dependency were studied. A composite score of axial motor features included the following Unified Parkinson Disease Rating Scale items: speech, rigidity of the neck, arising from chair, posture, gait, and postural stability. A composite score of limb motor signs included the following Unified Parkinson Disease Rating Scale items: tremor at rest of all extremities, action tremor, rigidity of all extremities, finger taps, hand movement, rapid alternating hand movements, and foot tapping. RESULTS: Axial motor features of PD were significantly correlated with physical inactivity (P < 0.001), decreased ADL (P < 0.001), and increase in ADL dependency (P < 0.001). Limb motor signs significantly correlated with decreased ADL (P < 0.001) and level of ADL dependency (P = 0.035) but did not correlate with physical inactivity. After controlling for age, sex, disease duration, and comorbidity, axial motor features contributed significantly to physical inactivity, decreased ADL, and increase in ADL dependency, whereas the limb motor signs did not. CONCLUSIONS: Axial motor impairment contributed to physical inactivity and decreased ability to perform ADLs in persons with PD.

Gait and step training to reduce falls in Parkinson's disease.

INTRODUCTION: Frequent falls and risk of injury are evident in individuals with Parkinson's disease (PD) as the disease progresses. There have been no reports of any interventions that reduce the incidence of falls in idiopathic PD. PURPOSE: Assess the benefit of gait and step perturbation training in individuals with PD. DESIGN: Randomized, controlled trial. SETTING: Outpatient research, education and clinical center in a tertiary care Veterans Affairs Medical Center. OUTCOME MEASURES: Gait parameters, 5-step test, report of falls. SUBJECTS: Eighteen men with idiopathic PD in stage 2 or 3 of the Hoehn and Yahr staging. METHODS: Subjects were randomly assigned to a trained or control group. They were asked about any falls 2 weeks prior to and after an 8 week period. Gait speed, cadence, and step length were tested on an instrumented walkway. Subjects were timed while stepping onto and back down from an 8.8 cm step for 5 consecutive steps. Gait training consisted of walking on a treadmill at a speed greater than over ground walking speed while walking in 4 directions and while supported in a harness for safety. Step training consisted of suddenly turning the treadmill on and off while the subject stood in the safety harness facing either forwards, backwards, or sideways. Training occurred 1 hour per day, three times per week for 8 weeks. A two-factor (time and group) analysis of variance with repeated measures was used to compare the groups. RESULTS: Substantial reduction occurred in falls in the trained group, but not in the control group. Gait speed increased in the trained group from 1.28+/-0.33 meters/sec to 1.45+/-0.37 meters/sec, but not in the control group (from 1.26 to 1.27 m/s). The cadence increased for both groups: from 112.8 to 120.3 steps/min for the trained group and 117.7 to 124.3 steps/min for the control group. Stride lengths increased for the trained group, but not the control group. The 5-step test speed increased in the trained group from 0.40+/-0.08 steps/sec to 0.51+/-0.12 steps/sec, and in the control group (0.36+/-0.11 steps/sec to 0.42+/-0.11 steps/sec). CONCLUSION: Gait and step perturbation training resulted in a reduction in falls and improvements in gait and dynamic balance. This is a promising approach to reduce falls for patients with PD.

Analysis of sEMG during voluntary movement--Part II: Voluntary response index sensitivity.

In this paper, a method for analyzing surface electromyographic (sEMG) data recorded from the lower-limb muscles of incomplete spinal-cord injured (iSCI) subjects is evaluated. sEMG was recorded bilaterally from quadriceps, adductor, hamstring, tibialis anterior, and triceps surae muscles during voluntary ankle dorsiflexion performed in the supine position as part of a comprehensive motor control assessment protocol. Analysis of the sEMG centered on two features, the magnitude of activation and the degree of similarity [similarity index (SI)] of the sEMG distribution to that of healthy subjects performing the same maneuver (n = 10). The analysis calculations resulted in response vectors (RV) that were compared to healthy-subject-derived prototype response vectors resulting in a voluntary response index (VRI). Incomplete SCI subjects (n = 9) were used to test the sensitivity of this analysis method. They were given supported-weight treadmill ambulation training, which is expected to improve or at least not cause a deterioration of voluntary motor control. The VRI provided evidence that the quantitative sEMG analysis method used was able to differentiate between healthy subjects and those with iSCI, characterize individual differences among iSCI subjects, and track motor control changes occurring over time.

Supported treadmill training for gait and balance in a patient with progressive supranuclear palsy.

BACKGROUND AND PURPOSE: Impaired balance, gait disturbances, and frequent falls are common problems in people with progressive supranuclear palsy (PSP). This case report describes the use of a modified body weight support treadmill training program to reduce falls and improve the balance and gait of a patient with PSP. CASE DESCRIPTION: The patient was a 62-year-old man diagnosed with PSP. His major problems were impaired balance and frequent, abrupt falls. METHODS: Physical therapy included walk training, balance perturbation, and step training using body weight support with a treadmill. Training sessions lasted 11/2 hours and occurred 3 days a week for 8 weeks. Fall incidence, balance, and gait were assessed before, during, and after the program. OUTCOMES: The patient reported fewer falls during and after training. Balance and gait improved after training. DISCUSSION: This case report is the first to report fall reduction, improved gait, and improved balance following physical therapy for a person with PSP.

