Freezing of Gait in Parkinson

1.
Freezing of gait in Parkinson's disease reflects a sudden derangement of locomotor

network dynamics.
Freezing of gait is a disabling symptom of Parkinson's disease that causes a paroxysmal

inability to generate effective stepping. The underlying pathophysiology has recently
migrated towards a dysfunctional supraspinal locomotor network, but the actual network
derangements during ongoing gait freezing are unknown. We investigated the
communication between the cortex and the subthalamic nucleus, two main nodes of the
locomotor network, in seven freely-moving subjects with Parkinson's disease with a novel
deep brain stimulation device, which allows on-demand recording of subthalamic neural
activity from the chronically-implanted electrodes months after the surgical procedure.
Multisite neurophysiological recordings during (effective) walking and ongoing gait freezing
were combined with kinematic measurements and individual molecular brain imaging
studies. Patients walked in a supervised environment closely resembling everyday life
challenges. We found that during (effective) walking, the cortex and subthalamic nucleus
were synchronized in a low frequency band (4-13 Hz). In contrast, gait freezing was
characterized in every patient by low frequency cortical-subthalamic decoupling in the
hemisphere with less striatal dopaminergic innervation. Of relevance, this decoupling was
already evident at the transition from normal (effective) walking into gait freezing, was
maintained during the freezing episode, and resolved with recovery of the effective walking
pattern. This is the first evidence for a decoding of the networked processing of locomotion
in Parkinson's disease and suggests that freezing of gait is a 'circuitopathy' related to a
dysfunctional cortical-subcortical communication. A successful therapeutic approach for gait
freezing in Parkinson's disease should aim at directly targeting derangements of neural
network dynamics.
https://www.ncbi.nlm.nih.gov/pubmed/31505548/
2. Effects of Preventive Treadmill Exercise on the Recovery of Metabolic and

Mitochondrial Factors in the 6-Hydroxydopamine Rat Model of Parkinson's Disease.
Metabolic and mitochondrial dysfunction has been implicated in Parkinson's disease, while
exercise can induce essential pathways of mitochondrial biogenesis. Here, we tested whether
long-term preventive treadmill training (16 weeks, 21 m/min, and 0° inclinations for 50 min/d, 5
d/week) effects the mitochondrial and neurodegeneration markers, in the striatum of rats in the 6-
hydroxydopamine (6-OHDA) model of Parkinson's disease. Following 16 weeks of exercise or
no exercise period (n = 16 rats per group), the animals were divided into four experimental
groups (n = 8 per group): (1) no exercise and saline (SED), (2) exercise and saline (EX), (3) no
exercise and 6-OHDA (SED + 6-OHDA), and (4) exercise and 6-OHDA (EX + 6-OHDA). For
the model, 8 μg of 6-OHDA (2 μg/μL prepared in a solution of 0.2% ascorbic acid and 0.9%
saline) was injected into the right medial forebrain bundle. Exposure to 6-OHDA resulted in a
significant reduction (P < 0.05) of mitochondrial factors AMP-activated protein kinase,
peroxisome proliferator-activated receptor gamma coactivator-1 alpha, and tyrosine hydroxylase,
and increased expression of silent information regulator T1, mitochondrial transcription factor A,
and p53 in the SED + 6-OHDA group relative to SED group. By contrast, gene and protein
expressions upon exercise were higher and p53 protein level was lower in the EX + 6-OHDA
group compared with SED + 6-OHDA. Further, exercise reduced the extent of weight loss
associated with the 6-OHDA injection. In conclusion, exercise might be used to reduce
mitochondrial disorders in Parkinson's disease.
3. Feasibility of home exercises to enhance the benefits of tango dancing in people with
Parkinson's disease.
BACKGROUND: A style of dance called tango translates clinical practice into a new philosophy
and rehabilitative approach for individuals with Parkinson's disease (PD). The style of dance
mixes music, self-generated and external cued strategies and social and emotional recovery. In
recent years, there has been an increase in the number of studies reporting health benefits for
people diagnosed with PD who dance tango. However, there are some organisational limitations
to people participating in dance classes, including having trained Tango teachers, an appropriate
space for dancing, and schedule that allows for participants with motor inabilities.
METHODS: This pilot study involved the observation of PD patients who completed four days
of home exercise plus a tango dance lesson each week for five weeks.
RESULTS: Ten PD patients improved their quality of life, their motor score on the Unified
Parkinson's Disease Rating Scale and their kinematic performances.
CONCLUSIONS: We propose a protocol of exercises that has been derived from the tango
dance and that can be performed in a patient's home.
4. Hemodynamic responses to an exercise stress test in Parkinson's disease patients without

orthostatic hypotension.
The presence of postganglionic sympathetic denervation is well established in Parkinson's

disease (PD). Denervation at cardiac and blood vessel sites may lead to abnormal cardiovascular
and hemodynamic responses to exercise. The aim of the present investigation was to examine
how heart rate (HR) and hemodynamics are affected by an exercise test in PD patients without
orthostatic hypotension. Thirty individuals without orthostatic hypotension, 14 individuals with
PD, and 16 age-matched healthy controls performed an exercise test on a cycle ergometer. Heart
rate, blood pressure, and other hemodynamic variables were measured in a fasted state during
supine rest, active standing, exercise, and supine recovery. Peak HR and percent of age-predicted
maximum HR (HRmax) achieved were significantly blunted in PD (p < 0.05, p < 0.01). HR
remained significantly elevated in PD during recovery compared with controls (p = 0.03, p <
0.05). Systolic, diastolic and mean arterial pressures were significantly lower at multiple time-
points during active standing in PD compared with controls. Systemic vascular resistance index
(SVRI) decreased significantly at the onset of exercise in PD, and remained significantly lower
during exercise and the first minute of supine recovery. End diastolic volume index (EDVI) was
significantly lower in PD during supine rest and recovery. Our results indicate for the first time
that normal hemodynamics are disrupted during orthostatic stress and exercise in PD. Despite
significant differences in EDVI at rest and during recovery, and SVRI during exercise, cardiac
index was unaffected. Our finding of significantly blunted HRmax and HR recovery in PD
patients has substantial implications for exercise prescription and recovery guidelines.
5. Whole body vibration and treadmill training in Parkinson's disease rehabilitation: effects
on energy cost and recovery phases.
BACKGROUND: Although physical treatment is recognized as being beneficial for patients

