The effect of an intense exercise program on mobility and quality of life in someone with
Parkinson’s disease: a single subject design
A Capstone Project for PTY 769
Presented to the Faculty of the Physical Therapy Department
The Sage Colleges
School of Health Sciences
In Partial Fulfillment
of the Requirements for the Degree of
Doctor of Physical Therapy
Megan Abraham, SPT
Danielle DeFrancesco, SPT
Christopher Denio, SPT
Jill Townsley, SPT
May 2011
Approved:
_________________________________
Gabriele Moriello, PT, PHD, MS, GCS, CEEAA
Research Advisor
_________________________________
Patricia Pohl, PT, PhD
Program Director and Chair, Doctor of Physical Therapy Program
The effect of an intense exercise program on mobility and quality of life in someone with
Parkinson’s disease: a single subject design
A Capstone Project for PTY 769
Presented to the Faculty of the Physical Therapy Department
The Sage Colleges
School of Health Sciences
In Partial Fulfillment
of the Requirements for the Degree of
Doctor of Physical Therapy
Megan Abraham, SPT
Danielle DeFrancesco, SPT
Christopher Denio, SPT
Jill Townsley, SPT
May 2011
Approved:
_________________________________
Gabriele Moriello, PT, PHD, MS, GCS, CEEAA
Research Advisor
_________________________________
Patricia Pohl, PT, PhD
Program Director and Chair, Doctor of Physical Therapy Program
SAGE GRADUATE SCHOOLS
I hereby give permission to Sage Graduate Schools to use my work,
The effect of an intense exercise program on mobility and quality of life in someone with
Parkinson’s disease: a single subject design
For the following purposes:
-
Place in the Sage Colleges Library collection and reproduce for Interlibrary Loan.
-
Keep in the Program office or library for use by students, faculty,
or staff.
-
Reproduce for distribution to other students, faculty, or staff.
-
Show to other students, faculty or outside individuals, such as accreditors
or licensing agencies, as an example of student work.
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Use as a resource for professional or academic work by faculty or staff.
Megan Abraham, SPT
11/19/10
Danielle DeFrancesco, SPT
11/19/10
Christopher Denio, SPT
11/19/10
Jill Townsley, SPT
11/19/10
We represent to The Sage Colleges that this project and abstract are the original work of the
authors, and do not infringe on the copyright or other rights of others.
The effect of an intense exercise program on mobility and quality of life in someone with
Parkinson’s disease: a single subject design
Megan Abraham, SPT
11/19/10
Danielle DeFrancesco, SPT
11/19/10
Christopher Denio, SPT
11/19/10
Jill Townsley, SPT
11/19/10
Acknowledgements
We would like to acknowledge Gabriele Moriello and all of the hard work and
priceless advisement that she provided during this entire process. We would also like to
thank our amazing participant. His dedication and motivation throughout this study was
greatly appreciated. We thank the Sage Colleges for the opportunity and resources to pursue
this study and the Broughton Fellowship Committee for honoring us as 2011 Broughton
Fellowship recipients. Finally, we would like to thank our family and friends for all of their
support throughout the course of this research.
The effect of an intense exercise program on mobility and quality of life in someone with
Parkinson’s disease: a single subject design
Megan Abraham, SPT
Danielle DeFrancesco, SPT
Christopher Denio, SPT
Jill Townsley, SPT
ABSTRACT
Background and Purpose: Current literature has documented the benefit of exercise in the
management of Parkinson’s disease in people with significant mobility limitations. Little
research is available on the effects of exercise in those with early Parkinson’s disease who
only exhibit mild symptoms. The purpose of this single subject design was to determine the
effects of a 12-week customized program integrating flexibility, strengthening, and agility
exercises and yoga on mobility and quality of life in someone with Parkinson’s disease.
Participant: The participant was a 55-year-old male diagnosed with Parkinson’s disease 2
years prior to the start of the study. Methods: An ABC single subject design was utilized.
During the baseline phase (A), the participant’s own home exercise program (HEP) was
performed. During the intervention phase (B), an intense 1½-hour program was implemented
twice weekly for 12 weeks. Interventions incorporated flexibility, strengthening, and agility
exercises and intense yoga training. During the next phase (C), the participant completed a
home exercise program developed by the researchers. Outcome measures included range of
motion, flexibility, posture, strength, aerobic power, functional mobility, dynamic balance,
and quality of life. Analyses: All outcome measures, excluding quality of life, were analyzed
using visual analysis and the two standard deviation band method. Results: There were
significant improvements from baseline to intervention in range of motion of 10 of 14 joints
tested, flexibility of 3 of 4 muscles tested, strength of 11 of 12 upper extremity muscles and
13 of 14 lower extremity muscles tested, posture, reaction time, and in 4 of the individual
items of the HIMAT. His score on the PDQ-39 improved 24 points. Conclusion: A 12-week
program integrating flexibility, strengthening, and agility exercises is an effective dose of
exercise for improving mobility and quality of life in someone with Parkinson’s disease.
3
INTRODUCTION
Parkinson’s disease (PD) is a chronic, degenerative disorder of the central nervous
system (CNS). The exact cause of the condition is unknown but the pathogenesis of the
disease involves the destruction of dopamine-producing neurons of the substantia nigra
within the basal ganglia. As a result, the complex and intricate circuit between the basal
ganglia and the motor cortex that is partially controlled by dopamine is altered. This loop is
critical for the smooth, controlled and automatic execution of motor planning and behavior.
In the case of PD, the interruption of this loop leads to a variety of potentially disabling
changes in body structure and function and subsequent activity and participation
restrictions.1,2 Of primary importance, in most cases, are the effects that the condition has on
a person’s mobility.3
Although the specific etiology of PD is not known, the natural process of aging is one
of the most significant risk factors for the development of the disease.4 Age-related changes
in the brain including, mitochondrial and proteosome dysfunction, increased production of
free radicals and oxidative stress all contribute to neurodegeneration.4 These processes
constitute the underlying factors leading to the pathological changes that are also seen in
people with PD. The difference lies in the degree and severity of damage and the body’s
ability to compensate in light of compromised cellular functioning. Collier et al.5 revealed
that with advanced age, the brain becomes less equipped to compensate for cellular
degeneration through the increased activity of remaining intact neurons. The failure of the
body’s compensatory strategies is thought to be an integral component to the development of
PD. Given that the onset of symptoms usually occurs between the ages of 50 and 79,1 this
4
disorder coupled with the natural aging process has significant ramifications for a large
population of people now entering their golden years.
The hallmark clinical manifestations of PD include bradykinesia, rigidity, postural
instability, and tremors.6 Bradykinesia refers to the reduction in speed and amplitude of
voluntary movement and the impaired ability to anticipate and accommodate for postural
disturbances.2,3 Bradykinesia is thought to occur in PD because of the disruption of normal
neural transmission between the globus pallidus of the basal ganglia and the motor areas
within the cerebral cortex.1 The severity of bradykinesia may vary as well as the degree of
involvement from one side of the body to the other. Functionally, bradykinesia can greatly
affect gait or any repetitive or sequential activity.2 Clinically, a person experiencing
bradykinesia may demonstrate decreased step length and gait velocity, diminished reciprocal
arm swing, and a compensatory narrow base of support.3 Over time, this impaired regulation
of centrally-controlled movement can lead to isolated muscle weakness.3
People with PD also exhibit rigidity, which may start unilaterally in an upper limb
and progress to the trunk and lower extremities.1 The rigidity is characterized by increased
resistance to passive movement of a limb but not typically seen with voluntary movement.2,6
Clinically, axial rigidity may contribute to a stooped posture, limitations in trunk rotation, cocontraction of agonist and antagonist muscles, and impaired postural control.3 According to
Schenkman,7 decreased trunk rotation and flexibility of the spine contributes to impaired
balance in people with PD as evidenced by decreased performance on the functional reach
test. This high axial tone can impair a person’s ability to perform normal everyday tasks such
as rolling in bed, negotiating turns while ambulating or any activity requiring trunk rotation.3
5
In addition to the presence of axial rigidity, people with PD are also at greater risk for
falls because of postural instability. The exact pathophysiology of postural instability for this
population is not fully understood, but impairments in both afferent and efferent systems for
balance control are considered partially responsible.8,9 Various resultant deficits contribute to
poor postural stability in people with PD including asymmetrical motor control, episodes of
freezing, poor automatic and anticipatory postural reactions, slowed compensatory strategies
and impaired sensorimotor integration.3,8,9
Resting tremor is yet another common clinical manifestation seen in people with PD.
Resting tremor is often exhibited unilaterally and distally and typically dissipates with
movement or while sleeping.6 Hand tremors, known as “pill-rolling”, are just one common
presentation of resting tremor in people with PD. Although prevalent, resting tremor is not
usually severe enough to cause functional restrictions. Resting tremor is also better managed
by many people because this symptom often dissipates with movement and responds well to
medical management.2
The treatment of PD is primarily pharmacological in nature. Medications, such as
levodopa and carbidopa, are used to replace depleted dopamine levels in an effort to restore
normal brain function. In addition to pharmacotherapeutics, surgical interventions have also
been implemented. Techniques in stereotactic neurosurgery have been utilized for deep brain
stimulation, particularly of the pedunculopontine and subthalamic nuclei.8 Although
somewhat effective, no combination of drugs or surgical procedures has been found to cure
or even prevent the progression of PD.10 In addition, many medications can have unwanted
side effects; and neurosurgery is invasive and risky.
6
The remaining therapeutic approach for the treatment of PD is therapeutic exercise.
