Benefits of Community Research-BasedProgramming to Improve Freezing of Gait

for Individuals with Parkinson Disease

Item Type text; Electronic Thesis

Authors Hamilton, Kristin Marie

Publisher The University of Arizona.

Rights Copyright © is held by the author. Digital access to this materialis made possible by the University Libraries, University of Arizona.Further transmission, reproduction or presentation (such aspublic display or performance) of protected items is prohibitedexcept with permission of the author.

Download date 15/06/2018 04:43:45

Link to Item http://hdl.handle.net/10150/297620

ABSTRACT

For one week, six subjects with Parkinson Disease (PD) attended a boot camp at the

Parkinson Wellness Recovery (PWR!) Gym. Each experienced a unique symptom of PD known

as freezing of gait (FOG). Previous research supports task-specific exercise for improving PD

symptoms; this study focuses on task-specific exercise to reduce FOG. Reducing the severity of

hypokinetic and bradykinetic movement was addressed during the week through large amplitude

training that was integrated into interval training during cardiovascular exercise, agility and

postural control exercises, and real world environments. Five out of six subjects improved on a

Freezing of Gait Assessment (FOGA) and four out of six subjects improved on the Pull

Backwards Assessment. Task- specific improvement for all six individuals was achieved, with

regards to typical freezing triggers-- narrow spaces, crowds, timed events, and more. These data

suggest that techniques learned throughout the week can appear to be reflected into real-life. In

addition, FOG specific training showed improvement in balance, a very important finidng in

people that fall almost daily. Overall, specific exercise techniques assisted these six subjects in

improving their quality of life, freezing severity, and postural control.

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INTRODUCTION

Epidemiology

Parkinson disease (PD) is a progressive neurological. Next to Alzheimer's Disease, it is

the most common neurodegenerative disease affecting the elderly. Nearly 1.6 million people

have PD in the United States, with an estimated diagnosis age of 62.5 years However, there is an

early onset PD which occurs among people under the age of 40; this makes up 5-10% of the PD

population.

Pathophysiology

Parkinson's disease affects an area of the brain called the basal ganglia (Fahn, 2003).

Nerve cells that produce the neurotransmitter, dopamine, begin to die in a person with PD (Fahn,

2003). Inadequate amounts of dopamine lead to loss of motor control for everyday movements

(Farley, 2004).

Primary Symptoms of PD

The cardinal motor manifestations of PD are bradykinesia (slow movements), rigidity

(increase tone), and resting tremor. Most people with PD will attest to recognizing the tremor as

the first sign of the disease, ultimately leading them to visit a neurologist. The motor

impairments of PD can best be explained by neural circuitry identified in the Motor Circuit in

Figure 1. Cognitive impairments most often affect executive functions that require planning,

cognitive flexibility, and dual-tasking. Cognitive impairment increases in severity with age and

length of time with PD; a situation often observed most readily by the carepartner and family of

the person with PD. The emotional circuit involves disturbances of mood, apathy, and anxiety.

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The cognitive and emotional impairments may diminish quality of life more than impaired

physical functioning (Fahn, 2003).

Bradykinesia is the most identifiable motor symptom of Parkinson disease, and leads to

the most disablement; this slow movement stems from voluntary to involuntary muscles across

the motor system including fine-motor, respiratory, and speech movements as well as postural

responses. During repetitive movements like walking and handwriting, each step or stroke may

become not only slower (bradykinetic), but also progressively reduced in amplitude

(hypokinesia) . As the disease progresses, other symptoms become more evident. For instance,

instead of just slow movement, the movement becomes uncoordinated and "arrythmical". Thus,

the internal timing cues for generating and sequencing movements become severely disrupted.

This incoordination (akinesia) interferes with the ability to initiate, terminate, or reverse

directions quickly, coordinate whole body movements or combine actions (stand, walk, turn).

Over time, postural instability and freezing of gait (FOG) become the major symptoms that

contribute to falls, and the eventual use of a wheelchair for mobility (Smania, 2010). Once falls

become prevalent, this decreases life expectancy by 7 years (Bloem, 2004).

Freezing of Gait (FOG)

The term "freezing of gait" is used to describe a sudden inability to move any part of the

body, or a feeling of being glued to the floor. People who suffer episodes of freezing may fall

the ground before reacting to move a foot or put their hands out to break their fall. Not all

people with PD experience freezing, which further demonstrates how each case of PD is

different (Bloem et al, 2004). Those who experience this inability to move are referred to as

"freezers", whereas other people with PD are known as "non-freezers", though both groups

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generally experience the primary symptoms (bradykinesia, rigidity) and eventually postural

instability) typical of PD. The most common situations which induce freezing include: narrow

spaces, doorways, and turning around (Bloem et al, 2004), with these affects being heightened

when the person with PD is distracted cognitively. Freezing episodes can occur multiple times a

day and lead to severe injuries.