with Parkinson's disease (PD), there is scant literature on the type of rehabilitation program
most useful for patients with PD. The aim of the present study was to investigate the effects
of two different training protocols (aerobic treadmill training, AER and whole body vibration
training, WBVT) on energy cost and adaptations after exercise and recovery phases, by
means of the oxygen consumption measurement and the assay of metabolic biochemical
substrates.
METHODS: Twenty male patients with idiopathic Parkinson's disease, aged 51-66 years,
were enrolled. Patients were randomly assigned to the training groups. The total work time
was 20 min per group for 4 weeks, four times a week. In both groups, training intensity was
monitored by the ratings of perceived exertion (RPE). Workload was gradually increased
until patients worked up to the exertion level of 13 to 15 on the 20-point Borg scale RPE.
The outcome measures were oxygen consumption, free fatty acid (FFA), and amino acid
(AA) levels.
RESULTS: The oxygen consumption during exercises does not show significant differences
between the two training groups. Instead, only in the AER group, excess post-exercise
oxygen consumption measurements increased significantly (p < 0.01) as well as FFA
availability (p < 0.01).
CONCLUSION: The WBVT does not appear to require a long time of recovery and leads to
less feeling of fatigue, whereas AER needs an appropriate recovery time after the training
session.
6. Characteristics and prognostic factors of Parkinson's disease patients with abnormal
postures subjected to subthalamic nucleus deep brain stimulation.
OBJECTIVE: In Parkinson's disease (PD), abnormal postures are often accompanied, which
interfere with rehabilitation and subsequent functional recovery. This study investigated the
relationship between clinical characteristics and improvement in abnormal postures of PD
patients who received subthalamic nucleus deep brain stimulation (STN-DBS).
METHODS: Seventy-four PD patients were included in this study. Clinical data were analyzed
using the patients' functional status at pre- and post-STN-DBS, including anteflexion vs. non-
anteflexion, scoliosis vs. non-scoliosis, improved anteflexion vs. non-improved anteflexion, and
improved scoliosis vs. non-improved scoliosis.
RESULTS: In patients with anteflexion, UPDRS III motor score at off medication was worse
than that of patients with non-anteflexion. Patients with scoliosis presented with more comorbid
spinal deformity and longer disease duration than those without scoliosis. Cobb angle of patients
with asymmetrical psoas major and erector spinal muscles was more than that of patients without
the asymmetry. Patients with improved anteflexion after STN-DBS had thicker abdominal
oblique muscle and transverse abdominal muscle than those of patients without improved
anteflexion. Patients with improved scoliosis were significantly younger at PD onset than those
without improvement.
CONCLUSIONS: There were only a few prognostic factors recognized in patients with
improved postures. The thick abdominal muscle for anteflexion and younger PD onset for
scoliosis were significant factors for improvement by STN-DBS. Rehabilitation designed to
maintain muscle for correct postures may contribute to the amelioration of abnormal postures by
STN-DBS, although multicenter trials are needed.
7. Is the aquatic thermal environment a suitable place for providing rehabilitative treatment
for person with Parkinson's disease? A retrospective study.
Many authors showed that aquatic physiotherapy could improve quality of life and reduce
postural instability and risk of falling in elderly subjects. The aim of this research was to explore
if the thermal aquatic environment is a suitable place for rehabilitative training in person with
Parkinson disease (PwP) with results comparable to the standard physiotherapy. A retrospective
study was conducted on a database of 14 persons with Parkinson who were admitted to a thermal
aquatic rehabilitation to undergo treatments made to improve gait and balance impairments. The
rehabilitation training consisted of 45-min sessions conducted twice a week, on non-consecutive
days, over 4 weeks of functional re-education and kinesitherapy in the thermal pool. Educational
and prevention instructions were also given to the patients during each session. Additionally,
nutrition (diet), health education, and cognitive behavioral advice were given to our patients by
therapists. The clinical characteristics of the sample were age 66 ± 9, disease duration 7 ± 5, and
Hoehn and Yahr 1.5 ± 0.5. The statistical analysis showed a statistically significant improvement
for the UPDRS p = 0.0005, for The Berg Balance Scale p = 0.0078, for the PDQ8 p = 0.0039,
Tinetti p = 0.0068, and for Mini BESTest p = 0.0002. Our data suggest that this intervention
could become a useful strategy in the rehabilitation program of PwP. The simplicity of treatment
and the lack of side effects endorse the use of thermal aquatic environment for the gait and
balance recovery in PwP.
8. The use of commercially available games for a combined physical and cognitive
challenge during exercise for individuals with Parkinson's disease - a case series report.
Complexity of an animal's environment has been shown to affect structural and functional
changes in the brain. Evidence from animal models of Parkinson's disease (PD) suggests that
exercising in an enriched environment may protect against the onset of Parkinsonian symptoms
in rats that are exposed to 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine. The variety of activities
and visual interfaces that can be created using commercially available gaming devices provide
cognitively stimulating as well as physically challenging environments for exercise. This case
series will: 1) elaborate on the rationale behind selection of specific games to target common
deficits seen in PD; and 2) present preliminary results on clinical outcomes from three pilot
participants who each completed six sessions of exercise. All three participants had mild to
moderate PD. They were functionally independent individuals leading an active lifestyle.
Participants were tested on the outcome measures before and after the six exercise sessions. On
average, participants showed a 33.8% (22.8) improvement in functional reach test, 12.7% (35.0)
improvement in single limb stance (SLS) time-right leg, 55.2% (33.9) improvement in SLS time-
left leg, 11.9% (7.3) improvement in 6-min walk test, 2% (6.8) improvement in self-selected gait
speed (GS), and 8.0% (5.8) improvement in fastest possible GS. Further investigation is
warranted to study if these effects can be replicated over a longer exercise intervention and in a
larger group, and if these effects are maintained at follow-up testing after the enriched exercise
intervention is discontinued.
9. Aerobic rehabilitation program for improving muscle function in Parkinson's disease.
BACKGROUND: Parkinson's Disease (PD) is characterized by progressive and disabling

symptoms. An impaired oxidative metabolism efficiency was supposed to be involved in the
systemic impairment. Rehabilitative treatment represents a valid tool in promoting skeletal
muscle's adaptations, even if no solid studies on muscle metabolic features are still available.
OBJECTIVE: To evaluate the efficiency of skeletal muscle oxidative metabolism in PD patients
in comparison with age-matched controls and test the role of an intensive aerobic treatment on
muscle oxidative metabolism and its clinical effects.
METHODS: 60 PD patients and 32 age-matched healthy controls participated. Haematic lactate

