Delaying Mobility Disability in People

With Parkinson Disease Using a

LA King, PT, PhD, is Post-doctoral
Fellow, Oregon Health and
Sciences University, Portland,
Oregon.
FB Horak, PT, PhD, is Research
Professor of Neurology and Ad-
junct Professor of Physiology and
Biomedicai Engineering, Depart-
ment of Neurology, Oregon
Health and Sciences University,
West Campus, Building 1, 505
NW 185th Ave, Beaverton, OR
97006-3499 (USA). Address all
correspondence to Dr Horak at:
horakf@ohsu.edu.
[King LA, Horak FB. Delaying mo-
bility disability in people with Par-
kinson disease using a sensorimo-
tor agility exercise program. Phys
Ther. 2009;89:384-393.]
Sensorimotor Agility Exercise Program
Laurie A King, Fay B Horak
This article introcliiccM u new framework for therapists to develop an exereise
program to delay mobilit)- disability in people with Parkinson disease <PD). Mobility,
or the ability to efficiently navigate and function in a variety of environments, requires
balance, agilit}'. and flexihilit)-. all of which are affected by PI). This article summa-
rizes recent research identify ing how constraints on mobility- specitic to PI), such as
rigidity, bradykinesia, freezing, poor sensory integration, inflexible program selec-
tion, and impaired cognitive processing, limit mobility in people with FI). Based on
these constraints, a conceptual framework for exercises to maintain and improve
mobility is presented. An example of a constraint-focused agility exercise program,
incorporating movement principles from tai cbi, kayaking, boxing, lunges, agility
training, and Pilâtes exercises, is presented. This new constraint-focused agilit)'
exercise program is based on a strong scientific framework and includes progressive
levels of sensorimotor, resistance, and coordination challenges that can be custom-
ized for each patient while maintaining fidelity. Principles for improving mobilit>-
pre.sented here can be incorporated into an ongoing or long-term exercise program
for people with PD.

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384 Physical Therapy Volume 89 Number 4 April 2009

