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Background and Purpose: Few persons with Parkinson disease (PD) appear to engage in moderate-intensity walking associated with disease-modifying health benefits. How much time is spent walking at lower, yet still potentially beneficial, intensities is poorly understood. The purpose of this exploratory, observational study was to describe natural walking intensity in ambulatory persons with PD. Methods: Accelerometer-derived real-world walking data were collected for more than 7 days at baseline from 82 participants enrolled in a PD clinical trial. Walking intensity was defined according to the number of steps in each active minute (1-19, 20-39, 40-59, 60-79, 80-99, or ≥100 steps). Daily minutes of walking and duration of the longest sustained walking bout were calculated at each intensity. Number of sustained 10 to 19, 20 to 29, and 30-minute bouts and greater at any intensity also were calculated. Values were analyzed in the context of physical activity guidelines. Results: Most daily walking occurred at lower intensities (157.3 ± 58.1 min of 1-19 steps; 81.3 ± 32.6 min of 20-39 steps; 38.2 ± 21.3 min of 40-59 steps; 15.1 ± 11.5 min of 60-79 steps; 7.4 ± 7.0 min of 80-99 steps; 7.3 ± 9.6 min of ≥100 steps). The longest daily sustained walking bout occurred at the lowest intensity level (15.9 ± 5.2 min of 1-19 steps). Few bouts lasting 20 minutes and greater occurred at any intensity. Discussion and Conclusions: Despite relatively high daily step counts, participants tended to walk at remarkably low intensity, in bouts of generally short duration, with relatively few instances of sustained walking. The findings reinforced the need for health promotion interventions designed specifically to increase walking intensity. Video Abstract available for more insight from authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A426). [ABSTRACT FROM AUTHOR]