values were detected during and after a submaximal incremental exercise on treadmill. The
number of steps completed during the exercise was recorded. From these patients 10 underwent
to an intensive aerobic treatment on treadmill (4 sessions/week for 4 weeks). Haematic lactate
values and functional scales were recorded before (T0) and after (T1) treatment.
RESULTS: At rest no significant difference in hematic lactate values between PD and control
subjects was found. Lactate blood levels were significantly higher (p < 0,001) after the aerobic
exercise test in PD patients compared to controls. These values remained higher at any time
during recovery period (p < 0,001). No significant relationship between lactate values and the
number of completed steps was found. After the rehabilitation treatment haematic value of
lactate showed a significant reduction (p < 0,05) at 0, 5 and 10 minutes of recovery period with a
normalization of value at 30'. All functional scales showed an improvement trend at T1, in
particular Berg Balance Scale and 6 Meter Walking Test showed a significant reduction
(p < 0,001 and p < 0,05 respectively).
CONCLUSION: Our data clearly show an impaired muscle oxidative efficiency in PD subjects.
The intensive rehabilitation program on treadmill showed a beneficial effect on muscle oxidative
metabolism, endurance and balance, confirming the focal role of rehabilitation in PD patients.
10. Effects of a low-resistance, interval bicycling intervention in Parkinson's Disease.
Previous studies have shown that people with Parkinson's disease (PD) benefit from a variety of
exercise modalities with respect to symptom management and function. Among the possible
exercise modalities, speedwork has been identified as a promising strategy, with direct
implications for the rate and amplitude of nervous system involvement. Considering that
previous speed-based exercise for PD has often been equipment, personnel and/or facility
dependent, and often time intensive, our purpose was to develop a population-specific exercise
program that could be self-administered with equipment that is readily found in fitness centers or
perhaps the home. Fourteen individuals with PD (Hoehn-Yahr (H-Y) stage of 3.0 or less)
participated in twelve 30-min sessions of low-resistance interval training on a stationary
recumbent bicycle. Motor examination section of the Unified Parkinson's Disease Rating Scale
(UPDRS), 10-meter walk (10mW), timed-up-and-go (TUG), functional reach, four-square step
test (4SST), nine-hole peg test (9HPT) and simple reaction time scores all exhibited significant
improvements (p < 0.05).
These results add further support to the practice of speedwork for people with PD and outline a
population-amenable program with high feasibility.
11. Mechanical Energy Recovery during Walking in Patients with Parkinson Disease.
The mechanisms of mechanical energy recovery during gait have been thoroughly investigated in
healthy subjects, but never described in patients with Parkinson disease (PD). The aim of this
study was to investigate whether such mechanisms are preserved in PD patients despite an
altered pattern of locomotion. We consecutively enrolled 23 PD patients (mean age 64±9 years)
with bilateral symptoms (H&Y ≥II) if able to walk unassisted in medication-off condition
(overnight suspension of all dopaminergic drugs). Ten healthy subjects (mean age 62±3 years)
walked both at their 'preferred' and 'slow' speeds, to match the whole range of PD velocities.
Kinematic data were recorded by means of an optoelectronic motion analyzer. For each stride we
computed spatio-temporal parameters, time-course and range of motion (ROM) of hip, knee and
ankle joint angles. We also measured kinetic (Wk), potential (Wp), total (WtotCM) energy
variations and the energy recovery index (ER). Along with PD progression, we found a
significant correlation of WtotCM and Wp with knee ROM and in particular with knee extension
in terminal stance phase. Wk and ER were instead mainly related to gait velocity. In PD subjects,
the reduction of knee ROM significantly diminished both Wp and WtotCM. Rehabilitation
treatments should possibly integrate passive and active mobilization of knee to prevent a
reduction of gait-related energetic components.
12. The characterization of a base-width neutral step as the first step for balance recovery in
moderate Parkinson's disease.
PURPOSE: The purpose of this study is to characterize the base-width neutral step (BNS) as the
first step in a compensatory step response in persons with moderate Parkinson's disease (PD),
and its effect on balance recovery.
MATERIALS AND METHODS: Ten PD and 10 healthy controls (HCs) responded to a

posterior waist pull. A BNS was defined if the first step was less than 50 mm. The length, height,
duration and velocity of the BNS and its effect on balance recovery time and center of mass
location at recovery were compared to the first step within other stepping strategies (single step
(SS), multiple step (MS)). A linear mixed model was used to compare across strategies.
RESULTS: Six of ten persons with PD compared to zero HC used a BNS. The BNS was shorter
in length and duration compared to MS responses in HC, and shorter in duration compared to
MS responses in PD. The BNS was slower in velocity compared to every other strategy. BNS
use resulted in a longer recovery time compared to all strategies in HC and SS responses in PD,
and trended toward a longer recovery time compared to MS responses in PD.
CONCLUSIONS: The BNS as the first step in a MS response may be an unreported strategy for
compensatory stepping in PD. This study suggests that the cost of utilizing the BNS may be a
longer time for recovery, but further work is necessary to understand the progression of the BNS
as PD severity increases.
13. Adaptive training with full-body movements to reduce bradykinesia in persons with
Parkinson's disease: a pilot study.
BACKGROUND: Bradykinesia (slow movements) is a common symptom of Parkinson's disease

(PD) and results in reduced mobility and postural instability. The objective of this study is to
develop and demonstrate a technology-assisted exercise protocol that is specifically aimed at
reducing bradykinesia.
METHODS: Seven persons with PD participated in this study. They were required to perform
whole body reaching movements toward targets placed in different directions and at different
elevations. Movements were recorded by a Microsoft Kinect movement sensor and used to
control a human-like avatar, which was continuously displayed on a screen placed in front of the
subjects. After completion of each movement, subjects received a 0-100 score that was inversely
proportional to movement time. Target distance in the next movements was automatically
adjusted in order to keep the score around a pre-specified target value. In this way, subjects
always exercised with the largest movement amplitude they could sustain. The training protocol
was organised into blocks of 45 movements toward targets placed in three different directions
and at three different elevations (a total of nine targets). Each training session included a finite
number of blocks, fitted within a fixed 40 minutes duration. The whole protocol included a total
of 10 sessions (approximately two sessions/week). As primary outcome measure we took the
absolute average acceleration. Various aspects of movement performance were taken as
secondary outcome measures, namely accuracy (undershoot error), path curvature, movement
time, and average speed.
RESULTS: Throughout sessions, we observed an increase of the absolute average acceleration

and speed and decreased undershoot error and movement time. Exercise also significantly
affected the relationship between target elevation and both speed and acceleration - the
improvement was greater at higher elevations.
CONCLUSIONS: The device and the protocol were well accepted by subjects and appeared safe
and easy to use. Our preliminary results point at a training-induced reduction of bradykinesia.
14. The effectiveness of Tai Chi for patients with Parkinson's disease: study protocol for a
randomized controlled trial.
BACKGROUND: Parkinson's disease (PD) is a common degenerative neurological disorder that

causes loss of independence and decreased quality of life. The prevalence of PD tends to increase
with age. In China, the morbidity rate of PD among people aged more than 65 years old is
1.70%. As an important component of traditional Chinese Qigong exercises, Tai Chi is a popular
and safe exercise, especially for older adults in China. And it may result in promising gains for
PD patients. However, current evidence is insufficient to inform the use of Tai Chi in the
management of PD. Therefore, the aim of this trial is to systematically evaluate the effect of Tai
Chi on PD and determine whether Tai Chi is an eligible exercise program for Chinese PD
patients.
METHODS/DESIGN: A single-blind, parallel randomized controlled trial will be conducted.

One hundred and forty-two patients with PD will be randomly assigned to a Tai Chi group (n =
71) or routine exercise group (n = 71). Subjects will participate in supervised study programs 3
times per week for 2 months and will be followed for an additional 6 months after formal
training stops. The primary outcome measures include Berg Balance Scale, Timed Up and Go
Test and Six-Minute Walk Test, which are known to be valid and reliable clinical instruments.
The Unified Parkinson's Disease Rating Scale Motor Section and Parkinson's Disease
Questionnaire-39 will be used as the secondary outcome measure. All outcomes will be
measured at baseline, 2 and 8 months. The sample for this trial (N = 142) will provide relevant
information to detect the improvement of balance, gait and quality of life in either of the 2
exercise groups.
DISCUSSION: Findings from this study will provide insights into the effects of Tai Chi in
people with PD. The information gained from this project has the potential to influence the
clinical decisions of Chinese doctors, and will provide clear evidence as to whether Tai Chi
should be advocated in people with PD.
TRIAL REGISTRATION: The trial was registered at ( ChiCTR-TRC-14004549 ) on 22 April

