Reduced performance in balance, walking and turning tasks is associated with increased neck tone in Parkinson's disease

The effects of myofascial release in combined with task-oriented circuit training on balance in people with Parkinson's disease: a randomized pilot trial

OBJECTIVES

Task-oriented circuit training (TOCT) has been used to improve balance in people with Parkinson's disease (pwPD). To investigate the effectiveness of TOCT on balance, quality of life, and disease symptoms when combined with myofascial release in pwPD.

METHODS

Twenty-six pwPD were randomized into two groups for this randomized controlled study. The groups received TOCT three days a week for eight weeks. At the end of each session, the myofascial release was applied to the neck, trunk, and lumbar region with three sets of 60-s foam rolling body weight (Intervention group-IG) and perceived discomfort level 0/10 (Control group-CG) using a numeric rating scale. Primary outcome measures were measured by the Berg Balance Scale (BBS), Parkinson's Disease Questionnaire (PDQ-8), and Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS). Secondary outcome measures included posturographic assessment, timed-up and go test (TUG), Trunk Impairment Scale (TIS), and rolling time.

RESULTS

Data obtained from 26 pwPDs in equal numbers in both groups were analyzed. All groups reported a significant change in MDS-UPDRS, MDS-UPDRS-III, PDQ-8, TIS, and rolling time after treatment compared to pretreatment. Post-hoc analyses showed that IG significantly improved motor symptoms, TUG, and TIS dynamics compared to CG. The mediolateral limits of stability and anterioposterior limits of stability distances of IG increased (p < 0.05).

DISCUSSION

Myofascial release, when combined with TOCT, may help to reduce disease-related motor symptoms and improve dynamic balance in pwPD. These findings suggest that myofascial release can be a beneficial addition to TOCT programs for pwPD.Clinical Trial Number: NCT05900934 (ClinicalTrials.gov).

Turns while walking among individuals with Parkinson's disease following overground locomotor training: A pilot study

BACKGROUND

Individuals with Parkinson's disease are challenged in making turns while walking, evidenced by reduced intersegmental coordination and reduced dynamic postural stability. Although overground locomotor training previously improved ambulation among people with Parkinson's disease, its effect on walking turns remained unknown. We sought to understand the effects of overground locomotor training on walking turns among individuals with mild-Parkinson's disease.

METHODS

Twelve participants with Parkinson's (7 Males/5 Females; Age: 68.5 ± 6.4 years) completed twenty-four sessions lasting approximately 60 min and over 12-15 weeks. Baseline and follow-up assessments included the ten-minute walk test using wearable sensors. Primary outcomes included changes to intersegmental coordination, measured by peak rotation and normalized peak rotation, and dynamic postural stability, measured by peak turn velocities in the frontal and transverse planes. Statistical analysis included one-tailed paired t-tests and Cohen's d effect sizes with α = 0.05.

FINDINGS

No effects of overground locomotor training on mean peak thoracic rotation (+0.23 ± 4.24°; Cohen's d = 0.05; P = 0.45) or mean normalized peak thoracic rotation (-0.59 ± 5.52 (unitless); Cohen's d = 0.10; P = 0.45) were observed. Moderate and small effects of overground locomotor training were observed on mean peak turn velocities in the frontal (+1.59 ± 2.18°/s; Cohen's d = 0.43; P = 0.01) and transverse planes (+0.88 ± 3.18°/s; Cohen's d = 0.25; P = 0.18).

INTERPRETATION

This pilot study provides preliminary evidence suggesting that individuals with mild-Parkinson's moderately improved frontal plane dynamic postural stability after overground locomotor training, likely attenuating the perturbations experienced while turning.

CLINICAL TRIAL REGISTRATION

NCT03864393.

Added forearm weights for gait pattern normalization in patients with Parkinson's disease

Patients with Parkinson's Disease presented gait impairment. Applying additional weights to enhancing sensory input may improve gait impairment. We assumed that gait impairment could be improved when patients walked with additional forearm weights, and the gait improvement was associated with clinical characteristic of Parkinson's Disease. Thirty patients with Parkinson's Disease and 30 age-sex matched controls were recruited. Spatiotemporal and joint kinematics parameters were evaluated by a three-dimensional motion capture system in normal walking and walking with sandbags, respectively. The comparisons of spatiotemporal parameters were analyzed using t-test or nonparametric tests. The comparison of joint kinematic data was analyzed using statistical parametric mapping. The correlation between motor symptom and gait parameters changes was analyzed using Pearson's correlation analysis. During normal walking, patients showed deteriorated gait compared with controls. After applying weights to forearms patients increased cadence (p = 0.004), speed (p < 0.001) and step length (p = 0.048), and decreased stride time (p = 0.003). The hip angles significantly increased during 5%-23% and 87%-100% of gait cycle, while knee angles during 9%-25% and 88%-98% of the gait cycle, and ankle angles in 92%-100% of gait cycle. The gait parameters of patients with forearm-loading showed no significant difference compared with healthy subjects walking normally. The change of gait parameters correlated positively with the axial and tremor severity while correlated negatively with the rigidity sub-score. Patients with tremor dominant subtype also showed greater improvement of speed and step time compared with patients with postural instability/gait difficulty subtype. Applying added weights bilaterally to the forearms of patients can normalize gait patterns. Notably, patients with higher scores on axial and tremor and lower rigidity scores gained more benefits.

Effects of Oral Levodopa on Balance in People with Idiopathic Parkinson's Disease

BACKGROUND

Balance impairment is a frequent cause of morbidity and mortality in people with Parkinson's disease (PD). As opposed to the effects of appendicular motor symptoms, the effects of Levodopa on balance impairment in idiopathic PD are less clear.

OBJECTIVE

To review the literature on the effects of oral Levodopa on clinical balance test performance, posturography, step initiation, and responses to perturbation in people with idiopathic PD (PwPD).

METHODS

A systematic search of three scientific databases (Pubmed, Embase, and Web of Science) was conducted in accordance with PRISMA guidelines. For the pilot meta-analysis, standardized mean differences with 95% confidence intervals were calculated using an inverse variance random effects model. Data not suitable for implementation in the meta-analysis (missing means or standard deviations, and non-independent outcomes) were analyzed narratively.

RESULTS

A total of 2772 unique studies were retrieved, of which 18 met the eligibility criteria and were analyzed, including data of 710 idiopathic PwPD. Levodopa had a significant positive effect on the Berg Balance Scale, the Push and Release test, and jerk and frequency parameters during posturography. In contrast, some significant negative effects on velocity-based sway parameters were found during posturography and step initiation. However, Levodopa had no significant effect on most step initiation- and all perturbation parameters.

CONCLUSION

The effects of Levodopa on balance in PwPD vary depending on the outcome parameters and patient inclusion criteria. A systematic approach with well-defined outcome parameters, and prespecified, sensitive and reliable tests is needed in future studies to unravel the effects of oral Levodopa on balance.

Effects of a Resistance Training Protocol on Physical Performance, Body Composition, Bone Metabolism, and Systemic Homeostasis in Patients Diagnosed with Parkinson's Disease: A Pilot Study

Parkinson's disease (PD) is a neurodegenerative disorder characterized by motor impairments and it is correlated with loss of bone mineral density. This study aimed to analyze the effects of resistance training on bone metabolism, systemic homeostasis, body composition, and physical performance in people with PD. Thirteen subjects (age 64.83 ± 5.70) with PD diagnosis were recruited. Participants performed neuromuscular tests, body composition assessment, and blood sample analysis at baseline, and after an 11 weeks-training period. Each training session lasted 90 min, three times a week. The participants had significant improvements in the timed up and go (p < 0.01), sit to stand (p < 0.01), dominant peg-board (p < 0.05), dominant foot-reaction time (p < 0.01), and functional reach tests (p < 0.05). They showed better pressure foot distributions in the left forefoot (p < 0.05) and hindfoot (p < 0.05) and increased cervical right lateral bending angle (p < 0.05). The protocol affects bone metabolism markers osteocalcin (p < 0.05), calcium (p < 0.01), PTH (p < 0.01), the C-terminal telopeptide (CTX) (p < 0.01), and vitamin D (p < 0.05). Eleven weeks of resistance training improved manual dexterity, static and dynamic balance, reaction time, cervical ROM, and reduced bone loss in people with PD.