Background and Purpose: We addressed questions about the potential discrepancy between improvements in activity capacity and improvements in activity performance in daily life. We asked whether this discrepancy is: Common in routine, outpatient care, or an artifact of intervention studies? Unique to upper limb (UL) rehabilitation, or is it seen in walking rehabilitation too? Only seen in persons with stroke, or a broader neurorehabilitation problem? Methods: A longitudinal, observational cohort of 156 participants with stroke or Parkinson disease (PD) receiving outpatient rehabilitation at 5 clinics was assessed around admission and monthly during their episode of care. Individual, longitudinal capacity (Action Research Arm Test or walking speed) and performance (wearable sensor measurements of use ratio or steps/day) data were modeled to extract predicted change scores. Simulation methods were used to determine whether an individual's change was greater than 1 standard error. Participants were classified into categories based on whether or not they improved in capacity (C+ or C−) and/or performance (P+ or P−). Results: A majority (59%) were classified as C+P−. Smaller portions of the sample were classified as C+P+ (20%) and C−P− (21%), with 1 participant (<1%) classified as C−P+. The proportions in the C+P− category were significantly larger in the stroke (χ2 = 48.7, P < 0.0001) and PD (χ2 = 24.3, P < 0.0001) walking subgroups than in the stroke UL subgroup. Discussion and Conclusions: The discrepancy between improvements in capacity and performance is a problem in routine, outpatient neurorehabilitation. If performance information were available, patients and clinicians could act to address it. Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A396). [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background and Purpose: Walking activity in persons with Parkinson disease (PD) is important for preventing functional decline. The contribution of walking activity to home and community mobility in PD is poorly understood. Methods: Cross-sectional baseline data (N = 69) were analyzed from a randomized controlled PD trial. The Life-Space Assessment (LSA) quantified the extent, frequency, and independence across 5 expanding levels of home and community mobility, producing individual subscores and a total score. Two additional summed scores were used to represent mobility within (Levels 1-3) and beyond (Levels 4-5) neighborhood limits. An accelerometer measured walking activity for 7 days. Regression and correlation analyses evaluated relationships between daily steps and mobility scores. Mann-Whitney U tests secondarily compared differences in mobility scores between the active and sedentary groups. Results: Walking activity contributed significantly to the summed Level 1-3 score (β = 0.001, P = 0.004) but not to the summed Level 4-5 (β = 0.001, P = 0.33) or total (β = 0.002, P = 0.07) scores. Walking activity was significantly related to Level 1 (ρ = 0.336, P = 0.005), Level 2 (ρ = 0.307, P = 0.010), and Level 3 (ρ = 0.314, P = 0.009) subscores. Only the summed Level 1-3 score (P = 0.030) was significantly different between the active and sedentary groups. Discussion and Conclusions: Persons with PD who demonstrated greater mobility beyond the neighborhood were not necessarily more active; walking activity contributed more so to home and neighborhood mobility. Compared with LSA total score, the Level 1-3 summed score may be a more useful participation-level measure for assessing the impact of changes in walking activity. Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A349) [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background and Purpose: Improvement of walking performance is a primary goal for individuals poststroke or with Parkinson disease (PD) who receive physical therapy. More data about day-to-day variability of walking performance are critical for determining if changes in performance have occurred. Methods: Baseline assessments were utilized from an ongoing, observational, prospective cohort study including 84 individuals poststroke (n = 37) or with PD (n = 47) receiving outpatient physical therapy services to improve mobility. Participants wore step activity monitors for up to 7 days to measure walking performance (steps per day, walking duration, maximum 30-minute output, and peak activity index) in daily life. Correlation analyses evaluated relationships between both capacity and performance measures as well as the relationships between mean performance variables and day-to-day variability. Regression analyses explored factors that contribute to variability in day-to-day performance variables. Results: Mean steps per day for participants poststroke (5376 ± 2804) and with PD (8149 ± 4490) were consistent with previously reported cohorts. Greater amounts of walking were related to more day-to-day variability, with moderate correlations found between the mean and day-to-day variability of each performance measure, regardless of medical diagnosis or walking speed. Day-to-day variability is large (upwards of 50% of the mean), with the amount of walking performance serving as the primary predictor of day-to-day variability in walking performance. Discussion and Conclusions: The results of this study elucidate the factors that are related to and predict day-to-day variability of performance. Walking performance metrics should be evaluated over multiple days and greater variability should be anticipated with greater amounts of performance. Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A319). [ABSTRACT FROM AUTHOR]