Treatment

Recent studies suggest that exercise programs can be beneficial for individuals with PD.

Clinical studies have shown exercise to reduce the detrimental effects of neuromuscular slowing,

improve coordination, strength, balance, mobility, cognition, and improve quality of life

(Ahlskog, 2011; Keus, 2007). In addition, studies suggest exercise supplements the isolated

benefit of medication or surgical procedures (Keus, 2007). More generally, exercise for people

with chronic diseases, including PD, has been shown to reduce morbidity and secondary

complications (States, 2011). Freezing requires specific exercise training to address the multiple

impairments that trigger the freeze (see Table 2). This requires an understanding of the

cognitive, emotional and motor symptoms that underlie freezing. Grasping how to approach

certain environments can affect whether an individual freezes or not (Morris, 2000).

Purpose

Understanding how to use neuroplasticity-principled exercise to reduce FOG is one aim

of this study. A major component of a neuroplasticity-principled exercise program is task-

specificity, or training to overcome a specific problem in a specific situation. Task-specific

training has been supported for PD, but application to the symptom of FOG sets this case series

study apart from the rest. Task-specific training includes learning skills to directly “put off” the

Hamilton 5

freezing episode or using cognitive strategies to avoid it. For example, one can practice what is

difficulty (as shown in Table 2) through “forced use” training to learn how to take big steps, or

turn and step backwards with wider base of support and rocking motions, or use proper

technique, at the initiation of a step or at the onset of a turn. Or, one can learn to use

visual/auditory cues or attentional strategies (go big), to avoid or reduce the triggers of FOG.

It is also important to address the fear, anxiety, apathy, loss of self-efficacy that occurs in

PD as this effects their ability to change their behaviors. Community-based programs provide a

unique environment to assist in this area. We will apply small group (N=3) training in a

community setting with opportunities for interaction to address these psychosocial issues that

also contribute to FOG.

The primary purpose of this case series report is to explore the use of neuroplasticity-

principled task-specific training (through forced use practice and cognitive strategy training) in a

community setting to reduce severity of FOG symptoms as measured by: reduced frequency and

duration or FOG during objective and subjective measures, and transfer to better postural

control and increased quality of life among subjects.

METHODS

Recruitment

An email regarding the "PWR! Over Freezing Boot Camp" was sent to all PWR! Gym

clientele and affiliated clinicians. Nobody was individually pursued to participate in the study.

The population for the study must be limited to participants who experience freezing symptoms

to help increase the validity and generalizability. Next, individuals began to contact the PWR!

Gym and underwent an intensive screening process. Questions aimed at number of years with

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PD diagnosis, level of independence, number of falls, speaking English fluently, age, and ability

to comprehend instructions. If the carepartner or spouse had to answer this phone questionnaire

because the person with PD was unable to comprehend, this made the candidate an unsuitable

participant. Potential subjects were required to meet all financial requirements for the study,

ranging from hotel expenses, rental car fees, and other travel expenditures.

Intervention

All activities for the recruitment, during the study, and analysis after were held at the

Parkinson Wellness Recovery (PWR!) Gym in Tucson, AZ which can be found at 134 W. Ft.

Lowell, Tucson, AZ 85705.

Participants gathered on the Sunday preceding the week, to gather pre-treatment

assessment data. For the following five days, the participants spent 1.5 hours in the morning

and afternoon engaging in intensive Parkinson-specific exercise. Exercises stressed the

following:

Task-specific activities directed at triggers

Progressive aerobics (treadmill, pole-walking, stationary bicycle, elliptical)

Large amplitude movement to overcome bradykinesia, rigidity, and coordination

Fall prevention (Re-train stepping and righting responses for reactive and anticipatory

conditions)

External cueing (with music or metronome) and attentional strategies customized to

optimize success

Real world problemsolving (i.e. movie theatre, airport, kitchen, closet)

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In addition to 3 hours of small group task-specific practice, participants also attended

group education nights during the week allowing researchers to grasp the real-world problems

experienced by participants. Yoga was also offered to participants and carepartners to address

stress, mindfulness (walking meditation), and stretching. Finally, one evening was "Game

Night" to help exercise the brain and incorporate fun for the community-based factor. At the

conclusion of the week, the same assessments were performed on Saturday for post-treatment

data. After all data was collected, researchers gathered to complete scoring.

Assessments

PD supported assessments measured FOG, gait and balance, fine motor, dual tasking,

endurance, and cognition. After data collection was complete, the subjects were scored via

videotape on their Freezing of Gait Assessment (FOGA). A change score was used to determine

progress over the week. Change score is the difference between the pre and post assessment

scores, demonstrating positive as improvement. The assessments included the following:

Freezing of Gait Assessment, Freezing of Gait Questionnaire, PDQ-39, 9-Hole Peg Test, Timed

Up and Go, 6-Minute Walk test, 10 meter Forward walk, 10 meter Backward walk, Trail-making

test, Push and Pull test, and the 4 Square Step Test. Each assessment has demonstrated to be

useful in evaluating Parkinson's disease. .

