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.

- 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, co-

contraction 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

Week 1-3 Week 4-8 Week 9-12

Forward Treadmill Walking (10min) * *a *a

Backwards Treadmill Walking

(10min) * *a *a

Breathing Exercise *

Balance Exercises on Airex Pad *

Agility Ladder Drills * *b,c

Circle Runs *

Core Stability Exercises

Various Bridges *

Hip Extension on Ball *

Boxing * *

Squats * *d *e

Hamstring Curl *f * *g

Balance Exercises on Toggles

*EO/EC *EO/EC

Yoga Tree Pose

* *EO/EC

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

50

Table 4. Phase (B) Yoga Practice

Week 1-3 Week 4-7 Week 8-12

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

* EO/EC

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

51

Table 5. Results of the 2 Standard Deviation (SD) Band Testing: Range of Motion and Muscle Length

Passive Range of Motion

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

Percentage

Change

from Phase A to Phase

B

Phase C Mean

(Degrees)

Six Month

Follow UP

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

Shoulder IR - Left 53.33±4.08 61.49 to 45.17 Yes 18.1 63±4.47 71.94 to 54.06 No -3.4

60.83

65

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 114.4 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

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 (-) 5 to (-) 5 Yes 180 4±2.24 8.48 to -0.48 No 4.3 4.17

10

Hip flexors - Left -4.17±2.04 (-) 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

Muscle Strength

Phase A

Mean ±SD (Kg)

Phase A

2 SD Band

Significant Change from

Phase A to

Phase B

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

Percent

Change

from Phase A

to Phase

B

Phase C

Mean

(Kg)

Six Month

Follow

Up

Shoulder Flexors – Right 8.28±0.64 9.56 to 7.00 Yes 80.2 14.92±2.44 19.78 to 10.04 No 19.2 17.78 16.1

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

HIMAT

Phase A

Mean ±SD

(Seconds)

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)

Six Month

Follow Up

Walk 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

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

Phase B

Mean ±SD

Phase B

2 SD Band

Significant

Change from

Phase B to

Phase C

Phase C

Mean

Six

Month

Follow

UP

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

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 ICC

Shoulder Flexors - Right 0.946

Shoulder Flexors - Left 0.962

Shoulder Extension - Right 0.956

Shoulder Extension - Left 0.887

Shoulder Abduction - Right 0.896

Shoulder Abduction - Left 0.938

Shoulder Adduction - Right 0.883

Shoulder Adduction - Left 0.918

Elbow flexion - Right 0.812

Elbow flexion - Left 0.870

Elbow extension - Right 0.943

Elbow extension - Left 0.968

Hip flexors - Right 0.939

Hip flexors - Left 0.973

Hip extensors - Right 0.838

Hip extensors - Left 0.827

Hip Abductors - Right 0.921

Hip Abductors - Left 0.960

Knee flexors - Right 0.917

Knee flexors - Left 0.944

Knee extensors - Right 0.946

Knee extensors - Left 0.928

Ankle DF - Right 0.947

Ankle DF - Left 0.953

Ankle PF - Right 0.977

Ankle PF - Left 0.964

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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. Towel rolled up between shoulder blades and arms overhead. Hold 30 seconds.

2. Towel rolled up between should blades. Bridge. Hold 30 seconds.

3. Single knee to chest (keep opposite leg flat on ground). Hold 15 seconds each side.

4. Double knee to chest. Hold 15 seconds.

5. Double knee twist. Hold 15 seconds each side.

6. 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.

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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.

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