Effects of experimentally induced cervical spine mobility alteration on the postural organisation of gait initiation

Gait initiation (GI), the transient period between quiet standing and locomotion, is a functional task classically used in the literature to investigate postural control. This study aimed to investigate the influence of an experimentally-induced alteration of cervical spine mobility (CSM) on GI postural organisation. Fifteen healthy young adults initiated gait on a force-plate in (1) two test conditions, where participants wore a neck orthosis that passively simulated low and high levels of CSM alteration; (2) one control condition, where participants wore no orthosis; and (3) one placebo condition, where participants wore a cervical bandage that did not limit CSM. Centre-of-pressure and centre-of-mass kinematics were computed based on force-plate recordings according to Newton’s second law. Main results showed that anticipatory postural adjustments amplitude (peak backward centre-of-pressure shift and forward centre-of-mass velocity at toe-off) and motor performance (step length and forward centre-of-mass velocity at foot-contact) were altered under the condition of high CSM restriction. These effects of CSM restriction may reflect the implementation of a more cautious strategy directed to attenuate head-in-space destabilisation and ease postural control. It follows that clinicians should be aware that the prescription of a rigid neck orthosis to posturo-deficient patients could exacerbate pre-existing GI deficits.

Surrogates for rigidity and PIGD MDS-UPDRS subscores using wearable sensors

BACKGROUND

Telemedicine has the advantage of expanding access to care for patients with Parkinson's Disease (PD). However, rigidity and postural instability in PD are difficult to measure remotely, and are important measures of functional impairment and fall risk.

RESEARCH QUESTION

Can measures from wearable sensors be used as future surrogates for the MDS-UPDRS rigidity and Postural Instability and Gait Difficulty (PIGD) subscores?

METHODS

Thirty-one individuals with mild to moderate PD wore 3 inertial sensors at home for one week to measure quantity and quality of gait and turning in daily life. Separately, we performed a clinical assessment and balance characterization of postural sway with the same wearable sensors in the laboratory (On medication). We then first performed a traditional correlation analysis between clinical scores and objective measures of gait and balance followed by multivariable linear regression employing a best subset selection strategy.

RESULTS

The number of walking bouts and turns correlated significantly with the rigidity subscore, while the number of turns, foot pitch angle, and sway area while standing correlated significantly with the PIGD subscore (p < 0.05). The multivariable linear regression showed that rigidity subscore was best predicted by the number of walking bouts while the PIGD subscore was best predicted by a combination of number of walking bouts, gait speed, and postural sway.

SIGNIFICANCE

The correlation between objective sensor data and MDS-UPDRS rigidity and PIGD scores paves the way for future larger studies that evaluate use of objective sensor data to supplement remote MDS-UPDRS assessment.

The starting distance of obstacle circumvention did not affect intersegmental coordination in individuals with Parkinson's disease

BACKGROUND

Obstacle circumvention is a challenging task in Parkinson's disease (PD). Body segments adjustments, such as changing the direction of the trunk, followed by a change in the direction of the head, and modifications in the positioning of the feet, are necessary to circumvent an obstacle during walking. For that, individuals need to identify the distance to the obstacle, its characteristics (such as its dimension), and perform well-coordinated movements. However, PD is characterized by rigidity, which may be increased in the axial axis and compromise the task execution. Also, worsening sensory integration in PD may increase the time to perform these body segments adjustments, thus impairing the movement coordination when starting obstacle circumvention near to the obstacle.

AIM

To determine if the starting distance (1.5 m, 3 m, or 5 m) from the obstacle could modify the intersegmental coordination (specifically, the coordination between head, trunk, and pelvis) during the obstacle circumvention steps in individuals with PD.

METHODS

Fourteen individuals with a diagnosis of idiopathic PD and 15 neurologically healthy individuals (CG) from the community were included in this study. The participants were evaluated in three different gait conditions, according to the starting distance from the obstacle: 1.5 m, 3 m, and 5 m away from the obstacle. Vector coding technique was employed to establish the coupling between head, trunk, and pelvis in the steps immediately before and during obstacle circumvention. Three-way ANOVA's (group, distance, and step) were calculated with the level of significance at p < 0.05.

RESULTS

For all couplings of coordination, there were no effects of distance. However, significant main effects of group and steps (p < 0.05) were found for all couplings with different patterns of coordination: head/pelvis (group: in-phase and anti-phase variables; steps: anti-phase variable), head/trunk (group: trunk variable; steps: in-phase and anti-phase variables) and trunk/pelvis (group: anti-phase; steps: trunk and pelvis). Finally, only head/trunk coupling showed an interaction between group*steps. Individuals with PD showed 7.95% lower head movement (p < 0.024) and 14.85% greater trunk movement than CG (p < 0.002). Also, individuals with PD performed 17.56% greater head movement in the step before the circumvention compared to the step during circumvention (p < 0.044).

CONCLUSION

The starting distance from the obstacle did not influence the pattern of axial intersegmental coordination in both groups. However, how these segments interact in the preparation and during the obstacle circumvention are opposite in individuals with PD. While on the previous step to obstacle circumvention, the head movement was greater than the trunk, during the obstacle circumvention step, individuals with PD rotated the trunk more.

Short-term effect and its retention of LSVT® BIG on QOL improvement: 1-year follow-up in a patient with Parkinson's disease

BACKGROUND

There are no reports regarding the long-term retention of effects of Lee Silverman Voice Treatment® BIG (LSVT® BIG) on improvements in quality of life (QOL) among patients with Parkinson's disease (PD).

OBJECTIVE

This study aimed to evaluate the short-term effect of LSVT® BIG on QOL improvement and its retention in a patient with PD. Motor symptoms, walking ability, and walking speed were evaluated as factors associated with QOL.

METHODS

A 63-year-old woman who was diagnosed with PD received a 4-week LSVT® BIG program under the supervision of certified LSVT® BIG physical therapists. The participant's disease severity was classified as Hoehn and Yahr stage 2. The Parkinson's Disease Questionnaire-39 (PDQ-39), Movement Disorder Society-sponsored Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part 3, timed up-and-go test (TUG), and 10 m walk test (10 MWT) were evaluated before, after, and 1-year after the intervention.

RESULTS

The results indicated short-term improvements in the PDQ-39, MDS-UPDRS part 3, TUG, and 10 MWT which were retained for up to 1 year.

CONCLUSIONS

This case report suggests the possibility of 1-year retention of improvements in QOL, motor symptoms, walking ability, and walking speed resulting from LSVT® BIG intervention in a patient with mild PD.

Objective measures of lingual and jaw function in healthy adults and persons with Parkinson's disease: Implications for swallowing

The study examines the effects of age and Parkinson's disease on lingual and jaw function in neurotypical adults, as well as persons with Parkinson's Disease. Preliminary results provide reference measures in these populations and support the systematic collection of objective data regarding lingual strength, lingual range of motion, and jaw range of motion in clinical populations. The application of this clinically meaningful protocol also provides a means to track physiological changes over time in order to maximize the results of rehabilitative efforts to restore swallow function.