 A Sensorimotor Agility Exercise Program for People With Parkinson Disease
M
ost people who are diag-
nosed with Parkinson dis-
ease (PD) do not constüt
with a physical therapist until they
already have obvious mobility prob-
lems. However, it is possible that a
rigorous exercise program that fo-
cuses on anticipated problems,
which are inevitable with progres-
sion of the disease, may help patients
who do not yet exhibit mobility
problems. Altbougb tbere are excel-
lent guidelines for physical thera-
pists to treat patients with PD who
exhibit mobility problems in order
to improve or maintain their mobili-
ty, ' '^ there is little research on
whether exercise may delay or re-
duce the eventual mobility disability
in patients diagnosed w^itb PD.
The maior cause of disabilit>' in peo-
ple witb HD is impaired mobility.^
Mobility, the ability of a person to
move safely in a variety of environ-
ments in order to accomplish func-
tional tasks.' requires dynamic neu-
ral control to quickly and effectively
adapt locomotion, balance, and pos-
tural transitions to changing environ-
mental and task conditions. Such dy-
namic control requires sensorimotor
agility, wliich involves coordination
of complex sequences of move-
ments, ongoing evaluation of envi-
ronmental cues and contexts, tbe
ability to quickly switcb motor pro-
grams wben environmental condi-
tions change, and the ability to main-
tain safe mobility during multiple
motor and cognitive tasks.•^•'' The
types of mobility deficits inevitable
with the progression of PD suggest
Available With
This Article at
www.ptjournal.org
• Audio Abstracts Podcast
This article was published ahead of
print on February 19, 2009, at
www.ptiournal.org.
April 2009
that the basal ganglia are critical for Why Exercise May Prevent
sensorimotor agility.^ Critical as- or Delay Mobility Disability
pects of mobilit)- disability in people in People With PD
with PD, sucb as postural instability, Exciting new findings in neuro-
are unresponsive to pharmacological science regarding tbe effects of ex-
and surgical therapies," making pre- ercise on neural plasticity and neu-
ventative exercise an attractive op- roprotection of the brain against
tion. As yet, there is no known on- neural degeneration suggest that an
going exercise program for people intense exercise program can im-
diagnosed with PD that focuses on prove brain function in patients with
maintaitiing or improving their agil- neurological disorders. Specifically,
ity to slow or reduce their decline in animal studies have demonstrated
mobilit}\ neurogenesis," an increase in dopa-
mine syntliesis and release.'' and in-
Tbis article uses the known sensori- creased dopamine in tbe striatum fol-
motor impairments of PD that affect lowing acute bouts of exercise.'"
balance, gait, and postural transi- Such changes in tbe brain may affect
tions to develop a conceptual frame- behavioral recovery' as a result of
work to design exercises that aim to neuroplasticity (the ability of the
delay disability and maintain or im- brain to make new synaptic connec-
prove mobility' in people with PD. tions), neuroprotection, and slowing
This framework is based on the cur- of neural degeneration." '- Studies
rent knowledge of the neurophysi- with parkinsonian rats have sug-
ology of PD and the inevitable c(ïn- gested that chronic exercise may
straints on mobility resulting from help reverse motor deficits in ani-
basal ganglia degeneration. The sci- mals b) changing brain function.
entilically based principles presented Specifically, rats that ran on a tread-
here, which are focused on mobility mill sbowed preservation of dopami-
disorders in people with PD. can be nergic cell bodies and terminals" '^
incorporated into an existing ther- associated witb improved nmning
apy program for people with PD. distance and speed,'- indicating a
neuroprotective effect of exercise.
Based on this framework, this article Conversely, nonuse of a limb in-
also presents an example of a novel duced by casting in parkinsonian rats
sensorimotor agility program that we increased motor deficits as well as
are currently testing in a clinical trial. loss of dopaminergic terminals. ' '
This program is unique in that it en- Aerobic exercise, sucb as treadmill
courages a partnership among phys- training and walking programs, bas
ical therapists, exercise trainers, and been tested in individuals with PD
patients to set up, progress, and re- and has been shown to improve gait
evaluate an exercise program that ul- parameters, quality of life, and leva-
timately can be carried out indepen- dopa efficacy,'''-'^However, it is not
dently in the communit). It is likely clear whether aerobic training, by
that a mobility program, sucb as the itself, is the best approach to improv-
one presented here, would need to ing inability, which depends upon
be sustained and modified through- dynamic balance, dual tasking, nego-
out the course of the disease to main- tiating complex environments, quick
cbanges in movement direction, and
tain maximal benefit.
other sensorimotor skills affected by
PD. It is possible that treadmill train-
ing, for example, could be even
more effective for addressing com-
plex mobility issues for people witb
Volume 89 Number 4 Physical Therapy 385
A Sensorimotor Agility Exercise Program for People With Parkinson Disease
PI) if the therapist could incoqîorate
tasks such as dual tasking, balance
iralninii. and set-switching into a
ircadniill program.
liiere currently are many untested
exercise program.s availahic tor peo-
ple with PD'"-''' as well as several
randomized controlled studies that
test specilic exercises, such as
strength (force-generating capacit>')
training or gait training.-"-"' llie ajv
proach presented in this article is
focused on exercises that challenge
sensorimotor control ot dynamic hal-
ance and gait to improve mobilit) in
people with PD. There are many
other aspects of PD that also must be
addressed in rehabilitation.
Drive Neuroplasticity
With Task-Specific
Agility Exercise
Studies in rats have demonstrated
tliat task-specihc agility training (eg.
acrobatic, environmental enricliiuent-
type. high-beam balance course) re-
sults in larger improvements in mo-
tor skills as well as larger changes in
synaptic plasticity than simple, re-
petitive aerobic training sucli as run-
ning on treadmills.^" ''^ Task-specific
exercise also has been shown to be
more effective than aerobic or gen-
eral exercise to improve task peribr-
niance in patients with stroke.^'••^''
Task-specific exercises targeted at a
single, specific balance or gait im-
pairment in patients with PD have
been shown to be effective. For
example, exercises targeted at im-
proving small step size, poor axial
mobility, difficulty with postural
transitions, small movement ampli-
tude, or slow speed of compen-
satory stepping have individually
been shown to be effective in im-
proving each particular aspect of mo-
hiiity.'»-¿¿.38-42 We have borrowed
singular techniques from .several suc-
cessful prognims and combined them
with task-specific components of mo-
bility and systematic sensorimotor
386 Physical Therapy Volume 89 Number 4
challenges into a comprehensive ex- Constraints Affecting
ercise program directed at delaying Mobility in People With PD,
and reducing mobility problems in With Implications for the
individuals with PD.
Sensorimotor Agility
Reduce Mobility Program
Constraints With Exercise Rigidity
People with mild or newly diag- Parkinsonian rigidit>' is characterized
nosed PD often do not have obvious by an increased resistance to passive
