Body Weight Support Combined With Treadmill in the Rehabilitation of Parkinsonian Gait: A Review of Literature and New Data From a Controlled Study

Do Patients with Parkinson's Disease Benefit from Dynamic Body Weight Support? A Pilot Study on the Emerging Role of Rysen

Parkinson's disease (PD) is a neurodegenerative disorder characterized by motor and non-motor alterations. Typical motor symptoms include resting tremors, bradykinesia (hypokinesia or akinesia), muscular stiffness, gait alterations, and postural instability. In this context, neurorehabilitation may have a pivotal role in slowing the progression of PD, using both conventional and innovative rehabilitation approaches. Thirty patients (15 males and 15 females) affected by PD were enrolled in our study. We randomly divided the patients into two groups, an experimental group (EG) and a control group (CG). In particular, the EG performed gait and balance training using the Rysen system, which is an innovative body weight support (BWS) system, whilst the CG received conventional physiotherapy. Both groups underwent 20 sessions, five times weekly, with each session lasting about 40 min. At the end of the training sessions (T1), we found that both groups (EG and CG) achieved clinical improvements, although the EG showed better scores for post-treatment regarding global motor functioning and postural stability compared to the CG. In conclusion, our results suggest that the Rysen system, which is an innovative BWS tool, could be considered a valid device for improving postural control and global motor functions, when compared to conventional gait training, in patients affected by PD.

Robot-assisted gait training in patients with Parkinson's disease: Implications for clinical practice. A systematic review

BACKGROUND

Gait impairments are common disabling symptoms of Parkinson's disease (PD). Among the approaches for gait rehabilitation, interest in robotic devices has grown in recent years. However, the effectiveness compared to other interventions, the optimum amount of training, the type of device, and which patients might benefit most remains unclear.

OBJECTIVE

To conduct a systematic review about the effects on gait of robot-assisted gait training (RAGT) in PD patients and to provide advice for clinical practice.

METHODS

A search was performed on PubMed, Scopus, PEDro, Cochrane library, Web of science, and guideline databases, following PRISMA guidelines. We included English articles if they used a robotic system with details about the intervention, the parameters, and the outcome measures. We evaluated the level and quality of evidence.

RESULTS

We included twenty papers out of 230 results: two systematic reviews, 9 randomized controlled trials, 4 uncontrolled studies, and 5 descriptive reports. Nine studies used an exoskeleton device and the remainders end-effector robots, with large variability in terms of subjects' disease-related disability.

CONCLUSIONS

RAGT showed benefits on gait and no adverse events were recorded. However, it does not seem superior to other interventions, except in patients with more severe symptoms and advanced disease.

Exercise-Boosted Mitochondrial Remodeling in Parkinson's Disease

Parkinson's disease (PD) is a movement disorder characterized by the progressive degeneration of dopaminergic neurons resulting in dopamine deficiency in the striatum. Given the estimated escalation in the number of people with PD in the coming decades, interventions aimed at minimizing morbidity and improving quality of life are crucial. Mitochondrial dysfunction and oxidative stress are intrinsic factors related to PD pathogenesis. Accumulating evidence suggests that patients with PD might benefit from various forms of exercise in diverse ways, from general health improvements to disease-specific effects and, potentially, disease-modifying effects. However, the signaling and mechanism connecting skeletal muscle-increased activity and brain remodeling are poorly elucidated. In this review, we describe skeletal muscle-brain crosstalk in PD, with a special focus on mitochondrial effects, proposing mitochondrial dysfunction as a linker in the muscle-brain axis in this neurodegenerative disease and as a promising therapeutic target. Moreover, we outline how exercise secretome can improve mitochondrial health and impact the nervous system to slow down PD progression. Understanding the regulation of the mitochondrial function by exercise in PD may be beneficial in defining interventions to delay the onset of this neurodegenerative disease.

Efficacy and evaluation of therapeutic exercises on adults with Parkinson's disease: a systematic review and network meta-analysis

Background

Exercises are an effective treatment in Parkinson’s disease (PD), but there is still controversy over which types should be used. We aimed to compare and rank the types of exercise that improve PD symptoms by quantifying information from randomised controlled trials.

