Four-week trunk-specific exercise program decreases forward trunk flexion in Parkinson's disease: A single-blinded, randomized controlled trial

doi:10.1016/j.parkreldis.2019.05.006

Parkinsonism & Related Disorders

Volume 64, July 2019, Pages 268-274

https://doi.org/10.1016/j.parkreldis.2019.05.006 Get rights and content

Highlights

•
Forward trunk flexion is a disabling and drug-refractory motor complication.
•
Promoting an early and multidisciplinary management is essential.
•
Specific trunk rehabilitation decreases forward trunk flexion posture.

Abstract

Introduction

Pathological forward trunk flexion is a disabling and drug-refractory motor complication of Parkinson's disease (PD) leading to imbalance, pain, and fall-related injuries. Since it might be reversible, early and multidisciplinary management is emphasised. The primary aim was to compare the effects of a four-week trunk-specific rehabilitation program on the severity of the forward trunk flexion. The secondary aim was to compare the training effects on the motor impairments, dynamic and static balance, pain, falls, and quality of life.

Methods

37 patients with PD (H&Y ≤ 4) and forward trunk flexion were randomized in the experimental (n = 19) or control group (n = 18). The former consisted of active self-correction exercises with visual and proprioceptive feedback, passive and active trunk stabilization exercises and functional tasks. The latter consisted of joint mobilization, muscle strengthening and stretching, gait and balance exercises. Protocols lasted 4 weeks (60 min/day, 5 days/week). Before, after, and at 1-month follow-up, a blinded examiner evaluated patients using primary and secondary outcomes. The primary outcome was the forward trunk flexion severity (degree). Secondary outcomes were the UPDRS III, dynamic and static balance, pain falls, and quality of life assessment.

Results

The experimental group reported a significantly greater reduction in forward trunk flexion than the control group from T0 to both T1 (p = 0.003) and T2 (p = 0.004). The improvements in dynamic and static balance were significantly greater for the experimental group than the control group from T0 to T2 (p = 0.017 and 0.004, respectively). Comparable effects were reported on the other outcomes. Pre-treatment forward trunk flexion values were highly correlated to post-treatment trunk deviation changes.

Conclusion

The four-week trunk-specific rehabilitation training decreased the forward trunk flexion severity and increased postural control in patients with PD. NCT03741959.

Introduction

Pathological forward trunk flexion (FTF) is a drug-refractory complication in patients with Parkinson's disease (PD) leading to imbalance, pain and fall-related injuries. It ultimately affects the quality of life and increases hospitalisation risk [1]. The pathophysiology of FTF in PD is not well understood. The bulk of the literature deriving from animal model and clinical studies suggests two mutually non-exclusive pathophysiologic hypotheses involving central (dystonia, rigidity, proprioceptive disintegration) and peripheral (myopathy, soft tissue changes) mechanisms [[1], [2], [3]]. The relative contribution of the different mechanisms might vary between patients and during the disease progression [1,3]. Dystonia might be an early and transient phenomenon followed, as the postural deformity becomes structured, by subsequent musculoskeletal changes [1,3]. Pharmacological treatments are the first-line strategy to improve clinical status in PD. However, pathological FTF in PD is not a levodopa-responsive phenomenon [[1], [2], [3]]. Examination and the evidence that some clinical presentations might be reversibly emphasised the importance of early and multidisciplinary management of this postural complication [[1], [2], [3]]. Rehabilitation is the cornerstone in PD management [[1], [2], [3]]. However, the current efforts are only partially able to resolve postural complications in PD [1,3]. Despite differences in methodologies, the few rehabilitative studies support the overall benefits of trunk rehabilitation in PD with postural complications [4,5]. Basic knowledge on the neurophysiological control of the trunk and spine has demonstrated that it is driven more by automatic and feed-forward schemes than voluntary control [6]. Moreover, active movements are more effective than passive positioning in determining to change in the trunk position. In this theoretical framework, rehabilitation of pathological forward trunk flexion should be focused on autocorrection and stabilization to maintain unconsciousness of the self-correction and trunk stabilization during the activities of daily living. The existing rehabilitation approaches on this topic are based on the passive elongation of back muscles associated with gait and balance exercises taken from the usual care rehabilitation in PD [4,5]. The benefit of applying this approach raised by the improvement of trunk automatic and feed-forward postural reactions by using postural perturbations. However, motor and non-motor domains (i.e. dual-task, rigidity, weakness) could interfere with the complicated neural control of the trunk in PD. The knowledge arising from research works to extend rehabilitation in idiopathic spinal deformities would pave the way for specific rehabilitation also approaches in PD [7]. Three main key factors can be identified for effective trunk rehabilitation: active self-correction technique, trunk stabilization exercises and functional tasks to train neuromotor function during the ADLs. To the best of our knowledge, no studies have been performed on this novel approach in patients with PD. Priorities for future research include well-design rehabilitation studies with larger numbers [1,3], the early detection and early rehabilitation to delay the occurrence of irreversible deformities and reduce complications (i.e. pain). The primary aim was to compare the effects of a four-week trunk-specific rehabilitation program on the severity of the FTF in patients with PD. The secondary aim was to compare the training effects on the Unified Parkinson Disease Rating Scale motor subscale (UPDRS III), dynamic and static balance, pain, falls, and quality of life. The hypothesis was that the specific features of the four-week trunk-specific rehabilitation program would allow improving passive and active neuromotor control of the trunk so to stimulate by reflex and self-corrected posture during the ADLs. It would decrease the severity of the FTF in patients with PD significantly more than the usual rehabilitative treatment. The training effects would parallel significant improvements in postural control suggesting the straight influence of postural orientation on postural control.