muscle weakness or poor balance. ^-^ movement thn)ugh(Hit the entire
Nevertheless, the literature suggests range of motion, in both agonist and
that muscle weakness, secondary- to antagonist muscle groups.'*'^°^~ The
abnormal muscle activation asstjci- functional outcomes ol rigidity, in
ated with brad\kinesia and rigidity, general, include a Hexed posture,"^^
can be present at all stages of lack of trunk rotation.'*'"''' and
PD."-'~ Similarly, balance and mo- reduced joint range of movement
bility problems ma)- be present in during postural transitions ant-l
people with mild PD but only be- gait.'^*''^"' Electrom)(>graphy studies
come apparent wben more-complex have shown that people with PD
coordination is required under chal- have high tonic background activity,
lenging conditions. '**•''' For example, especially in the flexors, and co-
mobility problems may only be ap- contraction of muscles during m()\ e-
parent when an individual with PD ment, especially in the axial mus-
is attempting to walk quickly in a cles.'''"'^" In addition, antagonist
cluttered environment while talking muscle activation is larger and ear-
on a cell phone. As the disease pro- lier, resulting in coactivation of mus-
gresses, balance problems become cle groups during automatic postural
more apparent, just as patients begin responses.*"'
to show impaired kinesthesia and
inability to quickly change postural Another characteristic of parkinso-
strategies.'^"'^' The basal ganglia af- nian rigidity is axial rigidity, which
fect balance and gait by contributing results in a loss of natural vertebral,
to automaticity, self-initiated gait and pelvis/shoulder girdle, and femur/
postural transitions, changing motor pelvis Hexibility and range of motion
programs quickly, sequencing ac- that accompanies efficient postural
tions, and using proprioceptive in- and locomotor activities.**"''-^ Wright
formation for kinesthesia and muiti- et aP'' found that rigidit)' in the neck,
segmental coordinatitjn.''-''' During torso, and hips of standing subjects
the progression of PD, mobility is was 3 to 5 times greater in subjects
progressively constrained by rigidity, with PD than in age-matched control
bradykinesia, freezing, sensor)' inte- subjects when measuring the tor-
gration, itillexible motor program sional resistance to passive move-
selection, and attention and cogni- ment along the longitudinal axis dur-
tion.- Table 1 summarizes con- ing twisting movements. Levodopa
straints on mobility due to PD, the medication did not improve their
Impact of these constraints on mo- axial rigidit)."^^ The high axial tone
bility, and the goals of exercises that (velocity-tlependent resistance to
could potentially reduce the impact stretch) in patients with PD contrib-
of each constraint.
utes to their characteristic 'en bloc"
trunk motions, which make it difli-
cult for them to perform activities
.such as rolling over in bed or turning
while walking.''-
April 2009
 A Sensorimotor Agility Exercise Program for People With Parkinson Disease
Table 1.
Parkinsonian Constraints Affecting Mobility and Exercise Principles Designed to Reduce These Constraints"
Constraints
1. Rigidity
tl. Bradykinesia
III. Freezing
IV. Infiexible program selection
(sequential coordination)
V. Impaired sensory integration
VI. Reduced executive function
and attention
'CoM = centef of mass.
Scheiikman et al'"'' showed that ex-
ercise can increase tnink flexibility
in people with PD. We propose
an agility program that includes
movements that minimize agonist-
aniagonist muscle co-contmction (ie,
reciprocal movements), promote ax-
ial rotation, lengthen the flexor mns-
clcs, and strengthen the extensor
muscles to promote an erect pos-
ture. Rigidity can potentially be ad-
dressed with kayaking, an exercise
in which the person counter-rotates
tiie slioiilder and pelvic girdle; tai
chi, a set of exercises that focuses on
the individuals awareness of pos-
tural alignment during postund tran-
sitions; and pre-Pilates, a series of
exercises aimed at increasing spinal
mohility and lengthening flexor mtis-
cles groups. In addition, the program
shouid include strategies for turning
and transitioning from a standing po-
sition to sitting on the floor and hack
again tliat emphasize trunk and head
rotation (Tahs. 2 and 3)-'"
April 2009
Impact on Mobility
Agonisl/antagonist co-contraction
Flexed alignment of trunk
Reduced trunk rotation
Reduced ¡oint range of movement
High axial tone (stiffness)
Slow, small movements
Narrow base of support
Lack of arm swing
Poor anticipatory postural adjustments
Abnormal mapping of body and movement
Abnormal visual-spatial maps
Divided attention affects mobility
Poor rolling, sit-to-stand maneuvers, turns
Difficult floor transfers
Inability to change strategy quickly
Inaccurate without vision
imbalance on unstable surface
Poor alignment witb environment
Difficulty with dual tasks and sequences of actions
Bradykinesia
Bradykinesia is most commonly de-
fined as slowness of voluntar>- move-
ment,^^ hut it also is associated with
slow and weak postural responses to
perturbations and atiticipatory pos-
tural adjustments. Reactive postural
responses to surface translations''' ''^
and anticipatory posturaJ movements
prior to rising onto toes'*** and prior
to step initiation*'*' arc hradykinetic
in patients with PD. Bradykinetic vol-
untary stepping and postural com-
pensatory- stepping are characterized
hy a delayed time to lift the swing
liiiib, a w^eak push-off, reduced leg lift,
a small stride length, and lack of ami
swing,*'' »'-•<'•'<'"• Bradykinesia also is
apparent in reduced voluntary and
reactive limits of stability, especially
in the backward direction,"**'" The
characteristic narrow stance of pa-
tients with PD may be compensatory
for bradykinetic anticipatory ixjstural
adjustments prior to a step, at the
expense of reduced lateral postural
stability'.*'" *''> Bnidykinetic postural
Volume 89
Exercise Principles
Trunk rotation
Reciprocal movements
Rhythmic movements
Erect alignment
Large CoM movements
Increase limits of stability
Fast, large steps
CoM control
Large arm swings
Improve weight shifting
Understand role of external cues
Exercise in small spaces
Practice dual tasks
Plan task in advance
Quick change strategies
Sequencing components of task
KInestbetic awareness
Decrease surface dependence
Flexible orientation
Practice gait and balance with secondary
task and sequences of actions (ie; boxing,
agility course)
responses in people with PD gener-
ally are not improved by antiparkin-
sonian medicatiotis, highlighting the
need for an exercise approach to this
constraint on mobility.'' Bradykinesia
aLso is seen in postural transitions such
as turning"'" and the supine-tostand
manuever,^'' as well as in single-joint
movements"' ;md multi-joint reacliiog
movements"- in people with PD.
Bnidy-kinesia is evident in slowed
rate of increase and decrease of mus-
cle activation patterns.""* Reduction
in muscle strength in people with PD
has been attributed primarily to re-
duced conical drive to muscles be-
cause volutitary contraction, but not
muscle response to nerve stimula-
tion, is weak in these intlividtials,"' ""^
Electromyographic acti\it>- in bradyki-
netic muscles often is fractionated into
multiple btirsts and is not well scaled
for changes in movement distance or
velcK'ity.^' Years of bradykinesia from
abnormal, centnilly driven muscle
control and abnormal, inefificient pat-
Number 4 Physical Therapy • 387
A Sensorimotor Agility Exercise Program for People With Parkinson Disease