Due to the fact that PD is currently incurable and progressive, physical therapy in the form of
specific exercise prescription becomes increasingly more important to aid in the
improvement of body structure and functions, activity limitations and participation
restrictions. As such, physical therapy has the potential to improve the overall quality of life
for an individual. The specific physical therapy approaches to the treatment of PD are widely
variable but there is relevant evidence to support its use. The ongoing goal of evidence-based
practice is to establish clinical practice guidelines that have been shown to be effective for a
given pathology or patient population. This process is just beginning for the treatment of PD,
but a marked amount of research has already emerged in the past 10 to 20 years.11
Encouraging research has also emerged supporting the process of neuroplasticity and the
neuroprotective and healing roles of exercise.
The first randomized controlled trial investigating the effects of physical therapy on
people with PD was first published in 1981.12 Since that time, the evidence has greatly
evolved. In 2004, the first clinical practice guideline for physical therapy and PD was
published.11 This guideline focused on six core areas of treatment for people with PD: gait,
balance and posture stability, physical capacity, transfers, and reaching/grasping. The
majority of the existing published research for the treatment of PD has revealed a variety of
treatment options and also focuses on these same 6 core areas with the exception of reaching
and grasping.13-17
The role of physical therapy in gait training for the person with PD is multifaceted.
Morris, Martin and Schenkman18 proposed 3 major components that should be included in
any program aimed at improving gait disturbances: cognitive strategy training, management
7
and prevention of musculoskeletal and cardiovascular changes related to primary
pathological changes and secondary comorbities, and the promotion of lifestyle changes that
encourage overall health, well-being and prevention of falls. An intervention that has the
potential of fulfilling all of these components is treadmill training. Current research utilizing
treadmill training for the treatment of PD has been promising. Intensive treadmill training has
been shown to improve multiple gait parameters including gait speed, stride length and
walking distance, as well as the rhythmicity of movement and overall quality of life.8,15,17,19-21
In addition to forward treadmill training, backward walking, particularly with the
addition of an incline, may prove beneficial for people with PD. Studies investigating joint
kinematics and lower extremity muscle activity during backward walking has revealed
benefit in activation of the hamstrings, gastronemius, anterior tibialis, and rectus femoris.22
Ankle dorsiflexion range of motion has also shown improvement, particularly when the
activity is performed on an incline. Given that the main source of momentum for backward
walking is the combination of knee and hip extension, backward walking may be useful as an
intervention for precipitating and strengthening these particular muscle actions.23,24 Since the
task of walking backwards may be particularly difficult for people with PD,25 further
research investigating the possible benefits of backward walking for this population is
necessary.
Balance training also plays a key role in a majority of physical therapy programs for
PD.8,14,17,26 The methods of intervention are highly variable and range from traditional
balance exercises to whole body vibration,27 dance, body weight support treadmill training,
and Tai Chi.8,14,17,26,28,29 Despite the variability among treatment protocols, the evidence
suggests that physical exercise exerts positive acute effects on balance and postural stability
8
for people with PD. As a result of balance interventions, betterment of balance/postural
stability scores, improvement of functional status assessments, and an increase in latency to
falls have been seen.8,14,15,17,21,26,29,30 Further work is required in order to determine definitive
long-term effects.
Another primary focus for many physical therapy interventions is geared toward
improving a person’s overall physical capacity, including muscle strength, endurance,
flexibility and mobility.3 The goal is to combat both the effects of the disease process itself as
well as the secondary effects of immobility and aging that may contribute to the person’s
physical decline.31 Muscle weakness in PD, for instance, is a two-fold problem that stems
from both the decline of muscle power secondary to centrally induced bradykinesia and the
peripheral loss of muscle function that results from disuse and the aging process.32.33 At
present, there is some promising evidence to support the use of strength training to combat
muscle weakness (both centrally and peripherally induced) and subsequent decreased
mobility in people with PD.15,31,32 In general, the literature reveals that people with PD reap
similar benefits from exercise as those who do not have PD, such as increased muscle
strength, flexibility, and aerobic capacity.14,15,17,32 What is most important to this population
is that the addition of exercise to a medical regimen for PD can aid and improve an
individual’s ability to function and perform everyday tasks with less restriction.30
Improving mobility is a unifying factor among many of the current interventions
within the literature for this population. In general, people chosen for inclusion in these
studies are between the ages of 60-75 years old and exhibit mild to moderately severe
symptoms of their condition (Hoehn and Yahr scale 1-3).14,17,18,26 This demographic
9
concentration on people who have not reached the greatest severity of PD places the focus on
preventing the progression of symptoms in the early stages of the disease process.
This idea of prevention of progression is also reflected in a novel approach to an
intervention protocol that accounts for all the mobility constraints seen with PD by focusing
on the role of sensorimotor agility.3 The authors of this program proposed the use of
exercises from multiple arenas, including tai chi, boxing, kayaking, pre-pilates, agility and
lunges to target the mobility constraints posed by PD.3 The program also encourages the
coordinated effort among physical therapists and patients to gauge the choice,
implementation and progression of the program both in the lab and in the community of its
participants.3 The goal of such a program is not only to improve existing deficits but to slow
or prevent the onset of subsequent mobility-related problems. According to Horak and King,3
sensorimotor agility involves the “coordination of complex sequences of movements,
ongoing evaluation of environmental cues and contexts, the ability to quickly switch motor
programs when environmental conditions change, and the ability to maintain safe mobility
during multiple motor and cognitive tasks.” The basal ganglia play a key role in the
preparation, organization, modulation and subsequent execution of complex motor tasks.34 It
stands to reason that by focusing interventional techniques on such complex tasks, the brain
will be challenged to re-organize and compensate for otherwise damaged circuits.
This theory hinges on the inherent flexibility of the central nervous system.
Fortunately, research has been emerging that supports neuroplasticity of the brain and that
exercise may further enhance this process. In 2009, Hirsch and Farley35 summarized the
promising results of preliminary studies implicating the neuroprotective and neurorestorative
effects of exercise on animal models of PD. After undergoing surgery to induce the
10
symptoms of PD, animals that were stimulated to exercise just 24 hours after the procedure
showed comparable neurotransmitter function and behavior to the sham models. Conversely,
forced inactivity in animal models of PD has led to the progression of pathological symptoms
and neurochemical changes. Finally, the research also revealed that despite the evidence of
significant neuronal cell death, motor function of affected animals was at least partially
restored through an intensive and progressive exercise protocol. The results of these studies
are promising, but much more research needs to be completed in order to verify similar
implications for people with PD.35
The purpose of this single subject design was to determine the specific effects of a
customized and intense sensorimotor program on the body structure and function and
mobility restrictions seen in a higher functioning individual with PD. The exercise plan was
adapted based on a program previously proposed by Horak and King3 to suit the specific
needs of the participant. The plan consisted of an intense program integrating yoga, boxing,
core stability, balance training, treadmill walking and agility exercises. Although the existing
literature does not include research on the effects of yoga practice for people with PD, there
are a number of studies that reveal the physical benefits of yoga. Specifically, yoga was
chosen as an intervention for this participant because yoga has been shown to increase
muscle strength, muscle endurance, balance and flexibility.36-38 In addition, yoga involves
explicit movement and sub-movement sequencing that is coordinated with controlled
breathing, as well as verbal cuing from an instructor. The use of cueing and conscious
coordination of movement bypasses the impaired automaticity of neural programming that
can be seen in people with PD.14
11
Given the evidence supporting neuroplasticity and the known benefits of exercise for
people with PD, it was hypothesized that improvements would be seen in the participant’s
passive range of motion (PROM), flexibility, thoracic posture, muscle strength, aerobic
power, functional mobility, dynamic balance, and quality of life.
12
METHODS
Participant
The participant was a 57 year old male who lived in upstate New York. Four years
prior to the start of the study, he reported having difficulties swallowing, weakness in his
lower extremities (LE) and low back pain that progressively worsened over time. A year
later, he developed a left foot-drop and began shuffling his feet when ambulating. As a result,
his running pace and endurance decreased. Two years prior to the start of the study, he
developed facial tingling, decreased fine motor skills, and difficulty with voice projection
and was finally diagnosed with PD. He was taking Stalevo, Azilect, and Mirapex to combat
his symptoms. His past medical history included a meniscal tear of the right knee (1980s),
surgery for a deviated septum in 2006, a X-stop procedure to correct spinal stenosis in 2007
and a history of left shoulder pain. He was classified as Stage 1 according to the Hoehn and
Yahr scale.39
His hobbies included running (road races), biking, water skiing, snow skiing, and
dancing. Since the onset of his disease, he has been unable to perform these activities as
much or with the same intensity as he used to due to the symptoms of the disease. He had
decided to stop running regularly in the year prior to the start of the study, but was able to
resume recently. In the 6 weeks prior to the start of the study, he was running 3 miles once a
week to prepare for a road race. He was not able to run on a daily basis or participate in other
activities (snow-ski, water-ski, dance) to his satisfaction. Every morning, the participant
completed 20 minutes of exercise including inclining sit-ups, trunk rotation exercises, upper
extremity (UE) weights and using an inversion traction device. He also completed 30 minutes
of exercise on an elliptical every morning.
13
He worked full time (40+ hours) as a heavy machinery mechanic where he was
required to lift heavy objects, climb, push/pull, and use a 20 lb sledge hammer. He was on a
40 lb weight-lifting restriction from his physician, which he reports he often neglected in
order to complete his tasks at work (lifting brake drums and truck tires). He became easily
fatigued at work from the continuous manual labor. He also had increased difficulty with
dexterity, which was a problem since he was required to work on motors for 10 hours a day.