Methods

We performed a systematic review and network meta-analysis and searched PubMed, MEDLINE, Embase, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and China National Knowledge Infrastructure (CNKI) from their inception date to June 30, 2022. We included randomized controlled trials of 24 types of exercise for the interventional treatment of adults (≥ 50 years old) with PD. Effect size measures were standardized mean differences (SMDs) with 95% credible intervals (CrIs). The confidence of evidence was examined using Confidence in Network Meta-Analysis (CINeMA).

Results

We identified 10 474 citations and included 250 studies involving 13 011 participants. Results of NMA showed that power training (PT) had the best benefits for motor symptoms compared with the control group (CON), with SMDs (95% CrI) (-1.46, [-2.18 to -0.74]). Body weight support treadmill training (BWS_TT) showed the best improvement in balance (1.55, [0.72 to 2.37]), gait velocity (1.15 [0.57 to 1.31]) and walking distance (1.96, [1.18 to 2.73]), and robotic assisted gait training (RA_GT) had the most benefits for freezing of gait (-1.09, [-1.80 to -0.38]). For non-motor symptoms, Dance showed the best benefits for depression (-1.71, [-2.79 to -0.73]). Only Yoga significantly reduced anxiety symptom compared with CON (-0.53, [0.96 to -0.11]). Only resistance training (RT) significantly enhanced sleep quality and cognition (-1.42, [-2.60 to -0.23]; 0.51, [0.09 to 0.94]). For muscle strength, PT showed the best advance (1.04, [0.64 to 1.44]). For concern of falling, five types of exercise were more effective than CON.

Conclusions

There is low quality evidence that PT, Yoga, BWS_TT, Dance, and RT are the most effective treatments, pending outcome of interest, for adults with PD.

Trial registration

PROSPERO (CRD42021220052).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03510-9.

Cognitive and Physical Intervention in Metals’ Dysfunction and Neurodegeneration

Metals—especially iron, copper and manganese—are important elements of brain functions and development. Metal-dysregulation homeostasis is associated with brain-structure damage to the motor, cognitive and emotional systems, and leads to neurodegenerative processes. There is more and more evidence that specialized cognitive and motor exercises can enhance brain function and attenuate neurodegeneration in mechanisms, such as improving neuroplasticity by altering the synaptic structure and function in many brain regions. Psychological and physical methods of rehabilitation are now becoming increasingly important, as pharmacological treatments for movement, cognitive and emotional symptoms are limited. The present study describes physical and cognitive rehabilitation methods of patients associated with metal-induced neurotoxicity such as Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis, Huntington’s disease and Wilson’s disease. In our review, we describe physical (e.g., virtual-reality environments, robotic-assists training) and psychological (cognitive training, cognitive stimulation, neuropsychological rehabilitation and cognitive-behavioral and mindfulness-based therapies) methods, significantly improving the quality of life and independence of patients associated with storage diseases. Storage diseases are a diverse group of hereditary metabolic defects characterized by the abnormal cumulation of storage material in cells. This topic is being addressed due to the fact that rehabilitation plays a vital role in the treatment of neurodegenerative diseases. Unfortunately so far there are no specific guidelines concerning physiotherapy in neurodegenerative disorders, especially in regards to duration of exercise, type of exercise and intensity, as well as frequency of exercise. This is in part due to the variety of symptoms of these diseases and the various levels of disease progression. This further proves the need for more research to be carried out on the role of exercise in neurodegenerative disorder treatment.

Effects of Endurance Training on Motor Signs of Parkinson's Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Evidence has demonstrated that endurance training (ET) reduces the motor signs of Parkinson's disease (PD). However, there has not been a comprehensive meta-analysis of studies to date.

OBJECTIVE

The aim of this study was to compare the effect of ET versus nonactive and active control conditions on motor signs as assessed by either the Unified Parkinson's Disease Rating Scale part III (UPDRS-III) or Movement Disorder Society-UPDRS-III (MDS-UPDRS-III).

METHODS

A random-effect meta-analysis model using standardized mean differences (Hedges' g) determined treatment effects. Moderators (e.g., combined endurance and physical therapy training [CEPTT]) and meta-regressors (e.g., number of sessions) were used for sub-analyses. Methodological quality was assessed by the Physiotherapy Evidence Database.