2014.
15. Robot-assisted walking training for individuals with Parkinson's disease: a pilot
randomized controlled trial.
BACKGROUND: Over the last years, the introduction of robotic technologies into Parkinson's
disease rehabilitation settings has progressed from concept to reality. However, the benefit of
robotic training remains elusive. This pilot randomized controlled observer trial is aimed at
investigating the feasibility, the effectiveness and the efficacy of new end-effector robot training
in people with mild Parkinson's disease.
METHODS: Design. Pilot randomized controlled trial.
RESULTS: Robot training was feasible, acceptable, safe, and the participants completed 100%
of the prescribed training sessions. A statistically significant improvement in gait index was
found in favour of the EG (T0 versus T1). In particular, the statistical analysis of primary
outcome (gait speed) using the Friedman test showed statistically significant improvements for
the EG (p = 0,0195). The statistical analysis performed by Friedman test of Step length left
(p = 0,0195) and right (p = 0,0195) and Stride length left (p = 0,0078) and right (p = 0,0195)
showed a significant statistical gain. No statistically significant improvements on the CG were
found.
CONCLUSIONS: Robot training is a feasible and safe form of rehabilitative exercise for
cognitively intact people with mild PD. This original approach can contribute to increase a short
time lower limb motor recovery in idiopathic PD patients. The focus on the gait recovery is a
further characteristic that makes this research relevant to clinical practice. On the whole, the
simplicity of treatment, the lack of side effects, and the positive results from patients support the
recommendation to extend the use of this treatment. Further investigation regarding the long-
time effectiveness of robot training is warranted.
16. Multidisciplinary Care in Parkinson's Disease.
Parkinson's disease (PD) is now known to be a multisystemic and multipeptide

neurodegenerative disorder, whereby patients have an array of symptoms both motor and
nonmotor. Nonmotor features of PD have been shown to arise almost 15-20 years prior to motor
symptoms and, as such, are also a key determinant to the quality of life of a patient. Therefore,
there is increasing evidence that a PD patient's management must encompass a multidisciplinary
approach to effectively manage and treat the patient's PD and also their individual symptoms.
Therefore, the notion that a PD nurse specialist and a neurologist are the only key players, is no
longer the case. Rather, the involvement of speech and language therapist, physiotherapists,
palliative care, and others is vital for a patient's recovery and their effective management. Here
we discuss a few professions who should ideally be present for each PD patient.
17. Reactive but not predictive locomotor adaptability is impaired in young Parkinson's
disease patients.
BACKGROUND: Gait and balance disorders are common in Parkinson's disease (PD) and major
contributors to increased falling risk. Predictive and reactive adjustments can improve recovery
performance after gait perturbations. However, these mechanisms have not been investigated in
young-onset PD.
OBJECTIVE: We aimed to investigate the effect of gait perturbations on dynamic stability
control as well as predictive and reactive adaptability to repeated gait perturbations in young PD
patients.
METHODS: Fifteen healthy controls and twenty-five young patients (48±5yrs.) walked on a
walkway. By means of a covered exchangeable element, the floor surface condition was altered
to induce gait perturbations. The experimental protocol included a baseline on a hard surface, an
unexpected trial on a soft surface and an adaptation phase with 5 soft trials to quantify the
reactive adaptation. After the first and sixth soft trials, the surface was changed to hard, to
examine after-effects and, thus, predictive motor control. Dynamic stability was assessed using
the 'extrapolated center of mass' concept.
RESULTS: Patients' unperturbed walking was less stable than controls' and this persisted in the
perturbed trials. Both groups demonstrated after-effects directly after the first perturbation,
showing similar predictive responses. However, PD patients did not improve their reactive
behavior after repeated perturbations while controls showed clear locomotor adaptation.
CONCLUSIONS: Our data suggest that more unstable gait patterns and a less effective reactive
adaptation to perturbed walking may be a disease-related characteristic in young PD patients.
These deficits were related to reduced ability to increase the base of support.
18. Perturbation training to promote safe independent mobility post-stroke: study protocol for
a randomized controlled trial.
BACKGROUND: Falls are one of the most common medical complications post-stroke.
Physical exercise, particularly exercise that challenges balance, reduces the risk of falls among
healthy and frail older adults. However, exercise has not proven effective for preventing falls
post-stroke. Falls ultimately occur when an individual fails to recover from a loss of balance.
Thus, training to specifically improve reactive balance control could prevent falls. Perturbation
training aims to improve reactive balance control by repeatedly exposing participants to postural
perturbations. There is emerging evidence that perturbation training reduces fall rates among
individuals with neurological conditions, such as Parkinson disease. The primary aim of this
work is to determine if perturbation-based balance training can reduce occurrence of falls in
daily life among individuals with chronic stroke. Secondary objectives are to determine the effect
of perturbation training on balance confidence and activity restriction, and functional balance
and mobility.
METHODS/DESIGN: Individuals with chronic stroke will be recruited. Participants will be

randomly assigned to one of two groups: 1) perturbation training, or 2) 'traditional' balance
training. Perturbation training will involve both manual perturbations (e.g., a push or pull from a
physiotherapist), and rapid voluntary movements to cause a loss of balance. Training will occur
twice per week for 6 weeks. Participants will record falls and activity for 12 months following
completion of the training program. Standardized clinical tools will be used to assess functional
balance and mobility, and balance confidence before and after training.
DISCUSSION: Falls are a significant problem for those with stroke. Despite the large body of
work demonstrating effective interventions, such as exercise, for preventing falls in other
populations, there is little evidence for interventions that prevent falls post-stroke. The proposed
study will investigate a novel and promising intervention: perturbation training. If effective, this
training has the potential to not only prevent falls, but to also improve safe independent mobility
and engagement in daily activities for those with stroke.
19. Effects of music and music therapy on mood in neurological patients.
Mood disorder and depressive syndromes represent a common comorbid condition in