Neuromechanical Assessment of Activated vs. Resting Leg Rigidity Using the Pendulum Test Is Associated With a Fall History in People With Parkinson's Disease

Leg rigidity is associated with frequent falls in people with Parkinson’s disease (PD), suggesting a potential role in functional balance and gait impairments. Changes in the neural state due to secondary tasks, e.g., activation maneuvers, can exacerbate (or “activate”) rigidity, possibly increasing the risk of falls. However, the subjective interpretation and coarse classification of the standard clinical rigidity scale has prohibited the systematic, objective assessment of resting and activated leg rigidity. The pendulum test is an objective diagnostic method that we hypothesized would be sensitive enough to characterize resting and activated leg rigidity. We recorded kinematic data and electromyographic signals from rectus femoris and biceps femoris during the pendulum test in 15 individuals with PD, spanning a range of leg rigidity severity. From the recorded data of leg swing kinematics, we measured biomechanical outcomes including first swing excursion, first extension peak, number and duration of the oscillations, resting angle, relaxation index, maximum and minimum angular velocity. We examined associations between biomechanical outcomes and clinical leg rigidity score. We evaluated the effect of increasing rigidity through activation maneuvers on biomechanical outcomes. Finally, we assessed whether either biomechanical outcomes or changes in outcomes with activation were associated with a fall history. Our results suggest that the biomechanical assessment of the pendulum test can objectively quantify parkinsonian leg rigidity. We found that the presence of high rigidity during clinical exam significantly impacted biomechanical outcomes, i.e., first extension peak, number of oscillations, relaxation index, and maximum angular velocity. No differences in the effect of activation maneuvers between groups with clinically assessed low rigidity were observed, suggesting that activated rigidity may be independent of resting rigidity and should be scored as independent variables. Moreover, we found that fall history was more common among people whose rigidity was increased with a secondary task, as measured by biomechanical outcomes. We conclude that different mechanisms contributing to resting and activated rigidity may play an important yet unexplored functional role in balance impairments. The pendulum test may contribute to a better understanding of fundamental mechanisms underlying motor symptoms in PD, evaluating the efficacy of treatments, and predicting the risk of falls.

The effects of light touch cue on gait initiation in patients with Parkinson's disease

INTRODUCTION

One of the common impairments in patients with Parkinson's disease (PD) is disturbance of gait initiation. A light touch cue improves postural stability in patients with PD. Little is known about the effects of a light touch cue on gait initiation. This study investigated the effects of a light touch on gait initiation in patients with PD.

METHODS

This study was a cross-sectional study design. Sixteen patients with PD (Hoehn & Yahr stage 2-3) participated in the study and were evaluated two gait conditions (no touch (NT) and light touch (LT) conditions). Gait initiation was divided into 5 events including event A, B, C, D, and E. Outcome measures included maximum center of pressure (COP) displacement and velocity in anteroposterior (AP) and mediolateral (ML) directions, and the first step time.

RESULTS

Participants with LT had greater COP displacement compared with the NT condition in all events of gait initiation except COP-AP displacement in event D. Additionally, the COP velocity in LT condition was faster than the NT condition in COP-ML velocity in event A, COP-AP velocity in event B, COP-AP velocity and COP-ML velocity in event C. Moreover, participants with LT presented significantly shorter the first step time than the NT condition.

CONCLUSIONS

These findings demonstrated that a light touch cue improved gait initiation in patients with PD by increased weight shifting to initial stance limb, increased postural stability of stance limb, increased velocity of weight transfer toward stance limb, and a shortened first step time.

Hatha yoga training improves standing balance but not gait in Parkinson's disease

Background and purpose

Complementary therapies, such as yoga, have been proposed to address gait and balance problems in Parkinson's disease (PD). However, the effects of yoga on gait and static balance have not been studied systematically in people with PD (PWP). Here we evaluated the effects of a 12-week long Hatha yoga intervention on biomechanical parameters of gait and posture in PWP.

Methods

We employed a pilot randomized controlled trial design with two groups of mild-to-moderate PWP (immediate treatment, waitlist control; N = 10 each; Mean Hoehn and Yahr score = 2 for each group). Baseline Unified Parkinson's Disease Rating Scale (UPDRS) motor scores, and gait and postural kinematics including postural sway path length, cadence, walking speed, and turning time were obtained. The immediate treatment group received a 60-min Hatha yoga training twice a week for 12 weeks, while the waitlisted control group received no training. After 12 weeks, gait and postural kinematics were assessed (post-test for treatment group and second-baseline for waitlist group). Then, the waitlist group received the same yoga training and was evaluated post-training.

Results

After Hatha yoga training, UPDRS motor scores improved with an 8-point mean decrease which is considered as a moderate clinically important change for mild-moderate PD. Sway path length during stance decreased significantly (mean reduction: -34.4%). No significant between-group differences or improvements in gait kinematics were observed.

Conclusion

This study showed that a 12-week Hatha yoga training can improve static balance in PWP. We found no evidence that it systematically improves gait performance in PWP.

A comparison of the relationship between manual dexterity and postural control in young and older individuals with Parkinson's disease

The motor symptoms of Parkinson's disease (PD) cause deterioration in manual dexterity. This deterioration affects independence in activities of daily living negatively. The loss of postural control, which occurs more frequently with disease progression, restricts physical functions and reduces mobility in patients with PD. Impaired postural control may affect distal mobility of an individual. The aim of this study was to investigate postural control and manual dexterity in individuals ≤ 65 and >65 years with PD and analyze the relationship between these variables according to age. Sixty-six individuals with PD participated in the study. The participants were categorized according to age (n = 29 for 65 years of age or younger and n = 37 for older). Manual dexterity (Dominant and Non-dominant hand) was assessed by the Nine Hole Peg Test (NHPT). Postural control was evaluated by the Limit of Stability Test (LoS) using a computerized balance measuring instrument. There was no statistically significant difference between the age groups on the combined dependent variables after controlling for disability, gender, weight, and height; F(7, 54) = 0.804, p = 0.587. Only LoS-Maximum Excursion was higher in the individuals ≤ 65 years (p = 0.035). Significant correlations were found between NHPT-Dominant and LoS-Reaction Time, LoS-Maximum Excursion; NHPT-Non-dominant and LoS-Reaction Time, LoS-Endpoint Excursion, LoS-Maximum Excursion in the older group (p < 0.05). There was no difference manual dexterity and postural control according to age except for LoS-Maximum Excursion. LoS-Maximum Excursion was higher in the young group. The manual dexterity was associated with postural control in individuals over 65 years of age with PD; however, not associated in younger individuals.

The EXPANd trial: effects of exercise and exploring neuroplastic changes in people with Parkinson's disease: a study protocol for a double-blinded randomized controlled trial

BACKGROUND

Parkinson's disease (PD) affects many physiological systems essential for balance control. Recent studies suggest that intensive and cognitively demanding physical exercise programs are capable of inducing plastic brain changes in PD. We have developed a highly challenging balance training (the HiBalance) program that emphasizes critical aspects of balance control through progressively introducing more challenging exercises which incorporates dual-tasking. Earlier studies have shown it to be effective in improving balance, gait and dual-tasking. The study design has thereafter been adjusted to link intervention-induced behavioral changes to brain morphology and function. Specifically, in this randomized controlled trial, we will determine the effects of the HiBalance program on balance, gait and cognition and relate this to task-evoked functional MRI (fMRI), as well as brain-derived neurotrophic factor (BDNF) in participants with mild-moderate PD.