RESULTS

Twenty-seven randomized controlled trials (RCTs) met inclusion criteria (1152 participants). ET is effective in decreasing UPDRS-III scores when compared with nonactive and active control conditions (g =  - 0.68 and g =  - 0.33, respectively). This decrease was greater (within- and between-groups average of - 8.0 and - 6.8 point reduction on UPDRS-III scores, respectively) than the moderate range of clinically important changes to UPDRS-III scores (- 4.5 to - 6.7 points) suggested for PD. Although considerable heterogeneity was observed between RCTs (I² = 74%), some moderators that increased the effect of ET on motor signs decreased the heterogeneity of the analyses, such as CEPTT (I² = 21%), intensity based on treadmill speed (I² = 0%), self-perceived exertion rate (I² = 33%), and studies composed of individuals with PD and freezing of gait (I² = 0%). Meta-regression did not produce significant relationships between ET dosage and UPDRS-III scores.

CONCLUSIONS

ET is effective in decreasing UPDRS-III scores. Questions remain about the dose-response relationship between ET and reduction in motor signs.

Neglected physical human-robot interaction may explain variable outcomes in gait neurorehabilitation research

[Figure: see text].

The Effects of Intensive Neurorehabilitation on Sequence Effect in Parkinson's Disease Patients With and Without Freezing of Gait

Background: The sequence effect (SE), defined as a reduction in amplitude of repetitive movements, is a common clinical feature of Parkinson's disease (PD) and is supposed to be a major contributor to freezing of gait (FOG). During walking, SE manifests as a step-by-step reduction in step length when approaching a turning point or gait destination, resulting in the so-called destination sequence effect (dSE). Previous studies explored the therapeutic effects of several strategies on SE, but none of them evaluated the role of an intensive rehabilitative program. Objectives: Here we aim to study the effects of a 4-week rehabilitative program on dSE in patients with PD with and without FOG. Methods: Forty-three patients (30 males, 70.6 ± 7.5 years old) with idiopathic PD were enrolled. The subjects were divided into two groups: patients with (PD + FOG, n = 23) and without FOG (PD - FOG, n = 20). All patients underwent a standardized 4-week intensive rehabilitation in-hospital program. At hospital admission (T0) and discharge (T1), all subjects were evaluated with an inertial gait analysis for dSE recording. Results: At T0, the dSE was more negative in the PD + FOG group (-0.80 ± 0.6) when compared to the PD - FOG group (-0.39 ± 0.3) (p = 0.007), even when controlling for several clinical and demographic features. At T1, the dSE was reduced in the overall study population (p = 0.001), with a more pronounced improvement in the PD + FOG group (T0: -0.80 ± 0.6; T1: -0.23 ± 0.4) when compared to the PD - FOG group (T0: -0.39 ± 0.3; T1: -0.22 ± 0.5) (p = 0.012). At T1, we described in the overall study population an improvement in speed, cadence, stride duration, and stride length (p = 0.001 for all variables). Conclusions: dSE is a core feature of PD gait dysfunction, specifically in patients with FOG. A 4-week intensive rehabilitative program improved dSE in PD patients, exerting a more notable beneficial effect in the PD + FOG group.

Body Weight Support Gait Training for Patients With Parkinson Disease: A Systematic Review and Meta-analyses

OBJECTIVE

To determine the effectiveness of body weight support (BWS) gait training to improve the clinical severity, gait, and balance in patients with Parkinson disease (PD).

DATA SOURCES

A literature search was conducted until July 2020 in MEDLINE, Physiotherapy Evidence Database, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature.

STUDY SELECTION

Randomized controlled trials that aimed at determining the effectiveness of physical activity interventions with BWS during gait training in patients with PD.

DATA EXTRACTION

The methodological quality of randomized controlled trials was assessed using the Cochrane risk of bias tool (RoB 2.0). Effect size (ES) and 95% confidence intervals [CIs] were calculated for the Unified Parkinson Disease Rating Scale (UPDRS), the UPDRS section III, the 6-minute walk test (6MWT), gait parameters (ie, velocity, cadence, stride length), and the Berg Balance Scale (BBS).

