Progressive resistance training improves gait initiation in individuals with Parkinson's disease
Highlights
► Strength training (ST) may improve postural control in Parkinson's disease patients. ► Studied a 10-week ST program and biomechanical analysis of gait initiation (GI). ► ST subjects improved GI anticipatory postural adjustments and stride performance. ► ST subjects increased strength and safely completed the 10 week program.
Introduction
Persons with Parkinson's disease (PWP) exhibit difficulty performing transitional movements where the center-of-mass (COM) moves outside the base-of-support; a common feature in such tasks as getting out of chair and gait initiation (GI) [1], [2], [3]. Impairments in the typical anticipatory postural adjustments (APA) are considered a major pathophysiological mechanism underlying impaired GI performance in PWP [2], [4]. Previous studies report that PWP exhibit prolonged movement preparation, reduced initial loading of the swing limb, and less effective uncoupling of the center of pressure (COP) and COM [2], [4]. Further, PWP display a reduction in propulsive forces, reduced step length and velocity [2], [3], [5]. The mechanisms underlying these impairments are likely multi-factorial including deficits in neurologic and neuromuscular function. Of note, Nocera et al. recently identified a significant positive correlation between lower extremity strength and GI performance [6]. Conversely, impaired lower extremity strength has been shown to negatively influence functional mobility and patient perceived quality of life [7], [8]. Thus, treatment modalities that enhance lower extremity strength may have important therapeutic ramifications.
Progressive resistance training (PRT) is an effective mode to circumvent age-related changes in the neuromuscular and musculoskeletal systems. PRT may be a particularly useful intervention for PWP where reduced muscle strength is associated with disease related reductions in central activation and reduced physical activity [9], [10]. Importantly, PRT induces neural adaptations at multiple levels of the neuraxis [9]. In a series of studies, Vaillancourt and colleagues have reported a prominent role for the basal ganglia in force production and have observed that the BOLD fMRI signal change is proportional to both the amplitude and the rate of change of force [11], [12]. Although this was an upper extremity task (squeezing), these findings suggest that tasks that required progressive increases in force such as PRT may influence basal ganglia output. Both experimental studies and recent systematic reviews propose that PRT can improve muscular strength and endurance, balance, gait, timed chair rise performance and static postural control in PWP [13], [14], [15]. Specifically, Dibble et al. suggested that high intensity exercises can be safely performed by PWP and improve muscle force production, reduce bradykinesia, and increase walking speed and quality of life [13]. However, it remains unknown if these improvements in strength have a carryover effect onto the displacements of the COP and stepping characteristics during GI. Therefore, the purpose of this exploratory pilot investigation was to examine the effects of PRT on GI performance in PWP. We hypothesize that PRT will result in improvements in both peak strength and performance of GI.
Section snippets
Participants
Eighteen individuals diagnosed with idiopathic PD by a movement disorder neurologist participated (Table 1). Inclusion criteria included a Modified Hoehn and Yahr stage of 1–3 and the ability to ambulate without assistance. All participants were on stable doses of anti-Parkinson medications which remained consistent throughout the testing and intervention protocol. Exclusion criteria included a history of significant cardiovascular, musculoskeletal, vestibular or other neurological disorder,
Results
All PRT subjects completed the exercise program without incident and all subjects completed the GI trials without falls or other difficulties. There were no differences between groups for any demographic variable and the median Hoehn and Yahr score was two for both groups (Table 1).
A significant Group × Time interaction was identified for the COP posterior displacement during the APA phase (F = 6.999, P = 0.02). Importantly, the PRT group demonstrated a significant 29% increase (P = 0.01), whereas
Discussion
Recent investigations have concluded that exercise is beneficial to PWP with respect to physical functioning, health related quality of life, strength, balance, and gait speed [2], [14], [15], [20]. The results of this preliminary study suggest that PRT may be an effective modality to optimize the performance of GI both by a more efficient anticipatory postural adjustment and improved spatiotemporal parameters of the initial steps. This may help reduce the risk of falls during GI when the COM
Limitations
The control subjects in this study comprised a non-contact patient group which potentially limits the extrapolation of these results; particularly as it relates to strength changes. The control subjects did not perform 1-RM testing at either PRE or POST because the investigators were concerned the multiple 1-RM testing protocols would serve as de facto exercise sessions and thus influence GI performance. An additional limitation in this study is the lack of electromyographic (EMG) data. The
Conclusions
The results of this preliminary investigation suggest PRT is an effective non-pharmacological and nonsurgical treatment to improve GI performance in PWP. The greater COP posterior displacement and increased stepping characteristics may be a result of restoration of the central-mediated anticipatory postural adjustments and force producing capabilities of the lower extremity. Future investigations of strength training for PWP should include large randomized clinical trials and examine its
Conflict of interest statement
The authors declare that there are no conflicts of interest.
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