METHODS

One hundred participants with idiopathic PD, Hoehn & Yahr stage 2 or 3, ≥ 60 years of age, ≥ 21 on Montreal Cognitive Assessment will be recruited in successive waves and randomized into either the HiBalance program or to an active control group (the HiCommunication program, targeting speech and communication). Both interventions will be performed in small groups, twice a week with 1 h sessions for 10 weeks. In addition, a 1 h, once a week, home exercise program will also be performed. A double-blinded design will be used. At the pre- and post-assessments, participants will be assessed on balance (main outcome), gait, cognitive functions, physical activity, voice/speech function, BDNF in serum and fMRI (3 T Philips) during performance of motor-cognitive tasks.

DISCUSSION

Since there is currently no cure for PD, findings of neuroplastic brain changes in response to exercise would revolutionize the way we treat PD, and, in turn, provide new hope to patients for a life with better health, greater independence and improved quality of life.

TRIAL REGISTRATION

ClincalTrials.gov: NCT03213873, first posted July 11, 2017.

Lower Limb Rigidity Is Associated with Frequent Falls in Parkinson's Disease

Background and Objective

The role of muscle rigidity as an etiological factor of falls in Parkinson's disease (PD) is poorly understood. Our objective was to determine whether lower leg rigidity was differentially associated with frequent falls in PD compared to upper limb, neck, and total rigidity measures.

Methods

We examined the associations between Unified Parkinson's Disease Rating Scale-Part III (motor) rigidity subscores and the history of monthly or more frequent falls in 216 individuals with PD (age, 66 ± 10 years; 36% female; disease duration, 7 ± 5 years) with logistic regression.

Results

A total of 35 individuals were frequent fallers. Significant associations were identified between lower limb rigidity and frequent falls (P = 0.01) after controlling for age, sex, PD duration, total Unified Parkinson's Disease Rating Scale- Part III score, and presence of freezing of gait. No significant associations (P ≥ 0.14) were identified for total, arm, or neck rigidity.

Conclusion

Lower limb rigidity is related to frequent falls in people with PD. Further investigation may be warranted into how parkinsonian rigidity could cause falls.

Walking Along Curved Trajectories. Changes With Age and Parkinson's Disease. Hints to Rehabilitation

In this review, we briefly recall the fundamental processes allowing us to change locomotion trajectory and keep walking along a curved path and provide a review of contemporary literature on turning in older adults and people with Parkinson's Disease (PD). The first part briefly summarizes the way the body exploits the physical laws to produce a curved walking trajectory. Then, the changes in muscle and brain activation underpinning this task, and the promoting role of proprioception, are briefly considered. Another section is devoted to the gait changes occurring in curved walking and steering with aging. Further, freezing during turning and rehabilitation of curved walking in patients with PD is mentioned in the last part. Obviously, as the research on body steering while walking or turning has boomed in the last 10 years, the relevant critical issues have been tackled and ways to improve this locomotor task proposed. Rationale and evidences for successful training procedures are available, to potentially reduce the risk of falling in both older adults and patients with PD. A better understanding of the pathophysiology of steering, of the subtle but vital interaction between posture, balance, and progression along non-linear trajectories, and of the residual motor learning capacities in these cohorts may provide solid bases for new rehabilitative approaches.

Tonic Neuromuscular Processing Affects Postural Adaptation Differently in Aging and Parkinson's Disease

The combination of phasic and tonic neuromuscular processes are involved in the maintenance of normal upright posture. The latter is of particular importance in some pathologies, such as Parkinson's Disease (PD), which is known by one of its cardinal symptoms—tonic dysfunction (i.e., rigidity). Changes in tonic function may also occur during healthy aging. In this investigation, somatosensory input was manipulated by changing the support surface orientation for prolonged periods of quiet stance (QS). The aim was to shed light on how long-term tonic responses called postural lean after-effects are affected by aging and age-related neuropathology. Forty one participants were tested: 19 healthy young (25±5 years), 13 healthy older (63±8 years), and 9 adults with PD (63±5 years). Baseline conditions were eyes-closed QS on a stable surface or standing on an unstable, sway-referenced (SR) surface. Four experimental conditions combined two types of toes-up ramp tilt adaptation (120 s of toes-up static 7° tilt or sinusoidal 7° ± 3° tilt) with two types of post-adaptation (120 s of QS or SR). Results revealed postural after-effects during post-adaptation QS showing significant anterior COP shift for both young and older adults (p < 0.0001), but not PD (p > 0.06, n.s.). Compared to young, postural after-effects in older adults showed longer decay constants and did not return to baseline COP within the 120 s post-adaptation period (p < 0.05). Postural after-effects during SR, which appeared as toes-up surface tilt were highly significant in healthy populations (p = 0.001), but took longer to develop in PD. Younger adults showed significantly larger dorsiflexion (p < 0.01) and faster decay constants than older adults (p < 0.05). In summary, (1) postural after-effects decayed to baseline when post-tilt surface was stable but were retained and even grew larger post-adaptation in the SR surface conditions in all groups, (2) postural after-effects differed between healthy age groups, (3) PD showed less adaptation to surface changes. Differences in size and decay of after-effects between healthy and PD groups suggest tonic neuromuscular processes play a role in how adaptable postural control is to changing surface conditions and this is affected by healthy aging and basal ganglia function.

Balance and mobility in patients with newly diagnosed Parkinson's disease - a five-year follow-up of a cohort in northern Sweden

Background: The presence of early balance impairment in patients with Parkinson's disease has not been fully investigated.Purpose: The purpose of this study was to examine balance and mobility, self-perceived unsteadiness, self-reported falls, and effects of medication on balance among patients at their first visit to a neurological clinic and during the ensuing five years.Materials and methods: The participants were collected from a prospective longitudinal study. One hundred and forty-five patients with idiopathic Parkinson's disease and 31 healthy controls were included. The outcome measures were the Berg Balance Scale, the Timed Up and Go, the Postural Stability test and a questionnaire.Results: At their first visit to the neurological clinic, the patients performed less well on the Berg Balance Scale (p < 0.001, r = 0.36), the Timed Up and Go (p < 0.001, r = 0.32), and the Postural Stability test (p < 0.001, r = 0.35) compared with the controls. In addition, a higher percentage of the patients reported self-perceived unsteadiness (p < 0.001, phi = 0.47). During the ensuing five years, balance and mobility worsened both with and without medication (p < 0.01, r = 0.24-0.37), although with small median differences.Conclusions: Further studies are needed to confirm that minor balance impairments exist even at the time of diagnosis and worsen during the ensuing five years.IMPLICATIONS FOR REHABILITATIONImpairments in balance and mobility may occur early in Parkinson's disease, especially in the elderly patients, and seem to worsen during the first five years.There is a need to use sensitive outcome measures and to ask the patients about unsteadiness and falls to detect balance impairment in this cohort.Parkinsonian medication has a limited effect on balance and may preferably be complemented with balance exercises to target balance impairment early in Parkinson's disease.

Preliminary evidence for feasibility, efficacy, and mechanisms of Alexander technique group classes for chronic neck pain

OBJECTIVES

To determine feasibility and potential of Alexander technique (AT) group classes for chronic neck pain and to assess changes in self-efficacy, posture, and neck muscle activity as potential mechanisms for pain reduction.

DESIGN

A single-group, multiple-baseline design, with two pre-tests to control for regression toward the mean, a post-test immediately after the intervention, and another post-test five weeks later to examine retention of benefits. Participants were predominately middle-aged; all had experienced neck pain for at least six months.