1. Freezing of Gait Assessment (FOGA)- The FOGA narrowed in on the

primary symptoms of interest and induced a festination of gait. First, the

participant was asked to sit in the chair 30 seconds; when the researcher said

"Begin," the participant stood up and walked to a box drawn on the floor. He was

to walk clockwise around the box, stop, and then walk counter-clockwise around

Hamilton 8

the box. Finally, he needed to walk towards a doorway and open the door, then

turn around and sit back in the chair. After completing the course once, the

participant was required to complete it again under dual task. When the

researcher said, "Begin," she also would say a number and the participant was

required to count backwards by 3s for the duration of the course. All trials were

videotaped and scored after the boot camp was finished. Four scores regarding

the quality were issued to this assessment: stand out of the chair, clockwise turn,

counter-clockwise turn, and maneuvering through the doorway. Each aspect of

this test analyzed where typical PD freezers will feel the sensation of being glued

to the ground. A score of 0-4 was assigned to each of these four tasks; a score of

4 indicated the researcher had to intervene to prevent injury from falling whereas

a score of 0 indicated there was no festination of gait.

2. Freezing of Gait Questionnaire (FOGQ)- The FOGQ analyzed how

freezing impacts the participants in their daily lives. Questions are scored based

on frequency of freezing episodes and how they impair one's lifestyle. An

addition to the questionnaire included scoring the participant's confidence with

performing typical tasks: "I can walk through a doorway without freezing."

Confidence was ranked using a percentage scale. All scores for this assessment

were a subjective score.

3. Parkinson Disease Questionnaire (PDQ-39)- Another subjective

assessment is the PDQ-39, which looked at quality of life with respect to how the

person with PD feels. Categories include mobility, emotional well being, stigma,

social support, cognitive impairment, communication, and body discomfort.

Hamilton 9

Participants were required to complete this questionnaire on their own, without

spousal or caretaker's influence. Each subject marked a score, ranging from 0-4,

with 4 being the most affected by PD.

4. 9-Hole Peg Test - The 9-Hole Peg Test assessed fine motor skills. A

small peg board with nine holes was used; when the researcher said "Begin,"

participant was required to use one hand to pick up one peg at a time and place it

in a hole until all nine holes were filled. This was completed with the right hand,

left hand, and then both hands again but with a dual task. The dual task required

each subject to say the days of the week backwards. Number of days said, as well

as time, was recorded for this assessment.

5. Timed Up and Go (TUG)- The TUG assessment analyzed ability to stand

out of a chair, with the option of pushing down on arms of the chair, and walking

to a line 3 meters distance from the chair. Participants were required to touch the

line and return to sitting in the chair. Three different loads were used for the

TUG: preferred speed, preferred speed with dual task, and as fast and as safe as

possible. The dual task used was the same as for Freezing of Gait Assessment,

when the researcher said "Begin," she also said a number and the participant

needed to count backwards by 3s for the duration of the course.

6. 6-minute walk test- The 6-minute walk test measured the stamina of each

participant. When the researcher said "Begin," each subject was required to walk

around two cones for six minutes. The cones were placed 8 meters apart and

there was no direction change. Upon the completion of six minutes, the

Hamilton 10

researcher said "Stop" and the distance between the participant and the previous

cone was measured to help attain accuracy.

7. 10 meter walk test: As a measure of step size, the 10 meter walk test was

used. A participant placed his feet at the beginning start line and was told

"Begin". The first two meters were used to get started, and then the clock began

to record the number of seconds it takes to reach the end of 10 meters. Just as at

the beginning, there were 2 meters at the end to slow down. This assessment also

was performed under preferred speed, and as fast and as safe as possible. Number

of steps were counted for each trial. For the final 10 meter assessment,

participants walked backwards at their preferred speed. The researcher stayed

with participant at all times as precaution.

8. Trail Making Test: Another fine motor task included the Trail Making

Test, where the participant sits at a table and is given a sheet of paper that

resembles a connect the dot activity. Before beginning the assessment,

participants were told the final number so they know when they are complete. As

the researcher says "Begin," the participant can pick up the pen and begin the

activity. As with all assessments, the researcher made the instructions clear at the

beginning and did not answer questions during the actual assessment. The Trail

Making assessment was timed. After finishing the first trail making test, which

only included numbers, the participant was then given a more challenging one

with numbers and letters. If the participant reached two minutes without

completing, the researchers considered this a quit.

