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Benefits of Community Research-BasedProgramming to Improve Freezing of Gait
for Individuals with Parkinson Disease
Item Type text; Electronic Thesis
Authors Hamilton, Kristin Marie
Publisher The University of Arizona.
Rights Copyright © is held by the author. Digital access to this materialis made possible by the University Libraries, University of Arizona.Further transmission, reproduction or presentation (such aspublic display or performance) of protected items is prohibitedexcept with permission of the author.
Download date 15/06/2018 04:43:45
Link to Item http://hdl.handle.net/10150/297620
ABSTRACT
For one week, six subjects with Parkinson Disease (PD) attended a boot camp at the
Parkinson Wellness Recovery (PWR!) Gym. Each experienced a unique symptom of PD known
as freezing of gait (FOG). Previous research supports task-specific exercise for improving PD
symptoms; this study focuses on task-specific exercise to reduce FOG. Reducing the severity of
hypokinetic and bradykinetic movement was addressed during the week through large amplitude
training that was integrated into interval training during cardiovascular exercise, agility and
postural control exercises, and real world environments. Five out of six subjects improved on a
Freezing of Gait Assessment (FOGA) and four out of six subjects improved on the Pull
Backwards Assessment. Task- specific improvement for all six individuals was achieved, with
regards to typical freezing triggers-- narrow spaces, crowds, timed events, and more. These data
suggest that techniques learned throughout the week can appear to be reflected into real-life. In
addition, FOG specific training showed improvement in balance, a very important finidng in
people that fall almost daily. Overall, specific exercise techniques assisted these six subjects in
improving their quality of life, freezing severity, and postural control.
Hamilton 2
INTRODUCTION
Epidemiology
Parkinson disease (PD) is a progressive neurological. Next to Alzheimer's Disease, it is
the most common neurodegenerative disease affecting the elderly. Nearly 1.6 million people
have PD in the United States, with an estimated diagnosis age of 62.5 years However, there is an
early onset PD which occurs among people under the age of 40; this makes up 5-10% of the PD
population.
Pathophysiology
Parkinson's disease affects an area of the brain called the basal ganglia (Fahn, 2003).
Nerve cells that produce the neurotransmitter, dopamine, begin to die in a person with PD (Fahn,
2003). Inadequate amounts of dopamine lead to loss of motor control for everyday movements
(Farley, 2004).
Primary Symptoms of PD
The cardinal motor manifestations of PD are bradykinesia (slow movements), rigidity
(increase tone), and resting tremor. Most people with PD will attest to recognizing the tremor as
the first sign of the disease, ultimately leading them to visit a neurologist. The motor
impairments of PD can best be explained by neural circuitry identified in the Motor Circuit in
Figure 1. Cognitive impairments most often affect executive functions that require planning,
cognitive flexibility, and dual-tasking. Cognitive impairment increases in severity with age and
length of time with PD; a situation often observed most readily by the carepartner and family of
the person with PD. The emotional circuit involves disturbances of mood, apathy, and anxiety.
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The cognitive and emotional impairments may diminish quality of life more than impaired
physical functioning (Fahn, 2003).
Bradykinesia is the most identifiable motor symptom of Parkinson disease, and leads to
the most disablement; this slow movement stems from voluntary to involuntary muscles across
the motor system including fine-motor, respiratory, and speech movements as well as postural
responses. During repetitive movements like walking and handwriting, each step or stroke may
become not only slower (bradykinetic), but also progressively reduced in amplitude
(hypokinesia) . As the disease progresses, other symptoms become more evident. For instance,
instead of just slow movement, the movement becomes uncoordinated and "arrythmical". Thus,
the internal timing cues for generating and sequencing movements become severely disrupted.
This incoordination (akinesia) interferes with the ability to initiate, terminate, or reverse
directions quickly, coordinate whole body movements or combine actions (stand, walk, turn).
Over time, postural instability and freezing of gait (FOG) become the major symptoms that
contribute to falls, and the eventual use of a wheelchair for mobility (Smania, 2010). Once falls
become prevalent, this decreases life expectancy by 7 years (Bloem, 2004).