Table 2.
Representative Agility Exercise Program, With Progressions

Exercise Actions Progressions

1. Tai chi: Increase limits ot stability,
improve perception of posture and
coordination of arms and legs and
backward and lateral large steps
Prayer wheel: anterior posterior slow, rhythmical Learn one action per week, starting with
weight shifts coordinated with large arm circles weight shifting and leg placement and
Cat walk; slow and purposeful steps, with progressing to coordinated arm, neck,
diagonal weight shifts and torso motion
Cloud hands: slow lateral steps, with trunk vertical
Part the wild horse's mane: coordination of arms
and legs whiie walking forward
Repulsing the monkey: deliberate slow, backward
walking, with diagonal weight shifts

IL Kayakirig: Trunk rotation, Kayaking stroke: diagonal trunk rotation, with Speed, surface, resistance, vision, dual task
segmental coordination, speed reciprocal forward arm extension and backward
arm retraction

III. Agility course: Agility,
multisegmental coordination, quick
changes in direction, and mobility
in tight spaces
High knees: high-amplitude stepping, with hand Speed, dual task, quick change in directions,
slapping knees tight and cluttered spaces, vision
Lateral shuffle: quick, lateral steps
Tire course: wide-based, quick and high steps, with
turns
Grapevine cross: over coordinated steps