Reliability of measures of gait performance and oxygen consumption with stroke survivors.

This study assessed the reliability of gait performance with concurrent measures of oxygen consumption (VO2) in stroke survivors (SS). Nine male SS (60.00 +/- 15.08 yr) had a recent history of stroke (44.56 +/- 51.35 days since the stroke) and were receiving rehabilitation. Four had a right cerebrovascular accident (CVA), and five had a left CVA. Subjects walked without assistance, although three used a single cane to complete the test. Within 30 minutes, subjects completed two trials of a 5 min walk while walking back and forth on a 5 m walkway wearing a portable gas analyzer to collect samples of gases. The intraclass correlation coefficient (ICC) was used to assess reliability. The ICC for gait energy expenditure, walk distance, gait speed, and gait energy cost were 0.64, 0.97, 0.95, and 0.97, respectively. Assessment of gait performance with concurrent measures of VO2 is a reliable procedure with SS.

Influence of fear of falling on gait and balance in Parkinson's disease.

PURPOSE: To study the relationship of fear of falling (FoF) with gait characteristics and balance in individuals with Parkinson's disease (PD). METHOD: Seventy-nine non-demented individuals (62 males) with PD were studied. Their mean age was 69.22 ± 8.93 years. The average time since diagnosis was 8.27 ± 5.31 years. FoF was assessed by the Activities-specific Balance Confidence (ABC) Scale in which high scores indicate less FoF. Gait was measured using a computerized walkway. Balance was measured by timed tests including the 5-step test, 360 degree turn, timed sideways walk, and timed up and go test. Participants were divided into two groups based on their ABC score (high FoF, ABC score <69; low FoF, ABC score ≥69). Gait characteristics and balance measures of the two groups were compared. RESULTS: Gait speed and stride length for forward walking (p < 0.0005 for both) and backward walking (p = 0.001 and 0.002, respectively) were lower for those with a high level of FoF compared to those with a low level of FoF. The time to take five steps (p = 0.025), time to turn (p < 0.0005), time to walk sideways (p = 0.001), and time to complete the up and go test (p = 0.003) were longer in those with a high level of FoF than in those with a low level of FoF. Number of steps to complete the turn (p = 0.001) and steps to walk sideways (p = 0.002) were greater in those with a high level of FoF than in those with a low level FoF. CONCLUSIONS: Gait and balance of individuals with PD with a high level of FoF were poorer than those with a low level of FoF, regardless of previous fall history. Implications for Rehabilitation The results demonstrates that fear of falling (FoF) is related to gait and balance in individuals with PD. Clinicians should be aware that FoF has a negative impact on gait and balance in individuals with PD.

FIM motor scores for classifying community discharge after inpatient rehabilitation for hip fracture.

OBJECTIVE: To assess the utility of functional status in classifying patients by discharge setting after inpatient rehabilitation for hip fracture. DESIGN: Retrospective cohort study. SETTING: A total of 1257 inpatient rehabilitation facilities in the United States. PATIENTS: Medicare beneficiaries (N = 117,168) receiving inpatient rehabilitation for hip fracture from 2007 to 2009. METHODS: Receiver operating characteristic curve analyses to assess the overall discriminatory ability of functional status scores (Functional Independence Measure [FIM] total, FIM cognition, and FIM motor) and to identify the functioning threshold that best differentiates patients by discharge setting. MAIN OUTCOME MEASUREMENTS: Discharge setting (community versus institutional). RESULTS: Approximately 68% of patients were discharged to the community after inpatient rehabilitation for hip fracture. Receiver operating characteristic curve analyses indicate that discharge FIM motor ratings (area under the curve: 0.84) alone are as effective as a multivariable model (area under the curve: 0.85), including sociodemographic and clinical factors, in discriminating patients discharged to the community from those discharged to an institution. A discharge FIM motor rating of 58 yielded the best balance in sensitivity and specificity for classifying patients by discharge setting. CONCLUSIONS: Discharge FIM motor ratings demonstrated good discriminatory ability for classifying discharge setting. An FIM motor rating of 58 may serve as a clinical tool to guide treatment plans and/or as additional information in complex discharge planning decisions for patients with hip fracture.

Reliability of the non-instrumented walk test in persons with Parkinson's disease.