Freezing of Gait (FOG)
The term "freezing of gait" is used to describe a sudden inability to move any part of the
body, or a feeling of being glued to the floor. People who suffer episodes of freezing may fall
the ground before reacting to move a foot or put their hands out to break their fall. Not all
people with PD experience freezing, which further demonstrates how each case of PD is
different (Bloem et al, 2004). Those who experience this inability to move are referred to as
"freezers", whereas other people with PD are known as "non-freezers", though both groups
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generally experience the primary symptoms (bradykinesia, rigidity) and eventually postural
instability) typical of PD. The most common situations which induce freezing include: narrow
spaces, doorways, and turning around (Bloem et al, 2004), with these affects being heightened
when the person with PD is distracted cognitively. Freezing episodes can occur multiple times a
day and lead to severe injuries.
Treatment
Recent studies suggest that exercise programs can be beneficial for individuals with PD.
Clinical studies have shown exercise to reduce the detrimental effects of neuromuscular slowing,
improve coordination, strength, balance, mobility, cognition, and improve quality of life
(Ahlskog, 2011; Keus, 2007). In addition, studies suggest exercise supplements the isolated
benefit of medication or surgical procedures (Keus, 2007). More generally, exercise for people
with chronic diseases, including PD, has been shown to reduce morbidity and secondary
complications (States, 2011). Freezing requires specific exercise training to address the multiple
impairments that trigger the freeze (see Table 2). This requires an understanding of the
cognitive, emotional and motor symptoms that underlie freezing. Grasping how to approach
certain environments can affect whether an individual freezes or not (Morris, 2000).
Purpose
Understanding how to use neuroplasticity-principled exercise to reduce FOG is one aim
of this study. A major component of a neuroplasticity-principled exercise program is task-
specificity, or training to overcome a specific problem in a specific situation. Task-specific
training has been supported for PD, but application to the symptom of FOG sets this case series
study apart from the rest. Task-specific training includes learning skills to directly “put off” the
Hamilton 5
freezing episode or using cognitive strategies to avoid it. For example, one can practice what is
difficulty (as shown in Table 2) through “forced use” training to learn how to take big steps, or
turn and step backwards with wider base of support and rocking motions, or use proper
technique, at the initiation of a step or at the onset of a turn. Or, one can learn to use
visual/auditory cues or attentional strategies (go big), to avoid or reduce the triggers of FOG.
It is also important to address the fear, anxiety, apathy, loss of self-efficacy that occurs in
PD as this effects their ability to change their behaviors. Community-based programs provide a
unique environment to assist in this area. We will apply small group (N=3) training in a
community setting with opportunities for interaction to address these psychosocial issues that
also contribute to FOG.
The primary purpose of this case series report is to explore the use of neuroplasticity-
principled task-specific training (through forced use practice and cognitive strategy training) in a
community setting to reduce severity of FOG symptoms as measured by: reduced frequency and
duration or FOG during objective and subjective measures, and transfer to better postural
control and increased quality of life among subjects.
METHODS
Recruitment
An email regarding the "PWR! Over Freezing Boot Camp" was sent to all PWR! Gym
clientele and affiliated clinicians. Nobody was individually pursued to participate in the study.
The population for the study must be limited to participants who experience freezing symptoms
to help increase the validity and generalizability. Next, individuals began to contact the PWR!
Gym and underwent an intensive screening process. Questions aimed at number of years with
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PD diagnosis, level of independence, number of falls, speaking English fluently, age, and ability
to comprehend instructions. If the carepartner or spouse had to answer this phone questionnaire
because the person with PD was unable to comprehend, this made the candidate an unsuitable
participant. Potential subjects were required to meet all financial requirements for the study,
ranging from hotel expenses, rental car fees, and other travel expenditures.
Intervention
All activities for the recruitment, during the study, and analysis after were held at the
Parkinson Wellness Recovery (PWR!) Gym in Tucson, AZ which can be found at 134 W. Ft.
Lowell, Tucson, AZ 85705.
Participants gathered on the Sunday preceding the week, to gather pre-treatment
assessment data. For the following five days, the participants spent 1.5 hours in the morning
and afternoon engaging in intensive Parkinson-specific exercise. Exercises stressed the
following:
Task-specific activities directed at triggers
Progressive aerobics (treadmill, pole-walking, stationary bicycle, elliptical)
Large amplitude movement to overcome bradykinesia, rigidity, and coordination
Fall prevention (Re-train stepping and righting responses for reactive and anticipatory
conditions)
External cueing (with music or metronome) and attentional strategies customized to
optimize success
Real world problemsolving (i.e. movie theatre, airport, kitchen, closet)
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In addition to 3 hours of small group task-specific practice, participants also attended
group education nights during the week allowing researchers to grasp the real-world problems
experienced by participants. Yoga was also offered to participants and carepartners to address
stress, mindfulness (walking meditation), and stretching. Finally, one evening was "Game
Night" to help exercise the brain and incorporate fun for the community-based factor. At the
conclusion of the week, the same assessments were performed on Saturday for post-treatment
data. After all data was collected, researchers gathered to complete scoring.