IV. Boxing: Anticipatory postural
adjustments, postural corrections,
fast arm and foot motions,
backward walking, timing,
sequencing actions
)ab: short, straight punch from shoulder Speed, dual task, walking fonward, walking
Cross: power punch, with trunk rotation, leading backward, turns, remembered sequences
arm crosses midline of action
Hook: short, lateral punch, with elbow bent and
wrist twisted inward, trunk rotation
Combinations: 2 or more punches delivered quickly
after one another

V. Lunges: Big steps, stepping for
postural correction, limits of
stability, quick changes in
direction, internal representation of
body
Postural correction: tear» until center of mass is
outside base of support, requiring a step; all
directions
Single multidirectional steps (clock stepping)
Dynamic multidirectional lunge walking
Surface (up and down stool), external cues,
vision, resistance, dual task (add arm
movements or cognitive task)

Vl. Pre-Pilates: Improve trunk control,
axial rotation and extension,
functional transitions, sequencing
actions
Cervical range of motion, sit-to-stand maneuver Improve form and speed
Floor transfer, supine (bridging)
Rolling (prone lying, progress to spinal extension
exercises)
Quadruped (bird-dog, cat-camel, thread the
needle)
Half-kneeling to stand

terns of muscle recruitment limit func-
tional mobility and eventually maj- re-
sult in focal muscle weakness.
Because bradykinesia is due io im-
paired central neural drive, rehabili-
tation to reduce bradykinesia sbould
focus on teaching patients to in-
crease the speed, amplitude, and
temporal pacing of their self-initiated
and reactive limb and body center-
of-mass (CoM) movements. Table 2
presents representative exercises
aimed at reducing bradykinesia for
mobility. These exercises may pro-
mote weight-shift control and pos-
tural adjustments in anticipation of
voluntary movements such as
lunges, kicks, and quick boxing
movements. Patients also practice
taking large, protective steps while
tilting past their limits of stability' and
in response to external displace-
ments associated with hitting or
punching a boxing bag. To reduce
bradykinesia. patients should be en-
couraged to "think big"^-* while in-
creasing the speed and amplitude of
large arm and leg mt)\'ement,s
throughout agility courses and dur-
ing multidirectional lunges and box-
ing (Tabs. 2 and 3). Walking sticks
may help patients attend to the lai^e,
symmetrical arm swing that is coor-
dinated with strides during gait.
Freezing
Freezing of gait manifests as a move-
ment hesitation in wliich a delay or
complete inability to initiate a step
occurs."'' Freezing not only slows
walking, but it also is a major con-
tributor to falls in people with PI).""
It is a poorly understood phenome-
non that is associated with executive
disorders in people with PD."''""
Freezing during gait occurs more of-
ten when a person is negotiating a
crowded environment or narrow
doorway, when making a turn, or
when attention is diverted by a sec-
ondan,' task."""''Jacobs and Horak""
recently found tbat freezing or "start
hesitation " in step initiation is asso-

388 Physical Therapy Volume 89 Number 4 April 2009

 A Sensorimotor Agility Exercise Program for People Witii Parltinson Disease

Table 3.
Progressions for Each Activity
A. Kayaking: Kayakint) focuses on counter^rotation of shoulder and pelvic girdle and axial trunk rotation.

Level Surface Vision Resistance Dual Task

1 Sit on a chair Normal, well-lit room Holding pole Counting

2 Sit on DynaDisc" Sunglasses 3-lb pole Verbal: make a list

3 Stand on firm surface No-body glasses 6-ib pole Verbal/cognitive; math

B. Agility course: The agility course Includes turns, doorways, hallways, and tmali areas. The tasks Include high knees
walking with hands touching knees, skipping, iateral shuffles, grapevine, and tire course. Advanced individuals may add
agility on an Incilned surface and bouncing or tossing a bali.
Arms and Trunk (High Knees
Level Speed/Agility Dual Task and Tire Course Only)

1 Self-paced Count steps out loud Self-selected

2 Increase speed Motor task; toss ball between hands Reciprocal arms

Quick changes in direction, pace, Cognitive task; math Add head and trunk rotation
stop and go