Individuals with Parkinson's disease (PD) experience postural instability, low-back pain (LBP), and anxiety. These symptoms increase the risk of falls and decrease quality of life. Research shows yoga improves balance and decreases LBP and anxiety in healthy adults, but its effects in PD are poorly understood. All participants were part of a larger intervention study. Participants received pretest and posttest evaluations, including the Balance Evaluation Systems Test (BESTest), Beck Anxiety Inventory (BAI), and Revised Oswestry Disability Index (ROSW). Total scores for each measure, as well as individual balance system section scores from the BESTest (biomechanical constraints, stability limits/verticality, transitions/anticipatory, reactive, sensory orientation, and stability in gait) were compared within groups pre- to posttest. Participants in the yoga group (n = 13) completed a twice-weekly 12-week yoga interve n t i o n , whereas controls (n = 13) continued their usual routines for 12 weeks. Both the yoga (Z = −3.20, p = 0.001) and control (Z = −2.10, p = 0.040) groups improved on the BESTest total score. The control group showed no changes in individual balance systems, whereas the yoga group improved in stability limits/verticality (Z = −2.3, p = 0.020), transitions/ anticipatory (Z = −2.50, p = 0.010), reactive (Z = −2.70, p = 0.008), and sensory orientation (Z = −2.30, p = 0.020). ROSW decreased in the yoga group only (Z = −2.10, p = 0.030). BAI did not change in either group. Yoga is a nonpharmacological intervention that can improve balance and LBP in people with PD. This study demonstrated that yoga is feasible for people with PD, and participants reported high levels of enjoyment and intent to practice yoga after the study. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background and Purpose: Previously, we showed that internal cues (such as singing) produce similar motor benefits as external cues (such as listening to music) for people with Parkinson disease (PD). This study takes that research further by exploring how singing—either aloud or mentally—at different tempos can ameliorate gait, and it offers insight into how internal cueing techniques may enhance motor performance for older adults and people with PD. Methods: Sixty participants aged 50 years and older (30 female) were recruited; 30 had PD and 30 were healthy age-matched controls. Participants completed walking trials involving internal and external cueing techniques at 90%, 100%, and 110% of preferred cadence. The effects of different cue types and rates were assessed in a repeated-measures cross-sectional study by comparing gait characteristics (velocity, cadence, stride length) and variabilities (coefficients of variation of stride length, stride time, single support time). Results: All participants modified their cadence and stride length during cued conditions, resulting in changes in gait velocity closely reflecting expected changes based upon cue rate. External cues resulted in increased gait variability, whereas internal cues decreased gait variability relative to uncued walking. Variability decreases were more substantial during mental singing at tempos at or above preferred cadence. Discussion and Conclusions: Matching movement to one's own voice improves gait characteristics while reducing gait variability for older adults and people with PD. Optimizing the use of internal cues to facilitate movement is an important step toward more effectively meeting the needs of people with gait disorders related to aging or neurological disease. Video Abstract available for more insights from authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A286) [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background and Purpose: Impaired gait, balance, and motor function are common in Parkinson disease (PD) and may lead to falls and injuries. Different forms of exercise improve motor function in persons with PD, but determining which form of exercise is most effective requires a direct comparison of various approaches. In this prospective, controlled trial, we evaluated the impact of tango, treadmill walking, and stretching on gait, balance, motor function, and quality of life. We hypothesized tango and treadmill would improve forward walking and motor symptom severity, and tango would also improve backward walking, balance, and quality of life. Methods: Ninety-six participants (age: 67.2 ± 8.9 years, 42% female) with mild to moderate idiopathic PD were serially assigned to tango, treadmill walking, or stretching (active control group) and attended 1-hour classes twice weekly for 12 weeks. Assessments occurred OFF anti-PD medication before and after the intervention and at follow-up 12 weeks after the intervention. Results: Forward velocity and backward velocity improved for the treadmill group from baseline to posttest and improvements persisted at follow-up. Backward velocity and motor functioning improved for the stretching group from baseline to posttest, but results did not persist at follow-up. There were no significant changes in the tango group across time points. Discussion and Conclusions: Contrary to our hypotheses, only treadmill improved forward walking, while backward walking improved with treadmill and stretching. Future research should examine combinations of exercises with a focus on optimizing dosing and examining whether specific characteristics of people with PD correlate with different types of exercise. Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A237). [ABSTRACT FROM AUTHOR]

Background and Purpose: The Maximum Step Length Test (MSLT), a measure of one's capacity to produce a large step, has been studied in older adults, but not in people with Parkinson disease (PD). We characterized performance and construct validity of the MSLT in PD. Methods: Forty participants (mean age: 65.12 ± 8.20 years; 45% female) with idiopathic PD completed the MSLT while "OFF" and "ON" anti-PD medication. Construct validity was investigated by examining relationships between MSLT and measures of motor performance. The following measures were collected: Mini-Balance Evaluation Systems Test (Mini-BESTest), Activities-specific Balance Confidence (ABC) scale, gait velocity, 6-minute walk test (6MWT), Movement Disorder Society-Unified Parkinson Disease Rating Scale subsection III (MDS-UPDRS III), and Timed Up and Go (TUG) test. A repeated-measures analysis of variance tested for main effects of medication and stepping direction and the interaction between the 2. Pearson or Spearman correlations were used to assess the relationships between MSLT and motor performance measures (α = 0.05). Results: Regardless of medication status, participants stepped further in the forward direction compared with the backward and lateral directions (P < 0.001). Participants increased MSLT performance when ON-medication compared with OFF-medication (P = 0.004). Regardless of medication status, MSLT was moderately to strongly related to Mini-BESTest, TUG, and 6MWT. Discussion and Conclusions: People with PD stepped furthest in the forward direction when performing the MSLT. Increased MSLT performance was observed in the ON-medication state compared with OFF-medication; however, the small increase may not be clinically meaningful. Given the relationships between the MSLT and the Mini-BESTest, 6MWT, and TUG, MSLT performance appears to be associated with balance and gait hypokinesia in people with PD. [ABSTRACT FROM AUTHOR]