Assessments
PD supported assessments measured FOG, gait and balance, fine motor, dual tasking,
endurance, and cognition. After data collection was complete, the subjects were scored via
videotape on their Freezing of Gait Assessment (FOGA). A change score was used to determine
progress over the week. Change score is the difference between the pre and post assessment
scores, demonstrating positive as improvement. The assessments included the following:
Freezing of Gait Assessment, Freezing of Gait Questionnaire, PDQ-39, 9-Hole Peg Test, Timed
Up and Go, 6-Minute Walk test, 10 meter Forward walk, 10 meter Backward walk, Trail-making
test, Push and Pull test, and the 4 Square Step Test. Each assessment has demonstrated to be
useful in evaluating Parkinson's disease. .
1. Freezing of Gait Assessment (FOGA)- The FOGA narrowed in on the
primary symptoms of interest and induced a festination of gait. First, the
participant was asked to sit in the chair 30 seconds; when the researcher said
"Begin," the participant stood up and walked to a box drawn on the floor. He was
to walk clockwise around the box, stop, and then walk counter-clockwise around
Hamilton 8
the box. Finally, he needed to walk towards a doorway and open the door, then
turn around and sit back in the chair. After completing the course once, the
participant was required to complete it again under dual task. When the
researcher said, "Begin," she also would say a number and the participant was
required to count backwards by 3s for the duration of the course. All trials were
videotaped and scored after the boot camp was finished. Four scores regarding
the quality were issued to this assessment: stand out of the chair, clockwise turn,
counter-clockwise turn, and maneuvering through the doorway. Each aspect of
this test analyzed where typical PD freezers will feel the sensation of being glued
to the ground. A score of 0-4 was assigned to each of these four tasks; a score of
4 indicated the researcher had to intervene to prevent injury from falling whereas
a score of 0 indicated there was no festination of gait.
2. Freezing of Gait Questionnaire (FOGQ)- The FOGQ analyzed how
freezing impacts the participants in their daily lives. Questions are scored based
on frequency of freezing episodes and how they impair one's lifestyle. An
addition to the questionnaire included scoring the participant's confidence with
performing typical tasks: "I can walk through a doorway without freezing."
Confidence was ranked using a percentage scale. All scores for this assessment
were a subjective score.
3. Parkinson Disease Questionnaire (PDQ-39)- Another subjective
assessment is the PDQ-39, which looked at quality of life with respect to how the
person with PD feels. Categories include mobility, emotional well being, stigma,
social support, cognitive impairment, communication, and body discomfort.
Hamilton 9
Participants were required to complete this questionnaire on their own, without
spousal or caretaker's influence. Each subject marked a score, ranging from 0-4,
with 4 being the most affected by PD.
4. 9-Hole Peg Test - The 9-Hole Peg Test assessed fine motor skills. A
small peg board with nine holes was used; when the researcher said "Begin,"
participant was required to use one hand to pick up one peg at a time and place it
in a hole until all nine holes were filled. This was completed with the right hand,
left hand, and then both hands again but with a dual task. The dual task required
each subject to say the days of the week backwards. Number of days said, as well
as time, was recorded for this assessment.
5. Timed Up and Go (TUG)- The TUG assessment analyzed ability to stand
out of a chair, with the option of pushing down on arms of the chair, and walking
to a line 3 meters distance from the chair. Participants were required to touch the
line and return to sitting in the chair. Three different loads were used for the
TUG: preferred speed, preferred speed with dual task, and as fast and as safe as
possible. The dual task used was the same as for Freezing of Gait Assessment,
when the researcher said "Begin," she also said a number and the participant
needed to count backwards by 3s for the duration of the course.
6. 6-minute walk test- The 6-minute walk test measured the stamina of each
participant. When the researcher said "Begin," each subject was required to walk
around two cones for six minutes. The cones were placed 8 meters apart and
there was no direction change. Upon the completion of six minutes, the
Hamilton 10
researcher said "Stop" and the distance between the participant and the previous
cone was measured to help attain accuracy.
