Effects of Home Exercise on Motor Performance in Patients with Parkinson’s Disease
Caglar, A. T., Gurses, H. N., Mutluay, F. K., & Kiziltan, G. (2005). Effects of home exercise on motor performance in patients with Parkinson’s disease. Clinical Rehabilitation, 19, 870-877.
Parkinson’s disease (PD) is a neurological disorder that causes loss of functional abilities and progressive loss of independence despite medical treatment. According to the National Parkinson Foundation (NPF), it is estimated that 1.5 million Americans currently have PD, and 60,000 new cases are diagnosed each year. While the condition usually develops after the age of 65, 15% of those diagnosed are under 50. It has also been found that PD affects both men and women in almost equal numbers and shows no social, ethnic, economic, or geographic boundaries. Depending on the severity of the disease, functional activity disorders may arise due to loss of trunk mobility and postural reflex, which may also result in dependency in activities requiring manipulation and skill, especially in the early stages of the disease. Despite the data obtained from previous studies, there is still insufficient evidence to support the efficacy of physiotherapy on motor performance in Parkinson’s disease as there are few controlled studies to date.
The subjects consisted of 30 men and women (average age = 65.5) recruited from the Movement Disorders Outpatient Clinic and Neurology Department at Istanbul University’s Cerrahpasa School of Medicine. Inclusion criteria for this study were: diagnosed with PD by a neurologist; at grade I, II, and III according to the Hoehn and Yahr Scale (a five-stage disability scale: stage one = least severe; stage five = most severe); on a stable drug regime; could walk independently with no assistance or walking aid; no orthopedic problems that would affect mobility and no systemic and metabolic disease; could come to the hospital three times for the physiotherapy assessments; and no previous involvement in a physiotherapy and rehabilitation program. There were no exclusion criteria.
Subjects were assigned into an exercise group (N=15) or the control group (N=15). Baseline measurements were taken for both groups: 10-meter walking time (walking over a set distance of 10 meters with no turn component at own preferred speed), 20-meter walking time (walking over a set distance of 10 meters, turning and walking back at own preferred speed), first pace length (distance measured between the fronts of the first and second footprints), pace number at a 10-meter distance (steps taken by both feet were noted), time to walk around a chair, and Nine Hole Peg Board test (evaluates hand coordination by asking the subject to place nine pegs from the table into the board, take the pegs out one by one, and place them on the table as quickly as possible). Lowest time taken to complete the tests was recorded. Home exercises were given to the subjects in the exercise group at the hospital, and after the initial training the subjects were instructed to continue the exercise program at home. A booklet outlining the movements from which the exercises were selected according to the needs of the participants was given to the subjects. The booklet included the following exercises: 1) Relaxation and stretching exercises such as bending and turning of trunk; 2) Exercises to ease breathing and facial muscle exercises to stress the mimic expressions and to enhance oral motor function; 3) Exercises to increase movement of head, neck, shoulder, elbow and hand, besides leg, knee, and feet and alternative exercise of the four limbs in supine position for recovery of muscular coordination; 4) Exercises to assist improving body movements, exercises to get in and out of bed, and also exercises to ease standing up and sitting down on a chair and turning around in the chair; and 5) Exercises done while standing up to improve balance. Finally, walking exercises were given. Participants were instructed to carry out each of the exercises 10 times, three times a day for a period of 2 months. The home exercise training period was 1 hour, and the primary goals were to improve range of motion and functional activity, balance and gait, and ultimately, fine motor dexterity. These programs were not recommended to the control group, which continued with its routine activities. All participants were evaluated at the end of the first and second month, and their results were compared to baseline levels.
It was determined at the start of the study that both groups were similar on all variables at baseline with no statistically significant differences. All variables were significantly improved in the exercise group, from baseline to second month. Comparison of the groups showed significant changes in 10-meter and 20-meter walking time, and time taken to turn around a chair at first-month assessment. When the results of the second-month assessments of the two groups were compared, there were significant changes in all parameters except pace number in 10 meters. A comparison of the groups showed that the changes were significant in 10-meter and 20-meter walking time in the first month. The differences were not statistically significant in the second month when compared with the first month but were still significant when compared with baseline. First pace length showed a significant improvement (p < /0.001) and pace number in the 10-meter walk test decreased significantly (p < /0.001) in the exercise group. This provided an increase in the walking speed of these participants. There was a significant decrease (p < /0.001) in both left- and right-hand Nine Hole Peg Board test completion times in the exercise group, which reflects distal motor performance. Compliance was very high and participants displayed great care and attention in keeping their exercise diaries. It should also be noted that during the study, there were no losses in either the exercise group or the control group in all assessments.
The results suggest that if individuals with PD are taught individualized and detailed home exercises by a physiotherapist, there is a statistically significant clinical improvement in their motor performance over an 8-week period. However, the study did show that the improvement associated with physiotherapy continued for longer than 2 weeks and the participants who were not referred to the exercise group for home exercise could not benefit from it. Instructing exercise at home may be feasible for participants, but it is not feasible for the hospital staff if they do not have a special home therapy visiting team. Some limitations of the study include sample size and not randomly assigning the participants to groups. The authors suggest that since the doctor and physiotherapist assessing the participants were blind to the participant group selection, as well as the participants themselves being blind to selection of groups, this strengthens the validity of the study. The authors conclude that individualized home exercises have a positive effect on motor performance in participants with PD, a home exercise program is easy for the participants, and further research is needed to examine the optimal training period that causes a significant improvement and how long the outcomes are sustained after the program is finished. The results of this study were consistent with previous studies and suggest the usefulness of physical therapy as a home exercise program done at home for participants with PD. The benefits of physiotherapy can be demonstrated at an earlier stage of disability and should therefore be part of managing the disease.
This study demonstrates the usefulness of individualized home exercises for persons with PD. Not randomly assigning individuals to groups and having a small sample size decreases the study’s reliability and the results may not transfer over to similar populations, as the authors have suggested. To address this, the authors could have recruited more individuals for the study and then randomly assigned these individuals into groups. Also, a longitudinal study would help show how many participants would continue their home exercise programs and to what extent these improvements are maintained. Such a study would give researchers a better understanding of the long-term effects and benefits of home exercise programs for participants with PD. From this study, one can see that this type of program is promising for individuals with PD, and more research should be done in this area.