The value of resistance training (RT) for people with Parkinson disease (PD) is disputed, but recent research shows promising results regarding effects of intensive RT. The main aim of this case report was to develop a combined model consisting of home-based training (HT) and supervised RT as a 1-year follow-up to evaluate changes in functional capacities of a patient with PD. The intervention consisted of 8 weeks of supervised progressive RT, followed by 12 weeks of individual HT. This sequence was then repeated, for a total follow-up of 12 months. Functional capacities were assessed between all training periods with a battery of clinical measures. During the second HT period, functional outcomes and muscle strength were better preserved compared with the first HT period. These results are important regarding how to design and implement efficient exercise regimens for patients with PD and show that progressive RT twice a week for 2 months combined with home training in periods is effective in improving muscular strength and functional capacities.
Maximum muscle strength, power, and rate of force development decrease with aging, even in highly trained master athletes.
Resistance training (RT), and particularly high-intensity RT, is effective for improving strength among older adults, and regular resistance exercise is considered a viable strategy to prevent generalized muscular weakness associated with aging.
To improve strength in elderly, the principle of progressive overload is important.
There is, however, no studies regarding how persons with PD disease respond to several periods of intensive RT interspaced by periods of general home-based physical activity. Hence, this case study reports on how the functional capacity of a person with PD respond to a regime of combined home-based training and supervised RT at an outpatient clinic and a new model for implementing combinations of supervised training and HT for this patient group.
We report on a 70-year-old man and his 12 months follow-up at an outpatient clinic. He reported taking medications for Morbus Parkinson (Mb Parkinson) and for moderate hypertension but needed no assistance in ADL. The patient lived with his wife in an apartment. The patient was active; he was competent in outdoor walking without walking aids and participated in social relationships with other people and his family. He did not participate in any organized training but went on a daily walk alone or together with his wife for about 30 minutes. After reporting to the outpatient clinic, the patient was initially examined clinically by a physiotherapist.
The patient was not severely affected by the disease. He was not characterized by tremor or rigidity. Furthermore, he had stiffness in the thoracic part of the column, compatible with both age and Mb Parkinson. He was not fearful of falling but reported that he sometimes kicked his foot in the uneven ground during walking. Furthermore, he reported that his wife often told him not to bend forward while he was walking. He was aware that this could be a part of the clinical picture of Mb Parkinson.
He was considered to be a good candidate to determine whether progressive strength training could improve his functional status, improve his activity level, and reduce his impairments and disabilities. He was motivated to improve his current level of functioning and improve posture and reduce stumbling by progressive RT exercises.
The patient assessment, RT intervention, and all tests were performed at an outpatient clinic. The intervention consisted of an 8-week supervised progressive RT program (RT Period 1), followed by a 12-week individual, unsupervised home-based exercise program (first HT period [HT Period 1]). This exercise sequence was subsequently followed by a new 8-week period of supervised progressive RT (RT Period 2) and then 12 + 8 weeks of unsupervised home-based exercise (HT Period 2 + 8 weeks). Outcome measurements and tests were obtained the same week the intervention started, then after 8 weeks of RT, furthermore, after 12 weeks of HT, 8 weeks of RT, 12 HT, and finally after 8 more weeks of HT. The person performing the measurements and tests was not the same person as the intervention therapist.
The supervised RT intervention was provided twice a week for the first 8 weeks, and each exercise sessions lasted 45 to 60 minutes, depending on the participant’s ability and tolerance. The participant was supervised by a physiotherapist during all RT sessions. The intervention was targeted toward improving strength of the main muscle groups in the upper and lower body, and the following exercises were included in the RT program: leg press, knee extension, chest press, sitting leg press, sitting pull down, sitting chest press, and sitting rowing.
Following a warm-up sequence on a stationary cycle for 10 to 15 minutes with a load corresponding to 12 to 13 on the Borg Rating of Perceived Exertion scale,
In addition, the exercise program also included standing lunges.
For the lunges, the participant was instructed to place each leg forward alternately with 90° of flexion in the hip and knee joint. Support was given initially and gradually reduced to no support. Eventually, a 2 kg weight in each hand was used for the last 3 weeks of the training period. The participant was gradually encouraged to increase the flexion in the hips and knees to 90°. The first 8-week RT period started with an introductory phase extending over 3 to 6 sessions to become familiar with both the equipment and the exercises. Progression in resistance and repetitions was noted in a training diary, as well as their position at the training equipment. He attended all training sessions at the outpatient clinic, ie, compliance was 100%.
For the unsupervised HT, the participant was required to perform daily walks and to perform lunges and squats twice per week for 12 weeks in his home environment. For both the lunges and the squats, the participant was instructed to do the exercises with 90° of flexion in the hip and knee joints. The training program was the same as during supervised training, ie, the patient performed 3 sets of 10 repetitions of each exercise, but these exercises were performed without the external loading as in the supervised RT. Compliance in home training was not registered.
Functional tests were the Timed Up-and-Go (TUG) test, the 2-minute step-in-place (2MSIP) test, the 6-minute walk test (6MWT), and the Sit-to-Stand (STS) test. In addition to the function tests, maximum strength (1RM) was measured in the leg press exercise (Technogym) and in the knee extension exercise (Technogym).
The TUG test is a functional mobility test used in the clinic to evaluate dynamic balance, gait, and transfers.
The STS test measures lower body muscle strength. We applied the performance measure, the 30-second chair stand, as described by Jones et al.
The 2MSIP test is a test to assess aerobic endurance and balance.