At initial evaluation, the participant reported increased left low back pain (4/10) in the
morning that increased when extending his left hip and which persisted at work. He was
independent with bed mobility, transfers, ambulation indoors and outdoors, negotiating stairs
and in activities of daily living. He reported using a railing whenever possible to negotiate
stairs. His cognitive status was intact to person, time, and place. He did display a slight
increase in muscle rigidity in all extremities especially on the left. His monosynaptic stretch
reflexes were normal on the right and slightly hypoactive on the left. UE and lower extremity
(LE) coordination was intact. Sensation was also intact throughout his body using a 5.07
monofilament and he denied any paresthesias. Position sense and kinesthesia were intact
distally.
The participant displayed the following impairments in body structures and function:
decreased PROM of shoulder flexion, abduction and internal rotation bilaterally, decreased
hip extension and internal rotation bilaterally, decreased ankle dorsiflexion bilaterally and
limited lumbar motion. He demonstrated limited flexibility of his hamstrings, hip flexors, and
tensor fascia latae bilaterally. See Table 1 for specific initial PROM measurements. He also
displayed significant weakness throughout his upper and lower extremities; however his
14
deficits were more prominent on the left side of his body. See Table 2 for specific initial
strength measurements.
The participant’s physician indicated that no precautions were necessary to physical
exercise, but that he should limit his road races to one race per year. The participant’s goals
were to improve his posture and to prevent worsening of his impairments in body structures
and functions and activity limitations. Informed consent was obtained by the participant. The
study was approved by the Institutional Review Board of The Sage Colleges.
Design
An ABC single subject design was utilized to determine the effects of a customized
and intense sensorimotor program in a higher functioning individual with PD. The dependent
variables used in this study were PROM, flexibility, thoracic posture, muscle strength,
aerobic power, functional mobility, dynamic balance, and quality of life. Repeated
measurements of the dependent variables were taken at biweekly intervals throughout the
course of the study.
During the baseline phase A, the participant performed his own 30-45 minute
exercise routine on a daily basis. The intervention phase (B) lasted 12 weeks, where
treatments were delivered twice a week for 1 1/2 hour sessions. The interventions were based
loosely on the exercise program developed by King and Horak3 and included balance
exercises; agility training; core stability; and strength and flexibility exercises. The original
exercises described by King and Horak were modified in order to meet the individualized
goals of the participant. Trunk rotation and lumbar extension were limited due to the
participant’s past medical and surgical history. During the final phase C, the participant was
15
instructed in an intense HEP which included two 30 minute dvd’s of guided yoga sessions
designed by the researchers.
Outcome Measures
The outcome measures were taken at The Sage Colleges in Troy, NY. The outcome
assessor was the principle investigator of the project who was a licensed physical therapist
with 22 years of clinical experience working with people with neurological diagnoses.
PROM, flexibility, thoracic posture, muscle strength, aerobic power, functional mobility, and
dynamic balance were investigated in this study. These tools were measured in the exact
same order every time. Quality of life was measured initially before the study began, after the
completion of the intervention, and then again 3 months later.
PROM and muscle length measurements were obtained using a Model G300
Whitehall Manufacturing goniometer. Only joint motions which were limited at initial
evaluation were monitored over the course of the study. The joints were measured from
proximal to distal in the following order: shoulder flexion, shoulder internal rotation, hip
extension, hip internal rotation, ankle dorsiflexion, hamstring muscle length, iliotibial (IT)
band muscle length, and hip flexor muscle length. The goniometer was aligned by using the
participant’s bony landmarks that were appropriate to identify each joint. The center of the
tool was aligned with the axis of the joint and the arms were positioned to bisect the rest of
the limbs in parallel. The extremity was moved just far enough so that no other bodily
compensations were present and no pain was elicited. Overall, intrarater goniometry has been
shown to be a reliable and valid tool when measuring upper and lower extremities of the
body.40-43
16
The BROM II was used to assess lateral trunk flexion and trunk rotation to both sides.
The procedures recommended by the instruction manual included with the BROM II, a
product of Performance Attainment Associates, St. Paul, MN were followed. Breum et al.44
found the BROM II to have good inter and intrarater reliability when tested on people
without lumbar hypomobility. The tool was suggested to be more reliable when measuring
flexion and lateral flexion (ICC=0.91 for intrarater and 0.85 for interrater). It was less
reliable when measuring extension and rotation (ICC=0.57 for intrarater and 0.36 for
interrater). Kachingwe45 also found the BROM to have good intrarater reliability for forward
flexion and sidebending (ICC=0.84-0.79 and 0.85-0.83 respectively), but poor interrater
reliability for those same motions. Tousignant et al.46 examined the criterion validity of the
BROM II and the gold standard, electrical digital inclinometer (EDI-320). They did find that
the EDI-320 demonstrated good validity, and there was also a good correlation between the
BROM II and the EDI.
A flexicurve ruler was utilized to measure the participant’s thoracic postural kyphosis
in the sagittal plane. This tool was a flexible ruler that could be contoured to fit the body to
record postural curvatures. With the participant standing as straight as possible, the ruler was
placed starting at the C7 spinous process and pressed along the thoracic spine down to the
lumbar spine at T12. The ruler was then placed flat on graph paper and its outline was traced.
Harrison et al.47 found the flexicurve to have poor concurrent validity when compared to the
gold standard (radiograph). It over-estimated cervical and lumbar lordoses and thoracic
kyphoses. However, Hinman48 found the flexicurve to have good interrater reliability
(ICC=0.94-0.73) when used to identify and document postural abnormalities in a community
based setting.
17
Muscle strength was measured using a Nicholas MMT Hand-Held Dynamometer,
produced by Lafayette Instruments, Lafayette, IN. This tool was used to measure the amount
of force (kg) generated by a group of muscles that performed a specific bodily action.
Procedures for use of this tool can be found in an article by Bohannon.49 The motions of the
upper and lower extremities were all measured from proximal to distal bilaterally from right
to left 2 consecutive times. The scores were then averaged before recording muscle strength
for that specific group. The participant was properly positioned on a plinth depending on
which motion was being tested at that time. He was then asked to “push” into the
dynamometer for a count of 5 by the researcher. The tool was reset, and the measurement
was repeated 5 seconds later. The Nicholas MMT dynamometer has been shown to be fairly
reliable between trials and days as long as the same researcher is providing the resistance and
the same dynamometer is used on the participant (ICC=0.58).50 When tested against the gold
standard (isokinetic dynamometry), hand-held dynamometry demonstrated concurrent
validity with acceptable values of 0.85 and 0.83.50 Bohannon49 found good to high reliability
when using a single, experienced researcher on 18 different body parts with correlations of
0.97 or 0.98.
Aerobic power was estimated using the Cooper 12 minute run/walk test to estimate
the participant’s endurance. The participant’s resting vitals (BP, HR, SaO2) were taken
before beginning the exercise test. He performed a 5 lap warm-up by walking in a 64’x 50’
rectangular area. He was instructed to run/walk at a comfortable pace for 12 minutes
(recorded using a digital stopwatch) while laps were counted to keep track of the distance
being traveled during the 12 minutes. When the time was up, his HR was immediately taken
and he was instructed to begin cool down (walking 5 laps). After 1 minute into the cool down
18
time, his BP was taken. His HR and SaO2 were taken 2 minutes after his BP was taken. The
total distance traveled was entered into a formula that computed VO2max. The formula for
this computation can be found in a previous article by Cooper.51 Grant52 compared the results
of the Cooper walk run test, multistage shuttle run test (MST), and a submaximal cycle test
on a treadmill for their ability to predict VO2max. They found that the Cooper test was the
best predictor out of the 3, with an ICC=0.92 when compared to the treadmill test. The MST
had an ICC of 0.86 when compared to the Cooper and an ICC=0.76 when compared to the
treadmill. Li et al.53 found the 6 minute walk test (6 MWT), which is a lesser demanding
form of the 12 MWT, to have good concurrent validity as well as a high degree of reliability
(ICC=0.96-0.89).
Functional mobility was assessed using the HiMAT.54 The HiMAT is a 13 item tool
which measures the participant’s ability to walk forward, walk backward, walk on toes, walk
over an obstacle, run, skip, hop forward, bound, and ascend and descend stairs with and
without a railing. All tasks were timed and given a specific score (0-5) with a possible
maximum score of 54 points. The tool required the participant to be able to ambulate 20m
independently without an assistive device. The tool came with instructions for the therapist
and verbal instructions to be delivered to the participant. The total of the task scores yielded
an overall score for that days’ performance. The actual total score cannot be equated to a
specific functional level and cannot be compared between different individuals. It can only
be used to monitor the performance and specific progress of the individual. The closer the
overall score is to the maximum score achieved, the higher functioning the participant.
Williams et al.54 found the HiMAT to have a high interrater reliability when the findings of 3
different therapists were compared (ICC=0.99). All items were in close agreement between
19
the therapists and varied by 0.1s or less. The tool demonstrates internal consistency, with a
Cronbach alpha equaling 0.97. The MDC with 95% confidence interval was determined to be
1±2.66 points. However, the HiMAT can only be scored in whole numbers, so the
participants would have to demonstrate decreased performance by 2 whole points or
improved performance by 4 points in order to demonstrate a statistically significant change.