The article reports a study which was conducted to examine the reliability of Four Square Step Test (4SST) in people with Parkinson disease (PD) and its ability to discriminate between freezers and nonfreezers, between fallers and nonfallers. The result revealed that 4SST is able to distinguish between off and on anti-medication states, but not between freezers and nonfreezers and between fallers and nonfallers.

Abstract: Objective: To determine the effects of a 12-month community-based tango dance program on activity participation among individuals with Parkinson''s disease (PD). Design: Randomized controlled trial with assessment at baseline, 3, 6, and 12 months. Setting: Intervention was administered in the community; assessments were completed in a university laboratory. Participants: Volunteers with PD (n=62) enrolled in the study and were randomized to a treatment group; 10 participants did not receive the allocated intervention, and therefore the final analyzed sample included 52 participants. Interventions: Participants were randomly assigned to the tango group, which involved 12 months of twice-weekly Argentine tango dance classes, or to the no intervention control group (n=26 per group). Main Outcome Measure: Current, new, and retained participation in instrumental, leisure, and social activities, as measured by the Activity Card Sort (with the dance activity removed). Results: Total current participation in the tango group was higher at 3, 6, and 12 months compared with baseline (Ps≤.008), while the control group did not change (Ps≥.11). Total activity retention (since onset of PD) in the tango group increased from 77% to 90% (P=.006) over the course of the study, whereas the control group remained around 80% (P=.60). These patterns were similar in the separate activity domains. The tango group gained a significant number of new social activities (P=.003), but the control group did not (P=.71). Conclusions: Individuals with PD who participated in a community-based Argentine tango class reported increased participation in complex daily activities, recovery of activities lost since the onset of PD, and engagement in new activities. Incorporating dance into the clinical management of PD may benefit participation and subsequently quality of life for this population. [Copyright &y& Elsevier]

The article discusses a study conducted to examine natural evolution of physical activity-related participation restrictions as seen in patients with Parkinson's Disease (PD). The study demonstrated significant improvement in the behavior due to rehabilitation and medical interventions. It concluded that continuous monitoring of ambulatory activity may be an important means of quantifying declining behavior resulting from rehabilitation. Limitations of the study are also discussed.

Abstract: Duncan RP, Leddy AL, Earhart GM. Five times sit-to-stand test performance in Parkinson''s disease. Objectives: To (1) determine intrarater and test-retest reliability of the Five times sit-to-stand test (FTSTS) in Parkinson''s disease (PD), (2) characterize FTSTS performance in PD at different disease stages, (3) determine predictors of FTSTS performance in PD, and (4) determine the utility of the FTSTS for discriminating between fallers and nonfallers with PD, identifying an appropriate cutoff score to delineate between these groups. Design: Measurement study of community-dwelling individuals with idiopathic PD. Setting: A medical school laboratory. Participants: Participants (N=82) were recruited via population-based sampling. The final sample included 80 participants. Two were excluded because of exclusion criteria and an unrelated illness, respectively. Interventions: Not applicable. Main Outcome Measures: FTSTS time (seconds) was the primary outcome measure. Secondary outcome measures included the Mini-Balance Evaluation Systems Test (Mini-BEST), Maximal Voluntary Isometric Contraction–Quadriceps, 9-Hole Peg Test (9HPT), 6-minute walk, Freezing of Gait Questionnaire, Activities-Specific Balance Confidence Scale, Physical Activity Scale for the Elderly, Parkinson''s Disease Questionnaire-39, and Movement Disorders Society–Unified Parkinson''s Disease Rating Scale. Results: Interrater and test-retest reliability for the FTSTS were high (intraclass correlation coefficients: .99 and .76, respectively). Mean FTSTS performance was 20.25±14.12 seconds. All mobility measures were significantly correlated with FTSTS (P<.01). The Mini-BEST and 9HPT together explained 53% of the variance in FTSTS. Receiver operating characteristic analysis determined a cutoff of 16.0 seconds (sensitivity, .75; specificity, .68) for discriminating between fallers and nonfallers, with an area under the curve of .77. Conclusions: The FTSTS is a quick, easily administered measure that is useful for gross determination of fall risk in individuals with PD. [Copyright &y& Elsevier]