INTERVENTION

Participants attended ten one-hour group classes in AT, an embodied mindful approach that may reduce habitual overactivation of muscles, including superficial neck muscles, over five weeks.

OUTCOME MEASURES

(1) self-reports: Northwick Park Questionnaire (to assess neck pain and associated disability) and Pain Self-Efficacy Questionnaire; (2) superficial neck flexor activation and fatigue (assessed by electromyography and power spectral analysis) during the cranio-cervical flexion test; (3) posture during a video game task.

RESULTS

There were no significant changes in outcomes between pre-tests. All participants completed the intervention. After the intervention: (1) participants reported significantly reduced neck pain; (2) fatigue of the superficial neck flexors during the cranio-cervical flexion test was substantially lower; (3) posture was marginally more upright, as compared to the second pre-intervention values. Changes in pain, self-efficacy, and neck muscle fatigue were retained at the second post-test and tended to be correlated with one another.

CONCLUSIONS

Group AT classes may provide a cost-effective approach to reducing neck pain by teaching participants to decrease excessive habitual muscle contraction during everyday activity.

What If Low Back Pain Is the Most Prevalent Parkinsonism in the World?

Low back pain (LBP) has a point prevalence of nearly 10% and ranks highest in global disease burden for years lived with disability; Parkinson’s disease (PD) ranks in the top 100 most disabling health conditions for years lost and years lived with disability (1). Recent evidence suggests that people with chronic, recurrent LBP exhibit many postural impairments reminiscent of a neurological postural disorder such as PD. We compare and contrast postural impairments associated with LBP and PD in order to inform treatment strategies for both conditions. The literature suggests that both LBP and PD associate with impaired proprioceptive function, sensory orientation during standing balance, anticipatory postural adjustments, automatic postural responses, and striatal-cortical function. Although postural impairments are similar in nature for LBP and PD, the postural impairments with LBP appear more specific to the trunk than for PD. Likewise, although both health conditions associate with altered striatal-cortical function, the nature of the altered neural structure or function differ for PD and LBP. Due to the high prevalence of LBP associated with PD, focused treatment of LBP in people with PD may render benefit to their postural impairments and disabilities. In addition, LBP would likely benefit from being considered more than just a musculoskeletal injury; as such, clinicians should consider including approaches that address impairments of postural motor control.

Temporomandibular joint dysfunction in Parkinson's Disease: an integrative literature review

ABSTRACT Temporomandibular joint dysfunction is a set of disorders involving the masticatory muscles, temporomandibular joint and associated structures. It is known that the progression of motor symptoms in Parkinson's disease is an indication that these people are more prone to the development of this dysfunction. Thus, this study aims to investigate the signs and symptoms of temporomandibular dysfunction in people with Parkinson's disease. The search was performed in the databases: MEDLINE/ PubMed, LILACs, CINAHL, SCOPUS, Web of Science and PEDro, without timing or language restriction. Specific descriptors were used for each database and keywords, evaluated by the instruments: Critical Appraisal Skill Program and Agency for Health care and Research and Quality. A total of 4,209 articles were found but only 5 were included. After critical analysis of the methodology of the articles, one did not reach the minimum score required by the evaluation instruments, thus, it was excluded. The selected articles addressed, as signs and symptoms of temporomandibular joint dysfunction, the following: myofascial pain, bruxism, limitation of mouth opening, dislocation of the articular disc and asymmetry in the distribution of occlusal contacts. Further studies are needed in order to determine the relationship between cause and effect of the analyzed variables, so as to contribute to more specific and effective therapeutic interventions.

Impairments of balance, stepping reactions and gait in people with cervical dystonia

BACKGROUND

Impaired balance is common in neurological disorders. Cervical dystonia is a neurological movement disorder affecting the neck. The effect of this aberrant head posture on physical function is unknown.

OBJECTIVES

To compare balance, mobility, gait and stepping reactions between ten people with cervical dystonia and ten control adults.

METHODS

Spatiotemporal gait parameters and walking speed were assessed using a computerised walkway. Step length and time, time in double support and gait variability were calculated, then normalised to gait speed. Centre of pressure path length was assessed with eyes open and eyes closed to calculate a Romberg Quotient. Simple and choice reaction times were measured using customised apparatus while mobility was assessed by the timed up and go. Cervical spine range of motion was measured using a head mounted goniometer. Self-reported scales included Falls Self Efficacy Scale and Dystonia Discomfort Scale.

RESULTS

There was a difference between groups for most outcome measures. The timed up-and-go and walking speed was slower (both P<0.005) and the Romberg Quotient lower (P=0.046) in cervical dystonia. People with cervical dystonia had lower falls self-efficacy (P=0.0002). Reduced cervical range of motion was correlated with balance, stepping reaction time and mobility (all P<0.05). Timed up and go was positively associated with stepping reaction time (P<0.01). Dystonia discomfort did not impact function.

CONCLUSIONS

People with cervical dystonia displayed deficits in balance, gait and stepping reactions, and expressed higher fear of falling. Studies to further elucidate functional limitations and their impact on activity and participation in daily life are required.

Flexed Truncal Posture in Parkinson Disease: Measurement Reliability and Relationship With Physical and Cognitive Impairments, Mobility, and Balance

BACKGROUND AND PURPOSE

Flexed truncal posture is common in people with Parkinson disease (PD); however, little is known about the mechanisms responsible or its effect on physical performance. This cross-sectional study aimed to establish the reliability of a truncal posture measurement and explore relationships between PD impairments and truncal posture, as well as truncal posture and balance and mobility.

METHODS

A total of 82 people with PD participated. Truncal posture was measured in standing as the distance between vertebra C7 and a wall. Univariate and multivariate regression analyses were performed with truncal posture and impairments, including global axial symptoms, tremor, bradykinesia, rigidity, freezing of gait (FOG), reactive stepping and executive function, as well as truncal posture with balance and mobility measures.

RESULTS

The truncal posture measure had excellent test-retest reliability (ICC3,1 0.79, 95% CI 0.60-0.89, P < 0.001). Global axial symptoms had the strongest association with truncal posture (adjusted R = 0.08, P = 0.01), although the majority of the variance remains unexplained. Post hoc analysis revealed that several impairments were associated with truncal posture only in those who did not report FOG. Flexed truncal posture was associated with poorer performance of most balance and mobility tasks after adjustment for age, gender, disease severity, and duration (adjusted R = 0.24-0.33, P < 0.001-0.03).

DISCUSSION AND CONCLUSIONS

The C7 to wall measurement is highly reliable in people with PD. Global axial symptoms were independently associated with truncal posture. Greater flexed truncal posture was associated with poorer balance and mobility. Further studies are required to elucidate the mechanisms responsible for flexed truncal posture and the impact on activity.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A164).

Pre- and unplanned walking turns in Parkinson's disease - Effects of dopaminergic medication

Although dopaminergic medication improves functional mobility in individuals with Parkinson's disease (PD), its effects on walking turns are uncertain. Our goals was to determine whether dopaminergic medication improves preplanned and unplanned walking turns in individuals with PD, compared to healthy controls. Nineteen older adults with mild-to-moderate PD and 17 healthy controls performed one of the following three tasks, presented randomly: walking straight, or walking and turning 180° to the right or left. The walking direction was visually cued before starting to walk (preplanned) or after (unplanned, i.e., 0.6m before reaching the turning point). Subjects with PD were assessed off dopaminergic medication (OFF) and on dopaminergic medication (ON) medication. Turning strategy (step and spin turns), turning performance (turning distance and body rotation) and walking pattern were analyzed for three turning steps. Irrespective of medication state and turning condition, step and spin turns followed a nearly 50:50 distribution. After intake of dopaminergic medication, subjects with PD increased their turning distance but not the amount of body rotation or their walking pattern. Compared to controls, turning impairments in subjects with PD remained while ON medication and problems regulating step width were the most prominent features of their walking pattern. Specifically, subjects with PD turned with narrower cross-over steps, i.e. when the external foot crossed over the line of progression of the internal leg. We conclude that turning impairments remained even after dopaminergic medication and problems modulating step width appears to be a critical feature for turning in PD.