Dynamic balance was measured using the limits of stability test (LOS) performed on
the NeuroCom Equi-Test, developed by NeuroCom International, Inc. The LOS quantifies
the maximum distance the participant can displace their center of gravity in 8 different
directions without losing their balance. It analyzes reaction time, movement velocity,
endpoint excursions, maximum excursion, and directional control. Reaction time was
measured in seconds and was defined by the amount of time it took the participant to begin to
weight shift or change his center of gravity (COG), once the cue was given. Movement
velocity was defined as the average speed used when performing a weight shift and was
measured in degrees times seconds. Endpoint excursion was the distance of the first attempt
to reach the target position and maximum excursion was the furthest distance the COG
travelled during the entire time trial. Directional control compared the amount of movement
in the intended direction to the amount of extraneous movement overall.
The protocols out of the Lab Manual included with the EquiTest were followed. The
participant was instructed to stand on the footplate inside the NeuroCom EquiTest. His feet
were positioned on the foot plate based on the instructions provided by the software for the
LOS assessment. The researcher corrected his foot alignment after each test to ensure
accurate results. An unpublished study written by Rose and McKillop in 1998 assessed the
reliability of each dimension measured by the LOS test. The correlation coefficient for
20
movement velocity was found to be high with an ICC=0.80. Reaction time (ICC=0.74),
maximum excursion (ICC=0.76), endpoint excursion (ICC=0.73), and directional control
(ICC=0.68) were found to have moderate reliability according to their correlation
coefficients. Clark et al.55 found this test to have a generalizability coefficient ranging from
0.69-0.91 (measures reliability of performance assessment). Liston et al.56 looked at the
reliability and validity of the balance master (BM), a computerized balance assessment tool
similar to the EquiTest. They found that the test was reliable in terms of both movement path
(ICC=0.84) and movement time (ICC=0.88). They also found concurrent validity only for
dynamic balance (r>0.48) and that dynamic balance is a better indicator of overall functional
balance.
The participant was administered the 39-item Parkinson’s Disease Questionnaire
(PDQ-39) at the commencement of the study, following phase B and after phase C. The
PDQ-39 is a quality of life questionnaire that specifically pertains to people living with PD.
There are 39 questions in total covering 8 different dimensions: mobility, ADL’s, emotional
well-being, stigma, social support, cognition, communication, and bodily discomfort. The
questionnaire allows one out of 5 possible responses (never, occasionally, sometimes, often,
always or cannot do at all) for how often each question has occurred over the last month.
Each dimension is calculated as a scale from 0 to 100, with zero being no problem at all and
100 being the maximum level of problem. Jenkinson et al.57 found the PDQ-39 to have high
internal reliability using a Cronbach alpha equaling 0.89, indicating the questionnaire was
internally consistent and also reproducible. Construct validity was also examined and found
to be moderate when the PDQ-39 was compared to both the Hoehn and Yahr scale (r=0.51)
21
as well as the Columbia scale (r=0.43) in regards to the mobility and ADL’s sections on the
PDQ-39.
The participant also kept track of his medications throughout the course of the study.
He recorded the type of medication taken each day along with the dosage. Data were
recorded into a Microsoft Excel 2003 spreadsheet on a Dell Latitude D520 laptop computer.
Procedure/ Interventions
Phase A consisted of a baseline period where the participant performed a home
program. He began his program by warming up on an elliptical machine for 10-15 minutes,
followed by stretches for lumbar musculature, triceps, and neck muscles. He then performed
core strengthening exercises (bridge and side bridges) as well as weighted sit ups on an
inclined bench, followed by arm curls, scapular retractions, bench presses, shoulder flies and
other free weight exercises to improve his UE strength. The exercises of his home routine
were observed initially to make sure the participant was performing them correctly; however
no new exercises were added. In general he was performing the exercises too quickly and
needed education to slow them down.
The purpose of Phase B was to target the participant’s impairments identified in the
initial evaluation. The aim was to give him a complete body workout emphasizing strength,
speed, agility, flexibility and balance. The participant received treatment twice a week for 12
weeks. The first session of the week consisted of general balance, agility, strengthening
exercises and stretches. These interventions were led by one of the researchers. The
participant started each session with a 20 minute warm up, which consisted of ten minutes of
forward treadmill walking and ten minutes of backward treadmill walking. Fifteen minutes of
balance exercises were performed after the warm up, progressing from Rhomberg stance to
22
more dynamic balance challenges. A variety of surfaces were used to challenge the
participant’s balance, including standing on foam, balance boards, toggles, and a foam roller.
To increase the challenge of exercises, ball passing, ball rolling, theraband pulls, trunk
rotations and varied stance positions were incorporated.
Agility followed balance training for 20 minutes, using an agility ladder and floor
exercises. Agility ladder drills consisted of shuffling, 90° and 180° rotations, single and
double leg hops, and braiding. Other treatments such as boxing, bounding, or circle running
were added based on participant response. He then participated in 20 minutes of core stability
as well as upper and lower body closed chain strengthening exercises using body weight as
resistance. All sessions ended with manual stretching for 5 minutes.
Over the intervention period the challenge and volume of the exercises increased.
Increasing the challenge of the exercises prescribed was based on visual analysis of the
participant’s form and his reports of increasing ease with the activity. The intention was to
create a repetitive but intense intervention program. Vitals were assessed before and after
warm-up and after the intervention was performed. Table 3 shows the specific exercises that
were performed for each session during the intervention phase.
The second session of the week consisted of yoga, where each session was personally
led by one of the researchers who had 12 years experience practicing yoga. Sessions ranged
from 1 to 1 1/2 hours long. He first warmed up by walking both forward and backward on a
treadmill for a total of 20 minutes. Traditional hatha yoga asanas (postures) were chosen to
address the participant’s specific physical needs.58-60 Standing, arm supported, seated, and
recumbent yoga poses were utilized to encourage overall strength, balance, and flexibility.
The participant was also taught diaphragmatic breathing to practice during each of the poses
23
to help with relaxation. Table 4 shows which poses were completed on which days over the
course of the 12 weeks. The participant’s blood pressure (BP) and heart rate (HR) were taken
before exercise, after warmup, and after the intervention for each session.
Phase C was similar to Phase A. The researchers modified his normal morning
exercise routine with the addition of several exercises learned throughout the intervention
phase. His HEP was performed 6 times each week and was broken into 3 types, an “arm
day”, a “leg day” and a yoga day. Each day began with UE and LE stretching. On an arm day
the workout consisted of UE isometrics, abdominal strengthening, UE free weight
strengthening, press-ups, and planks. On a leg day, he would perform isometrics, abdominal
strengthening, bicycle kicks, squats, toe raises, and agility work. On a yoga day, he would
perform various beginner poses to increase the flexibility of his trunk, upper and lower
extremities. See Appendix A for a copy of the HEP and the exact intervention routine given
to the participant. On a yoga day, he performed yoga exercises by following one of two tapes
developed by the researcher. The first tape was a recording of the participant’s last yoga
session during phase B, including both the participant and one of the researchers performing
basic yoga poses that had been incorporated into the intervention. The second tape featured
the researcher performing slightly more challenging poses that had been used in the
intervention phase of the study.
Data Analysis
Data analysis was conducted using visual analysis and the two standard deviation
band method. Visual analysis was performed on all outcome measures to identify changes in
level, trend and variability.
24
The two standard deviation band method was performed on all outcome measures
except the quality of life measure PDQ-36 and the IT band range of motion. The PDQ-36
was not measured at 2 week intervals, thus there were not enough data points for proper
analysis. Also, the accepted measure of the IT band does not provide continuous data for
analysis. The two standard deviation band method was used for analysis as it is appropriate
for baselines with greater variability.61,62 Data from Phase A was compared to Phase B and
data from Phase B was also compared to Phase C. In order for a phase to be considered
significant at the 0.05 alpha level, at least 2 points had to fall outside the 2 standard deviation
band.
25
RESULTS
The results demonstrate an increase in PROM, flexibility, thoracic posture, muscle
strength, certain aspects of functional mobility and reaction time. There were significant
improvements in PROM of right trunk lateral flexion, shoulder flexion bilaterally, shoulder
internal rotation bilaterally, hip extension bilaterally, right hip internal rotation and ankle
dorsiflexors bilaterally from Phase A to Phase B. Trunk rotation bilaterally, left trunk lateral
flexion, and left hip internal rotation were not significant from Phase A to Phase B.
Significant findings from Phase B to Phase C were in left shoulder flexion, left hip extension,
right hip internal rotation, and ankle dorsiflexors bilaterally. There was no significant loss of
PROM in any phase. See Table 5 for results of PROM testing. There was a significant
improvement in thoracic posture from Phase A to Phase B, with no significant change from
Phase B to Phase C.
Significant improvements were noted in flexibility of the right hamstrings, and hip
flexors bilaterally from Phase A to Phase B. Left hamstring flexibility did not change. There
were no significant changes from Phase B to Phase C in flexibility. IT band muscle length
testing was not evaluated using the 2 standard deviation band method. However, the IT band
range improved from 25 to 0 centimeters in the sidelying position which put the participant’s
leg on the examination table. There was no significant loss of muscle length in any phase.
See Table 5 for results of muscle length analyses.
There were significant improvements in muscle strength for all evaluated muscle
groups from Phase A to Phase B except for left elbow flexion and right hip extension. From
Phase B to Phase C, the only significant improvement in muscle strength was with the right
26
ankle plantarflexors. There was no significant loss of muscle strength in any phase. See Table
6 for results of the muscle strength testing.