Hamilton 11

9. Push and Release Test/Pull Backwards assessments: The Push and Release

assessment narrowed in on each participant's balance capabilities and fall

prevention techniques. The researcher took a split stance and put pressure into the

candidates scapula region to assure she was there to catch him, then she asked the

participant to "Lean back into my hands. I will let go and I want you to catch

yourself. I am here to catch you if you do not." When the researcher let go, the

participant would take steps to catch himself. A score was issued to this

assessment based on the number of steps taken and if intervention by the

researcher was required. Again, a 0-4 scale was used, with 4 requiring assistance

of the researcher. This assessment was then performed on the front, right side,

and left side. An additional test for the backwards was the Pull Backwards test.

As the researcher stood behind the participant, she would pull backwards on their

shoulders at a random moment. This tested their ability to react to an unforeseen

event. The same score scale was used for the pull test as the push test.

10. Four Square Step Test (4SST): The Four Square Step Test analyzed speed

and deliberateness of movement. For this assessment, a "+" sign was created

from PVC piping, of 1.5" diameter. The length of the plus sign was about 3'.

Participants were instructed to start in "Square 1", the bottom left square, and then

step into each box with both feet while moving clockwise; upon arriving back to

square 1, the participant must remember to go back in a counter-clockwise

fashion until back to square 1 again. This was a timed task, but it was noted if the

participant did not remember instructions or if he stepped on the PVC piping.

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RESULTS

Participants

Six white males who experienced FOG symptoms were recruited for the "unfreezing"

boot camp. All subjects provided written consent prior to participation, and this study was

approved by the University of Arizona Human Subjects Research Protection Program. Refer to

Table 1. for participant demographics. Three of the subjects had attended a PWR! Gym event in

the past. Two (S04 and S05) attended an intensive work shop, or retreat, in 2012 whereas one

subject (S06) had been attending a high intensity PWR! Gym class for about two months prior.

Due to the different ability among participants, researchers divided the group of six males

into two separate groups of three for the week. This would maintain a certain level of challenge

for each participant. One group (S02, S05, S06) of three individuals was a higher challenge

group, whereas the second group had a modified program due to their severity of symptoms.

Refer to Table 2 for each participants' freezing triggers.

Subject Age Year of Diagnosis Group in Boot Camp Frequency Duration

S01 68 2010 2 > once/daily 1 sec

S02 61 2000 1 > once/daily 5-30 sec

S03 65 2005 2 > once/daily >30 sec

S04 66 2004 2 > once/daily 5-30 sec

S05 71 2006 1 > once/daily >30 sec

S06 66 2000 1 < once/week 2-5 sec

Table 1. Participant Data

Subject Initiating

Move-ment

Terminating

Movement

Narrow

Space

Crowd Turning Multitask Chairs Timing

S01 X X X X

S02 X X X

S03 X X X X X

S04 X X X X X X X

S05 X X X X X

S06 X

Table 2. FOG symptoms experienced by subjects.

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Data

Freezing of Gait

Based on the scoring assessed via videotape, Figure 2 shows the FOGA change score was

positive for each subject, except Subject 06. Recall that the change score is the difference

between the Pre and the Post score and the upward direction indicates a positive change. The

two different bars in Figure 2 represent a single task and dual task. The dual task consisted of

counting backwards by 3s; Subjects 02 and 05 scored even higher on the dual task versus their

positive change on single task.

The Freezing of Gait Questionnaire (FOGQ) also showed a positive change score (Figure

3) for five out of six subjects (01, 02, 03, 05, and 06) during the course of the week. The

questionnaire is a subjective and personal assessment of FOG influences that individual's life.

Altogether , four out of six participants earned a positive change score for both FOGA and

FOGQ assessments.

-2

0

2

4

6

8

10

12

14

16

S1 S2 S3 S4 S5 S6

Figure 3. Freezing of Gait Questionnaire

Pre - Post1

-2

-1

0

1

2

3

4

5

S1 S2 S3 S4 S5 S6

Subject

Figure 2. Freezing of Gait Assessment

FOGA ST

FOGA DT

FOGA shows positive change scores

for single task (ST) and dual task (DT)

for 5 out of 6 subjects.

FOGQ shows positive change score

for 5 out of 6 subjects.

Hamilton 14

Postural Control

Figure 4. reveals the change scores for the participants' times on the "Four Square Step

Test" (4SST). A positive change score represents a faster time for the post test. All subjects

demonstrate a positive change score, with the exception of Subject 04.

Figure 5. represents the Push and Release test in the sidewards directions. A direct

measure of anticipatory postural control, this test showed a positive change score for four out of

six subjects to at least one direction. Subjects 01, 02, and 06 showed a positive change to the

right and Subjects, 01, 02, 04, and 06 showed positive change scores to the left.