Pharmacological treatment in Parkinson's disease: Effects on gait

Gait impairments are a hallmark of Parkinson's disease (PD), both as early symptom and an important cause of disability later in the disease course. Although levodopa has been shown to improve gait speed and step length, the effect of dopamine replacement therapy on other aspects of gait is less well understood. In fact, falls are not reduced and some aspects of postural instability during gait are unresponsive to dopaminergic treatment. Moreover, many medications other than dopaminergic agents, can benefit or impair gait in people with PD. We review the effects of pharmacological interventions used in PD on gait, discriminating, whenever possible, among effects on four components of everyday mobility: straight walking, gait initiation, turning, gait adaptability. Additionally, we summarize the effects on freezing of gait. There is substantial evidence for improvement of spatial characteristics of simple, straight-ahead gait with levodopa and levodopa-enhancing drugs. Recent work suggests that drugs aiming to enhance the acetylcholine system might improve gait stability measures. There is a lack of well-designed studies to evaluate effects on more complex, but highly relevant walking abilities such as turning and making flexible adjustments to gait. Finally, paucity in the literature exists on detrimental effects of drugs used in PD that are known to worsen gait and postural stability in the elderly population.

Constraining eye movement in individuals with Parkinson's disease during walking turns

Walking and turning is a movement that places individuals with Parkinson's disease (PD) at increased risk for fall-related injury. However, turning is an essential movement in activities of daily living, making up to 45 % of the total steps taken in a given day. Hypotheses regarding how turning is controlled suggest an essential role of anticipatory eye movements to provide feedforward information for body coordination. However, little research has investigated control of turning in individuals with PD with specific consideration for eye movements. The purpose of this study was to examine eye movement behavior and body segment coordination in individuals with PD during walking turns. Three experimental groups, a group of individuals with PD, a group of healthy young adults (YAC), and a group of healthy older adults (OAC), performed walking and turning tasks under two visual conditions: free gaze and fixed gaze. Whole-body motion capture and eye tracking characterized body segment coordination and eye movement behavior during walking trials. Statistical analysis revealed significant main effects of group (PD, YAC, and OAC) and visual condition (free and fixed gaze) on timing of segment rotation and horizontal eye movement. Within group comparisons, revealed timing of eye and head movement was significantly different between the free and fixed gaze conditions for YAC (p < 0.001) and OAC (p < 0.05), but not for the PD group (p > 0.05). In addition, while intersegment timings (reflecting segment coordination) were significantly different for YAC and OAC during free gaze (p < 0.05), they were not significantly different in PD. These results suggest individuals with PD do not make anticipatory eye and head movements ahead of turning and that this may result in altered segment coordination during turning. As such, eye movements may be an important addition to training programs for those with PD, possibly promoting better coordination during turning and potentially reducing the risk of falls.

Quantitative Timed-Up-and-Go Parameters in Relation to Cognitive Parameters and Health-Related Quality of Life in Mild-to-Moderate Parkinson's Disease

Introduction

The instrumented-Timed-Up-and-Go test (iTUG) provides detailed information about the following movement patterns: sit-to-walk (siwa), straight walking, turning and walk-to-sit (wasi). We were interested in the relative contributions of respective iTUG sub-phases to specific clinical deficits most relevant for daily life in Parkinson’s disease (PD). More specifically, we investigated which condition–fast speed (FS) or convenient speed (CS)–differentiates best between mild- to moderate-stage PD patients and controls, which parameters of the iTUG sub-phases are significantly different between PD patients and controls, and how the iTUG parameters associate with cognitive parameters (with particular focus on cognitive flexibility and working memory) and Health-Related-Quality of Life (HRQoL).

Methods

Twenty-eight PD participants (65.1±7.1 years, H&Y stage 1–3, medication OFF state) and 20 controls (66.1±7.5 years) performed an iTUG (DynaPort^®, McRoberts BV, The Netherlands) under CS and FS conditions. The PD Questionnaire 39 (PDQ-39) was employed to assess HRQoL. General cognitive and executive functions were assessed using the Montreal Cognitive Assessment and the Trail Making Test.

Results

The total iTUG duration and sub-phases durations under FS condition differentiated PD patients slightly better from controls, compared to the CS condition. The following sub-phases were responsible for the observed longer total duration PD patients needed to perform the iTUG: siwa, turn and wasi. None of the iTUG parameters correlated relevantly with general cognitive function. Turning duration and wasi maximum flexion velocity correlated strongest with executive function. Walking back duration correlated strongest with HRQoL.

Discussion

This study confirms that mild- to moderate-stage PD patients need more time to perform the iTUG than controls, and adds the following aspects to current literature: FS may be more powerful than CS to delineate subtle movement deficits in mild- to moderate-stage PD patients; correlation levels of intra-individual siwa and wasi parameters may be interesting surrogate markers for the level of automaticity of performed movements; and sub-phases and kinematic parameters of the iTUG may have the potential to reflect executive functioning and HRQoL aspects of PD patients.

Neural Control of Walking in People with Parkinsonism

People with Parkinson's disease exhibit debilitating gait impairments, including gait slowness, increased step variability, and poor postural control. A widespread supraspinal locomotor network including the cortex, cerebellum, basal ganglia, and brain stem contributes to the control of human locomotion, and altered activity of these structures underlies gait dysfunction due to Parkinson's disease.

Development of a clinical assessment test of 180-degree standing turn strategy (CAT-STS) and investigation of its reliability and validity

[Purpose] To develop a clinical assessment test of 180-degree standing turn strategy (CAT-STS) and quantify its reliability and construct validity. [Subjects] Outpatients with stroke that occurred at least 6 months previously (N = 27) who could walk 10 m without physical assistance were included. [Methods] The CAT-STS was based on the literature and discussion with four physical therapists. The final version of the CAT-STS includes seven items: direction, use of space, foot movement, initiation, termination, instability, and non-fluidity. Patients were videotaped performing a 180-degree turn while standing. The Motricity Index, gait speed and Functional Ambulation Category were also evaluated. Two raters evaluated the turn on two occasions, and inter- and intra-rater reliability were calculated. Construct validity was also calculated. [Results] Inter-rater reliability was fair or moderate for many items (kappa = 0.221-0.746). Intra-rater reliability was good-to-excellent for all items (kappa = 0.681-0.846) except direction and termination. Inter- and intra-rater reliability of the total CAT-STS score were substantial and excellent, respectively (intraclass correlation coefficient = 0.725 and 0.865, respectively). The total CAT-STS score was associated with walking ability and the time and number of steps taken to turn. [Conclusion] The total CAT-STS score is a reliable and valid measure.

Continuous Monitoring of Turning Mobility and Its Association to Falls and Cognitive Function: A Pilot Study

BACKGROUND

Difficulty turning is a major contributor to mobility disability, falls, and reduced quality of life in older people because it requires dynamic balance control that worsens with age. However, no study has quantified the quality and quantity of turning during normal daily activities in older people. The objective of this pilot study was to determine if quality of turning during daily activities is associated with falls and/or cognitive function.