There were no significant changes on the overall functional mobility scores, using the
HiMAT, from Phase A to Phase B or from Phase B to Phase C. Walking over obstacles,
bounding with either leg, and ascending stairs did improve significantly from Phase A to
Phase B. Walking, walking backwards, walking on toes, running, skipping, hopping forward
and descending stairs did not significantly improve. There were no significant improvements
from Phase B to Phase C in any individual category. There was no significant loss on
functional mobility in any category during any phase. See Table 7 for the results of HiMAT
testing.
There were significant changes in reaction time with LOS testing from Phase A to
Phase B. There were no significant changes in LOS testing in movement, end point
excursions, max excursions, or directional control from Phase A to Phase B. There were
significant changes in dynamic balance with LOS testing in the category of end point
excursion from Phase B to Phase C, but no significant change in reaction time, movement
velocity, max excursion or directional control from Phase B to Phase C. See Table 8 for
results LOS testing.
Self reported quality of life was measured using the PDQ-39 at the start of the study
and after the intervention. His scores improved from 24.35 prior to intervention, to 20.28 at
the end of the intervention, to 4.75 at the end of post intervention assessment. See Table 9 for
PDQ-39 results.
The participant has reported several instances where coworkers have noted an
improvement in his physical appearance and fitness level. In one instance, the participant’s
27
increased flexibility allowed him to work on a heavy motor in a tight space while a younger
coworker remarked at his flexibility and dexterity. The participant’s friends and relatives
have noted that he now stands more erect and has the body of a younger man. Several friends
have told the participant that he looks great and inquired what he was doing to stay in such
great shape.
At the beginning of the study the participant was taking 6 doses of 150 mg Stalevo,
one dose of 1mg Alilect, and 3 doses of 0.5 mg Myoplex daily. His medications were
updated February 2010 to 6 doses of 200 mg Stalevo, one dose of 1 mg Azilect, 3 doses of
0.5 mg Pramipexole daily. His medications were updated again August 2010 to 4 doses of
200 mg Stalevo and one 1 mg Azilect daily. See Table 10 for a listing of his medications
throughout the study.
ICCs were calculated for all strength outcome measures and were found to be at least
0.80, demonstrating a high level of reliability. During all interventions, HR and BP were
monitored and remained within the American College of Sports Medicine guidelines.63
He appeared to maintain muscle length, posture, strength (except for bilateral knee
flexion and extension) and times on the limits of stability testing at 6 month follow up. He
performed all items on the HiMAT faster, although he was not able to bound as far. His total
score improved another 6 points. See Tables 5, 6, 8 and 9 for specific values at 6 month
follow up. He reported he completed one 5K road race, had gone downhill skiing and still
worked 46 hours/week.
28
DISCUSSION
The purpose of this single subject design was to determine the effects of a 12-week
customized program integrating flexibility, strengthening, and agility exercises on a 57 year
old man diagnosed with Parkinson’s disease. The results support the hypothesis that the use
of such a program can increase PROM, flexibility, thoracic posture, muscle strength, certain
aspects of functional mobility, and reaction time. In addition, the results support the use of
this program for enhancing perceived quality of life.
Improvements in PROM were noted in all areas following the intervention except for
left trunk lateral flexion, bilateral trunk rotation, bilateral hip internal rotation, and left ankle
dorsiflexion. The large improvements in PROM and flexibility were expected since
previously published literature has found stretching, performing a warm-up, and/or yoga can
significantly increase range of motion and flexibility.64-68
Our results support the use of yoga to improve overall flexibility. We were somewhat
surprised that not all motions significantly improved. However, plausible reasons have been
provided to explain our findings. The poses utilized may not have had a strong enough focus
on rotational movements in the trunk. Due to his history of spinal stenosis and X-stop
procedure, the therapist chose not to have a prominent emphasis on trunk rotation for concern
of adverse effects. It is also possible that the participant actually improved in trunk rotation
PROM, but the BROM was not a reliable tool for detecting the change. As stated earlier, the
BROM has weak reliability in detecting rotation changes with an interrater reliability of only
0.36.44
29
The lack of improvement seen in bilateral hip internal rotation PROM can also be
contributed to the lack of emphasis in the exercise program. Specific exercises, stretches, and
yoga poses were not employed to increase motion to the internal rotators.
Interventions such as walking on an incline should have improved the participant’s
left ankle dorsiflexion PROM as evidenced by research from McIntosh and collegues.69 The
participant was at nearly 0° of dorsiflexion at the beginning of the study, displaying almost
no passive dorsiflexion. By the end of phase B, the participant was able to passively reach
10° of motion. According to Neumann, the average speed of ambulation requires
approximately 10° of dorsiflexion.70 Although statistically significant changes were not
found, the difference of 10° of motion can be enough to decrease or abolish an abnormal gait
pattern.70
The results of our research study were similar to those reported by Tekur and
colleagues71 that flexibility in lateral flexion significantly improved only on one side.
Justification of the findings was not provided in the study. Likewise, we also could not find
a logical explanation to rationalize the results.
Improvements were seen in muscle length of bilateral IT bands, hip flexors, and the
right hamstrings which were the expected outcomes based on the stretches that were
provided for these areas. Yoga poses that were used to target the IT bands included extended
side angle, pigeon, warrior II, and a modified child’s pose that incorporated twisting to either
side. Hip flexor lengthening was achieved through multiple yoga poses including warrior I
and II, pigeon, lunges, bridge, upward plank and the tabletop pose. The hamstrings were
targeted through warrior III, extended hand-to-toe, seated forward bend, wide stance forward
bend, staff, great seal, boat, and downward-facing dog pose. On non-yoga days, sessions
30
were concluded by the therapist performing manual stretches to bilateral hamstrings,
quadriceps, piriformis, and gastrocs. Self stretches to these areas including the IT band were
given in a HEP. It was expected the left hamstrings would also improve as both sides started
out at the same muscle length and there does not seem to be a limiting factor preventing the
left side from improving. The fact that it did not improve was surprising.
The participant’s thoracic kyphosis improved significantly and positively affected his
posture. Although lumbar extension exercises were intentionally limited during yoga, a large
emphasis was placed on thoracic extension and upper chest expansion during yoga as well as
other parts of the exercise program. The main methods for improving the participant’s
kyphosis were through scapular strengthening exercises and performing a thoracic extension
stretch over a bolster at the completion of each session. Specific yoga poses used to target
this area included warrior I, cat/cow, staff, bridge, tabletop, butterfly, and the sun salutation
series.
Almost all muscle groups in the upper and lower extremity were stronger at the end
of the intervention phase except for the left elbow flexors and the right hip extensors. In the
areas that did improve, substantial gains were made. The results are consistent with the
literature that exercise of appropriate intensity can be effective in improving strength.15, 31,72
The majority of the research related to PD has reported improvements in LE muscle strength
with limited attention to UE strength. It is important to note that the whole body should be
addressed and that improvements in upper body strength can be enhanced through exercise
also. Most of the upper body strength in this exercise protocol was addressed using yoga and
included poses such as static plank, downward dog, push-ups, and quadruped while
maintaining contralateral arm and leg in an elevated position.
31
The right hip extensors were stronger than the left at the start of the study. Due to the
fact that they were already fairly strong, a more intense strengthening protocol may have
been required to see significant changes. Likewise, the left elbow flexors were stronger than
the right at the start of the study. The results are inconsistent with literature reported by Tran
and colleagues that found yoga to increase elbow strength.38 Unilateral exercises may have
been a better choice so that each arm could work to its strength potential.
Measurements for muscle strength were taken twice per muscle so intraclass
correlation coefficients were calculated to compare the two repeated measures. ICC values
were over 0.81, indicating good to excellent agreement and 19 of the 26 muscles had ICC
values greater than .90 indicating excellent agreement, thereby demonstrating acceptable
measurement reliability.73
Aerobic power did not improve over the course of the study. This could be because
his VO2 max was already within normal ranges at the start of the study. The Phase A
baseline value was 51.99, which is not only above the 90th percentile for his age and gender,
but is also above the 90th percentile for males between ages 20-29.51 Since the participant
had very high values at the start of the study, there was minimal room for improvement to
occur. In addition, the exercise program lacked endurance training.
Although major improvements were noted in the participant’s impairments, carry
over to functional mobility was not completely supported by our data since his total score on
the HiMAT was not found to be statistically significant. In addition, statistically significant
changes were not noted on the total score but his score improved by 9 points, which is greater
than the documented MDC value of 4.74 Although his total score did not improve, significant
improvements were found in the participant’s ability to walk over obstacles, bound, and
32
ascend stairs which are areas that may help improve the participant’s ability to negotiate his
work and community environments. The remaining items on the HiMAT showed
improvements in the raw scores but were found to be statistically insignificant; for example,
backwards walking speed improved by 0.9 seconds and walking on tip toes improved by 1.2
seconds. At the initial evaluation only 3 of the testing areas scored at the highest level (1-5
point scale with 5 being the highest score). At the final evaluation, all of the participant’s
scores improved by at least 1 point with 7 of the 11 items scoring at the highest level. The
results indicate that the participant either met or was approaching normative values.
The participant's improvement in reaction time on the LOS test can most likely be
attributed to the extensive use of agility exercises in Phase B. Faster reaction times are
important for people with PD because bradykinesia affects voluntary and reactive LOS.3 As
reported by King and Horak,3 increasing the speed of self-initiated movements will help
lessen the effects of bradykinesia. The participant’s data was compared to normative data for
a 57 year old on the LOS test and the results showed he was within normal ranges for
reaction time by the end of the intervention. Our results agree with the study published by
Lord and collegues72 that a sensorimotor exercise program can increase reaction time.