7. 10 meter walk test: As a measure of step size, the 10 meter walk test was
used. A participant placed his feet at the beginning start line and was told
"Begin". The first two meters were used to get started, and then the clock began
to record the number of seconds it takes to reach the end of 10 meters. Just as at
the beginning, there were 2 meters at the end to slow down. This assessment also
was performed under preferred speed, and as fast and as safe as possible. Number
of steps were counted for each trial. For the final 10 meter assessment,
participants walked backwards at their preferred speed. The researcher stayed
with participant at all times as precaution.
8. Trail Making Test: Another fine motor task included the Trail Making
Test, where the participant sits at a table and is given a sheet of paper that
resembles a connect the dot activity. Before beginning the assessment,
participants were told the final number so they know when they are complete. As
the researcher says "Begin," the participant can pick up the pen and begin the
activity. As with all assessments, the researcher made the instructions clear at the
beginning and did not answer questions during the actual assessment. The Trail
Making assessment was timed. After finishing the first trail making test, which
only included numbers, the participant was then given a more challenging one
with numbers and letters. If the participant reached two minutes without
completing, the researchers considered this a quit.
Hamilton 11
9. Push and Release Test/Pull Backwards assessments: The Push and Release
assessment narrowed in on each participant's balance capabilities and fall
prevention techniques. The researcher took a split stance and put pressure into the
candidates scapula region to assure she was there to catch him, then she asked the
participant to "Lean back into my hands. I will let go and I want you to catch
yourself. I am here to catch you if you do not." When the researcher let go, the
participant would take steps to catch himself. A score was issued to this
assessment based on the number of steps taken and if intervention by the
researcher was required. Again, a 0-4 scale was used, with 4 requiring assistance
of the researcher. This assessment was then performed on the front, right side,
and left side. An additional test for the backwards was the Pull Backwards test.
As the researcher stood behind the participant, she would pull backwards on their
shoulders at a random moment. This tested their ability to react to an unforeseen
event. The same score scale was used for the pull test as the push test.
10. Four Square Step Test (4SST): The Four Square Step Test analyzed speed
and deliberateness of movement. For this assessment, a "+" sign was created
from PVC piping, of 1.5" diameter. The length of the plus sign was about 3'.
Participants were instructed to start in "Square 1", the bottom left square, and then
step into each box with both feet while moving clockwise; upon arriving back to
square 1, the participant must remember to go back in a counter-clockwise
fashion until back to square 1 again. This was a timed task, but it was noted if the
participant did not remember instructions or if he stepped on the PVC piping.
Hamilton 12
RESULTS
Participants
Six white males who experienced FOG symptoms were recruited for the "unfreezing"
boot camp. All subjects provided written consent prior to participation, and this study was
approved by the University of Arizona Human Subjects Research Protection Program. Refer to
Table 1. for participant demographics. Three of the subjects had attended a PWR! Gym event in
the past. Two (S04 and S05) attended an intensive work shop, or retreat, in 2012 whereas one
subject (S06) had been attending a high intensity PWR! Gym class for about two months prior.
Due to the different ability among participants, researchers divided the group of six males
into two separate groups of three for the week. This would maintain a certain level of challenge
for each participant. One group (S02, S05, S06) of three individuals was a higher challenge
group, whereas the second group had a modified program due to their severity of symptoms.
Refer to Table 2 for each participants' freezing triggers.
Subject Age Year of Diagnosis Group in Boot Camp Frequency Duration
S01 68 2010 2 > once/daily 1 sec
S02 61 2000 1 > once/daily 5-30 sec
S03 65 2005 2 > once/daily >30 sec
S04 66 2004 2 > once/daily 5-30 sec
S05 71 2006 1 > once/daily >30 sec
S06 66 2000 1 < once/week 2-5 sec
Table 1. Participant Data
Subject Initiating
Move-ment
Terminating
Movement
Narrow
Space
Crowd Turning Multitask Chairs Timing
S01 X X X X
S02 X X X
S03 X X X X X
S04 X X X X X X X
S05 X X X X X
S06 X
Table 2. FOG symptoms experienced by subjects.