Figure 6. represents the Pull Backwards test, in the backwards direction. The backwards

test also showed a positive change score for four out of six subjects (01, 02, 03 and 06). S04

performed worse on the post assessment than the pre assessment. S05 had no change. Subject

03 improved only backwards, while Subjects 01, 02 and 06 improved in both sidewards and

backwards anticipatory testing.

Throughout the data, Subject 01 had a positive change score for every assessment while

the rest varied.

-2

0

2

4

6

8

10

12

14

S01_

RE

S02_

DN

S03

_LN

S04

_RO

S05

_JP

S06_

CZ

Figure 4.

Four Square Step Test (4SST)

Change in 4SST

-2

-1

0

1

2

3

Figure 5.

Push & Release Assessment

Push & Release Right

Push & Release Left

-1

0

1

2

3

Figure 6.

Pull Backward

Pull BW

Hamilton 15

DISCUSSION

The data gathered during these 6 case studies indicated that there was improvement in

each subject, though the area for improvement was often specific to each individual. Five out of

six participants improved on their FOGA score in both ST and DT. Four out of six participants

improved on both the FOGA and FOGQ assessments. For postural control, five out of six

subjects improved their score for the 4SST and four out of six subjects improved their Push and

Release scores for left, right, and Pull Backwards scores.

One key factor includes the parallel between both subjective and objective measures for

the FOG assessments. FOGQ is a subjective measure, whereas FOGA measure is a more

objective approach as the scoring is quantitative. The FOGQ allowed the participant to rank

their confidence in dealing with real world situations which presented problems for them prior to

the study. A parallel can be drawn between the improvement from these two measures, which

supports one key aim of the study-- reducing FOG symptoms.

One subject (S06) did not improve on either the objective or subjective approach.

Subject 06 is the exception to the trend found in this series of case studies, as his baseline was

generally "better" (i.e. less impaired) than the other participants. His physical history includes a

high intensity and frequency of exercise, where he worked out and engaged in sports for nearly

every day of the week. While he did not show improvement on the FOGA nor FOGQ during the

week of data collection, his case does indeed support the theory of exercise as medication for PD

(States, 2011). Among the group, S06 has been diagnosed with PD for the longest of the group,

yet his baseline measurements exceeded those of rest of the group. Involvement with exercise

programs has been shown to prevent the progression of the neurological disease (Hirsch, 2009;

Ahlskog, 2011; Farley, 2007). Moreover, S06 had been attending group classes at the PWR!

Hamilton 16

Gym for the month preceding data collection. It is possible that engaging in Parkinson-specific

exercise routines prepared S06 for a more advanced level of training. Since the conclusion of the

boot camp, S06 has reported he has not fallen on the golf course; prior to the study, S06 reported

his main complaint as falling on the golf course which started to become a frequent event.

Another subject (S04) did not rank himself as improving over the course of the week, yet

the objective test suggested he did improve. Unlike S06, S04 did not engage in regular exercise

and the intensive 3+ hours a day took a large toll on his body by the conclusion of the boot camp.

While he may not have felt he improved as reported on the FOGQ, the severity of his FOG

decreased as determined by the FOGA change score.

It is interesting that participants generally improved on what they trained (unfreezing) as

shown in the FOGA and FOGQ. These improvements were translated to quality of life (QoL).

It is also possible that task-specific training that reduced the severity of FOG may have

generalized to improved balance. Studies suggest that reduced postural control, or ability to

move laterally and backwards without falling, contributes greatly to FOG. In effect, task-

specific "unlearning" may be related to improvements in other areas like balance. The Four

Square Step Test (4SST) and the Push and Release/Pull Backwards Tests have been

demonstrated to assess postural control. For freezers, falls may be as frequent as daily which can

occur from small steps. As the individual tries to take several small steps to compensate for the

unbalanced feeling, he/she instead trips over their feet or experiences a freezing episode, "being

glued to the floor" and not moving at all. The Push and Release/Pull Backwards tests aimed at

eliciting a typical, non-PD reaction-- stepping backwards with a big step and reaching the arms

forward for the Pull Backwards test-- from the participants. The results demonstrate an

improvement for Subjects 01, 02, 03 and 06. The positive change score of these subjects

Hamilton 17

suggests they needed to take fewer steps when undergoing the Push and Release/Pull Backwards

tests. For the Push and Release to the back assessment, the subject leaned backwards into the

researchers palms; at a random moment, the researcher would let go. A similar exercise was

performed during the boot camp, known as fall prevention. A mat was placed surrounding the

corner area of a room; then subjects learned to lean backwards onto their heels until they finally

needed to take a large step to catch their weight. The Pull Backwards test required subjects to

react to the researcher's pull of the subjects' shoulders backwards. At pre-testing, subjects

reacted in a typical PD manner, taking several small steps and no upper body reaction. At post

testing, S06 showed a dramatic quantitative and qualitative improvement, eliciting both upper

and lower body reactions. He immediately moved his arms forward, and he took one large step

backwards. Subject 06 reported complaints of postural control and falling in his history; while

he did not improve on the FOGA or FOGQ, he did improve on the Push and Release test.