Changes in movement velocity, maximum and endpoint excursions, and directional
control on the LOS were not statistically significant. These results were inconsistent with
our expectations and other findings26 since a large emphasis was placed on dynamic balance
activities. Even though his improvements were not statistically significant, his improvements
did place him close to or at normal ranges for all of the tests. Normative values for the LOS
test have been noted by Rose and McKillop (unpublished data, 1998). When taking standard
deviations into account, maximum excursion was within normal limits after completing the
33
intervention phase of the study (Phase B). The normative range for maximum excursion is
from 92.1-103.9 and our participant scored a 97. Endpoint excursion was also very close to
normal ranges. Normal values range from 76.6-93.2 and he scored a 75.67. His movement
velocity was 3.12 degrees/second while normative values range from 3.5-6.5 and his
directional control score was 86.17 with normal values between 69.2-81. The participant
reached 100% on the maximum excursion test during Phase B which hindered his ability to
make improvements in this area during the remaining time of this phase. As a result,
statistical analysis did not pick up on the improvement. At this time there is no information
regarding values of clinical significance for the LOS test.
The focus of Phase C was to maintain the newly acquired improvements from Phase
B. The scores on all outcome measures either remained the same or improved, indicating the
improvements were maintained even after the exercise program was terminated. This could
be because the participant continued to utilize his HEP which included stretching, upper and
lower extremity strengthening exercises, core stability exercises, yoga, and balance
activities.
The exercise program utilized was intensive in nature. It incorporated high intensity
activities with repetition and long durations which is probably why it yielded positive results.
By using an intensive program, the participant was pushed to his maximum potential which
is necessary to achieve optimal results. One of the drawbacks of using an intensive exercise
program is the risk of injury. During the study the participant had a flare up of a reoccurring
shoulder injury which was believed to be attributed to doing too many push-ups during yoga.
Following ice, the problem quickly resolved with no lasting implications.
34
It is important to note that the participant in this study was highly motivated and
reported that he enjoyed coming to the sessions. It is believed that his determination and
dedication to the program were important components to his success. The participant
reported an improved quality of life when in Phases B and C of the research study. He
reported increased energy and strength, improvements in his posture, and improvement in his
shuffling and bradykinesia over extended periods of time. The participant informed the
research team that his doctor was able to decrease his medications from 11+ pills a day to 4
pills per day and could not be more thankful to the research team.
There were several limitations to this study. First, generalizability is limited in single
subject designs. However, since we used a single subject, the exercise program could be
tailored to his impairments and goals, which is an important aspect to physical therapy
practice. We were able to start him at a level that was appropriate for his capabilities and
progress him as needed. A less individualized approach would be required if a protocol was
developed for multiple participants for a randomized controlled trial (RCT).
Second, the outcome assessor was the primary investigator and was not blinded
which could have introduced bias. An independent scorer masked to the study would have
eliminated the risk of a potential examiner bias. Third, although the HiMAT is a reliable and
valid tool for evaluating higher level function for 18-25 years old who have been diagnosed
with a TBI, it has not been validated in those with PD. In addition, the items of the HiMAT
were not specific to the goals of this participant. The outcome assessment tool did not include
work related tasks and we were not able to objectively measure his self reported
improvements in functioning at work. Using a modified functional capacity evaluation
35
(FCE) tool given at the start and end of the study may have picked up changes in work
functioning which were not picked up by the HiMAT.
Fourth, the likelihood that this intense 12-week program could be carried over to the
clinical setting may be hindered by limited insurance coverage unless the person was able to
private pay. An alternative solution could be to set up the program so it begins in an
outpatient clinical setting with one-on-one supervision and progress to a group class at the
clinical site using private pay. This concept is similar to the approach currently utilized in
cardiac rehab. Some physical therapy clinics already allow for memberships to use their gym.
This could be an added class to the membership for an additional fee. Another option is to
set up a program at a local YMCA or another type of fitness/wellness center where group
classes could be given as part of the facility membership.
One of the most noteworthy strengths of this study is that the exercise program
administered was of adequate intensity to produce positive and lasting results on all outcome
measures at 6 month follow up. The intensity allowed for long lasting results after treatment
was terminated with possible changes in neuroplasticity or learned motor control. When
considering the nature of the disease, one would expect the participant to become
progressively more debilitated with time. Since all areas tested remained the same or
improved, it is possible that debilitating changes were halted through the use of an exercise
regimen. Having a way to control the snowballing effects of the disease through means other
than medication is a valuable tool that can be implemented with very minimal adverse
effects.
A second strength of this study is that the research design was set up to control for
various factors and show some evidence of cause and effect. The intervention phase was long
36
enough to allow for sufficient time to see changes in both the neuromuscular and
musculoskeletal systems. In addition, by having a Phase C and 6-month follow up we were
able to see if the program was sufficient enough to providing lasting effects once the program
was terminated.
A third strength of the study is that there were a sufficient number of outcome
measures. By having several outcome measures, we were able to assess the effectiveness of
our treatment program in multiple dimensions.
Suggestions for future research would be to increase the sample size and conduct an
RCT utilizing a program that integrates flexibility, strengthening, and agility exercises. A
blinded examiner to take measurements would be beneficial to eliminate the risk of examiner
bias. Last, find an evaluation tool for function that has been norm-referenced for the
population in the study.
37
CONCLUSION
A 12 week customized program integrating flexibility, strengthening, and agility
exercises is an effective dose of exercise and intensity for improving PROM, flexibility,
thoracic posture, muscle strength, and certain aspects of functional mobility, dynamic
balance and perceived quality of life. The exercise program utilized in this study seems to
have a promising future in delaying the effects of the disease process as well as provide a
means of counteracting the impairments that are associated with the disease. In just 3
months, dramatic changes were made in the participant’s capabilities. The hope is that
through future research, this type of exercise program could be used to help delay the onset
of symptoms related to Parkinson’s disease and allow individuals to continue to participate