Hamilton 13
Data
Freezing of Gait
Based on the scoring assessed via videotape, Figure 2 shows the FOGA change score was
positive for each subject, except Subject 06. Recall that the change score is the difference
between the Pre and the Post score and the upward direction indicates a positive change. The
two different bars in Figure 2 represent a single task and dual task. The dual task consisted of
counting backwards by 3s; Subjects 02 and 05 scored even higher on the dual task versus their
positive change on single task.
The Freezing of Gait Questionnaire (FOGQ) also showed a positive change score (Figure
3) for five out of six subjects (01, 02, 03, 05, and 06) during the course of the week. The
questionnaire is a subjective and personal assessment of FOG influences that individual's life.
Altogether , four out of six participants earned a positive change score for both FOGA and
FOGQ assessments.
-2
0
2
4
6
8
10
12
14
16
S1 S2 S3 S4 S5 S6
Figure 3. Freezing of Gait Questionnaire
Pre - Post1
-2
-1
0
1
2
3
4
5
S1 S2 S3 S4 S5 S6
Subject
Figure 2. Freezing of Gait Assessment
FOGA ST
FOGA DT
FOGA shows positive change scores
for single task (ST) and dual task (DT)
for 5 out of 6 subjects.
FOGQ shows positive change score
for 5 out of 6 subjects.
Hamilton 14
Postural Control
Figure 4. reveals the change scores for the participants' times on the "Four Square Step
Test" (4SST). A positive change score represents a faster time for the post test. All subjects
demonstrate a positive change score, with the exception of Subject 04.
Figure 5. represents the Push and Release test in the sidewards directions. A direct
measure of anticipatory postural control, this test showed a positive change score for four out of
six subjects to at least one direction. Subjects 01, 02, and 06 showed a positive change to the
right and Subjects, 01, 02, 04, and 06 showed positive change scores to the left.
Figure 6. represents the Pull Backwards test, in the backwards direction. The backwards
test also showed a positive change score for four out of six subjects (01, 02, 03 and 06). S04
performed worse on the post assessment than the pre assessment. S05 had no change. Subject
03 improved only backwards, while Subjects 01, 02 and 06 improved in both sidewards and
backwards anticipatory testing.
Throughout the data, Subject 01 had a positive change score for every assessment while
the rest varied.
-2
0
2
4
6
8
10
12
14
S01_
RE
S02_
DN
S03
_LN
S04
_RO
S05
_JP
S06_
CZ
Figure 4.
Four Square Step Test (4SST)
Change in 4SST
-2
-1
0
1
2
3
Figure 5.
Push & Release Assessment
Push & Release Right
Push & Release Left
-1
0
1
2
3
Figure 6.
Pull Backward
Pull BW
Hamilton 15
DISCUSSION
The data gathered during these 6 case studies indicated that there was improvement in
each subject, though the area for improvement was often specific to each individual. Five out of
six participants improved on their FOGA score in both ST and DT. Four out of six participants
improved on both the FOGA and FOGQ assessments. For postural control, five out of six
subjects improved their score for the 4SST and four out of six subjects improved their Push and
Release scores for left, right, and Pull Backwards scores.
One key factor includes the parallel between both subjective and objective measures for
the FOG assessments. FOGQ is a subjective measure, whereas FOGA measure is a more
objective approach as the scoring is quantitative. The FOGQ allowed the participant to rank
their confidence in dealing with real world situations which presented problems for them prior to
the study. A parallel can be drawn between the improvement from these two measures, which
supports one key aim of the study-- reducing FOG symptoms.
One subject (S06) did not improve on either the objective or subjective approach.
Subject 06 is the exception to the trend found in this series of case studies, as his baseline was
generally "better" (i.e. less impaired) than the other participants. His physical history includes a
high intensity and frequency of exercise, where he worked out and engaged in sports for nearly
every day of the week. While he did not show improvement on the FOGA nor FOGQ during the
week of data collection, his case does indeed support the theory of exercise as medication for PD
(States, 2011). Among the group, S06 has been diagnosed with PD for the longest of the group,
yet his baseline measurements exceeded those of rest of the group. Involvement with exercise
programs has been shown to prevent the progression of the neurological disease (Hirsch, 2009;
Ahlskog, 2011; Farley, 2007). Moreover, S06 had been attending group classes at the PWR!
Hamilton 16
Gym for the month preceding data collection. It is possible that engaging in Parkinson-specific
exercise routines prepared S06 for a more advanced level of training. Since the conclusion of the
boot camp, S06 has reported he has not fallen on the golf course; prior to the study, S06 reported
his main complaint as falling on the golf course which started to become a frequent event.