Subjects 01, 02, 03 revealed a similar reaction, but to a lesser qualitative degree.

Comprehending how to react to various situations presents difficulty to all people with

PD; for freezers, these stressful situations often overcome any learned behavior preventing the

individual from remembering techniques of how to escape a freezing episode. The method for

this study was task-specific exercise. By mimicking real-world situations, the participants

elicited the frozen response in the gym and learned cues to help mitigate the severity. For

example, cueing assists participants in a multitude of ways. Subject 04 suffered freezing when

turning, whether turning to face a different side of the room or turning while walking, he froze.

A cue that proved successful for him was, "Use your turn signal." As PD reduces executive

function of the basal ganglia, thus reducing the degree of voluntary control of the body,

individuals have less automaticity (Morris, 1999; Hallet, 2008). Typical automatic reactions by

Hamilton 18

people without PD include picking up the foot and turning to face the other side of the room,

however this does not happen in PD. Verbal cueing can influence people with PD more as it

triggers a different response from an internal response. A person with PD may think "Turn

signal," but this relays the message to a more frontal area of the brain versus an external, verbal

cue that is relayed to a different portion of the brain in the temporal lobe. PD impacts this region

less severely (Morris, 1999), as it primarily weakens the midbrain. S04 was able to make turns

around cones, and other narrow areas, by hearing and thinking, "Use your turn signal."

Another instance of external cueing existed with S03. S03 experienced severe

dyskinesia. He would need to lean to nearly a ninety degree angle before regaining balance and

standing up. His attentional focus far surpassed the norms of most people with PD. When

Subject 03 added a metronome to walk with, his dyskinesia dissolved to almost none at all,

especially with the assistance of poles. The external cueing of the beat from the metronome

helped create automaticity. Pole walking assisted him as well by producing reciprocity, or

reciprocal movement of left arm forward and right foot forward simultaneously.

Reciprocity affects postural control by counterbalancing where the body's weight is

situated in space. People without PD tend to walk with their left foot forward and their right arm

swinging simultaneously, or reciprocity. People with PD lack this natural instinct, which

demonstrates why pole walking and treadmill are so valuable to relearning reciprocity. S03's

dyskinesia was dramatically reduced when his body felt balanced with the poles and via external

cueing. A similar experience was created when S05 stepped onto the treadmill. A supported

technique of turning on the treadmill, from forward stepping to side stepping and then return to

forward stepping, assists with postural control in people with PD. S05 experienced rigidity, a

primary symptom of PD; when turning on the treadmill, he "powered up" to ease the direction

Hamilton 19

change. Powering up is a term used at the PWR! Gym to make oneself as tall as possible to

diminish rigidity, and to be ready for the next task instead of being hunched over. When turning

on the moving treadmill, one needs to be able to make the directional change moderately quickly

so his feet do not get caught on one another. Because PD is assymmetrical, or impacts one side

of the body more than the other, directional change on the treadmill works both sides of the

body. Subject 05 had a more difficult time turning to one side, as most people with PD could

attest to. As metronome or verbal cueing assisted Subjects 03 and 04, the external cueing of the

moving treadmill triggered Subject 05 to move bigger (Farley, 2007) and be more deliberate with

the movement.

Deliberate movement presents a challenge to those with PD, as their movments become

smaller as the disease progresses. Looking at the Four Square Step Test (4SST), deliberate

movement is assessed. While the scores are purely quantitative, researchers took note of the

quality of the movement such as whether or not subjects stepped fully over the piping separating

the four boxes. Subject 01 gained awareness of where his body was spatially, or proprioception

(Hackney, 2009), and increased the quality of his movement on the 4SST. Learning how to move

bigger and increasing exercise bouts may have helped Subject 01 to build new pathways in the

brain, and release more dopamine. His quality of life score improved dramatically from the

beginning of the boot camp until the end.

CONCLUSIONS

Task-specific training in a small community setting helps translate into success in the real

world. The subjects who practiced their real world problems in the gym had an easier time

Hamilton 20

improving their symptoms at the conclusion of the week. Whether it was practicing catching

oneself before falling or turning the foot with a "turn signal," each subject improved in at least

one area. External cueing assists in eliciting normal movement such as reciprocity and balanced

postural control. This study supports neuroplasticity-principled task-specific exercise as

treatment for the FOG symptoms of PD.

LIMITATIONS

This series of case studies required subjects to have an adequate level of physical fitness.