METHODS

Thirty-five elderly participants (85 ± 8 years) wore three Opal inertial sensors. Turning and activity rate were measured. Based on retrospective falls, participants were grouped into nonfallers (N = 16), single fallers (N = 12), and recurrent fallers (N = 7). We also determined which turning characteristic predicted falls in the 6 months following the week of monitoring.

RESULTS

Quality of turning was significantly compromised in recurrent fallers compared with nonfallers (p < .05). In contrast, activity rate and mean number of turns per hour were similar across the three groups. Also, quality of turning during a prescribed test was similar across the three groups. Visuospatial and memory functions and the Tinetti Balance Scores were associated with quality of turning. Future falls were related to an increased variability of number of steps to turn.

CONCLUSIONS

Continuous monitoring of turning characteristics, while walking during daily activities, is feasible in older people. Turning characteristics during daily life appear to be more sensitive to fall risk than prescribed turning tasks. These findings suggest a slower, less variable, cautious turning strategy in elderly volunteers with a history of falls.

Motion analysis of axial rotation and gait stability during turning in people with Parkinson's disease

BACKGROUND

Axial rigidity and postural instability in people with Parkinson's disease (PD) may contribute to turning difficulty. This study examined the rotation of axial segments and gait instability during turning in people with PD.

METHODS

Thirteen PD and twelve age-matched healthy adults were recruited. Participants performed the timed Up-and-Go test and were recorded by a 3D motion capture system. Axial rotation was evaluated by the rotation onset of the head, thorax and pelvis. Gait stability was evaluated by the center of mass and center of pressure inclination angle. Turning performance was evaluated by turning time and turning steps.

RESULTS

During turning, PD adults rotated the head, thorax and pelvis simultaneously, whereas healthy adults rotated in a cranial to caudal sequence. Further, PD adults had a smaller sagittal inclination angle (p<0.001) but larger frontal inclination angle (p=0.006) than healthy adults. PD adults also turned slower (p=0.002) with a greater number of steps (p<0.001) than healthy adults. Last, PD adults showed a significant correlation between the sagittal inclination angle and turning steps (Spearman's ρ=-0.63), while healthy adults showed a significant correlation between frontal inclination angle and turning steps (Spearman's ρ=-0.67).

CONCLUSION

This study demonstrated the axial rigidity in PD adults during turning may reduce forward progression and increase lateral instability. The reduced progression is associated with extra turning steps and the increased lateral instability may result in great fall risk.

Dopaminergic modulation of arm swing during gait among Parkinson's disease patients

BACKGROUND

Reduced arm swing amplitude, symmetry, and coordination during gait have been reported in Parkinson's disease (PD), but the relationship between dopaminergic depletion and these upper limb gait changes remains unclear.

OBJECTIVE

We aimed to investigate the effects of dopaminergic drugs on arm swing velocity, symmetry, and coordination in PD.

METHODS

Forearm angular velocity was recorded in 16 PD and 17 control subjects (Controls) during free walking trials. Angular velocity amplitude of each arm, arm swing asymmetry, and maximum cross-correlation were compared between control and PD groups, and between OFF- and ON-medication states among PD subjects.

RESULTS

Compared to Controls, PD subjects in the OFF-medication state exhibited lower angular velocity amplitude of the slower- (p = 0.0018), but not faster- (p = 0.2801) swinging arm. In addition, PD subjects demonstrated increased arm swing asymmetry (p = 0.0046) and lower maximum cross-correlation (p = 0.0026). Following dopaminergic treatment, angular velocity amplitude increased in the slower- (p = 0.0182), but not faster- (p = 0.2312) swinging arm among PD subjects. Furthermore, arm swing asymmetry decreased (p = 0.0386), whereas maximum cross-correlation showed no change (p = 0.7436). Pre-drug angular velocity amplitude of the slower-swinging arm was correlated inversely with the change in arm swing asymmetry (R = -0.73824, p = 0.0011).

CONCLUSIONS

This study provides quantitative evidence that reduced arm swing and symmetry in PD can be modulated by dopaminergic replacement. The lack of modulations of bilateral arm coordination suggests that additional neurotransmitters may also be involved in arm swing changes in PD. Further studies are warranted to investigate the longitudinal trajectory of arm swing dynamics throughout PD progression.

What Is Wrong with Balance in Parkinson's Disease?

Postural instability and resulting falls are major factors determining quality of life, morbidity, and mortality in individuals with Parkinson’s disease (PD). A better understanding of balance impairments would improve management of balance dysfunction and prevent falls in patients with PD. The effects of bradykinesia, rigidity, impaired proprioception, freezing of gait and attention on postural stability in patients with idiopathic PD have been well characterized in laboratory studies. The purpose of this review is to systematically summarize the types of balance impairments contributing to postural instability in people with PD.

Randomized controlled trial protocol: balance training with rhythmical cues to improve and maintain balance control in Parkinson's disease

Background

Postural instability is a particularly incapacitating disorder, whose loss of motor independence by Parkinson´s Disease (PD) patients marks a significant stage of disease onset. Evidence suggests that deficits in automatic motor control, sensory integration and attention are associated with the lack of balance in PD. Physiotherapy together with medication play an important role in the treatment of this state, although no consensus has been reached on the best treatment modality. The aim of this randomized controlled trial protocol is to evaluate the effects of balance training with rhythmical (BRT), which is a motor program to improve balance associated with rhythmical auditory cues (RACs). This study is ongoing in the stage 1.

Methods and design

A total of 150 PD patients at H&Y stages II–III and asymptomatic for depression and dementia are enrolled in a single-blind randomized study. Randomization is achieved via a computer-generated random-sequence table. All patients should also present a fall history. They will be assigned into one of three groups, and their balance and gait will be assessed before and after 10 training sessions, and after 4 and 30 weeks subsequent to the end of the training. The BRT group will receive a motor program to improve balance associated with RACs, the MT group will perform motor training with the same aims as those in the BRT group but without RACs, and the control group (CG) will be trained only in orientations. The exercise program specific to balance is of 5 weeks’ duration with two sessions per week, 45 min each, and consists of general physiotherapy exercises. Each session will be divided into five warm-up minutes—30 min for the main part and 10 min for the cool down. The training progresses and intensifies each week depending on the individual’s performance. The subjects should be able to execute 10 repetitions of the exercise sequences correctly to progress to the next movement.

Discussion

This randomized study protocol will evaluate the effects of a motor program designed to improve balance associated with RACs, and will also assess whether balance training leads to activation of balance reactions at the appropriate time. We hypothesize that if this motor program is maintained long-term, it will prevent falls.

Trial registration

Clinicaltrials.gov NCT02488265; Ethics Committee of the University of São Paulo Faculty of Medicine Clinics Hospital 1.102.464.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-015-0418-x) contains supplementary material, which is available to authorized users.

Levels and Patterns of Physical Activity and Sedentary Behavior in Elderly People With Mild to Moderate Parkinson Disease

BACKGROUND

Decreased movement ability, one of the hallmarks of Parkinson disease (PD), may lead to inadequate physical activity (PA) and excessive time spent in sedentary behaviors-2 factors associated with an elevated risk for lifestyle-related diseases, poor management of PD, and premature death. To identify the extent to which people with PD are physically active, a comprehensive characterization of PA in this population is needed.

OBJECTIVE

The study objective was to describe levels and patterns of PA and sedentary behaviors in elderly people with PD.

DESIGN

This cross-sectional study involved a free-living setting and 53 men and 42 women (mean age=73.4 years) with mild to moderate idiopathic PD.

METHODS

Time spent in PA and sedentary behaviors was assessed for 1 week with accelerometers.