C. Boxing: The hoxing task inciudes slmpie to complex combinations involving jabs, hooks, and crosses.

Level Plane of Movement Speed Dual Task

1 Lateral stance to the bag Self-paced Count punches

2 Pivot with back foot Bursts of speed; combo punches for 15 s Name punches (hook, jab, cross)

3 Walk backward around bag Bursts of speed: combo punches for 30 s Cognitive task while maintaining pattern

D. Lunges: Three types of lunges use these progressions: (1) iunges for posturai correction, (2) clock stepping (muitldirectionai,
in-place) lunges, and (3) dynamic lunges during locomotion.
Arms and Trunk
(Dynamic
Level Surface External Cue Vision Resistance Dual Task Lunges Only)

1 Firm surface Rubber discs Well-lit room No[ie None None

designate foot
placement

2 One foot on compliant Decrease disc size Sunglasses Weight vest (start Motor task; trunk Use arms
surface (DynaDisc/ or number with 10% of reciprocally
foam mat) body weight)

3 Foam mat (both feet) No discs No-body glasses Increase vest Verbal or cognitive Lift arms over head
weight, 5% of while holding
body weight ball
increments

' DynaDisk manufactured by Exertools Inc, 320 Professional Center Dr, #100, Rohnert Park, CA 94928.

dated with repetitive, anticipatory,
lateral weight shifts and that people
who are healthy can be made to
"freeze" when they do not have time
to preplan which foot to use when
initiating a compensator>' or volun-
tary step. Therefore, freezing may
be related to difficulties in shifts of
attention, preplanning movement
strategies, or quickly selecting a cor-
rect central motor program.
To help people in the early stages of
PD reduce their chances of heing
affected by freezing, agility exercises
should be performed in environ-
ments in which freezing typically oc-
curs. As shown in Tables 2 and 3,
exercises that involve high stepping,
skipping, or taking large steps in dif-
ferent directions through doorways
and over and around obstacles, such
as between chairs placed shoulder-
width apart, could potentially re-
duce freezing episodes. Quick turns
should he practiced in corners and
near walls. Individuals with PI) could
perform these exercises in the home
or gym, where obstacle courses have
been set up that require turning
quickly, negotiating narrow and
tight spaces such as comers, ducking
under and stepping over obstacles,
picking up objects while walking,
and quickly changing directions and
foot placement. Once a person suc-
cessfully performs the agility- exer-
cises on an obstacle course, more-
advanced progressions could be
introduced, such as performing dual
cognitive task.s while maintaining
form and speed on agility tasks.