Because PD is often misdiagnosed, the level of impairment may be too severe to engage in a

quality PD specific exercise program. All participants for this study were required to be

independent of their carepartner for the duration of the exercise bouts. Moreover, the monetary

requirements for each subject included travel fare, hotel expense, and most meals during the time

of treatment. None of the subjects live in Tucson, AZ year-round which further heightened their

travel costs. Due to the strict criteria and uniqueness of freezing symptoms, a screening process

was utilized to assure all participants experienced similar issues. While the group aspect

enhanced each person's experience (Crizzle, 2006), it also created a limit on the group size as the

space at PWR! Gym could not accommodate more than 3 subject's treatments at one time. The

small sample size reduced the amount of generalizability to PD freezers around the world, but it

allowed more one-on-one time. The short duration of training and the fatigue from such a high

intensity of the study may have affected the change score in some subjects.

Hamilton 21

FUTURE RESEARCH

In future research, the duration of the boot camp may be longer to allow for more

repetition and practice and still provide some rest time-- this may decrease fatigue and improve

performance at post testing. Future studies may also benefit from additional time for the entire

group to interact, instead of just the two groups of 3. Participants reported they would have

enjoyed more time altogether to build support. It may have been beneficial to have spent more

one-on-one time early in the week with each participant to detect unique triggers of freezing

earlier on in the process of treatment to help cater their program towards individual goals. For

the Freezing of Gait Assessment (FOGA), future research may include an additional score of

how the subject sits down at the completion of the assessment. Currently, there are scores for: 1-

standing out of chair, 2- clockwise turn, 3- counterclockwise turn, and 4- walking through

doorway. Postural control impacts how the subject seats himself into the chair, such as leaning

forward or reaching for the chair.

ACKNOWLEDGEMENT

The PWR! Gym advertised and allowed all research to take place in their facility.

Hamilton 22

REFERENCES

1. Ahlskog JE. Does vigorous exercise have a neuroprotective effect in Parkinson disease?

Neurology. 2011;77:288-284.

2. Bloem BR, Hausdorff JM, Visser JE, Giladi N. Falls and Freezing of Gait in Parkinson’s

Disease: A Review of Two Interconnected, Episodic Phenomena. Mov Disorders 2004;

19:871-884.

3. Crizzle AM, Newhouse IJ. Is physical exercise beneficial for persons with Parkinson’s

disease? Clin J Sport Med. 2006;16:422-425.

4. Fahn, S. (2003). Description of Parkinson's disease as a clinical syndrome.Annals of the

New York Academy of Sciences, 991(1), 1-14.

5. Farley, B. (2004). Developing Parkinson’s-specific exercise programs. J Active Aging,

22-28.

6. Farley BG, Koshland GF. Training BIG to move faster: The application of the speed-

amplitude relation as a rehabilitation strategy for people with Parkinson’s disease. Exp

Brain Res 2005;167(3):462-7 (Epub 2005 Nov 11)

7. Farley BG, Fox CM, Ramig LO, McFarland, D. Intensive amplitude-specific therapeutic

approaches for Parkinson disease: Toward a neuroplasticity-principled rehabilitation

model. Top Geriatr Rehabil 2008;24(2):99-114.

8. Hirsch MA, Farley BG. Exercise and Neuroplasticity in Persons Living with Parkinson’s

Disease. European J Phys Rehabil Med 2009;45:215-229.

9. Hallet M. The Intrinsic and Extrinsic Aspects of Freezing of Gait. Mov Disorders 2008;

22:S439-S443.

Hamilton 23

10. Keus SHJ, Bloem BR, Hendricks EJM, Bredero-Cohen AB, Munneke M. Evidence-

based analysis of physical therapy in Parkinson’s disease with recommendations for

practice and research. Mov Disord. 2007;22:451- 460.

11. Morris ME. Movement disorders in people with Parkinson disease: a model for physical

therapy. Phys Ther 2000;80:578 –597.

12. States RA, Spierer DK, CSCS, Salem Y. Long-term Group Exercise for People with

Parkinson’s Disease: A Feasibility Study. JNPT 2011;35:122-128.

References for assessments:

13. Blennerhassett JM, Jayalath VM. The four square step test is a feasible and valid clinical

test of dynamic standing balance for use in ambulant people poststroke. Arch Phys Med

Rehabil 2008;89(11):2156-2161.

14. Chou KL, Amick MM, Brandt J, Camicioli R, Frei K, Gitelman D, Goldman J, Growdon

J, Hurtig HI, Levin B, Litvan I, Marsh L, Simuni T, Troster AI, Uc EY. A Reommended

Scale for Cognitive Screening in Clinical Trials of Parkinson’s Disease. Movement

Disorders, 2010;25(15):2501-2507.

15. Franchignoni F, Velozo C. Use of the Berg Balance Scale in Rehabilitation Evaluation of

Patients with Parkinson’s Disease. Arch Phys Med Rehabil 2005;86:2225-2226.