Section snippets

Trial design

This single-blind randomized controlled trial (RCT) compared the effects of a four-week trunk-specific rehabilitation program (experimental group [EG]) versus conventional (control group [CG]) training. One physician with experience in the assessment of PD patients was blinded to group assignment and evaluated study participants.

Participants

From June 2017 to June 2018, consecutive outpatients with PD and FTF referred to the UOC Neurology B, and the UOC Neurorehabilitation were assessed. Inclusion criteria

Results

In all 45 patients were consecutively assessed. Four patients were excluded because they did not meet inclusion criteria and 4 patients declined to participate. A total of 37 patients were randomly assigned to either the EG (n = 19) or the CG (n = 18). Two patients in the EG and 1 in the CG discontinued interventions (Fig. 1). No significant between-group differences in demographics and clinical data (Table 1) or in primary and secondary outcome measures were measured at T0 except for the

Discussion

The main findings of the present study are that the four-week trunk-specific exercise program reduced the degrees of FTF in patients with PD more than the conventional treatment, and the training effects were maintained at one-month post-treatment. These positive training effects were associated with improvements in dynamic balance and central integration of sensory input processes, as assessed by the Mini BESTest and the stabilometric assessment respectively. The good correlation between the

Conclusion

FFT might be reversibly in patients with PD. The trunk-specific training can significantly improve not only postural orientation but also postural control by improving particular sensorimotor strategies. These preliminary findings need for validation in a more extensive study.

Funding

This work was supported by the Brain Research Foundation Verona ONLUS [grant n.1/2017].

Author contributions statement

All Authors have approved the final article.

MG: study coordination, analysis and interpretation of data, drafting the article.

MT: conception and study design, study supervision, interpretation of data and revising the manuscript critically.

FM: clinical assessment, revising the article.

GB: acquisition of clinical data.

ED and NP: patients’ treatment.

AF: revising the article, final approval of the version to be submitted.

PM and NS: final approval of the version to be submitted.

CG: the conception

Acknowledgements

None.

Conflict of interest statement

None.

References (24)

K.M. Doherty et al.
Postural deformities in Parkinson's disease
Lancet Neurol.
(2011)
M. Capecci et al.
Postural rehabilitation and Kinesio taping for axial postural disorders in Parkinson's disease
Arch. Phys. Med. Rehabil.
(2014)
M.F. Folstein et al.
‘Mini-mental state’. A practical method for grading the cognitive state of patients for the clinician
J. Psychiatr. Res.
(1975)
N.G. Margraf et al.
Consensus for the measurement of the camptocormia angle in the standing patient
Park. Relat. Disord.
(52 2018 Jul)
L. Chiari et al.
Classification of visual strategies in human postural control by stochastic parameters
Hum. Mov. Sci.
(2000)
C. Geroin et al.
Does the Pisa syndrome affect postural control, balance, and gait in patients with Parkinson's disease? An observational cross-sectional study
Park. Relat. Disord.
(2015)
A. Fasano et al.
Diagnostic criteria for camptocormia in Parkinson's disease: a consensus-based proposal
Park. Relat. Disord.
(2018)
P. Srivanitchapoom et al.
Camptocormia in Parkinson's disease: definition, epidemiology, pathogenesis and treatment modalities
J. Neurol. Neurosurg. Psychiatry
(2016)
M. Bartolo et al.
Four-week trunk-specific rehabilitation treatment improves lateral trunk flexion in Parkinson's disease
Mov. Disord.
(2010)
N. Smania et al.
Neurophysiological basis of rehabilitation of adolescent idiopathic scoliosis
Disabil. Rehabil.
(2008)

M. Romano et al.

SEAS (Scientific Exercises Approach to Scoliosis): a modern and effective evidence based approach to physiotherapic specific scoliosis exercises

Scoliosis

(2015)

R.B. Postuma et al.

MDS clinical diagnostic criteria for Parkinson's disease

Mov. Disord.

(2015)

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¹: Both authors contributed equally to this work.

²: Both authors contributed equally to this work.

View full text

Four-week trunk-specific exercise program decreases forward trunk flexion in Parkinson's disease: A single-blinded, randomized controlled trial

Highlights

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Section snippets

Trial design

Participants

Results

Discussion

Conclusion

Funding

Author contributions statement

Acknowledgements

Conflict of interest statement

Lancet Neurol.

Arch. Phys. Med. Rehabil.

J. Psychiatr. Res.

Park. Relat. Disord.

Hum. Mov. Sci.

Park. Relat. Disord.

Diagnostic criteria for camptocormia in Parkinson's disease: a consensus-based proposal

Park. Relat. Disord.

Camptocormia in Parkinson's disease: definition, epidemiology, pathogenesis and treatment modalities

J. Neurol. Neurosurg. Psychiatry

Four-week trunk-specific rehabilitation treatment improves lateral trunk flexion in Parkinson's disease

Mov. Disord.

Neurophysiological basis of rehabilitation of adolescent idiopathic scoliosis

Disabil. Rehabil.

SEAS (Scientific Exercises Approach to Scoliosis): a modern and effective evidence based approach to physiotherapic specific scoliosis exercises

Scoliosis

MDS clinical diagnostic criteria for Parkinson's disease

Mov. Disord.