neurological disorders with a prevalence rate that ranges between 20% and 50% of patients with
stroke, epilepsy, multiple sclerosis, and Parkinson's disease. Notwithstanding, these conditions
are often under-diagnosed and under-treated in the clinical practice and negatively affect the
functional recovery, the adherence to treatment, the quality of life, and even the mortality risk. In
addition, a bidirectional association between depression and neurological disorders may be
possible being that depressive syndromes may be considered as a risk factor for certain
neurological diseases. Despite the large amount of evidence regarding the effects of music
therapy (MT) and other musical interventions on different aspects of neurological disorders, no
updated article reviewing outcomes such as mood, emotions, depression, activity of daily living
and so on is actually available; for this reason, little is known about the effectiveness of music
and MT on these important outcomes in neurological patients. The aim of this article is to
provide a narrative review of the current literature on musical interventions and their effects on
mood and depression in patients with neurological disorders. Searching on PubMed and PsycInfo
databases, 25 studies corresponding to the inclusion criteria have been selected; 11 of them
assess the effects of music or MT in Dementia, 9 explore the efficacy on patients with Stroke,
and 5 regard other neurological diseases like Multiple Sclerosis, Amyotrophic Lateral
Sclerosis/motor neuron disease, Chronic quadriplegia, Parkinson's Disease, and Acquired Brain
dysfunctions. Selected studies are based on relational and rehabilitative music therapy
approaches or concern music listening interventions. Most of the studies support the efficacy of
MT and other musical interventions on mood, depressive syndromes, and quality of life on
neurological patients.
20. Daily electromyography in females with Parkinson's disease: a potential indicator of
frailty.
Females with Parkinson's disease (PD) are at increased risk for frailty, yet are often excluded
from frailty studies. Daily electromyography (EMG) recordings of muscle activity can dissociate
stages of frailty and indicate functional decline in non-neurological conditions. The purpose of
this investigation was to determine whether muscle activity can be used to identify frailty
phenotypes in females with PD. EMG during a typical 6.5-h day was examined in biceps brachii,
triceps brachii, vastus lateralis and biceps femoris on less-affected PD side. Muscle activity was
quantified through burst (>2% maximum exertion, >0.1s) and gap characteristics (<1%
maximum exertion, >0.1s). Differences across frailty phenotype (nonfrail, prefrail, frail) and
muscle (biceps brachii, BB; triceps brachii, TB; vastus lateralis, VL; biceps femoris, BF) were
evaluated with a 2-way repeated measure ANOVA for each burst/gap characteristic. Thirteen
right-handed females (mean=67 ± 8 years) were classified as nonfrail (n = 4), prefrail (n = 6),
and frail (n = 3) according to the Cardiovascular Health Study frailty index (CHSfi). Frail
females had 73% decreased gaps and 48% increased burst duration compared with nonfrail.
Decreased gaps may be interpreted as reduced muscle recovery time, which may result in earlier
onset fatigue and eventually culminating in frailty. Longer burst durations suggest more muscle
activity is required to initiate movement leading to slower movement time in frail females with
PD. This is the first study to use EMG to dissociate frailty phenotypes in females with PD during
routine daily activities and provides insight into how PD-associated motor declines contributes to
frailty and functional decline.
21. Training effects of a 12-week walking program on Parkinson disease patients and
community-dwelling older adults.
ACKGROUND: Introducing evidence-based exercise guidelines of Parkinson's disease (PD) into

clinical practice and community settings has been highlighted.
AIM: This study tested the feasibility and compared the weekly effects of a 12-week walking
training program on PD patients and community-dwelling seniors.
DESIGN: A prospective quasi-experimental design was used. PD patients in Hoehn and Yahr
Stage I through III (PG) and community-dwelling adults older than 65 were recruited (CG).
METHODS: In the outpatient department of a hospital, the information of personal data,

coordination test, and walking ability of participants were collected first. They then participated
in a 36-session, 12-week treadmill walking training program.
RESULTS: Weekly data of step length and velocity in PG and CG were collected. The walking
training program achieved significant velocity (χ² = 126.38, p < 0.001) and step length (χ² =
27.27, p = 0.001) improvements in PG. Differences in improvement between PG and CG in
terms of velocity (χ² = 7.089, df = 1, p = 0.008) and step length (χ² = 7.718, df = 1, p = 0.005)
were also identified.
CONCLUSION: The applicability of this 12-week walking program both for PD patients and
community-dwelling older adults was identified. Conducting the economic evaluation and
neurology studies of the 12-week walking program and test the effects of five-week walking
program are suggested.
22. Changes in motor cortex excitability associated with muscle fatigue in patients with
BACKGROUND/AIM: Transcranial magnetic stimulation (TMS) is a standard technique for

noninvasive assessment of changes in central nervous system excitability. The aim of this study
was to examine changes in responses to TMS in patients suffering from Parkinson's disease (PD)
during sustained submaximal isometric voluntary contraction [60% of maximal voluntary
contraction (MVC)] of the adductor pollicis muscle, as well as during a subsequent recovery
period.
METHODS: Cortical excitability was tested by single TMS pulses of twice of the motor
threshold intensity applied over the vertex. Testing was carried out during the sustained
contraction phase every 10 s before and every 5 s after the endurance point, as well as at rest and
during brief 60% MVC contractions before (control), immediately after the sustained
contraction, and at 5 min intervals during the recovery period.
RESULTS: Although the PD patients could sustain the contraction at the required level for as
long period of time as the healthy subjects (though contraction level subsided more rapidly after
the endurance point), effects of muscle fatigue on the responses to TMS were different. In
contrast to the findings observed in the healthy people where motor evoked potentials (MEP) and
EMG silent period (SP) in fatigued muscle gradually diminished during contraction up to the
endurance point, and increased thereafter, in the majority of patients no changes occurred in
MEP size (peak and area) of the adductor pollicis muscle, either before or after the endurance
point. On the other hand, changes in the SP of this muscle differed among the subjects, showing
a gradual increase, a decrease or no changes in duration. The trends of changes in both MEP size
and SP duration in the musculus brachioradialis varied among the tested PD patients, without
any consistent pattern, which was in contrast with the findings in the healthy people where both
measures showed a gradual increase from the beginning of the sustained contraction. A complete
dissociation between changes in MEP and SP during fatigue was also of note, which differed
sharply from the findings in the healthy people in who fatigue induced changes in these measures
followed identical patterns.
CONCLUSION: These results in the PD patients suggest the presence of impairment and/or
compensatory changes in mechanisms responsible for adaptation of voluntary drive as well as for
matching between cortical excitation and inhibition which become manifest in demanding motor
tasks such as those imposed by muscle fatigue.
23. Source memory in normal aging and Parkinson's disease.
Several theorists have described memory in Parkinson's disease (PD) as involving an

amplification of the deficits seen in normal aging, and drawn parallels between PD and frontal
lesion patients. Both normal aging and frontal lobe damage impair memory for the context in
which one has encountered information (i.e., source memory). We thus sought to determine
whether PD patients would show especially poor source memory. We assessed memory for
perceptual (voice), spatial (location of loudspeaker), and temporal (list) source memory in 18 PD
patients, 23 healthy older adults, and 35 young people. Although both the healthy aged and PD
groups performed more poorly than the young on most of the memory tests, the PD patients
failed to show significantly greater impairments than the healthy older adults. The PD patients
did perform more poorly, however, on a measure of executive function (the Wisconsin Card
Sorting Test [WCST]). We discuss potential reasons why PD had a surprisingly minimal effect
on source memory in our study, and relate our data to broader theories of memory impairment in
24. Recovery of behavioral symptoms in hemi-parkinsonian rhesus monkeys through

combined gene and stem cell therapy.
BACKGROUND AIMS: The use of adipose mesenchymal stromal cells (ASCs) in cellular
and genic therapy has attracted considerable attention as a possible treatment for
neurodegenerative disorders, including Parkinson disease. However, the effects of gene
therapy combined with intracerebral cell transplantation have not been well defined. Recent
studies have demonstrated the respective roles of LIM homeobox transcription factor 1, alpha
(LMX1A) and Neurturin (NTN) in the commitment of embryonic stem cells (ESCs) to a
midbrain dopaminergic neuronal fate and the commitment of mesenchymal stromal cells to
cells supporting the nutrition and protection of neurons.
METHODS: We investigated a novel in vitro neuronal differentiation strategy with the use of
LMX1A and Neurturin. We were able to elicit a neural phenotype regarding cell
morphology, specific gene/protein expression and physiological function. Neuronal-primed
ASCs derived from rhesus monkey (rASCs) combined with adenovirus containing NTN and
tyrosine hydroxylase (TH) (Ad-NTN-TH) were implanted into the striatum and substantia
nigra of methyl-4-phenyl-1, 2, 3, 6-tetrahydropyridine (MPTP)-lesioned hemi-parkinsonian
rhesus monkeys. Monkeys were monitored with the use of behavioral tests and health
measures until the fourth month after implantation.
RESULTS: The differentiated cells transcribed and expressed a variety of dopaminergic