The 6MWT measures walking capacity, walked distance (m),
As shown in
Maximum strength of (A) leg press exercise following supervised resistance training and unsupervised home-based training and (B) knee extension exercise following supervised resistance training and unsupervised home-based training. RT P1 and P2 = resistance training periods 1 and 2. HT P1 and HT P2 = home-based training periods 1 and 2. Dotted and solid lines are 1 repetition maximum (1RM) values for right and left legs, respectively. Baseline measurements of maximum strength were performed prior to the first RT period. All other measurements are performed at the end of each RT period and HT period, respectively. In addition, measurements were performed 20 weeks after the start of HT P2 (HT P2 + 8 weeks).
As shown in
Progression of functional capacities during supervised resistance training and unsupervised home-based training.
Tests | Baseline, 0 wk | RT P1, 8 wk | HT P1, 12 wk | RT P2, 8 wk | HT P2, 12 wk | HT P2 + 8 wk |
---|---|---|---|---|---|---|
STS, times | 12 | 16 | 11 | 17 | 15 | 13 |
TUG, s | 8.5 | 7.1 | 10.4 | 7.0 | 7.3 | 7.2 |
6MWT, m | 484 | 554 | 501 | 584 | 561 | 534 |
Walk speed, s−1 | 1.34 | 1.54 | 1.39 | 1.62 | 1.56 | 1.48 |
2MSIP, steps | 86 | 93 | 81 | 100 | 98 | 96 |
Abbreviations: 2MSIP, 2-minute step in place; 6MWT, 6-minute walk test; HT, home-based training; P1 and P2, Period 1 and Period 2; RT, supervised resistance training; STS, Sit to Stand; TUG, Timed Up and Go; walking speed, average walking speed during the 6MWT.
Baseline measurements were performed prior to the first RT period. All other measurements are performed at the end of each RT period and HT period, respectively. In addition, measurements were performed 20 weeks after the start of HT Period 2 (HT P2 + 8 weeks).
Changes in functional capacity during supervised resistance training and unsupervised home-based training Baseline measurements were performed prior to the first RT period. All other measurements are performed at the end of each RT period and HT period, respectively. In addition, measurements were performed 20 weeks after the start of HT Period 2 (HT Period 2 + 8 weeks). 2MSIP, 2-minute step in place; 6MWT, 6-minute walk test; HT P1 and P2, home-based training periods 1 and 2; RT P1 and P2, resistance training periods 1 and 2; STS, Sit-to-Stand; TUG, Timed Up and Go.
At follow-up after his HT Period 1, the results for all measurements decreased with about the same magnitude as the increase in the previous training period. Improvements from baseline in STS, TUG, 6MWT, walking speed, and 2MSIP following RT Period 2 were 41.6%, 17.1%, 20.5%, and 16.3%, respectively.
At follow-up after HT Period 2 and HT Period 2 + 8 weeks, all functional measurements still were about 10% better than at baseline; hence following RT Period 2, functional capacities seem to be better preserved than following RT Period 1. Average walking speed at HT Period 2 and HT Period 2 + 8 weeks was about 16% and 10% faster than at baseline and similar to data from a healthy population.
The main aim of this case report was to evaluate how a combined model consisting of unsupervised HT and supervised RT at an outpatient clinic affected functional capacity of a person with PD during a 1-year follow-up. A recent systematic review and meta-analysis demonstrate that an RT intervention improves muscular strength of persons with PD, but information is limited regarding the outcome of functional capacities of patients with PD when they, in periods, are left to perform HT on their own.
Treatment of chronic illnesses, such as PD, puts a large burden on the health and welfare system if patients having these illnesses continuously need physiotherapy or other health care services for follow-up. In this perspective, it is important to establish interventions that, at least in periods, enable people to take larger responsibility for their own health. This is also important considering that independent living is a key factor for health-related quality of life.
In this study, there is clear effect of supervised RT on muscle strength and functional outcomes, both following the first and the second training periods. In the first RT intervention period, functional outcomes improved by about 8% to 30% compared with baseline, and in the second RT period, the improvement ranged from about 16% to 40% (
Improvements of this magnitude may be significant for maintaining the level of independence which active living persons with PD actually desire. The functional performance of the patient with PD in this study prior to start of the RT interventions was generally in the low end of normal values for healthy men of similar age. After the second RT period, his performance had improved greatly and was generally in the upper range of values for healthy men of similar age.
During HT, however, there is a gradual decline in strength and physical capacity, especially in this case, during the first training period. During the second HT period, functional outcomes and muscle strength are better preserved, and at the end of the follow-up period, most outcome variables still showed 10% to 20% improvement compared with baseline recordings. These results are important regarding how to design and implement exercise regimens for patients with PD.
The improvements in outcome measurements in this study are in line with other studies.
Following bouts of intensive physiotherapy treatment, it may not be economically feasible for many patients with PD to continue seeing a physiotherapist throughout the year. Thus, to lessen the burden on municipal health and welfare services, and to promote independent living, we suggest that people with PD are relegated to supervised RT 2 to 3 times a year and that they perform home-based exercises in the interregnum between supervised training. With increasing proficiency in performing RT, the patients with PD may gradually need less supervision and gain independence also when performing these exercises.
The clinically most important findings of this case study are that individually tailored progressive RT may be a suitable intervention to make a patient with PD more independent. Furthermore, a program of home-based maintenance training seems to be effective in partially maintaining functional capacities.
Four peer reviewers contributed to the peer review report. Reviewers’ reports totaled 974 words, excluding any confidential comments to the academic editor.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
HS wrote the first draft of the manuscript. TG contributed to the writing of the manuscript and made critical revisions. HS and TG agree with manuscript results and conclusions, reviewed, and approved the final manuscript.