16. Giladi N, Shabtai H, Simon ES, Biran S, Tal J, Korczyn AD. Construction of freezing of

gait questionnaire for patients with Parkinsonism. Parkinsonism & Related Disorders,

2000;6:165-170.

17. Giladi N, Tal J, Azulay T, Rascol O, Brooks DJ, Malamed E, Oertel W, Poewe WH,

Stocchi F, Tolosa E. Validation of the Freezing of Gait Questionnaire in Patients with

Parkinson’s Disease. Mov Disorders 2009;24:655-661.

Hamilton 24

18. Gill DJ, Freshman A, Blender JA, Ravina B. The Montreal Cognitive Assessment as a

Screening tool for Cognitive Impairment in Parkinson’s Disease. Movement Disorders

2008;23(7):1043-1046.

19. Herman T, Giladi N, Gruendlinger L, Haus- dorff JM. Six weeks of intensive treadmill

training improves gait and quality of life in patients with Parkinson’s disease: a pilot

study. Arch Phys Med Rehabil 2007;88:1154-8.

20. King LA, Priest KC, Salarian A, Pierce D, Horak FB. Comparing the Mini-BESTest with

the Berg Balance Scale to Evaluate Balance Disorders in Parkinson’s Disease. Hindawi

Publishing Corporation 2011.

21. King LA, Horak FB. Delaying Mobility Disability in People with Parkinson Disease

Using a Sensorimotor Agility Exercise Program. Phys Ther. 2009;89:384-393.

22. Leddy AL, Crowner BE, Earhart GM. Utility of the Mini-BESTest, BESTest, and

BESTest sections for balance assessments in individuals with Parkinson disease.J Neurol

Phys Ther 2011;35(2):90-7.

23. Leroi I, Andrews M, McDonald K, Karbishettar V, Elliot R, Byrne EJ, Burns A. Apathy

and Impulse Control Disorders in Parkinson’s Disease: A Direct Comparison.

Parkinsonism and Related Disorders.

24. Lessig S, Nie D, Xu R, Corey-Bloom J. Changes on Brief Cognitive Instruments Over

Time in Parkinson’s Disease. Movement Disorders 2012;27(9):1125-1128.

25. Marinus J, Visser M, Verwey NA, Verhey FRJ, Middelkoop HAM, Stiggelbout AM, van

Hilten JJ. Assessment of cognition in Parkinson’s disease. Neurology 2003;61:1222-

1228.

Hamilton 25

26. Morris S, Morris ME, Iansek R. Reliability of measurements obtained with the timed get

up & go test in people with Parkinson’s disease. Pysical Therapy, 1999;81:810-818.

27. Nimwegen MV, Speelman AD, Rossum EJMH, Overeem S, Deeg DJ, Borm GF, van der

Horse MHL, Bloem BR, Munneke M. Physical inactivity in Parkinson’s disease. J

Neurol. 2011;258:2214-2221.

28. Pang MY, Mak MK. Influence of contraction type, speed, and joint angle on ankle

muscle weakness in Parkinson’s disease: implications for rehabilitation. Arch Phys Med

Rehabil 2012;xx:xxx.

29. Qutubuddin AA, Pegg PO, Cifu DX, Brown R, McNamee S, Carne W. Validating the

Berg Balance Scale for patients with Parkinson’s disease: a key to rehabilitation evalua-

tion. Arch Phys Med Rehabil 2005;86:789-92.

30. Ridgel AL, Vitek JL, Alberts JL. Forced, Not Voluntary, Exercise Improves Motor

Function in Parkinson’s Disease Patients. Neurorehabil Neural Repair. 2009;23:600-608.

31. Schenkman M, Cutson TM, Kuchibhatla M, et al. Reliability of impairment and physical

performance measures for persons with Parkinson's disease. Physical Therapy

1997;77:19-27.

32. Smania N, Corato E, Tinazzi M, Stanzani C, Fiaschi A, Girardi P, Gandolfi M. Effect of

balance Training on Postural Instability in Patients with Idiopathic Parkinson’s Disease.

Neurorehabil Neural Repair. 2010;24:826-834.

33. Snijders AH, Haaxma CA, Hagen YJ, Munneke M, Bloem BR. Freezer or non-freezer:

Clinical assessment of freezing of gait. Parkinsonism and Related Disorders

2012;18:149-154.

Hamilton 26

34. Steffen T.M, Hacker T.A, Mollinger L. Age- and gender-related test performance in

community-dwelling elderly people: six-minute walk test, berg balance scale, timed up &

go test, and gait speeds. Physical Therapy 2002;82(2):128-37.

35. Yogev-Seligmann G, Giladi N, Brozgol M, Hausdorff JM. A training program to improve

gait while dual tasking in patients with Parkinson’s disease: a pilot study. Arch Phys Med

Rehabil 2012;93:176-81.