and enjoy work, leisure, and community activities without being hindered by the effects of
the disease for longer periods. Further research in this area should be explored to support the
findings.
38
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47
Table 1. Initial Passive Range of Motion Measurements
PROM
Right
Left
Shoulder Flexion
0-160º
0-150º
Extension
WNL
WNL
Abduction
0-160º
0-150º
Internal Rotation
0-55º
0-50º
External Rotation
WNL
WNL
Elbow Flexion
WNL
WNL
Extension
WNL
WNL
Wrist Flexion
WNL
WNL
Extension
WNL
WNL
Fingers
WNL
WNL
Hip Flexion
WNL
WNL
Extension
0-10º
0º *
Abduction
WNL
WNL
Internal Rotation
0-30º
0-40º
External Rotation
WNL
WNL
Knee Flexion
WNL
WNL
Extension
WNL
WNL
Ankle Dorsiflexion
0-5º
0-5º
Plantarflexion
WNL
WNL
Inversion
WNL
WNL
Eversion
WNL
WNL
48
Table 2. Initial Strength Measurements
STRENGTH (kg)
Shoulder Flexion
9.8/7.1
2.0/3.3
Extension
7.8/6.1
7.3/1.4*
Abduction
13.4/13.7
8.9/7.1
Adduction
9.1/5.9
5.1/4.4
Elbow Flexion
12.6/10.7
17.1/3.8*
Extension
10.6/8.6
11.3/12.6
Hip Flexion
11.3/10.0
12.0/7.1
Extension
11.4/10.1
4.7/7.7
Abduction
8.8/9.5
1.8/3.0
Knee Flexion
0.0/0.0
0.0/0.0
Extension
9.5/5.0
11.5/4.2
Ankle Dorsiflexion
4.3/8.2
0.0/0.0
Plantarflexion
5.8/4.4
1.2/1.6
49
Table 3. Phase (B) Exercises Completed During the First Session of the Week
Forward Treadmill Walking (10min)
Backwards Treadmill Walking
(10min)
Breathing Exercise
Balance Exercises on Airex Pad
Agility Ladder Drills
Circle Runs
Core Stability Exercises
Various Bridges
Hip Extension on Ball
Boxing
Squats
Hamstring Curl
Balance Exercises on Toggles
Yoga Tree Pose
Skipping
Bounding
Core Stability Exercises
Prepilates
Limits of Stability on Equitest
LE Stretches
Thoracic Stretch
Toggle Tug of War
Balance on Foam Roller
a added incline
b while holding water
c with rotation and hops
d on Airex Pad
e on toggles
f required assistant to complete
g with weights
EO/EC: Eyes Open Eyes Closed
* activity performed
Week 1-3
*
Week 4-8 Week 9-12
*a
*a
*
*
*
*
*
*a
*
*
*
*
*f
*b,c
*
*d
*
*EO/EC
*
*
*
*
*
*a
*
*
*e
*g
*EO/EC
*EO/EC
*
*
*
*
*
*
*
*
50
Table 4. Phase (B) Yoga Practice
Cat/Cow
Sun Salutation
Chatarunga
Modified Lunges
Chair Pose
Warrior III
Table Top
Reverse Plank
Straddle Kicks
Scissor Kicks
Savasana
Quadraped with Arm/Leg Lifts
Lat Pulls in Prone
Lunges
Warrior I
Warrior III
One Legged Warrior II
Reverse Warrior
Long Sit Stretch
Tree Pose
Pigeon
Ankle to Knee Pose
Straddle Forward Bend
Standing Single Limb SLR
Pilates 100s
One Leg Chair
Seated SLR
Side Angle Lunge
EO/EC: Eyes Open/Eyes Closed
SLR: Straight Leg Raise
* Activity performed
Week 1-3
*
*
*
*
*
*
*
*
*
*
*
*
*
Week 4-7
*
*
*
Week 8-12
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
EO/EC
*
*
*
*
*
*
*
51
Table 5. Results of the 2 Standard Deviation (SD) Band Testing: Range of Motion and Muscle Length
Percentage
Change from
Phase A to
Phase B
Phase B
Mean ±SD (Degrees)
Phase B
2 SD Band
Significant
Change from
Phase B to
Phase C
Percentage
Change
from Phase
A to Phase
B
Phase C
Mean
(Degrees)
Passive Range of Motion
Phase A
Mean ±SD
(Degrees)
Phase A
2 SD Band
Significant
Change from
Phase A to
Phase B
Trunk lateral flexion – Right
9±1.1
11.20 to 6.80
Yes
37.0
12.33±3.44
19.21 to 5.45
No
(-)5.9
11.6
NT
Trunk lateral flexion – Left
8.67±1.63
11.92 to 5.4
No
42.2
12.33±3.44
19.21 to 5.45
No
(-) 9.2
11.2
NT
Trunk rotation – Right
4.5±2.17
8.84 to 0.16
No
10
4.95±2.42
9.79 to 0.11
No
21.2
6
NT
Trunk rotation – Left
4.5±1.22
6.94 to 2.06
No
33.3
6±1.26
8.52 to 3.48
No
0
6
NT
Shoulder flexion - Right
154.17±4.92
164.01 to 144.33
Yes
5.9
163.33±6.83
176.99 to 149.67
No
(-)0.5
162.5
160
Shoulder flexion - Left
149.17±2.04
153.22 to 145.09
Yes
5.9
158±2.74
163.48 to 152.52
Yes
1.3
160
165
Shoulder IR - Right
54.17±3.76
61.70 to 46.65
Yes
18.5
64.17±6.65
77.47 to 50.87
No
(-) 3.9
61.67
65
60.83
65
-3.4
Six Month
Follow
UP
Shoulder IR - Left
53.33±4.08
61.49 to 45.17
Yes
18.1
63±4.47
71.94 to 54.06
No
Hip extension - Right
-3.33±4.08
4.83 to -11.49
Yes
300
6.67±2.58
11.83 to 1.51
No
50
10
10
Hip extension - Left
-0.83±2.04
3.25 to -4.91
Yes
602
4.17±2.04
8.25 to 0.09
Yes
99.8
8.33
10
Hip IR- Right
33.33±4.08
41.49 to 25.17
No
17.5
39.17±2.04
43.25 to 35.09
Yes
6.4
41.67
30
Hip IR - Left
36.67±4.08
44.83 to 28.51
No
11.3
40.83±4.92
50.67 to 30.99
No
2.1
41.67
30
Ankle DF - Right
3.33±2.58
8.49 to -1.83
Yes
125.2
7.5±2.74
12.98 to 2.02
Yes
88.9
14.17
10
Ankle DF - Left
1.67±2.58
6.83 to -3.49
No
249.1
5.83±3.76
13.35 to -1.69
Yes
12.5
10
Muscle Length
Phase A
Mean ±SD
(Degrees)
Phase A
2 SD Band
Significant
Change from
Phase A to
Phase B
Percentage
Change from
Phase A to
Phase B
Phase B
Mean ±SD (Degrees)
Phase B
2 SD Band
Significant
Change from
Phase B to
Phase C
114.4
Percentage
Change
from Phase
A to Phase
B
Phase C
Mean
(Degrees)
Hamstring – Right
53.33±4.08
57.49 to 45.17
Yes
21.9
65±6.12
77.24 to 52.76
No
5.1
68.33
70
Hamstring – Left
53.33±8.16
69.65 to 37.01
No
23.8
66±4.18
74.36 to 57.64
No
6.1
70
65
Hip flexors – Right
-5.00±0.00
Yes
180
4±2.24
8.48 to -0.48
No
4.3
4.17
10
Hip flexors - Left
-4.17±2.04
(-) 5 to (-) 5
(-) 0.08 to
(-)8.24
Yes
124.0
1±2.24
5.48 to -3.48
No
317.0
4.17
5
NT – Not tested at follow up
52
Table 6. Results of the 2 Standard Deviation (SD) Band Testing: Muscle Strength
Percent
Change
from
Phase A
to Phase
B
Phase C
Mean
(Kg)
Six
Month
Follow
Up
Percent Change from
Phase A to Phase B
Phase B
Mean ±SD (Kg)
Phase B
2 SD Band
Significant
Change
from Phase
B to Phase
C
19.78 to 10.04
No
19.2
17.78
16.1
Muscle Strength
Phase A
Mean ±SD (Kg)
Phase A
2 SD Band
Significant
Change from
Phase A to
Phase B
Shoulder Flexors – Right
8.28±0.64
9.56 to 7.00
Yes
80.2
14.92±2.44
Shoulder Flexors – Left
5.21±2.27
9.75 to 0.67
Yes
152.0
13.13±2.95
19.03 to 7.23
No
25.2
16.31
17.1
Shoulder Extension – Right
8.6±2.42
13.44 to 3.76
Yes
121.5
19.05±1.56
22.17 to 15.93
No
10.7
21.08
16.8
Shoulder Extension – Left
6.11±1.28
8.67 to 3.55
Yes
141.6
14.76±3.31
21.38 to 8.14
No
11.3
16.42
15.5
Shoulder Abduction – Right
14.5±1.54
17.58 to 11.42
Yes
21.9
17.68±0.56
18.80 to 16.56
No
3.1
18.23
19.9
Shoulder Abduction – Left
9.84±2.36
14.56 to 5.12
Yes
58.3
15.58±1.91
19.40 to 11.76
No
7.8
16.8
16.9
Shoulder Adduction – Right
6.65±3.99
14.63 to -1.33
Yes
139.6
15.93±4.98
25.89 to 5.97
No
4.7
16.67
13.5
Shoulder Adduction – Left
5.83±3.11
12.05 to -0.39
Yes
100.7
11.7±3.24
18.18 to 5.22
No
40.6
16.45
14.6
Elbow flexion – Right
10.38±3.79
17.96 to 2.80
Yes
82.9
18.98±3.96
26.9 to 11.06
No
16.3
22.08
24.0
Elbow flexion – Left
7.76±4.8
17.36 to -1.84
No
134.0
18.16±3.2
24.56 to 11.76
No
19.2
21.64
23.5
Elbow extension – Right
8.63±1.12
10.87 to 6.39
Yes
79.4
15.48±2.28
20.04 to 10.92
No
16.5
18.03
16.1
Elbow extension – Left
8.08±2.99
14.06 to 2.10
Yes
105.1
16.57±1.75
20.07 to 13.07
No
17.9
19.54
15.9
Hip flexors – Right
8.27±2.44
13.15 to 3.39
Yes
101.9
16.7±3.2
23.10 to 10.30
No
13.5
18.96
16.5
Hip flexors – Left
4.08±3.64
11.36 to -3.20
Yes
295.8
16.15±4.56
25.27 to 7.03
No
25.6
20.28
19.0
Hip extensors – Right
9.7±2.37
14.44 to 4.96
No
21.75
11.81±2.38
16.57 to 7.05
No
14.2
13.49
16.45
Hip extensors – Left
5.46±1.74
8.94 to 1.98
Yes
66.1
9.07±1.32
11.71 to 6.43
No
6.4
9.65
14.1
Hip Abductors – Right
7.35±1.86
11.07 to 3.63
Yes
152.2
11.19±2.31
15.81 to 6.57
No
44.3
16.15
13.0
Hip Abductors – Left
4.03±1.2
6.43 to 1.63
Yes
130.0
9.27±2.87
15.01 to 3.53
No
58.8
14.72
11.0
Knee flexors – Right
2.05±3.25
8.55 to -4.45
Yes
409.8
10.45±4.12
18.69 to 2.21
No
-20.8
8.28
2.8
Knee flexors – Left
0.28±0.63
1.54 to -0.98
Yes
2182.1
6.39±5.3
16.99 to -4.21
No
15.5
7.38
5.0
Knee extensors – Right
11.17±3.06
17.29 to 5.05
Yes
115.9
24.11±6.83
37.77 to 10.46
No
36.2
32.84
20.1
Knee extensors – Left
6.86±2.15
11.16 to 2.56
Yes
273.8
25.64±5.33
36.30 to 14.98
No
21.6
31.18
24.5
Ankle DF – Right
1.83±2.71
7.25 to (-) 3.59
Yes
742.1
15.41±3.77
22.95 to 7.87
No
19.7
18.45
22.2
Ankle DF – Left
1.83±2.35
