examination reveals deficits in single-limb stance time, single- limb stance activity should be incorporated into the therapy program. Proprioception and postural control are impaired in PD, and there is evidence that deficits in the integration of visual and proprioceptive input underlie the impaired postural control (Abbruzzese & Berardelli, 2003; Jacobs & Horak, 2006). In addition, studies show impaired recognition of tilt, indicating central vestibular integration failure (Bertolini et al., 2015). Individuals with PD are very visually reliant during balance testing, and postural control does not improve with the administration of dopamine medications (Jacobs & Horak, 2006). Balance training that focuses on the proprioceptive system should be incorporated into treatment planning, with the goal of decreasing visual reliance or, in more severe cases, teaching individuals to use vision to compensate for proprioceptive deficits. Activities requiring increased use of the proprioceptive system include walking on foam, walking while turning the head side to side, or walking while wearing dark glasses. Additionally, many forms of tai chi focus on proprioceptive awareness and have been shown to be beneficial for balance (Li et al., 2012). The overall recommendation is to follow a function-based, task-oriented approach that will address balance deficits during functional activities (Keus et al., 2009; Soke, et al., 2019). Compared with those receiving physical therapist-directed gait training, individuals using the treadmill demonstrated greater improvement in gait velocity and maintained the improvement longer (Miyai et al., 2002). Treadmill training may work better than gait training directed by a physical therapist because treadmill training is better able to address the specific mechanisms underlying gait deficits in PD. Mechanisms that appear to be most beneficial across treadmill studies are pace training, motor learning, and dosage (Herman et al., 2009). The treadmill is better able to set a consistent pace and maintain that pace for longer durations. It also forces a more invariant gait pattern, meaning that the individual is practicing the same stepping pattern over and over across thousands of repetitions. One study demonstrated that improvements in gait after treadmill training were correlated with concomitant changes in corticomotor excitability. Aerobic capacity and strength did not appear to be mechanisms that were critical to improving gait through treadmill training based on both the Herman and Cochrane reviews (Herman et al., 2009; Mehrholz et al., 2015). Based on systematic reviews of the literature, the current recommendation for the use of treadmill training in individuals with PD Hoehn and Yahr stages 1 to 3 is to conduct three sessions per week that each last 20 to 30 minutes (Herman et al., 2009; Mehrholz et al., 2015). The training should be based on pace retraining; starting speed should be a comfortable walking pace and increased by approximately 10% or 0.4 miles per hour after a warm-up period. Over the course of treatment, the participant should be able to increase the pace with a goal of attaining a speed of at least 1.2 m/s without increasing to running speed. Running mechanics are different from walking and should be trained separately if it is a goal for the client. Training in running does not carry over to walking, or vice versa. Treadmill training should be conducted while the participant is at peak dose of any dopaminergic medication. There is no need to unload the patient through body weight support unless a specific issue or safety concern arises. Typically, the use of the harness with no body weight support is sufficient to ensure safety. There is no evidence of any benefit from treadmill training for individuals in the later stages of the disease (Hoehn & Yahr stages 4 to 5).
also performed eccentric exercise (Dibble et al., 2009). There is some clinical evidence to suggest that there are strength deficits in the trunk musculature early in the disease (Cano-de-la- Cuerda et al., 2010). Because postural changes are noted early in the disease, core strengthening may be of benefit. Decreased trunk muscle strength in PD was found to be present when grip strength was still intact and equal to control subjects (Pang & Mak, 2009). Interestingly, decreased trunk strength correlated with loss of bone mineral density, and it was found that 56% of the clients with PD in the Pang and Mak (2009) study had either osteopenia or osteoporosis but were not less active than control subjects. Trunk strengthening exercises were shown to improve balance in individuals with PD (Hubble et al., 2019). Balance Most falls occur when an individual with PD is either turning or getting in or out of a chair (Bloem et al., 2004). These activities typically require stepping laterally and backward and being able to manage the body mass of the trunk. Based on changes noted in backward walking velocity in both the elderly (Fritz et al., 2012) and individuals with PD (Hackney & Earhart, 2009), practicing backward walking would be beneficial for individuals with PD. Functional activities such as stepping up onto curbs, climbing stairs, and walking on uneven ground require prolonged periods of time spent in single-limb stance. If the Activity Clients with PD have deficits in mobility and balance leading to increased fall risk. Some individuals fall as much as several times a day. Impairments in gait and transfers both lead to falls in clients with PD. These falls can be injurious, and the fear of future falls along with the difficulty in walking leads to restriction of activity. Inactivity leads to poor fitness and negative health consequences (Cugusi et al., 2014). Mobility Treadmill training has been shown to improve gait, walking confidence, and quality of life in individuals with PD (Herman et al., 2009). The use of a treadmill for gait training has the advantage of allowing the pace of walking to be preset and consistently maintained. Such pace setting shows long-term carryover in stride length and increased velocity. Individuals walking on a treadmill tend to take longer strides and have a more invariant stride length. Because variability in gait correlates with increased fall risk in individuals with PD, it is recommended that treatment programs address this issue (Hoskovcová et al., 2015; Schaafsma et al., 2003). Treadmill training may be administered to obtain an aerobic benefit or may be done at submaximal intensity with no aerobic effect; both paradigms have been studied. There is strong evidence for the benefits of treadmill training in individuals in Hoehn and Yahr stages 1 to 3 of PD that has been summarized in a systemic review by Herman and colleagues (2009) and a Cochrane review by Mehrholz and colleagues (2015). Studies to date show that treadmill training for individuals with PD decreases symptoms such as bradykinesia and hypokinesia and promotes neuroplasticity (Herman et al., 2009; Mehrholz et al., 2015). The majority of studies show that participants were not working at an aerobic level, did not have a goal of increasing their heart rate to cardiac training levels, and, in fact, their reported target heart rate was consistently below 60% of heart rate capacity (Herman et al., 2009). All these studies used a speed-dependent paradigm in which speed was progressively increased across training sessions with the goal of attaining age-normed gait speed. Body weight support was used in some studies but showed no additional benefit over standard treadmill training, so should be used only if needed to ensure safety (Herman et al., 2009). One study compared treadmill training with over-ground gait training directed by a physical therapist with expertise in PD. The therapist focused on retraining longer strides and faster velocity.
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