Another subject (S04) did not rank himself as improving over the course of the week, yet
the objective test suggested he did improve. Unlike S06, S04 did not engage in regular exercise
and the intensive 3+ hours a day took a large toll on his body by the conclusion of the boot camp.
While he may not have felt he improved as reported on the FOGQ, the severity of his FOG
decreased as determined by the FOGA change score.
It is interesting that participants generally improved on what they trained (unfreezing) as
shown in the FOGA and FOGQ. These improvements were translated to quality of life (QoL).
It is also possible that task-specific training that reduced the severity of FOG may have
generalized to improved balance. Studies suggest that reduced postural control, or ability to
move laterally and backwards without falling, contributes greatly to FOG. In effect, task-
specific "unlearning" may be related to improvements in other areas like balance. The Four
Square Step Test (4SST) and the Push and Release/Pull Backwards Tests have been
demonstrated to assess postural control. For freezers, falls may be as frequent as daily which can
occur from small steps. As the individual tries to take several small steps to compensate for the
unbalanced feeling, he/she instead trips over their feet or experiences a freezing episode, "being
glued to the floor" and not moving at all. The Push and Release/Pull Backwards tests aimed at
eliciting a typical, non-PD reaction-- stepping backwards with a big step and reaching the arms
forward for the Pull Backwards test-- from the participants. The results demonstrate an
improvement for Subjects 01, 02, 03 and 06. The positive change score of these subjects
Hamilton 17
suggests they needed to take fewer steps when undergoing the Push and Release/Pull Backwards
tests. For the Push and Release to the back assessment, the subject leaned backwards into the
researchers palms; at a random moment, the researcher would let go. A similar exercise was
performed during the boot camp, known as fall prevention. A mat was placed surrounding the
corner area of a room; then subjects learned to lean backwards onto their heels until they finally
needed to take a large step to catch their weight. The Pull Backwards test required subjects to
react to the researcher's pull of the subjects' shoulders backwards. At pre-testing, subjects
reacted in a typical PD manner, taking several small steps and no upper body reaction. At post
testing, S06 showed a dramatic quantitative and qualitative improvement, eliciting both upper
and lower body reactions. He immediately moved his arms forward, and he took one large step
backwards. Subject 06 reported complaints of postural control and falling in his history; while
he did not improve on the FOGA or FOGQ, he did improve on the Push and Release test.
Subjects 01, 02, 03 revealed a similar reaction, but to a lesser qualitative degree.
Comprehending how to react to various situations presents difficulty to all people with
PD; for freezers, these stressful situations often overcome any learned behavior preventing the
individual from remembering techniques of how to escape a freezing episode. The method for
this study was task-specific exercise. By mimicking real-world situations, the participants
elicited the frozen response in the gym and learned cues to help mitigate the severity. For
example, cueing assists participants in a multitude of ways. Subject 04 suffered freezing when
turning, whether turning to face a different side of the room or turning while walking, he froze.
A cue that proved successful for him was, "Use your turn signal." As PD reduces executive
function of the basal ganglia, thus reducing the degree of voluntary control of the body,
individuals have less automaticity (Morris, 1999; Hallet, 2008). Typical automatic reactions by
Hamilton 18
people without PD include picking up the foot and turning to face the other side of the room,
however this does not happen in PD. Verbal cueing can influence people with PD more as it
triggers a different response from an internal response. A person with PD may think "Turn
signal," but this relays the message to a more frontal area of the brain versus an external, verbal
cue that is relayed to a different portion of the brain in the temporal lobe. PD impacts this region
less severely (Morris, 1999), as it primarily weakens the midbrain. S04 was able to make turns
around cones, and other narrow areas, by hearing and thinking, "Use your turn signal."
Another instance of external cueing existed with S03. S03 experienced severe
dyskinesia. He would need to lean to nearly a ninety degree angle before regaining balance and
standing up. His attentional focus far surpassed the norms of most people with PD. When
Subject 03 added a metronome to walk with, his dyskinesia dissolved to almost none at all,
especially with the assistance of poles. The external cueing of the beat from the metronome
helped create automaticity. Pole walking assisted him as well by producing reciprocity, or
reciprocal movement of left arm forward and right foot forward simultaneously.