DATA SYNTHESIS

Twelve studies were included in the systematic review. The pooled ES for the effect of BWS on total UPDRS was -0.35 (95% CI, -0.57 to -0.12; I²=1.9%, P=.418), whereas for UPDRS III it was -0.35 (95% CI, -0.68 to -0.01; I²=66.4 %, P<.001). Furthermore, the pooled ES for 6MWT was 0.56 (95% CI, -0.07 to 1.18; I²=77.1%, P=.002), for gait velocity was 0.37 (95% CI, -0.10 to 0.84); I²=78.9%, P<.001), for cadence was 0.03 (95% CI, -0.25 to 0.30; I²=0.0%, P=.930), for stride length was 1.00 (95% CI, 0.23 to 1.78; I²=79.5%, P=.001), and for BBS was 0.65 (95% CI, 0.30, 0.99; I²=51.8%, P=.042).

CONCLUSIONS

Interventions with BWS could improve the general and motor clinical severity of patients with PD, as well as other parameters such as stride length and balance. However, the effect does not appear to be statistically significant in improving gait parameters such as velocity, cadence, and distance.

Effects of insole on the less affected side during execution of treadmill walking training on gait ability in chronic stroke patients: A preliminary study

BACKGROUND

People who have had hemiplegic stoke generally move more weight to the unaffected side than the affected side, resulting in asymmetrical posture and decreased ability in walking.

OBJECTIVES

This study sought to investigate the effect of inducing a weight shift to the affected side by raising the shoe height of the less affected side using an insole during the execution of treadmill training on gait ability in people with chronic stroke.

METHODS

The subjects were randomly assigned into two groups: insole on less affected side for execution of treadmill walking training (ILTW) group and normal treadmill training (NTW) group. The treadmill training was conducted for 30 minutes per session, 5 times a week, for 4 weeks. A gait analyzer based on body center, Functional Gait Assessment (FGA), Figure-of-Eight Walk Test (F8WT), and 6 min Walk Test (6 MWT), was measured before first intervention and after twentieth treadmill training intervention (Trial registration number is KCT0003830).

RESULTS

The results revealed statistically significant differences between the two groups in the Speed, Cadence, Stride Length/Height, Stride Length, Double Support Duration, Single Support Duration, FGA, F8WT, and 6 MWT of the gait test. In the ILTW group, statistically significant improvements were observed in the Speed, Stride Length/Height, Stride Length, Stance Phase Duration, Swing Phase Duration, Double Support Duration, Single Support Duration, FGA, F8WT, and 6 MWT after execution of training, while in the NTW group, statistically significant improvements were observed only in Speed, Cadence, FGA, F8WT, and 6 MWT.

CONCLUSIONS

ILTW, more than NTW, may improve walking ability in people with chronic stroke as it increases the weight-support ratio by adjusting the shoe height of the unaffected side using an insole.

KSNR Clinical Consensus Statements: Rehabilitation of Patients with Parkinson's Disease

Clinical consensus statements (CCSs) aim to improve care for patients with Parkinson's disease (PD) and reduce the variability of rehabilitation methods in clinical practice. A literature search was conducted to find available evidence on the rehabilitation of patients with PD and to determine the scope of CCSs. The selection of PD rehabilitation domains and key questions was done using the modified Delphi method in 43 expert panels. These panels achieved a consensus on 11 key questions regarding rehabilitation assessment and goal setting, gait and balance, activities of daily living, and swallowing and communication disorders. After the completion of an agreement procedure, 11 key consensus statements were developed by the consensus panel. These statements addressed the needs of rehabilitation as a continuum in patients with PD. They included the appropriate rehabilitation initiation time, assessment items, rehabilitation contents, and complication management. This agreement can be used by physiatrists, rehabilitation therapists, and other practitioners who take care of patients with PD. The consensus panel also highlighted areas where a consensus could not be reached. The development of more focused CCS or clinical practice guidelines that target specific rehabilitation approaches is considered the next needed step.