6.53 to (-) 2.87
Yes
518.0
11.31±4.13
19.57 to 3.05
No
16.8
13.21
15.7
Ankle PF – Right
6.9±1.39
9.68 to 4.12
Yes
160.6
17.98±4.36
26.70 to 9.26
Yes
54.8
27.83
25.5
Ankle PF – Left
4.65±3.25
11.15 to (-)1.85
Yes
278.1
17.58±6.72
31.02 to 4.14
No
60.3
28.18
22.6
53
Table 7. Results of the 2 Standard Deviation (SD) Band Testing: HIMAT
Phase A
2 SD Band
Significant
Change from
Phase A to
Phase B
Phase B
Mean ±SD
(Seconds)
Phase B
2 SD Band
Significant
Change from
Phase B to Phase
C
Phase C Mean
(Seconds)
5.11±0.19
5.49 to 4.73
No
4.85±0.35
5.55 to 4.15
No
4.53
3.97
Walk Backward
6.45±0.48
7.41 to 5.49
No
5.54±0.26
6.06 to 5.02
No
5.8
5.06
Walk on Toes
5.98±0.34
6.66 to 5.30
No
5.45±0.3
6.05 to 4.85
No
5.44
4.87
Walk over Obstacle
5.32±0.17
5.66 to 4.98
Yes
4.85±0.63
6.11 to 3.59
No
4.84
4.15
Run
1.97±0.3
2.57 to 1.37
No
1.47±0.42
2.31 to 0.63
No
1.94
1.6
Skip
4.23±0.33
4.89 to 3.57
No
4.06±0.41
4.88 to 3.24
No
3.89
2.9
Hop forward (affected)
6.48±0.91
8.30 to 4.66
No
4.97±0.53
6.03 to 3.91
No
4.32
4.1
Bound (Affected)
142.4±10.25
162.90 to 121.90
Yes
160.8±12.36
185.52 to
136.08
No
172.59
164.3
Bound (Less-Affected)
154.02±10.65
175.32 to 132.72
Yes
172.78±4.26
181.30 to
164.26
No
169.46
164.7
Up Stairs Dependent
6.02±0.45
6.92 to 5.12
Yes
5.1±0.68
6.46 to 3.74
No
5.04
4.44
Down Stairs Dependent
4.94±1.06
7.06 to 2.82
No
3.86±0.23
4.32 to 3.4
No
4.51
3.97
Total Score
30.83±4.12
39.07 to 22.59
No
37.5±2.17
41.84 to 33.16
No
37
43
HIMAT
Phase A
Mean ±SD
(Seconds)
Walk
Six Month
Follow Up
54
Table 8. Results of the 2 Standard Deviation (SD) Band Testing: Limits of Stability
Limits of Stability
Phase A
Mean ±SD
Phase A
2 SD Band
Significant
Change from
Phase A to
Phase B
Reaction time
1.02±0.11
1.24 to .80
Yes
0.84±0.13
1.1 to 0.58
No
0.84
.64
Movement Velocity
2.9±0.59
4.08 to 1.72
No
3.15±1.23
5.61 to 0.69
No
4.27
4.8
Endpoint excursions
64.4±10.21
84.82 to 43.98
No
75.67±5.01
85.69 to 65.66
Yes
85.33
80
Max Excursions
89±7.75
104.5 to 73.5
No
97±4.73
106.46 to 87.54
No
102.17
99
Directional Control
84±1.73
87.46 to 80.54
No
86.17±2.71
91.59 to 80.75
No
87.17
84
Thoracic range of
motion with
flexicurve
2.74±0.37
3.44 to 1.984
Yes
1.65±0.33
2.30 to 1.00
No
1.65
1.9
Phase B
Mean ±SD
Phase B
2 SD Band
Significant
Change from
Phase B to
Phase C
Phase C
Mean
Six
Month
Follow
UP
55
Table 9. Quality of Life Measure PDQ-39
Parkinson’s Disease
Questionnaire
(PDQ-39)
At Start of
Study
After Phase B
After
Phase C
Mobility
15
15
0
Activities of daily living
0
0
0
Emotional well being
21
27
21
Stigma
0
8
0
Social support
25
NA
0
Cognitive impairment
50
25
0
Communication
33
25
0
Bodily discomfort
50
42
17
Average
24.25
20.28571
4.75
56
Table 10. Medications
May2009-Feb 2010
Feb2010-Aug2010
Aug2010-Present
Stalevo 150mg
Stalevo 200mg
Stalevo 200mg
5am
5am
5am
8am
8am
10am
11am
11am
3pm
2pm
2pm
9pm
5pm
5pm
10pm
10pm
Azilect 1mg
Azilect 1mg
Azilect 1mg
5am
5am
5am
Myoplex 0.5mg
Pramipexole 0.5mg
5am
5am
11am
11am
5pm
5pm
57
Table 11. Interclass Correlation Coefficients
Muscle Strength
Shoulder Flexors - Right
Shoulder Flexors - Left
Shoulder Extension - Right
Shoulder Extension - Left
Shoulder Abduction - Right
Shoulder Abduction - Left
Shoulder Adduction - Right
Shoulder Adduction - Left
Elbow flexion - Right
Elbow flexion - Left
Elbow extension - Right
Elbow extension - Left
Hip flexors - Right
Hip flexors - Left
Hip extensors - Right
Hip extensors - Left
Hip Abductors - Right
Hip Abductors - Left
Knee flexors - Right
Knee flexors - Left
Knee extensors - Right
Knee extensors - Left
Ankle DF - Right
Ankle DF - Left
Ankle PF - Right
Ankle PF - Left
ICC
0.946
0.962
0.956
0.887
0.896
0.938
0.883
0.918
0.812
0.870
0.943
0.968
0.939
0.973
0.838
0.827
0.921
0.960
0.917
0.944
0.946
0.928
0.947
0.953
0.977
0.964
58
Appendix A
Arm Day
Standing
1. Trunk rotation with arms straight at 90°. Hold 15 seconds each side.
2. Trunk lateral flexion. Hold 15 seconds each side.
3. Trunk rotation with arms in goal post position. Hold 15 seconds each side.
4. Quad stretch. Hold 15 seconds each side.
5. Trunk lateral flexion with bands. 15 times to each side (GO SLOW!!!)
Lying
1.
2.
3.
4.
5.
6.
Towel rolled up between shoulder blades and arms overhead. Hold 30 seconds.
Towel rolled up between should blades. Bridge. Hold 30 seconds.
Single knee to chest (keep opposite leg flat on ground). Hold 15 seconds each side.
Double knee to chest. Hold 15 seconds.
Double knee twist. Hold 15 seconds each side.
Hamstring stretch. Hold 15 seconds each side.
Inclined bench
1. Abdominals.
Standing
1. Stand facing away from wall. Stand straight and remember to tuck the chin in. Hold 15
seconds.
2. Stand facing wall with arms overhead. Bring arms back behind you. 10 reps. GO
SLOW.
Lying
1. Cross one leg over the other. Pull knee to chest. Hold 15 seconds each side.
2. Cross one leg over the other. Gently push the knee down into more rotation. Hold 15
seconds each side.
Bar bells
1. Bench press. 8 reps
2. Biceps curls. 8 reps.
3. Lying on your stomach with arms out at the side. Lift up towards ceiling. Make sure
you keep your forward on the ground. 8 reps using soup cans.
4. Lying on your stomach with arms down at side. Lift up toward the ceiling. Make sure
you keep your forehead on the ground. 8 reps using soup cans.
Lying
1. Love yourself stretch. Hold 15 seconds.
59
Inclined bench
1. Abdominals
Standing
1. Neck circles with arms behind back. 15 times each way. GO SLOW.
2. Look up and down. 15 times each way. GO SLOW.
3. Neck rotation. 15 times each way. GO SLOW.
4. ITB stretch. Hold 15 seconds each side.
5. Trunk rotation. 10 times each side. GO SLOW.
6. Trunk lateral flexion. 10 times each side. GO SLOW.
Bench
1. Military press ups. 12 reps
Lying
1. Plank. Hold 15 seconds.
2. Plank push ups with elbows tucked into side. 5 reps (SLOWLY increase to 12)
Standing
1. Tree Pose. Eyes open. Eyes closed.
2. Pulls backs with theraband. 10 reps.
Side plank with arm rotation. 5 times. Slowly increase to 10 times.
Breathing Exercises.
Leg Day
Standing
1. Trunk rotation with arms straight at 90°. Hold 15 seconds each side.
2. Trunk lateral flexion. Hold 15 seconds each side.
3. Trunk rotation with arms in goal post position. Hold 15 seconds each side.
4. Quad stretch. Hold 15 seconds each side.
5. Trunk lateral flexion with bands. 15 times to each side (GO SLOW!!!)
Lying
7. Towel rolled up between shoulder blades and arms overhead. Hold 30 seconds.
8. Towel rolled up between should blades. Bridge. Hold 30 seconds.
9. Single knee to chest (keep opposite leg flat on ground). Hold 15 seconds each side.
10. Double knee to chest. Hold 15 seconds.
11. Double knee twist. Hold 15 seconds each side.
12. Hamstring stretch. Hold 15 seconds each side.
Inclined bench
2. Abdominals.
60
Standing
3. Stand facing away from wall. Stand straight and remember to tuck the chin in. Hold 15
seconds.
Lying
3. Cross one leg over the other. Pull knee to chest. Hold 15 seconds each side.
4. Cross one leg over the other. Gently push the knee down into more rotation. Hold 15
seconds each side.
Lying
2. 90° Leg Lift: Push your palms against your thighs. Hold 15 seconds. Repeat by pushing
to one side and then the other. Hold 15 seconds each side.
3. Love yourself stretch. Hold 15 seconds.
4. Bicycle.
Bench
1. Knee flexion. 8 reps.
2. Hip extension. 8 reps.
Squats down toward a chair. Start by holding for 15 seconds, then 14, and so forth until you
reach one second.
Toe Raises. 20 reps. Then try single toe raises. 10 times.
On your hands and knees. Lift one arm and opposite leg. Hold for a count of 5. Repeat to
other side. 5 reps.
Agility ladder exercises for 3 minutes.
Standing
7. Neck circles with arms behind back. 15 times each way. GO SLOW.
8. Look up and down. 15 times each way. GO SLOW.
9. Neck rotation. 15 times each way. GO SLOW.
10. ITB stretch. Hold 15 seconds each side.
11. Trunk rotation. 10 times each side. GO SLOW.
12. Trunk lateral flexion. 10 times each side. GO SLOW.
Breathing Exercises.
61