April 2009 Volume 89 Number 4 Physical Therapy 389

A Sensorimotor Agility Exercise Program for People With Parkinson Disease

Inflexible Program Selection and tion of whole-body movements. In- seen. In addition, many of the exer-
Poor Sequential Coordination corporating boxing actions into a re- cises can be performed on a variety
Research suggests that the basal gan- membered sequence is another way of surfaces to require adaptation to
glia play an imponant role in task to practice tbe quick selection and altered somatosensory information
switching, motor program selection, sequencing of complex motor pro- from the surface. External feedback
and suppression of irrelevant infor- grams for mobility. To address prol> and sensory cues from the therapist
mation before executing an action.'^- lems of quick program selection, regarding quality and size of the
The inability to quickly switch motor lunges and agility exercises also prt> movements should be used initially
programs has been demonstrated in vide practice changing motor strate- and progressively decreased as pa-
individuals with PD b) an inability to gies during stopping, starting, chang- tients develop a more accurate inter-
change postural response synergies ing direction, changing stepping limb, nal setise of body position. As shown
in the first perturbation trial after a and changing the size and placement in Table 3. the sensorimotor agility
change in support, change in instruc- of steps. program used as an example in this
tions, or change in perturbation di- article progresses with traditional
rection.^'"' Dopamine replacement Sensory Integration progressive challenges"'^ (increasing
does not improve inflexible program Tbere is strong evidence that the resistance, speed of gait, endurance.
selection.'*2"^ The difficulty with basal ganglia are critical for high- atid so on) and witb sensorimotor
switching motor programs manifests level integration of somatosensory challenges (dual tasking and changes
in difficulty maneuvering in new and and visual information necessary to in base of support, visual input, and
challenging environments and in form an internal representation of surface conditions).
changes in postural transitions, such the body and the environment.*^"""
as turning, standing irom a sitting Despite clinical examinations of pa-
position, and rolling over.*^* In addi- Cognitive Constraints
tients with PD revealing only incon- The inability to simultaneously carry
tion to difficulty switching motor sistent, subtle signs of abnormal sen-
¡irograms. people with FD have dif- out a cognitive task and a balance or
sory perception,""'"' an increasing walking task has been found to be :i
ficulty sequencing motor ac- number of studies are showing ab-
tions.''^ ""'«*' Patients with PD show a predictor of falls in elderly people.'^'
normal kinesthesia and use of propri- It is even more difficult for a person
delay between their anticipator)' oception in people with PD. For ex-
postural adjustments and voluntary- witb PD tban age-matched elderly
ample. Wright et aP"* and Horak et people to perform multiple tasks,"'~
movements, such as rising onto al"^ found that individuals with PD
toes''** or a voluntary' step.*"'' These possibly because the basal ganglia
have an impaired ability to detect the are responsible for allowing auto-
findings suggest that mobility in peo- rotation of a surface or the passive
ple with PD is constrained by poor matic control of balance and gait and
rotation of the torso and tbat this for switching attention between
coordination among body parts and poor kinesthesia is worsened by
between voluntary' movements and tasks.'^-•"'^' Postural sway increases
levodopa medication. Individuals most in individuals with PD who
their associated postural adjust- with PD also show impaired percep-
ments, as well as by difficulty in have a history of falls when a cogni-
tion of arm position and movement tive task is added to the task of quiet
switching motor programs appropri- and decreased response to muscle
ate for changes in task constraints. stance."" These findings suggest that
vibration.'^'-'^^ The poor use of pro- the ability to carry out a secondary
prioceptive information and de- cognitive or motor tasks while walk-
creased perceptiiin of movement are ing or balancing is a critical element
Consequently, an exercise program associated witb over-estimation of
should include complex, multiseg- body motion (bradykinesia) and of mobility that is a particular chal-
mental. whole-body movements and over-dependence on vision.'^"'" lenge in people with PD.
should include tasks requiring quick
selection and sequencing of motor An agility program could progress
programs such as practicing postural To facilitate use of propdoceptive task difficulty by adding cognitive or
transitions (eg. moving from stance information and reduce over- mottjr tasks tbat teach patients with
to the floor, roiling, and arising from reliance on vision, an agility program PD to maintain postural stability dur-
the floor to stance). As shown in should progress balancing and walk- ing performance of secondary tasks.
Table 2, one such exercise approach ing tasks by: (1) wearing dark sun- Table 5 presents exercises in wbich
is tai chi, wbich helps patients to glasses to reduce visual contrast sen- it is safe and appropriate to add a
learn increasingly complex se- sitivity and (2) use of "no body" dual cognitive or motor task. Ibe
quences of movement and to focus glasses to obscure the bottom half of exercises at level 1 bave no dual
on smooth timing and synchroniza- the visualfieldso the body cannot be tasks, level 2 has a motor task (eg.