Gait Characteristics Based on Shoe-Type Inertial Measurement Units in Healthy Young Adults during Treadmill Walking

This study investigated the gait characteristics of healthy young adults using shoe-type inertial measurement units (IMU) during treadmill walking. A total of 1478 participants were tested. Principal component analyses (PCA) were conducted to determine which principal components (PC_s) best defined the characteristics of healthy young adults. A non-hierarchical cluster analysis was conducted to evaluate the essential gait ability, according to the results of the PC₁ score. One-way repeated analysis of variance with the Bonferroni correction was used to compare gait performances in the cluster groups. PCA outcomes indicated 76.9% variance for PC₁–PC₆, where PC₁ (gait variability (GV): 18.5%), PC₂ (pace: 17.8%), PC₃ (rhythm and phase: 13.9%), and PC₄ (bilateral coordination: 11.2%) were the gait-related factors. All of the pace, rhythm, GV, and variables for bilateral coordination classified the gait ability in the cluster groups. We suggest that the treadmill walking task may be reliable to evaluate the gait performances, which may provide insight into understanding the decline of gait ability. The presented results are considered meaningful for understanding the gait patterns of healthy adults and may prove useful as reference outcomes for future gait analyses.

The benefits and mechanisms of exercise training for Parkinson's disease

Parkinson's disease (PD) is a significantly progressive neurodegenerative disease characterised by both motor and nonmotor disorders. The main pathological characteristics of PD consist of the loss of dopaminergic neurons and the formation of alpha-synuclein-containing Lewy bodies in the substantia nigra. Currently, the main therapeutic method for PD is anti-Parkinson medications, including levodopa, madopar, sirelin, and so on. However, the effect of pharmacological treatment has its own limitations, the most significant of which is that the therapeutic effect of dopaminergic treatments gradually diminishes with time. Exercise training, as an adjunctive treatment and complementary therapy, can improve the plasticity of cortical striatum and increase the release of dopamine. Exercise training has been proven to effectively improve motor disorders (including balance, gait, risk of falls and physical function) and nonmotor disorders (such as sleep impairments, cognitive function and quality of life) in PD patients. In recent years, various types of exercise training have been used to treat PD. In this review, we summarise the exercise therapy mechanisms and the protective effects of different types of exercise training on PD patients.

Effects of different percentages of body weight-supported treadmill training in Parkinson’s disease: a double-blind randomized controlled trial

Background/aim

Body weight-supported treadmill training (BWSTT) might have greater effects than conventional treadmill training (TT) in neurological diseases such as Parkinson’s disease (PD). The aim of this study was to evaluate the effects of different percentages of BWSTT on gait, balance, quality of life, and fatigue in PD.

Materials and methods

Thirty-five patients with moderate to advanced PD were randomized into three BWSTT groups according to the supported percentage of body weight: 0% BWSTT (control group; unsupported TT), 10% BWSTT, or 20% BWSTT. Five patients were excluded due to early discharge and 30 patients completed BWSTT sessions lasting 30 min, 5 days a week, for 6 weeks during their inpatient rehabilitation stay. The primary outcome was 6-min walk distance (6MWD). Secondary outcomes were Unified Parkinson’s Disease Rating Scale (UPDRS), Berg Balance Scale (BBS), Nottingham Health Profile (NHP), Fatigue Impact Scale, and Fatigue Severity Scale scores. Measurements were performed before and after the training.

Results

The unsupported TT group demonstrated no significant improvement in the outcome measures after a 6-week training except for BBS and NHP emotional subscores. Moreover, the NHP pain subscore increased in the unsupported TT group after training. The 10% and 20% supported BWSTT groups demonstrated significant improvements in 6MWD (P = 0.004 and P < 0.001, respectively), UPDRS - motor score (P = 0.012 and P = 0.005, respectively), NHP pain subscore (P = 0.003 and P = 0.002, respectively), and fatigue (P = 0.005 for both) after training. The 20% BWSTT provided the highest improvement in balance among the three groups (P < 0.001) and greater relief of fatigue than 10% BWSTT (P = 0.002).

Conclusion

Six weeks of BWSTT improved walking distance and balance ability, relieved fatigue, and additionally reduced pain in patients with moderate to advanced PD.