neuron-specific genes involved in the SHH/LMX1A pathway. Single-photon emission
computed tomography analysis and postmortem analysis revealed that the grafting of rASCs
combined with Ad-NTN-TH had neuroprotective effects compared with Ad-NTN-TH or
rASCs alone. Behavioral measures demonstrated autograft survival and symptom
amelioration.
CONCLUSIONS: These findings may lead to cellular sources for autologous transplantation
of Parkinson disease. Combined transplantation of Ad-NTN-TH and induced rASCs
expressing LMX1A and NTN may be a better therapy candidate for the treatment of
Parkinson disease.
25. Robotic therapy: the tipping point.
The last two decades have seen a remarkable shift in the neurorehabilitation paradigm.
Neuroscientists and clinicians moved away from the perception that the brain is static and
hardwired to a new dynamic understanding that plasticity is a fundamental property of the
adult human brain and might be harnessed to remap or create new neural pathways.
Capitalizing on this innovative understanding, the authors introduced a paradigm shift in the
clinical practice in 1989 when they initiated the development of the Massachusetts Institute
of Technology-Manus robot for neurorehabilitation and deployed it in the clinic in 1994
(Krebs et al. 1998). Since then, the authors and others have developed and tested a multitude
of robotic devices for stroke, spinal cord injury, cerebral palsy, multiple sclerosis, and
Parkinson disease. Here, the authors discuss whether robotic therapy has achieved a level of
maturity to justify its broad adoption in the clinical realm as a tool for motor recovery.
26. Imaging of compensatory mechanisms in Parkinson's disease.
PURPOSE OF REVIEW: The on-going quest for potentially disease-modifying therapies in

Parkinson's disease has prompted the development of methods that can differentiate direct
disease effects from compensatory processes.
RECENT FINDINGS: PET studies have suggested a number of changes at the synaptic level to
maintain integrity of dopaminergic systems. Functional MRI studies support the long-held belief
that relatively intact cerebellar circuits may compensate for impaired basal ganglia function.
Altered connectivity and increased spatial extent of activation also appear to be mechanisms
through which motor and cognitive performance can be maintained.
SUMMARY: Ascertaining which changes in brain activation in Parkinson's disease are, in fact,
compensatory represents a serious challenge. Compensatory mechanisms have been
demonstrated from the microscopic, synaptic level to the macroscopic, system level.
Augmentation of compensatory mechanisms, in addition to ameliorating the loss of
dopaminergic neurons, may represent a joint strategy for overall minimization of disability.
27. The ParkinsonNet concept: development, implementation and initial experience.
The quality and efficiency of allied health care in Parkinson's disease (PD) must be improved.
We have developed the ParkinsonNet concept: a professional regional network within the
catchment area of hospitals. ParkinsonNet aims to: (1) improve PD-specific expertise among
allied health personnel, by training a selected number of therapists according to evidence-based
guidelines; (2) enhance the accuracy of referrals by neurologists; (3) boost patient volumes per
therapist, by stimulating preferred referral to ParkinsonNet therapists; and (4) stimulate
collaboration between therapists, neurologists, and patients. We describe the procedures for
developing a ParkinsonNet network. Our initial experience with this new concept is promising,
showing an increase in PD-specific and a steady rise in the patient volume of individual
therapists.
28. Early biomechanical markers of postural instability in Parkinson's disease.
Current clinical assessments do not adequately detect the onset of postural instability in the early
stages of Parkinson's disease (PD). The aim of this study was to identify biomechanical variables
that are sensitive to the effects of early Parkinson's disease on the ability to recovery from a
balance disturbance. Ten adults diagnosed with idiopathic PD and no clinically detectable
postural instability, and ten healthy age-range matched controls (HC) completed the study. The
first step in the response to a backwards waist pull was quantified in terms of strategy, temporal,
kinematic, kinetic, and center of pressure (COP) variables. People with PD, compared to HC,
tended to be less consistent in the choice of stepping limb, utilized more time for weight shift,
used a modified ankle joint motion prior to liftoff, and the COP was further posterior at landing.
The study results demonstrate that PD changes the response to a balance disturbance which can
be quantified using biomechanical variables even before the presence of clinically detectable
postural instability. Further studies are required to determine if these variables are sensitive and
specific to postural instability.
29. Exercise and neuroplasticity in persons living with Parkinson's disease.
For many years, exercise was not a recommended rehabilitation strategy for persons with a
diagnosis of idiopathic Parkinson's disease (PD). Since it was believed that exercise had no
measurable effect on PD, or might worsen the underlying pathology, it was to be avoided. A rich
vein of bench and translational research now suggest non-pharmacological approaches, such as
exercise or physiotherapy, have a far greater effect on the cardinal features of PD than previously
believed. In particular, recent studies utilizing animal models of PD have begun to explore the
molecular mechanisms of exercise-induced changes in the pathophysiology of PD. Yet, many
clinicians and communities remain unaware of the scientific literature underlying exercise-
induced brain repair or reorganization (neuroplasticity) and accompanying behavioral recovery
in animal models of PD. The authors will summarize some noteworthy preliminary studies
suggesting that continuous, deficit targeted, intensive training may confer neuroprotection and
thereby, slow, stop or reverse the progression of the disease or promote neurorestoration through
adaptation of compromised signaling pathways. While much work remains and these preliminary
results await replication in larger prospective human trials, we believe a major challenge in the
field of non-pharmacological, rehabilitative intervention for PD will be the extent to which
healthcare providers are able to translate the science of exercise and PD to the level of the
community.
30. Motor cortex stimulation in patients with Parkinson disease: 12-month follow-up in 4
patients.
OBJECT: Since the initial 1991 report by Tsubokawa et al., stimulation of the M1 region of
cortex has been used to treat chronic pain conditions and a variety of movement disorders.
METHODS: A Medline search of the literature published between 1991 and the beginning of
2007 revealed 459 cases in which motor cortex stimulation (MCS) was used. Of these, 72 were
related to a movement disorder. More recently, up to 16 patients specifically with Parkinson
disease were treated with MCS, and a variety of results were reported. In this report the authors
describe 4 patients who were treated with extradural MCS.
RESULTS: Although there were benefits seen within the first 6 months in Unified Parkinson's
Disease Rating Scale Part III scores (decreased by 60%), tremor was only modestly managed
with MCS in this group, and most benefits seen initially were lost by the end of 12 months.
CONCLUSIONS: Although there have been some positive findings using MCS for Parkinson
disease, a larger study may be needed to better determine if it should be pursued as an alternative
surgical treatment to DBS.
31. Tai Chi improves balance and mobility in people with Parkinson disease.
This pilot study examines the effects of Tai Chi on balance, gait and mobility in people with
Parkinson disease (PD). Thirty-three people with PD were randomly assigned to either a Tai Chi
group or a control group. The Tai Chi group participated in 20 1-h long training sessions
completed within 10-13 weeks; whereas, the control group had two testing sessions between 10
and 13 weeks apart without interposed training. The Tai Chi group improved more than the
control group on the Berg Balance Scale, UPDRS, Timed Up and Go, tandem stance test, six-
minute walk, and backward walking. Neither group improved in forward walking or the one leg
stance test. All Tai Chi participants reported satisfaction with the program and improvements in
well-being. Tai Chi appears to be an appropriate, safe and effective form of exercise for some
individuals with mild-moderately severe PD.
32. Community-based Argentine tango dance program is associated with increased activity
participation among individuals with Parkinson's disease.
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.
33. Stimulating music increases motor coordination in patients afflicted with Morbus Parkinson.
The present study measured the short-term effect of special stimulating music on motor
coordination in Parkinson patients. Eleven patients with a dominant akinetic Parkinson syndrome
as well as ten healthy persons (age-matched control group) participated in this study. In the
Parkinson group, the measurement of fine motor coordination with the 'Vienna Test System'
showed an improvement in two (aiming, line tracking) of the four subtests after listening to the
music. The patients improved their performance with the right arm significantly in the subtest
aiming-error-time. No statistical differences were found in the other two subtests (steadiness,
tapping) in both groups. There was also no improvement in frequency of tapping movement on
the power-force-working-plate. Accordingly, music effects more the precision of a movement
than the speediness. The measurements on the power-force-working-plate showed a significant
improvement in two of five measured parameters: contact time, variability coefficient for total
step and impact maximum changed significantly. This study gives evidence that specific music
can improve the precision of arm and finger movements.
34. Underwater gait analysis in Parkinson's disease.
Although hydrotherapy is one of the physical therapies adopted to optimize gait rehabilitation in
people with Parkinson disease, the quantitative measurement of gait-related outcomes has not
been provided yet. This work aims to document the gait improvements in a group of
parkinsonians after a hydrotherapy program through 2D and 3D underwater and on land gait
analysis. Thirty-four parkinsonians and twenty-two controls were enrolled, divided into two
different cohorts. In the first one, 2 groups of patients underwent underwater or land based
walking training; controls underwent underwater walking training. Hence pre-treatment 2D
underwater and on land gait analysis were performed, together with post-treatment on land gait
analysis. Considering that current literature documented a reduced movement amplitude in
parkinsonians across all lower limb joints in all movement planes, 3D underwater and on land
gait analysis were performed on a second cohort of subjects (10 parkinsonians and 10 controls)
who underwent underwater gait training. Baseline land 2D and 3D gait analysis in parkinsonians
showed shorter stride length and slower speed than controls, in agreement with previous
findings. Comparison between underwater and on land gait analysis showed reduction in stride
length, cadence and speed on both parkinsonians and controls. Although patients who underwent
underwater treatment exhibited significant changes on spatiotemporal parameters and sagittal
plane lower limb kinematics, 3D gait analysis documented a significant (p<0.05) improvement in
all movement planes. These data deserve attention for research directions promoting the optimal
recovery and maintenance of walking ability.
35. Effectiveness of aquatic therapy for the control of pain and increased functionality in people
with Parkinson's disease: a randomized clinical trial.
BACKGROUND: Gait, balance disorders and pain associated with Parkinson's disease represent
important therapeutic challenges, as they are related with an increased risk of falls, together with
disability and physical decline.
AIM: To compare the effects of an aquatic ai chi training program on the perception of pain, the
maintenance of balance and the functional independence of patients with Parkinson's disease.
DESIGN: A single-blind randomized controlled trial.
SETTING: Parkinson's associations and municipal pools.
POPULATION: Thirty individuals from two Parkinson's associations in Spain participated in the
study.
INCLUSION CRITERIA: individuals diagnosed with Parkinson's disease in stages 1 to 3