Reciprocity affects postural control by counterbalancing where the body's weight is
situated in space. People without PD tend to walk with their left foot forward and their right arm
swinging simultaneously, or reciprocity. People with PD lack this natural instinct, which
demonstrates why pole walking and treadmill are so valuable to relearning reciprocity. S03's
dyskinesia was dramatically reduced when his body felt balanced with the poles and via external
cueing. A similar experience was created when S05 stepped onto the treadmill. A supported
technique of turning on the treadmill, from forward stepping to side stepping and then return to
forward stepping, assists with postural control in people with PD. S05 experienced rigidity, a
primary symptom of PD; when turning on the treadmill, he "powered up" to ease the direction
Hamilton 19
change. Powering up is a term used at the PWR! Gym to make oneself as tall as possible to
diminish rigidity, and to be ready for the next task instead of being hunched over. When turning
on the moving treadmill, one needs to be able to make the directional change moderately quickly
so his feet do not get caught on one another. Because PD is assymmetrical, or impacts one side
of the body more than the other, directional change on the treadmill works both sides of the
body. Subject 05 had a more difficult time turning to one side, as most people with PD could
attest to. As metronome or verbal cueing assisted Subjects 03 and 04, the external cueing of the
moving treadmill triggered Subject 05 to move bigger (Farley, 2007) and be more deliberate with
the movement.
Deliberate movement presents a challenge to those with PD, as their movments become
smaller as the disease progresses. Looking at the Four Square Step Test (4SST), deliberate
movement is assessed. While the scores are purely quantitative, researchers took note of the
quality of the movement such as whether or not subjects stepped fully over the piping separating
the four boxes. Subject 01 gained awareness of where his body was spatially, or proprioception
(Hackney, 2009), and increased the quality of his movement on the 4SST. Learning how to move
bigger and increasing exercise bouts may have helped Subject 01 to build new pathways in the
brain, and release more dopamine. His quality of life score improved dramatically from the
beginning of the boot camp until the end.
CONCLUSIONS
Task-specific training in a small community setting helps translate into success in the real
world. The subjects who practiced their real world problems in the gym had an easier time
Hamilton 20
improving their symptoms at the conclusion of the week. Whether it was practicing catching
oneself before falling or turning the foot with a "turn signal," each subject improved in at least
one area. External cueing assists in eliciting normal movement such as reciprocity and balanced
postural control. This study supports neuroplasticity-principled task-specific exercise as
treatment for the FOG symptoms of PD.
LIMITATIONS
This series of case studies required subjects to have an adequate level of physical fitness.
Because PD is often misdiagnosed, the level of impairment may be too severe to engage in a
quality PD specific exercise program. All participants for this study were required to be
independent of their carepartner for the duration of the exercise bouts. Moreover, the monetary
requirements for each subject included travel fare, hotel expense, and most meals during the time
of treatment. None of the subjects live in Tucson, AZ year-round which further heightened their
travel costs. Due to the strict criteria and uniqueness of freezing symptoms, a screening process
was utilized to assure all participants experienced similar issues. While the group aspect
enhanced each person's experience (Crizzle, 2006), it also created a limit on the group size as the
space at PWR! Gym could not accommodate more than 3 subject's treatments at one time. The
small sample size reduced the amount of generalizability to PD freezers around the world, but it
allowed more one-on-one time. The short duration of training and the fatigue from such a high
intensity of the study may have affected the change score in some subjects.
Hamilton 21
FUTURE RESEARCH
In future research, the duration of the boot camp may be longer to allow for more
repetition and practice and still provide some rest time-- this may decrease fatigue and improve
performance at post testing. Future studies may also benefit from additional time for the entire
group to interact, instead of just the two groups of 3. Participants reported they would have
enjoyed more time altogether to build support. It may have been beneficial to have spent more
one-on-one time early in the week with each participant to detect unique triggers of freezing
earlier on in the process of treatment to help cater their program towards individual goals. For
the Freezing of Gait Assessment (FOGA), future research may include an additional score of
how the subject sits down at the completion of the assessment. Currently, there are scores for: 1-
standing out of chair, 2- clockwise turn, 3- counterclockwise turn, and 4- walking through
doorway. Postural control impacts how the subject seats himself into the chair, such as leaning
forward or reaching for the chair.
ACKNOWLEDGEMENT
The PWR! Gym advertised and allowed all research to take place in their facility.
Hamilton 22
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