PURPOSE: To study the reliability of a Non-Instrumented Walk Test in individuals with Parkinson's disease (PD). METHOD: Thirty individuals (21 Males) with PD were studied. Their mean age was 68.90 ± 9.28 years. The average time since diagnosis was 8.75 ± 5.68 years. The reliability of the manual Non-Instrumented Walk Test was studied while "OFF" and "ON" dopaminergic medication. Subjects walked at their self-selected, usual speed during a Non-Instrumented Walk Test and while walking on a computerized instrumented walkway. Intraclass correlation coefficients (ICCs) were calculated and means were compared for three gait parameters as measured by the two methods. RESULTS: During "OFF" medication testing, ICCs between the Non-Instrumented Walk Test and the instrumented measures for gait speed, cadence and stride length were 0.96 (p < 0.0005), 0.72 (p = 0.001) and 0.97 (p < 0.0005), respectively. During "ON" medication testing, the ICCs were 0.96 (p < 0.0005), 0.86 (p < 0.0005) and 0.96 (p < 0.0005), respectively. The means of the non-instrumented measures tended to be lower than those obtained on the instrumented walkway. CONCLUSIONS: The Non-Instrumented Walk Test is a quick, simple and inexpensive gait evaluation for individuals with PD. The method is sufficiently reliable to be used clinically in this population during different medication cycles. IMPLICATIONS FOR REHABILITATION: • The Non-Instrumented Walk Test in individuals with PD is reliable. • Results supported the use of the measure. This simple walk test is quick and easy to administer in both clinical and community settings.

Ambulatory activity of older adults hospitalized with acute medical illness.

OBJECTIVES: To describe the amount and patterns of ambulatory activity in hospitalized older adults over consecutive hospital days. DESIGN: Observational cohort study. SETTING: University teaching hospital Acute Care for Elderly (ACE) unit. PARTICIPANTS: Adults aged 65 and older (N = 239) who wore a step activity monitor during their hospital stay. MEASUREMENTS: Total number of steps per 24-hour day. Mean daily steps were calculated based on number of days the step activity monitor was worn. RESULTS: Mean age was 76.6 ± 7.6; 55.1% of participants were female. Patients took a mean number of 739.7 (interquartile range 89-1,014) steps per day during their hospital stay. Patients with shorter stays tended to ambulate more on the first complete day of hospitalization and had a markedly greater increase in mobility on the second day than patients with longer lengths of stay. There were no significant differences in mean daily steps according to illness severity or reason for admission. CONCLUSION: Objective information on patient mobility can be collected for hospitalized older persons. Findings may increase understanding of the level of ambulation required to maintain functional status and promote recovery from acute illness.

Gait variability in Parkinson's disease: influence of walking speed and dopaminergic treatment.

OBJECTIVES: To study the effects of levodopa and walking speed on gait variability in individuals with Parkinson's disease (PD). METHODS: Thirty-three individuals with PD were studied. Their mean age was 70.61±9.23 year. The average time since diagnosis was 9.65±5.80 year. Gait variability was studied while 'OFF' and 'ON' dopaminergic medication when the subjects walked at their usual and fastest speeds. RESULTS: Variability of step time, double support time, stride length and stride velocity decreased significantly (P=0.037; P=0.037; P=0.022; P=0.043, respectively) after dopaminergic treatment. When subjects increased walking speed, the variability of stride length and stride velocity decreased significantly (P=0.038 and P=0.004, respectively) both while 'OFF' and 'ON' levodopa. Increasing walking speed did not change the variability of step time and double support time regardless of medication status. CONCLUSIONS: Levodopa decreased gait variability in persons with PD. Stride length and stride velocity variability appeared to be speed dependent parameters, whereas, the variability of step time and double support time appeared to be speed independent measures. Levodopa had positive effects on gait stability in PD.

A pilot study: influence of visual cue color on freezing of gait in persons with Parkinson's disease.

PURPOSE: To investigate the effect of red and green light beams on gait and freezing of gait (FOG) in persons with Parkinson's disease (PD). METHODS: Seven persons with PD who experienced FOG participated in the study. Gait and turning performances were studied while walking with canes with red, green, and no light beams while "off" and "on" anti-Parkinsonian medications. Gait speed, cadence, and stride were recorded. Time and number of freezing episodes were recorded during a 50-foot walk and a 360° turn. RESULTS: During 'off' medication, compared to no light, stride length improved when using the green light, but not the red. During the 50-foot walk, freezing episodes were reduced when using the green light compared to both the red and no light. During the 360° turn, time, number of steps and number of freezing episodes were reduced using the green light compared to the red and no light. During 'on' medication, gait speed and stride length improved more with the green light compared to the red. Neither color showed any effect on cadence during either medication state. CONCLUSION: A green light improved gait and alleviate FOG in persons with PD better than a red light or no light.

Strength and speed training for elders with mobility disability.

The purpose of this study was to pilot test a function-focused exercise intervention consisting of strength and gait-speed training in elders with reduced walking speed, decreased walking endurance, and functional impairment. Twelve participants, 77.2 years old (+/-7.34), whose usual gait speed was <0.85 m/s, with walking endurance of <305 m in 5 min, and who were functionally impaired participated in a moderate-intensity exercise intervention. The training occurred 3 times per week, 75 min per session, for 3 months and combined 4 weeks of gait-speed training, walking exercise, and functional strengthening. The participants demonstrated mean usual gait speeds (> or =1.0 m/s), endurance (> or =350 m), and functional ability (> or =10 score on performance battery) that were within normal limits after 12 weeks of training. Fastest gait speed (> or =1.5 m/s) and muscle strength also improved significantly. Improvements were maintained during follow-up testing after 3-6 months. In summary, a 12-week intervention for frail, mobility-disabled participants led to improvements in walking, function, and strength.