RESULTS

Mean daily step counts were 4,765; participants spent 589 minutes in sedentary behaviors, 141 minutes in low-intensity activities, 30 minutes in moderate-intensity lifestyle activities, and 16 minutes in moderate- to vigorous-intensity ambulatory activities. No differences were found between weekdays and weekend days. Patterns were characterized by a rise in total PA in the morning, peaking between 10 am and 3 pm, and a gradual decline toward the late evening. The proportion achieving 150 minutes of moderate- to vigorous-intensity PA per week was 27%, and 16% achieved 7,000 or more steps per day.

LIMITATIONS

Nonrandomized selection of participants may limit the generalizability of the results.

CONCLUSIONS

Physical activity levels were generally low, in terms of both total volume and intensity, with only minor variations over the course of a day or between days. These results emphasize the need to develop strategies to increase PA and reduce time spent in sedentary behaviors in elderly people with mild to moderate PD.

Postural instability in Parkinson Disease: to step or not to step

Postural instability is a key feature of Parkinson Disease that is associated with falls and morbidity. We designed a pull apparatus to quantitatively measure the force needed to pull subjects off-balance. Thirteen Controls and eight individuals with Parkinson Disease (PD) were evaluated. All individuals with PD reported subjective symptoms of postural instability and were symptomatic for approximately 9.4years when tested. No significant differences were found between Controls and PD subjects in the magnitude of force required to pull them off-balance. None of the Controls fell and all took a step into the direction of pull to maintain their balance. 59% of the time PD subjects fell because they did not take a step in the direction of pull to maintain their center of mass (COM) over their feet, thus indicating a deficiency in postural reflexes. If they fell on the first pull, PD subjects did not show a learning effect when pulled multiple times in the same direction. The utility of the Pull Test to detect postural instability is related to the subject's behavioral response, not the force needed to pull them off balance. Our findings may also help explain certain features of the PD gait as an attempt by subjects to avoid postural instability by not placing their COM in gravitationally unstable positions.

Long-lasting effects of neck muscle vibration and contraction on self-motion perception of vestibular origin

OBJECTIVE

To show that neck proprioceptive input can induce long-term effects on vestibular-dependent self-motion perception.

METHODS

Motion perception was assessed by measuring the subject's error in tracking in the dark the remembered position of a fixed target during whole-body yaw asymmetric rotation of a supporting platform, consisting in a fast rightward half-cycle and a slow leftward half-cycle returning the subject to the initial position. Neck muscles were relaxed or voluntarily contracted, and/or vibrated. Whole-body rotation was administered during or at various intervals after the vibration train. The tracking position error (TPE) at the end of the platform rotation was measured during and after the muscle conditioning maneuvers.

RESULTS

Neck input produced immediate and sustained changes in the vestibular perceptual response to whole-body rotation. Vibration of the left sterno-cleido-mastoideus (SCM) or right splenius capitis (SC) or isometric neck muscle effort to rotate the head to the right enhanced the TPE by decreasing the perception of the slow rotation. The reverse effect was observed by activating the contralateral muscle. The effects persisted after the end of SCM conditioning, and slowly vanished within several hours, as tested by late asymmetric rotations. The aftereffect increased in amplitude and persistence by extending the duration of the vibration train (from 1 to 10min), augmenting the vibration frequency (from 5 to 100Hz) or contracting the vibrated muscle. Symmetric yaw rotation elicited a negligible TPE, upon which neck muscle vibrations were ineffective.

CONCLUSIONS

Neck proprioceptive input induces enduring changes in vestibular-dependent self-motion perception, conditional on the vestibular stimulus feature, and on the side and the characteristics of vibration and status of vibrated muscles. This shows that our perception of whole-body yaw-rotation is not only dependent on accurate vestibular information, but is modulated by proprioceptive information related to previously experienced position of head with respect to trunk.

SIGNIFICANCE

Tonic proprioceptive inflow, as might occur as a consequence of enduring or permanent head postures, can induce adaptive plastic changes in vestibular-dependent motion sensitiveness. These changes might be counteracted by vibration of selected neck muscles.

Lighten Up: Specific Postural Instructions Affect Axial Rigidity and Step Initiation in Patients With Parkinson's Disease

BACKGROUND

Parkinson's disease (PD) is associated with stooped postural alignment, increased postural sway, and reduced mobility. The Alexander Technique (AT) is a mindfulness-based approach to improving posture and mobility by reducing muscular interference while maintaining upward intentions. Evidence suggests that AT can reduce disability associated with PD, but a mechanism for this effect has not yet been established.

OBJECTIVE

We investigated whether AT-based instructions reduce axial rigidity and increase upright postural alignment, and whether these instructions have different effects on postural alignment, axial rigidity, postural sway, and mobility than effort-based instructions regarding posture.

METHOD

Twenty subjects with PD practiced 2 sets of instructions and then attempted to implement both approaches (as well as a relaxed control condition) during quiet standing and step initiation. The "Lighten Up" instructions relied on AT principles of reducing excess tension while encouraging length. The "Pull Up" instructions relied on popular concepts of effortful posture correction. We measured kinematics, resistance to axial rotation, and ground reaction forces.

RESULTS

Both sets of experimental instructions led to increases in upright postural alignment relative to the control condition. Only the Lighten Up instructions led to reduced postural sway, reduced axial postural tone, greater modifiability of tone, and a smoother center of pressure trajectory during step initiation, possibly indicating greater movement efficiency.

CONCLUSION

Mindful movement approaches such as AT may benefit balance and mobility in subjects with PD by acutely facilitating increased upright postural alignment while decreasing rigidity.

Balance dysfunction in Parkinson's disease

Stability and mobility in functional motor activities depend on a precise regulation of phasic and tonic muscular activity that is carried out automatically, without conscious awareness. The sensorimotor control of posture involves a complex integration of multisensory inputs that results in a final motor adjustment process. All or some of the components of this system may be dysfunctional in Parkinsonian patients, rendering postural instability one of the most disabling features of Parkinson's disease (PD). Balance control is critical for moving safely in and adapting to the environment. PD induces a multilevel impairment of this function, therefore worsening the patients' physical and psychosocial disability. In this review, we describe the complex ways in which PD impairs posture and balance, collecting and reviewing the available experimental evidence.

The effects of medication on turning in people with Parkinson disease with and without freezing of gait

Turning difficulty is prevalent in Parkinson disease (PD) and may lead to falls or freezing. Medication improves motor symptoms of PD, but its effects on turning in people with PD with (PD+FOG) and without (PD-FOG) freezing of gait are unclear. This study evaluated the effects of medication on turning in PD compared to healthy older adults (controls), and in PD+FOG compared to PD-FOG. We assessed timed-up-and-go (TUG), and in-place turns in 16 controls and 20 people with PD (10 PD+FOG, 10 PD-FOG) OFF and ON medication. PD+FOG performed worse than PD-FOG (p < 0.05) in TUG, turn duration, step count, and had earlier head rotation onset (HTO). These measures improved ON medication in PD+FOG and PD-FOG (p < 0.05). Turn duration and step count improved more with medication in PD+FOG than PD-FOG (p < 0.005). There were subtle differences in gastrocnemius and sternocleidomastoid onsets, with PD OFF or ON activating muscles earlier than controls. Tibialis anterior, gastrocnemius, and sternocleidomastoid initial onset times were similar between PD+FOG and PD-FOG. Though medication improved turning, turn duration and step count impairments still existed in PD ON, compared to controls. Relative to PD-FOG, PD+FOG turned worse, but improved more with medication, potentially because PD+FOG were initially more impaired than PD-FOG or were taking higher medication dosages. Further treatment options may be needed to address ON medication turning deficits.