(Hoehn and Yahr Scale), older than 40 years, in the off phase (not medicated) and with a score
greater or equal to 24 on the Mini-Mental State Examination Scale, without any medical
contraindications and who accepted the study norms.
METHODS: The experimental group (N.=15 patients) participated in a program of aquatic ai

chi. The control group (N.=15) received therapy on dry land. The intervention lasted 10 weeks
with sessions held twice weekly. The pain VAS, Tinetti, Berg, Test Get Up and Go, Five Times
Test and Unified Parkinson's Disease Rating Scale were used.
RESULTS: Significant differences were found between the baseline and one-month follow up
assessments in pain perception values (F=26.89, P<0.001), and the Tinetti Test (F=21.57,
P<0.001) in the experimental group compared to the control group (P<0.05) with the exception
of the FTSTS (P=0.006). In the control group, improvements were only seen on the VAS Pain
Scale (F=8.3, P=0.004) and these were less significant than the changes found in the
experimental group. Regarding the scores obtained on the UPDRS scale in the experimental
group, there were significant differences in activities of daily living and motor examination, with
the exception of mentation, behavior and mood.
CONCLUSIONS: An aquatic ai chi program appears to be a valid treatment option for patients
diagnosed with mild to moderate Parkinson's disease for the treatment of pain, balance and
functional capacity.
CLINICAL REHABILITATION IMPACT: Physical exercise performed in water has positive
effects on some of the necessary elements that contribute towards improved biomechanical gait
patterns in our patients with Parkinson's disease.
36. The effects of exergaming and treadmill training on gait, balance, and cognition in a person
with Parkinson's disease: A case study.
BACKGROUND: Parkinson's disease (PD) commonly impairs posture, gait, and cognition.
Exercise in the form of aerobic activity as well as exergaming may improve motor ability and
cognition in persons with PD. Exergaming and treadmill training can be a practical form of
exercise within the home; however, there is minimal research on this combined multimodal
intervention for persons with PD.
OBJECTIVE: We investigated the effects of this combined intervention on cognition, balance,

and gait in a person with PD through supervised lab sessions augmented by home-based
sessions.
METHODS: This case study utilized an ABA single subject experimental design with 4 weeks of
pre-intervention, followed by 8 weeks of intervention, and 4 weeks of post-intervention. The
intervention consisted of treadmill walking and Xbox Kinect exergaming, 30 minutes each,
performed unsupervised at home and at supervised lab sessions. The two standard deviation band
method was used to determine significance.
RESULTS: MiniBEST test, 2-minute walk distance, sway area, endurance test, and a few
parameters of gait initiation and gait improved significantly throughout the intervention period.
Only a few measures sustained the improvement 4 weeks after completion of intervention.
CONCLUSION: Eight weeks of treadmill and exergaming intervention with a person with PD
improved static and dynamic postural control measures, but not gait, cognition, endurance, and
clinical measures of balance. Longer and more intense multimodal intervention may be
warranted.
37. The Impact of Expiratory Muscle Strength Training on Speech Breathing in Individuals With
Parkinson's Disease: A Preliminary Study.
Purpose: The purpose of this study was to examine the impact of expiratory muscle strength
training on speech breathing and functional speech outcomes in individuals with Parkinson's
disease (PD).
Method: Twelve individuals with PD were seen once a week for 8 weeks: 4 pretraining
(baseline) sessions followed by a 4-week training period. Posttraining data were collected at the
end of the 4th week of training. Maximum expiratory pressure, an indicator of expiratory muscle
strength, and lung volume at speech initiation were the primary outcome measures. Secondary
outcomes included lung volume at speech termination, lung volume excursion, utterance length,
and vocal intensity. Data were collected during a spontaneous speech sample. Individual effect
sizes > 1 were considered significant.
Results: Maximum expiratory pressure increased in a majority of participants after training.

