Evidence for Early and Regular Physical Therapy and Exercise in Parkinson's Disease.

Advances in medical management of Parkinson's disease (PD) have resulted in living longer with disability. Although disability worsens over the course of the disease, there are signs of disability even in the early stages. Several studies reveal an early decline in gait and balance and a high prevalence of nonmotor signs in the prodromal period that contribute to early disability. There is a growing body of evidence revealing the benefits of physical therapy and exercise to mitigate motor and nonmotor signs while improving physical function and reducing disability. The presence of early disability coupled with the benefits of exercise suggests that physical therapy should be initiated earlier in the disease. In this review, we present the evidence revealing early disability in PD and the effectiveness of physical therapy and exercise, followed by a discussion of a secondary prevention model of rehabilitation to reduce early disability and optimize long-term outcomes.

Are Mobile Persons With Parkinson Disease Necessarily More Active?

BACKGROUND AND PURPOSE: Walking activity in persons with Parkinson disease (PD) is important for preventing functional decline. The contribution of walking activity to home and community mobility in PD is poorly understood. METHODS: Cross-sectional baseline data (N = 69) were analyzed from a randomized controlled PD trial. The Life-Space Assessment (LSA) quantified the extent, frequency, and independence across 5 expanding levels of home and community mobility, producing individual subscores and a total score. Two additional summed scores were used to represent mobility within (Levels 1-3) and beyond (Levels 4-5) neighborhood limits. An accelerometer measured walking activity for 7 days. Regression and correlation analyses evaluated relationships between daily steps and mobility scores. Mann-Whitney U tests secondarily compared differences in mobility scores between the active and sedentary groups. RESULTS: Walking activity contributed significantly to the summed Level 1-3 score (ß = 0.001, P = 0.004) but not to the summed Level 4-5 (ß = 0.001, P = 0.33) or total (ß = 0.002, P = 0.07) scores. Walking activity was significantly related to Level 1 (ρ = 0.336, P = 0.005), Level 2 (ρ = 0.307, P = 0.010), and Level 3 (ρ = 0.314, P = 0.009) subscores. Only the summed Level 1-3 score (P = 0.030) was significantly different between the active and sedentary groups. DISCUSSION AND CONCLUSIONS: Persons with PD who demonstrated greater mobility beyond the neighborhood were not necessarily more active; walking activity contributed more so to home and neighborhood mobility. Compared with LSA total score, the Level 1-3 summed score may be a more useful participation-level measure for assessing the impact of changes in walking activity.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A349).

The Rehabilitation Enhancing Aging Through Connected Health Prehabilitation Trial.

OBJECTIVE: To evaluate the proof of concept of an innovative model of physical therapy Rehabilitation Enhancing Aging through Connected Health (REACH) and evaluated its feasibility and effect on physical function and health care utilization. DESIGN: Quasi-experimental 12-month clinical trial. SETTING: Two outpatient rehabilitation centers. PARTICIPANTS: Community-dwelling older primary care patients with a treatment arm undergoing the intervention (n=75; mean age=77±5.9y; 54% women) and propensity matched controls derived from a longitudinal cohort study (n=430; mean age=71±7.0y; 68% women) using identical recruitment criteria (N=505). INTERVENTION: Combined outpatient and home PT augmented with a commercially available app and computer tablet. MEASUREMENTS: Primary outcomes included a feasibility questionnaire, exercise adherence, self-reported function, and the Short Physical Performance Battery (SPPB). Secondary outcomes included the rates of emergency department (ED) visits and hospitalizations. RESULTS: Among REACH participants, we observed a 9% dropout rate. After accounting for dropouts, with propensity matching, n=68 treatments and n=100 controls were analyzed. Over the 12-month study duration, 85% of participants adhered to the exercise program an average of 2 times a week and evaluated the treatment experience favorably. In comparison to controls, after 1 year of treatment and within multivariable regression models, REACH participants did not manifest a significant difference in patient reported function (group x time effect 1.67 units, P=.10) but did manifest significant differences in SPPB (group x time effect 0.69 units, P=.03) and gait speed (group x time effect .08m/s, P=.02). In comparison to controls, after 1 year, the rate of ED visits (group x time treatment rate=0.27, P<.004) were significantly reduced, but a significant reduction in hospitalizations was not observed. CONCLUSION: The REACH intervention is feasible and has proof of concept in preventing functional decline and favorably affecting health care utilization. Evaluation on a larger scale is warranted.

Highly Challenging Balance Program Reduces Fall Rate in Parkinson Disease.