390 Physical Therapy VolurTie 89 Number 4 April 2009

 A Sensorimotor Agility Exercise Program for People With Parkinson Disease
bouncing a ball) added to the basie
exercise such as an agility course,
and level 3 has a cognitive task (eg,
performing math or memor)' prob-
lems) added to the same basic exer-
cise. The progression of adding sec-
ondary' tasks to gait and balance tasks
serves as a training device as well as
a tcM)I to help patients understand the
relationship between safe mohilirj'
and secondar>' tasks in everyday life.
A Sensorimotor Agility
Program for People
With PD
In this article, we propose a novel
sensorimotor agility program tar-
geted at constraints on mobility in
people with PD. The expertise that
contributed to the program includes
an internationally recognized neurol-
ogist specializing in movement disor-
ders for more 3^ years and 5 physical
therapists experienced in treating
people with PD, including 3 with
PhDs with a focus on PD. Six certi-
fied athletic trainers who regularly
work with people with PD also were
helpful in designing the program.
We propose that the exercise pro-
gram outlined in Table 2 could last
60 minutes, with about 10 minvites
for each category of exercise. The
exercises in the 6 categories were
selected to target one or more of the
constraints on mobility' (Tab. 1).
Although not all people witb PD
have all ot the constraints addressed
in this article, it may be that exercise
should target all of these constraints,
as each constraint generally is asso-
ciated with the progression of PD
and eventually has a marked effect
on mohilit)'. Addressing constraints
early may delay the onset of related
mobility deficits. Category' I, tai chi,"
is a wliole-body exercise that focuses
on developing a sense of body kines-
thesia, improving postunil alignment,
and sequencing of whole-bod> move-
ments that move the CoM. Category
II, "kayaking," focuses on trunk and
April 2009
cervical rotation and speed, with posture and gait, the principles of
large, coordinated arm movements. neural plasticity, and the inevitable
Category III, "agility- course," focuses constraints of PD that ultimately af-
()n quickly changing motor programs fect dynamic balance and mobility.
sueh as quick turns, sequencing ac- These principles of the program in-
tions, and overcoming freezing. Cat- clude a focus on self-initiated move-
egory IV, boxing,' focuses on build- ments, big and quick movements,
ing the patient s agility and speed, large and flexible CoM control, re-
backward walking, and components ciprocal and coordinated move-
of anticipator)' and reactive postural ments of arms and legs, and rota-
adjustments in response to a moving tional movements of ton>o over
hag. Categor\' V. •'lunges," helps pa- pelvis and pelvis over legs. Flexible,
tients with PD practice large CoM rotational axial motion of trunk and
neck are stressed to achieve erect
movements, mtiltidirectit)nal limits of
stability, and steps for postural correc-postural alignment, strengthening of
tion. Category VI, pre-Pilates," is a setextensors, and lengthening of Ilex-
of exercises that help patients with PD ors. Our program is designed to fa-
extend and strengthen the spine, as cilitate sensory integration for bal-
well as practice postural transitions ance, emphasizing the use of
such as sit-to-stand maneuvers, floor somatosensory information to move
transfers, and rolling.'** the body's CoM quickly and effec-
tively for balance and mobility. Sec-
ondary cognitive tasks are added to
The sensorimotor progressions of
mobility tasks to automatize control
exercises II through V follow 3 levels
of balance and gait. This sensorimo-
of difficulty (Tab. 3)- Progressions in-
tor agility approach to mobility train-
clude: (1) reducing the base of
ing is intended for prevention of m o
support. (2) increasing surface com-
bility disability^ but may be modified
pliance to reduce surface somato-
for patients at later stages of PD p r o
sensor>' information for postural ori-
gression to improve their mobility.
entation, (3) increasing speed or
resistance with weights. (4) adding
secondary cognitive tasks to auto-
mate posture and gait, and (5) limit- Both authors provided concept/idea/project
design, writing, and project management.
ing visual input of the body with "no Dr Horak provided fund procurement, facil-
body ' glasses or of the environment ities/equipment, institutional liaisons, and
with dark sunglasses to increase use consultation {including reviev^f of manuscript
of kinesthetic information. Categor\' before submission),
I (tai chi) and category VI (pre- The exercise program developed out of
Pilates) exercises progress by in- brainstorming sessions with the follovi/ing
creasing the length of remembered expert neurologists, scientists, physical ther-
sequences and improving the form apists, and trainers: Fay B Horak, PT, PhD, Jay
of each subcomponent of the move- Nutt, MD, Laurie A King, PT, PhD, Sue Scott,
CT, Andrea Serdar, PT, CNS, Chad Swanson,
ments. All of these sensorimotor pro- CT, Valerie Kelly, PT, PhD, Ashley Scott, CT,
gressions were chosen spccificalh' to David Vecto, CT, Triana Nagel-Nelson, CT,
target the predictable constraints on Kimberly Berg, CT, Nandini Deshpande, PT,
mobility- due to PD, and testing of the PhD, and Cristiane Zampieri, PT, PhD. Straw-
program is currently under way. berry Gatts, PhD, provided expert advice to
select and modify tai chi moves for people
with Parkinson disease.
Summary This work was supported by a grant from the
We present a progressive sensorimo- Kinetics Foundation and by a grant from the
tor agility exercise program for pre- National Institute on Aging (AG006457).
vention of mobility disability in peo- Dr Horak was a consultant for the Kinetics
ple with PD. The program is based Foundation. This potential conflict of interest
on the role of the basal ganglia in
Volume 89 Number 4 Physical Therapy 391
A Sensorimotor Agility Exercise Program for People With Parkinson Disease
has been reviewed and managed by Oregon
Health and Sciences University.
This article was received ¡uly 1 /, 2008, and
was accepted January 12, 2009.
DOI: 10.2522/ptj.20080214
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