Training resulted in 2 main respiratory patterns: increasing or decreasing lung volume initiation.
Lung volume termination and excursion, utterance length, and vocal loudness were not
consistently altered by training.
Conclusions: Preliminary evidence suggests that the direct physiologic intervention of the
respiratory system via expiratory muscle strength training improves speech breathing in
individuals with PD, with participants using more typical lung volumes for speech following
treatment.
38. What About the Role of Virtual Reality in Parkinson Disease's Cognitive Rehabilitation?
Preliminary Findings From a Randomized Clinical Trial.
BACKGROUND: The purpose of this study is to evaluate the effects of a virtual reality training
with BTS Nirvana (BTS-N) system in the cognitive and behavioral recovery in patients with
Parkinson disease (PD). The BTS-N is a semi-immersive therapy system used for motor and
cognitive rehabilitation of patients with neurological diseases, by creating virtual scenarios with
which the patient may interact.
METHODS: We enrolled 20 patients with PD undergoing neurorehabilitation. All the patients

were randomized into 2 groups: experimental group performing semi-immersive virtual reality
training with BTS-N and control group undergoing traditional cognitive training. Each
participant was evaluated before and immediately after the end of the training. Each cognitive
training consisted of 3 sessions a week, each lasting 60 minutes, for 8 weeks, for a total of 24
sessions in each group.
RESULTS: Experimental group showed a greater improvement in cognitive functioning, with

regard to executive and visuospatial abilities, as compared with the control group.
CONCLUSION: Our findings suggest that rehabilitation through a new virtual reality instrument
could be a valuable tool in improving cognitive and behavioral outcomes of patients with PD.
39. Feasibility of home exercises to enhance the benefits of tango dancing in people with
BACKGROUND: A style of dance called tango translates clinical practice into a new philosophy
and rehabilitative approach for individuals with Parkinson's disease (PD). The style of dance
mixes music, self-generated and external cued strategies and social and emotional recovery. In
recent years, there has been an increase in the number of studies reporting health benefits for
people diagnosed with PD who dance tango. However, there are some organisational limitations
to people participating in dance classes, including having trained Tango teachers, an appropriate
space for dancing, and schedule that allows for participants with motor inabilities.
METHODS: This pilot study involved the observation of PD patients who completed four days
of home exercise plus a tango dance lesson each week for five weeks.
RESULTS: Ten PD patients improved their quality of life, their motor score on the Unified
Parkinson's Disease Rating Scale and their kinematic performances.
CONCLUSIONS: We propose a protocol of exercises that has been derived from the tango
dance and that can be performed in a patient's home.
40. Wearable technological platform for multidomain diagnostic and exercise interventions in
Physical activity and exercise have become a central component of medical management of
chronic illness, particular for the elderly who suffer from neurodegenerative disorders that impair
their cognition and mobility. This chapter summarizes our recent research showing that a new
generation of wearable technology can be adopted as diagnostic and rehabilitation tools for
people living with Parkinson's disease. For example, wearable device-enabled 6-min walking test
can be automated to eliminate human supervision and many other technical factors that confound
the results with conventional testing. With reduced cost and increased test standardization, the
technology can be adopted for population-based screening of cardiovascular fitness and gait
rehabilitation training efficacy associated with many medical conditions. The Ambulosono
platform for multidomain exercise intervention, in particular, has the potential to deliver lasting
clinical benefits in slowing PD progression. The platform, through the integration of brisk
walking with behavioral shaping strategies such as contingency reinforcement, anticipatory
motor control and musical motivational stimulation, creates a home exercise regime that can
transform monotonous walking into a pleasurable daily activity and habit.
https://www.ncbi.nlm.nih.gov/pubmed/31607363

Freezing of Gait in Parkinson

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1.

Freezing of gait in Parkinson's disease reflects a sudden derangement of locomotor

Freezing of gait is a disabling symptom of Parkinson's disease that causes a paroxysmal

2. Effects of Preventive Treadmill Exercise on the Recovery of Metabolic and

4. Hemodynamic responses to an exercise stress test in Parkinson's disease patients without

The presence of postganglionic sympathetic denervation is well established in Parkinson's

BACKGROUND: Although physical treatment is recognized as being beneficial for patients

9. Aerobic rehabilitation program for improving muscle function in Parkinson's disease.

BACKGROUND: Parkinson's Disease (PD) is characterized by progressive and disabling

METHODS: 60 PD patients and 32 age-matched healthy controls participated. Haematic lactate

10. Effects of a low-resistance, interval bicycling intervention in Parkinson's Disease.

MATERIALS AND METHODS: Ten PD and 10 healthy controls (HCs) responded to a

BACKGROUND: Bradykinesia (slow movements) is a common symptom of Parkinson's disease

RESULTS: Throughout sessions, we observed an increase of the absolute average acceleration

BACKGROUND: Parkinson's disease (PD) is a common degenerative neurological disorder that

METHODS/DESIGN: A single-blind, parallel randomized controlled trial will be conducted.

TRIAL REGISTRATION: The trial was registered at ( ChiCTR-TRC-14004549 ) on 22 April

16. Multidisciplinary Care in Parkinson's Disease.

Parkinson's disease (PD) is now known to be a multisystemic and multipeptide

METHODS/DESIGN: Individuals with chronic stroke will be recruited. Participants will be

19. Effects of music and music therapy on mood in neurological patients.

Mood disorder and depressive syndromes represent a common comorbid condition in

ACKGROUND: Introducing evidence-based exercise guidelines of Parkinson's disease (PD) into

METHODS: In the outpatient department of a hospital, the information of personal data,

BACKGROUND/AIM: Transcranial magnetic stimulation (TMS) is a standard technique for

23. Source memory in normal aging and Parkinson's disease.

Several theorists have described memory in Parkinson's disease (PD) as involving an

24. Recovery of behavioral symptoms in hemi-parkinsonian rhesus monkeys through

RESULTS: The differentiated cells transcribed and expressed a variety of dopaminergic

25. Robotic therapy: the tipping point.

26. Imaging of compensatory mechanisms in Parkinson's disease.

PURPOSE OF REVIEW: The on-going quest for potentially disease-modifying therapies in

27. The ParkinsonNet concept: development, implementation and initial experience.

28. Early biomechanical markers of postural instability in Parkinson's disease.

OBJECTIVE: To determine the effects of a 12-month community-based tango dance program on

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

MAIN OUTCOME MEASURE: Current, new, and retained participation in instrumental,

34. Underwater gait analysis in Parkinson's disease.

DESIGN: A single-blind randomized controlled trial.

SETTING: Parkinson's associations and municipal pools.

INCLUSION CRITERIA: individuals diagnosed with Parkinson's disease in stages 1 to 3

METHODS: The experimental group (N.=15 patients) participated in a program of aquatic ai

OBJECTIVE: We investigated the effects of this combined intervention on cognition, balance,

Results: Maximum expiratory pressure increased in a majority of participants after training.

METHODS: We enrolled 20 patients with PD undergoing neurorehabilitation. All the patients

RESULTS: Experimental group showed a greater improvement in cognitive functioning, with

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