Summary: Objectives: This study explored the feasibility and possible benefits of contact improvisation (CI) as an exercise intervention for individuals with PD. Design: This was an uncontrolled pilot study. Intervention: Eleven people with PD (H&Y=2.4±0.4) participated in a workshop of 10 1.5-h CI classes over 2 weeks, dancing with previously trained student CI dancers. Main outcome measures: Measures of disease severity, balance, functional mobility, and gait were compared 1 week before and after the workshop. Results: Participants demonstrated improvements on the Unified Parkinson Disease Rating Scale—Motor Subsection and Berg balance scores, along with increased swing and decreased stance percentages during walking. Backward step length also increased. Participants expressed a high level of enjoyment and interest in taking future CI classes. Conclusions: This pilot study supports the feasibility of CI as an intervention to address mobility limitations associated with PD. [Copyright &y& Elsevier]

Background and Purpose: People with Parkinson's disease often have difficulty executing turns. To date, most studies of turning have examined subjects ON their anti-Parkinson medications. No studies have examined what specific aspects of turning are modified or remain unchanged when medication is administered. The purpose of this study was to determine how anti-Parkinson medications affect temporal and spatial features of turning performance in individuals with Parkinson's disease. Methods: We examined turning kinematics in 10 people with Parkinson's disease who were assessed both OFF and ON medication. For both conditions, participants were evaluated with the Unified Parkinson's Disease Rating Scale motor subscale, rated how well their medication was working on a visual analog scale, and performed straight-line walking and 180-degree in-place turns. We determined the average walking velocity, time and number of steps to execute turns, sequence of yaw rotation onsets of the head, trunk, and pelvis during turns, and amplitudes of yaw rotation of the head, trunk, and pelvis during turns. Results: Medication significantly improved the Unified Parkinson's Disease Rating Scale scores (P = 0.02), visual analog scale ratings (P = 0.03), and walking velocity (P = 0.02). Although improvements in turning were not statistically significant, medication did reduce the time and number of steps required to turn, slightly increased the amplitudes of yaw rotation of the various segments, and increased the rotation of the head relative to the other segments. Medication did not improve the timing of segment rotations, which showed en bloc turn initiation in both the OFF and ON medication conditions. Discussion and Conclusion: These results suggest that only certain aspects of turning may be responsive to anti-Parkinson medications. As such, additional rehabilitative approaches to address turning are needed because turning may not be effectively addressed by pharmacologic approaches. These results should be interpreted cautiously given the small sample size. [ABSTRACT FROM AUTHOR]

