Physical Training June 2009
 
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THE EFFECT OF A 12-WEEK LOW-IMPACT EXERCISE PROGRAM FOR ELDERLY PEOPLE WITH EARLY PARKINSON’S DISEASE IN LOWER EXTREMITIES’ JOINT RANGE OF MOTION

Kitsios Athanasios


The purpose of this study was to evaluate the effect of an intervention exercise program for persons with Parkinson’s disease on lower extremities range of motion. 14 elderly Parkinson Disease (PD) patients and 14 serving as control group took part in the study. Measurements, including knee and hip range of motion (ROM) at flexion and extension condition, were tested before and after a 12-week physical low-impact program. Treatment provided by community trainers consisted of conscious movement control and low-impact resistance training 3 times a week. The study revealed that patients had significantly increased their joints’ ROM at both conditions (flexion/extension) after the intervention program. The same trend was not found for the case of the control group. The results support application and development of the treatment concept and highlight that physical activity at its simple status can improve function in Parkinson’s disease patients. Progressive low-impact exercise is a potentially effective method of preventing disability in PD elderly patients. If sustained, the increases in joints ROM may increase their daily physical activity through this improvement and finally reduce the risk of osteoporotic fracture.

Key words: Parkinson’s disease; ROM; knee; hip


INTRODUCTION

It is already well known, from basic research and clinical studies, that high intensity exercises may be important in promoting activity-dependent neuroplasticity of the injured brain (in our study for PD patients) with alterations within the CNS in response to physical activity (Nudo et al., 1996; ,Fisher et al., 2004). There is also a body of literature that supports exercise-induced alterations in functional performance at different levels of intensity in people with Parkinson disease (PD) (Cakit et al., 2007; Herman et al., 2007; Pohl et al., 2003). The hypothesis is that there are changes in knee and hip joint ROM after this program in PD patients. There are encouraging indications that physiotherapy may be effective in improving many mobility deficits in PD (Smidt et al., 2005; Deane et al., 2005; Goede et al., 2001). In addition, physical activity can modify other risk factors for fracture (Fisher et al., 2004; Robinson et al., 1998). However, there are few studies measuring ROM in elderly people with PD after an intervention program.

The aim of this randomized controlled study was to evaluate the effects of a 12-week low-impact exercise training program on lower extremity range of motion in patients with PD. The program was home based to achieve maximum compliance and consisted of site-specific low-impact exercises of increasing intensity.


METHODS

Patients and controls

The present study included fourteen elderly subjects with early-stage, seven women and seven men, Hoehn and Yahr stages 1 or 2 PD who voluntarily consented to participate in the study (16).Early stages of PD were chosen because people with greater physical capability could engage in higher intensity exercise (4).14 sex and age matched (7 women and 7 men) healthy elderly controls, randomly selected from the regional population register of the same geographical area were also included. All subjects were required to sign an informed consent document approved by the Aristotle University of Thessaloniki. The age of the PD patients was 63.4± 6.1 years (mean± SD) and of the controls 66.9± 2.7 years. The patients had had PD for 121.6± 36.5 months and all had been treated with levodopa for at least 1 year at the time of the first examination. All participants were living independently in their own homes, without any difference in civil status between patients and controls. The inclusion criteria for the study were the following: diagnosis of PD within 3 years of study participation, 60 years of age or older and for women that at least 5 years had elapsed since the menopause, medical clearance from the primary care physician to participate in an exercise program and ability to walk. Potential participants were excluded if there were physician-determined major medical problems such as cardiac dysfunction, musculoskeletal impairments or excessive pain in any joint, depression, gastrointestinal or endocrine disease, and if they had insufficient endurance to participate in exercise program 3 times a week for a 1-hour session. The criteria were the same for the PD patients and the controls, with the exception of PD symptoms. All the characteristics of the participants are presented in table 1.


Procedures

All subjects with PD (14) completed the intervention program which lasted 12weeks. Two patients with PD were excluded from the study after randomization. 1 patient had passed away and the second one stopped the program due to personal reasons. So, people who participated fully in the intervention program were 14 from 16.

The emphasis of the exercise program was to dynamically load the axial skeleton at the hip and lumbar spine sites using home-based, low-impact exercises. At baseline, subjects in the exercise group attended a series of induction meetings during which the correct exercise techniques were demonstrated and a supporting resource package was provided.

Each exercise session involved a 5-minute warm-up consisting of general whole body pulse-raising and mobility-promoting activities, followed by preparatory stretching of muscles being worked during the main session. A 5-minute period of pulse-lowering activity and stretching was performed after the exercises were completed. The main section of the home-based program was comprised of 12 core floor-based low-impact exercises. Exercises were focused on the hip and lumbar region, consisting of dynamic muscular conditioning of the major muscle groups of the trunk and legs including quadriceps, hamstrings, gluteals, erector spinae, and muscles of the anterior abdominal wall. Subjects were asked to exercise at least twice a week, with a minimum of 10 sessions per month considered necessary for full compliance. Additional meetings were held at the 4th and 8th week to provide motivation and support for exercising individuals and to supervise the increase in training intensity. Intensity of exercise was increased by developing the core exercises, increasing the number of repetitions of each exercise, advancing body positions to increase resistance to movement (lever principles), and using resistive tubing or free weights. The program was intentionally flexible to allow individuals of different fitness levels to reach an exercise overload effect.

Subjects in all groups were allowed to continue their customary exercise routines. They were asked, however, not to change their exercise routines.

Data collection

Data were collected before intervention and immediately after completion of exercise. Subjects began exercise within 1 to 2 weeks after the baseline assessment. All subjects took their customary medications at the same time relative to each assessment.