BACKGROUND AND PURPOSE: There is a paucity of effective treatment options to reduce falls in Parkinson disease (PD). Although a variety of rehabilitative approaches have been shown to improve balance, evidence of a reduction in falls has been mixed. Prior balance trials suggest that programs with highly challenging exercises had superior outcomes. We investigated the effects of a theory-driven, progressive, highly challenging group exercise program on fall rate, balance, and fear of falling. METHODS: Twenty-three subjects with PD participated in this randomized cross-over trial. Subjects were randomly allocated to 3 months of active balance exercises or usual care followed by the reverse. During the active condition, subjects participated in a progressive, highly challenging group exercise program twice weekly for 90 minutes. Outcomes included a change in fall rate over the 3-month active period and differences in balance (Mini-Balance Evaluation Systems Test [Mini-BESTest]), and fear of falling (Falls Efficacy Scale-International [FES-I]) between active and usual care conditions. RESULTS: The effect of time on falls was significant (regression coefficient = -0.015 per day, P < 0.001). The estimated rate ratio comparing incidence rates at time points 1 month apart was 0.632 (95% confidence interval, 0.524-0.763). Thus, there was an estimated 37% decline in fall rate per month (95% confidence interval, 24%-48%). Improvements were also observed on the Mini-BESTest (P = 0.037) and FES-I (P = 0.059). DISCUSSION AND CONCLUSIONS: The results of this study show that a theory-based, highly challenging, and progressive exercise program was effective in reducing falls, improving balance, and reducing fear of falling in PD.Video abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A120).

ICF classification of therapeutic goals for outpatient episodes of neurorehabilitation in post-stroke and Parkinson disease.

PURPOSE: To understand therapeutic priorities, a secondary data analysis on a retrospective cohort was conducted to classify rehabilitation goals according to the International Classification of Functioning, Disability, and Health (ICF). MATERIALS AND METHODS: Therapeutic goals from an initial outpatient physical or occupational therapy evaluation for patients post-stroke or with Parkinson disease, were classified into Level 1 of the ICF. Goals in the Activity and Participation component were further sub-classified as activity capacity or activity performance (self-report or direct) in daily life. RESULTS: 776 goals across 104 participants were classified into Level 1 of the ICF. The majority, 73% (563/776) were classified as Activity and Participation, 20% (155/776) as Body Function and 2% (17/776) as Environmental Factors. Fifty-two percent (400/776) of all goals were classified as activity capacity and 21% (163/776) as activity performance in daily life, with 21% (160/776) of goals measuring self-report activity performance in daily life and less than 1% (3/776) of goals measuring direct activity performance in daily life. CONCLUSIONS: While the majority of therapeutic goals were classified into the Activity and Participation component, less than 1% of goals measured direct activity performance in daily life. If people seek outpatient rehabilitation to improve functioning in their real-world environment, therapeutic goal setting should reflect this.

The majority of therapeutic goals for an episode of outpatient neurorehabilitation were classified into the Activity and Participation component of the International Classification of Functioning, Disability, and Health.However, less than 1% of therapeutic goals measured direct activity performance in daily life.If people with neurological diagnoses seek out outpatient rehabilitation to improve functioning in their real-world environment, than therapeutic goal setting should reflect this.

Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association.

A clinical practice guideline on Parkinson disease was developed by an American Physical Therapy Association volunteer guideline development group that consisted of physical therapists and a neurologist. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for management of Parkinson disease. The Spanish version of this clinical practice guideline is available as a supplement (Suppl. Appendix 1).

Feasibility of a virtual exercise coach to promote walking in community-dwelling persons with Parkinson disease.

OBJECTIVE: The short-term benefits of exercise for persons with Parkinson disease (PD) are well established, but long-term adherence is limited. The aim of this study was to explore the feasibility, acceptability, and preliminary evidence of the effectiveness of a virtual exercise coach to promote daily walking in community-dwelling persons with Parkinson disease. DESIGN: Twenty subjects with Parkinson disease participated in this phase 1, single-group, nonrandomized clinical trial. The subjects were instructed to interact with the virtual exercise coach for 5 mins, wear a pedometer, and walk daily for 1 mo. Retention rate, satisfaction, and interaction history were assessed at 1 mo. Six-minute walk and gait speed were assessed at baseline and after the intervention. RESULTS: Fifty-five percent of the participants were women, and the mean age was 65.6 yrs. At the study completion, there was 100% retention rate. The subjects had a mean satisfaction score of 5.6/7 (with 7 indicating maximal satisfaction) with the virtual exercise coach. Interaction history revealed that the participants logged in for a mean (SD) of 25.4 (7) days of the recommended 30 days. The mean adherence to daily walking was 85%. Both gait speed and the 6-min walk test significantly improved (P < 0.05). No adverse events were reported. CONCLUSIONS: Sedentary persons with Parkinson disease successfully used a computer and interacted with a virtual exercise coach. Retention, satisfaction, and adherence to daily walking were high for 1 mo, and significant improvements were seen in mobility.

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.