Summary: Objective: The goal of this pilot study was to determine the effects of short duration, intensive tango lessons on functional mobility in people with Parkinson disease. Design: This study employed a within-subject, prospective, repeated measures design. Subjects/patients: Fourteen people with idiopathic Parkinson disease participated. Setting: All balance and gait assessments were performed in a laboratory, but dance classes took place in a large, open classroom. Interventions: Participants completed ten 1.5-h long Argentine tango dance lessons within 2 weeks. Their balance, gait and mobility were assessed before and after the training sessions. Main outcome measures: Measures included the Berg Balance Scale, the Unified Parkinson Disease Rating Scale, gait velocity, functional ambulation profile, step length, stance and single support percent of gait, Timed Up and Go, and the 6min walk. Results: Participants significantly improved on the Berg Balance Scale (effect size (ES)=0.83, p =0.021), Unified Parkinson Disease Rating Scale Motor Subscale III (ES=−0.64, p =0.029), and percent of time spent in stance during forward walking (ES=0.97, p =0.015). Non-significant improvements were noted on the Timed Up and Go (ES=−0.38, p =0.220) and 6min walk (ES=0.35, p =0.170). Conclusions: Frequent social dance lessons completed within a short time period appear to be appropriate and effective for these individuals with mild-moderately severe Parkinson disease. [Copyright &y& Elsevier]

Abstract: Falvo MJ, Earhart GM. Six-minute walk distance in persons with Parkinson disease: a hierarchical regression model. Objectives: To determine the six-minute walk distance (6MWD) in subjects with Parkinson disease (PD) and to determine the impairments that contribute to walking capacity. Design: Descriptive cross-sectional study of subjects with PD. Setting: University laboratory. Participants: Subjects with PD (N=75; 65.0±9.5y) of mild to moderate severity, as defined by an average Hoehn and Yahr (HY) rating of 2.0±0.4 and Unified Parkinson Disease Rating Scale (UPDRS) motor score of 27±8.9, were tested on medication. Interventions: Not applicable. Main Outcome Measures: Subjects were administered the motor subsection of the UPDRS and completed the following tests: Berg Balance Scale (BBS), Timed Up & Go (TUG), and six-minute walk test. In addition, they also provided self-reports of freezing of gait and number of falls in the past 6 months. Results: The average 6MWD was 391.6±99.9m. All of the aforementioned tests, with the exception of fall number (P=.07), correlated significantly with 6MWD (r range, −.64 to .55). By using a hierarchical regression model, we entered age, HY, and UPDRS motor score into the first block (ie, set of independent variables) to represent parkinsonian characteristics, which explained a significant amount of variability in 6MWD (R 2=.196, P<.001). The second block entered (eg, functional measures scores, self-reports) explained a significant amount of additional variability (R 2 change=.355, P<.001). The TUG, BBS, and number of falls contributed independently in the presence of all independent variables. Conclusions: The 6MWD in subjects with PD is explained in part by disease-specific characteristics and perhaps to a greater extent by impaired balance and predisposition to falling. Training targeted at improving balance and reducing falling risk factors may increase 6MWD (ie, walking capacity) in subjects with PD. [Copyright &y& Elsevier]

Recent research has shown that dance, specifically tango, may be an appropriate and effective strategy for ameliorating functional mobility deficits in people who frail and elderly. Individuals with Parkinson's disease (PD) experience declines in functional mobility that may be even more pronounced than those experienced by frail elderly individuals without PD. The purpose of this study was to compare the effects of two movement programs: tango classes or exercise classes. Nineteen subjects with PD were randomly assigned to a tango group or a group exercise class representative of the current classes offered in our geographical area for individuals with PD. Subjects completed a total of 20 tango or exercise classes and were evaluated the week before and the week following the intervention. Both groups showed significant improvements in overall Unified Parkinson's Disease Rating Scale (UP-DRS) score and nonsignificant improvements in self-reported Freezing of Gait. In addition, the tango group showed significant improvements on the Berg Balance Scale. The exercise group did not improve on this measure. Finally, the tango group showed a trend toward improvement on the Timed Up and Go test that was not observed in the exercise group. Future studies with a larger sample are needed to confirm and extend our observation that tango may be an effective intervention to target functional mobility deficits in individuals with PD. [ABSTRACT FROM AUTHOR]