Assessments

Knee and hip range of motion (ROM)

Joint range of motion (º) was measured at baseline and after 12 weeks at the knee (right and left) and hip (right and left) both in flexion and extension conditions with a Myrin goniometer. All measurements were performed by a single trained operator; the limits for knee joint were 140 to 0 º and the ones for hip joint were 15-0-90 º.

Body weight and height

Body weight was assessed in all participants before and after the intervention program, when lightly dressed and without shoes, using a calibrated analogue scale. The assessments were made in the morning. The participant’s height was assessed when they were in a standing position without shoes.


Table 1. Characteristics of PD patients and PD control group.



PD

Controls

Characteristics



Patients

14

14

Sex(male/female)

7/7

7/7

Age (years)

63.4± 6.1

66.9± 2.7

Hoehn and Yahr stage

1.9± 0.4


Duration of PD (months)

121.6± 34.5


Body weight (kg)

73.8± 9.5

65.6± 8

Height (cm)

173.2± 5

170.8± 6.4


Statistical analysis

The results are presented as mean and standard deviation (mean± SD). Changes during the 12 weeks were calculated and compared between groups using Student's unpaired t tests with 95% confidence intervals (CIs). The Mann–Whitney U test was used when the data were not normally distributed. Two-tailed significance tests were used in all the statistical analysis. The Statistical Package for Social Sciences (SPSS 16 Inc., Chicago, IL) was used for the analysis.


RESULTS

Knee and hip range of motion (ROM)

Knee and hip range of motion values were almost the same at baseline both in PD patients and control group. Knee and hip ROM were statistically increased in both extremities in PD groups as a result of the intervention program, and this was true mainly for the flexion and at a minor degree for the extension condition (p<0.05). None of the examined parameters was found to be altered in the case of control group. Generally, the joints ROM of the examined parameters was increased in the PD population and not for their age matched control counterparts. All the available data are presented below in table 2.


Table 2. Knee and hip range of motion of both lower extremities in patients with PD and in controls at the two investigated periods


JOINT

Baseline

After


Baseline

After



PD n=14, mean ± SD

p

Controls n=14, mean ± SD

p

Right knee flexion

124,7±2,6

127±1,3

*

122,4±3,1

121,7±3,5

ns

Right knee extension

-4±4

-1,1±1,5

*

-5,2±2,7

-5,7±1,8

ns

Left knee flexion

124,4±2,3

127±1,2

*

122,7±2,8

121,3±3,1

ns

Left knee extension

-4±4

-1,2±1,6

*

-5,2±2,7

-5,9±1,8

ns

Right hip flexion

77,8±5,8

82±3,4

*

77,3±3,3

75,2±2,8

ns

Right hip extension

12,5±1,3

14,1±1

ns

11,8±1,7

11±1

ns

Left hip flexion

78,7±6,5

82,2±3,3

*

77,2±3,3

75,2±2,8

ns

Left hip extension

12,6±1,3

14,1±1

ns

11,8±1,7

11±1

ns


NOTE. At baseline there were no significant differences between the two groups. Results are presented as mean (SD).


DISCUSSION

The limitation of the current study is the relatively small number of PD patients. On the other hand, there is a well-matched design for age and group and in addition to this all participants were investigated by the same team and by well-defined instructions. We measured the range of motion of the hip and knee joints bilateral in flexion and extension condition. Significant increments of ROM in both joints mainly in flexion condition as a result of the intervention program were found in PD patients compared with age matched controls. Our results show that a 12-week low-impact exercise program may have a positive effect on ROM at the knee and hip joint and spine in patients with Parkinson’s disease. The results of the present study agree with a recent work done by Fisher et al., 2008, who among other kinematic parameters found that an exercise training program improved the motor performance and specifically the range of motion in the same joints which our study focused on, in people with early PD. Changes in joints’ ROM in the case of exercise group, may have occurred as a result of alterations in dopamine handling and neurotransmission within the basal ganglia (Fisher et al., 2004).

However, a low-impact program was chosen for our study because it could be performed readily at home without special equipment or supervision and was unlikely to lead to training injuries or fracture in patients with established osteoporosis. The exercises were site specific for the hip and lumbar spine, with body positions and additional resistive devices used in intensive bouts of exercise to produce strain and osteogenic stimulus in these areas. In view of our results, we conclude that prescription of a home-based, low-impact exercise program is feasible in patients with Parkinson’s disease and is a potentially effective method of improving joints range of motion and generally mobility. The exercises were simple to perform by people of varying levels of fitness and required only minimal instruction, supervision, and monitoring. Future studies should address methods of increasing uptake and compliance with exercise in this high-risk group and study the effect of more intense modes of exercise training and better understand the effects of moderate exercise on neuroplasticity.


REFERENCES


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B., Wu A., Salem G., Song J., Lin C., Yip J., Cen S., Gordon J., Jakowec M., Petzinger G. The Effect of Exercise Training in Improving Motor Performance and Corticomotor Excitability in People With Early Parkinson’s Disease Archives of Physical Medicine and Rehabilitation, Volume 89, Issue 7, Pages 1221-1229


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Nudo R.J.,. Milliken G.W,. Jenkin W.M and. Merzenich M.M, Use-dependent alterations of movement representations in primary motor cortex of adult squirrel monkeys, J Neurosci 16 (1996), pp. 785–807.

Pohl M, Rockstroh G, Ruckriem S, Mrass G, Mehrholz J. Immediate effects of speed-dependent treadmill training on gait parameters in early Parkinson’s disease. Arch Phys Med Rehabil 2003;84:1760-6

Robinson RJ, Krzywicki T, Almond L, al-Azzawi F, Abrams K, Iqbal SJ, Mayberry JF Effect of a low-impact exercise program on bone mineral density in Crohn's disease: a randomized controlled trial. Gastroenterology. 1998 Jul;115(1):36-41.

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