18701142

Clinical Rehabilitation 2005; 19: 870 Á/877

Effects of home exercises on motor performance in
patients with Parkinson’s disease
AT Caglar Istanbul University, Neurology Department, Cerrahpasa School of Medicine, HN Gurses Istanbul University,
Cardiopulmonary Department, Institute of Cardiology, FK Mutluay Istanbul University, Neurology Department, Cerrahpasa
School of Medicine and G Kiziltan Istanbul University, Neurology Department, Cerrahpasa School of Medicine, Turkey

Received 31st January 2004; accepted 21st April 2005.

Objective: To investigate the effect of home exercises on the motor performance of
patients with Parkinson’s disease.
Design: A prospective blinded study with allocation of patients into their groups by
alternate weeks.
Setting: A University Hospital neurology and physiotherapy department.
Subjects: Recruited from a movement disorders outpatient clinic of Cerrahpasa
School of Medicine diagnosed with Parkinson’s disease, classified as Hoehn and Yahr
Grades I, II and III.
Interventions: Patients who fulfilled the inclusion criteria were recruited to the
study. Each patient was evaluated at the end of first and second month after the
baseline evaluation. Patients were divided into two groups. Those in the first and
third week were put in the exercise group and second and fourth week in the control
group. Patients in the exercise group (n 0/15) were given a schedule of exercises to
undertake at home; the others (n 0/15) did not receive this instruction.
Measures: Ten- and 20-m walking test, first pace length, pace number in 10 m,
walking around a chair, Nine Hole Peg Board (NHPB) test.
Results: Following the home exercise programme, patients in the exercise group
showed improvement in walking 10 and 20 m, time elapsed to complete walking
around a chair and length of the first pace length, and in the motor performance of
both hands (p B/0.001).
Conclusions: A home-based rehabilitation programme for patients with Parkinson’s
disease helped to improve motor performance compared to patients who did not
take advantage of a regular, professionally designed exercise programme.

Introduction tional activity disorders may arise due to loss
of trunk mobility and postural reflex, which may
Parkinson’s disease (PD) is a neurological disorder also result in dependency in activities requiring
causing loss of functional abilities and progressive manipulation and skill, especially in the early
loss of independence despite medical treatment.1 Á 3 stages.4 Á 7 Progressive bradykinesia and hypokine-
Depending on the severity of the disease, func- sia result in difficulty in performing daily activities.
Akinesia may hinder initiation of activity by
Address for correspondence: Professor H Nilgun Gurses, seconds or even minutes. Although levodopa
Physiotherapist, Prof. B. Tarcan, sok. Meric Konak 4 ap./ 4
Gayrettepe, 80290 Á/ Istanbul, Turkey. decreases the bradykinesia, it alone would not be
e-mail: fztnilgun@yahoo.com effective in increasing movement, and therefore
# 2005 Edward Arnold (Publishers) Ltd 10.1191/0269215505cr924oa

Home exercise for Parkinson’s disease patients 871

aggressive intervention in the early stages is Patients were evaluated by the same phy-
necessary.8 siotherapist (FKM) at baseline, first month and
In general, the combination of pharmacother- second month a total of three times, at the same
apy with rehabilitation is the optimal treatment time post dose. Patients and relatives were ques-
strategy for symptom control.2 Patients with tioned whether medication was taken or not.
milder disase severity have a better potential of Following the assessments, patient allocation to
improvement, hence commencing physiotherapy the exercise or control group was done by a
and rehabilitation programmes at an early stage research physiotherapist, who was also the co-
can be beneficial.9 In addition, patients at the ordinator of the study (HNG). Patients recruited in
chronic stage who are independent at home and in the first and third week were included in the
the community are known to benefit from a home exercise group and patients recruited in the second
programme.9 Á 12 Despite the data obtained from and fourth week were included in the control
these trials, there is still insufficient evidence to group. The appointments for assessments and
support the efficacy of physiotherapy on motor exercise instructions were made for a day best
performance in Parkinson’s disease as there are few suited for the patients. The home exercise pro-
controlled studies to date.13 gramme was given to the exercise group by another
The aim of this study was to evaluate the effects physiotherapist (ATC).
of a suitable home exercise programme on motor Both the neurologist and physiotherapist who
tests evaluating walking and hand skills in did the assessments and the patients were
patients diagnosed with Parkinson’s disease seen blinded to the study grouping and they did not
as outpatients and who had not previously been know which treatment was to be given in a certain
involved in a physiotherapy and rehabilitation week.
programme. Patients’ inclusion criteria:

. Patients had been diagnosed Parkinson’s disease
by a neurologist.
. Patients had to be at grade I, II and III
Patients and methods according to Hoehn and Yahr Scale.14
. Patients had to be on a stable drug regime.
Patients with Parkinson’s disease referred to the . Patients could walk independently with no
Movement Disorders Outpatient Clinic at Istanbul assistance or walking aid.
University Cerrahpasa School of Medicine from . Patients had no orthopaedic problems that
the Neurology Department of the same university would affect mobility and had no systemic and
were included in the study. We used a prospective, metabolic disease.
blinded and controlled design and the selection of . Patients could come to the hospital three times
patients for the groups were done by an alternate for the physiotherapy assessments.
week method. Disease stage of the patients was . Patients had not been previously involved in a
determined by one of the neurologists of the physiotherapy and rehabilitation programme.
Movement Disorders Outpatient Clinic (GK),
and the eligible patients who fulfilled the inclusion The following assessments were performed on
criteria for the study and who agreed to participate patients; 10-m walking time (s), 20-m walking time
when they were informed about the study were sent (s), first pace length (cm), pace number at a 10-m
to the physiotherapist (FKM) for other assess- distance, time to walk around a chair (s) and Nine
ments (Figure 1). Each week six referred patients Hole Peg Board test.14 The 10-m timed walk
were evaluated by our neurologist. The range of involves asking the patient to walk over a set
eligible patients for the study per week was 0 Á/2 distance of 10 m (with no turn component) and a
patients according to our patient inclusion criteria. 20 m walk (10 m, return, 10 m) at their own
All eligible patients who fulfilled the selection preferred speed. The second one is the time test
criteria were actually included. Selection of pa- often used with patients with Parkinson’s disease
tients for the study lasted for eight months. but, since two tests were used in different studies,

872 AT Caglar et al.

Neurology Department
(Patient (Pt) Reference)

Movement Disorders
Outpatient Clinic

Neurologist Neurologist
Neurologist (GK)
(Pt Selection)

Physical Therapist
(FKM)
(Assessment) 1st & 2nd Month
1st & 2nd Month Assessments
Assessments

Physical Therapist (HNG)
(Group Selection & Coordination)

Exercise Group Control Group

Physical Therapist (ATC)
(Exercise Training)

Figure 1 Design of the study.

we decided to use both of them in order to be able hands. Lowest time taken to complete the test
to compare our results with the others. Time to was recorded by a chronometer.
walk around a chair (s) was assessed independently Home exercises were given to the patients in the
from 20-m walking time (s). exercise group at hospital and after the initial
First pace length was determined after the training the patients were instructed to continue
patient walked on a slightly wet floor and the the exercise programme at home. Patients were
distance was measured between the fronts of instructed to carry out each of the exercises
the first and second footprints. In order to avoid 10 times, three times a day for a period of
patient awareness, the patient was not informed of two months. Home exercise training period was
such a measurement. In the 10-m walking time 1 h and the primary goals were to improve range
test, steps taken by both feet were noted. The peg of motion and functional activity, balance and
board test (which evaluates hand co-ordination) gait, and ultimately fine motor dexterity. A book-
was performed while the patient was sitting. The let outlining the movements from which the
patient was requested to place the nine pegs from exercises were selected according to the needs of
the table into the board, and then to take the pegs the patients were also given to them, aiming to
out one by one and place them on the table as assist the patients visually in performing their
quickly as possible. Test was started with the exercises. The booklet included the following
dominant hand and repeated twice with both exercises:


1) Relaxation and stretching exercises such as Results
bending and turning of trunk.
2) Exercises to ease breathing and facial muscle During the eight months, of the patients who were
exercises to stress the mimic expressions and referred to the Movement Disorders Outpatient
to enhance oral motor function. Clinic from the Neurology Department, only 30
3) Exercises to increase movement of head, neck, fulfilled the inclusion criteria and registered to the
shoulder, elbow and hand, besides leg, knee study. Difficulties with transport, severity of the
and feet and alternative exercise of the four illness (at grade IV or over) and having systemic
limbs in supine position for recovery of and metabolic disease were the main reasons for
muscular co-ordination. withdrawal from the study. Some patients had
4) Exercises to assist improving body move- already had physiotherapy, so they were not
ments; exercises to get in and out of bed and allocated to the study. There was no loss in either
also exercises to ease standing up and sitting the exercise group or the control group in all
down on a chair and turning around in the assessments, since the patients who already agreed
chair. to come to hospital for three times were recruited
5) Exercises done while standing up to improve to the study. The baseline characteristics of the
balance and finally walking exercises were patients in exercise and control groups are shown
given. in Table 1.
The control and exercise groups were compar-
These programmes were not recommended to the
able with respect to age, sex, stage and duration of
control group and they continued with their
the disease with no statistically significant differ-
routine activities. In order to track the compliance
ences.
of the exercise group, a daily follow-up diary was The assessment results of the parameters in the
given to be completed by the patient or his or her first and second months in both groups and the
relative. At the second and third visit after the comparison of these parameters in the exercise and
assessments, the exercise group was referred to control groups at baseline, first month and second
physiotherapist (ATC) again in order to check the month evaluation are shown in Table 2.
diary and exercise compliance. At the end of the All variables were significantly improved in the
second month final evaluations were carried out, exercise group, from baseline to second month,
exercises were instructed and an individualized whereas there was a significant impairment in the
exercise booklet was given to the control group. control group in 10-m and 20-m walking times.
The exercise group consisted of 15 patients The two groups were similar on all variables at
(mean age 679/5 years) and the control group baseline with no statistically significant differences.
consisted of 15 patients (mean age 649/3 years). Comparison of groups showed significant changes
There was no loss in either group in all assess-
ments.
A patient’s treatment regimen remained constant Table 1 Comparison of patient characteristics (n 0/30)
throughout this study. Except for two in the Control group Exercise group p-value
control and one in the exercise group taking
selegiline, all patients were on L-dopa and a Age (years) 64.3 (9/12.3) 67.4 (9/5.04) 0.325a
Sex (male/female) 10 M/5 F 11 M/4 F 0.5b
dopamine agonist.
Statistical analysis of the data was carried out Hoehn and Yahr
Stage I 1 2
using the Kruskal Á/Wallis test for evaluating each Stage II 11 10
group and the Mann Á/Whitney U -test and Stu- Stage III 3 3
dent’s t-test in comparing the two groups. Non- 0.827c
Duration of 5.2 (9/2.7) 5.5 (9/2.7) 0.79d
parametric statistics chi-squared test was used to disease (years)
analyse the proportion of disease stage and Fish-
er’s exact test for the distribution of male and a
Mann Á/Whitney U-test; bFisher exact; cChi-squared; dStu-
female subjects in the two groups. dent’s t.


Table 2 Improvement of motor tests and the comparison between groups

Assessment time Control group Exercise group p-value
Mean (SD) Mean (SD) (DBG)

10-m walking time (s) Baseline 14.3 (7.7) 13.6 (5.3) !/0.762
1st month 16.2 (9.1) 10.3 (4.2) B/0.029
2nd month 15.3 (8.7) 9.46 (3.9) B/0.01
p-value (DEG) B/0.03 B/0.001

20-m walking time (s) Baseline 29.7 (15.8) 28.2 (12.4) !/0.779
1st month 33.2 (18.9) 22.2 (8.9) B/0.045
2nd month 33.9 (20.5) 19.3 (8.3) B/0.009
p-value (DEG) B/0.013 B/0.001

First pace length (cm) Baseline 50.7 (18.1) 45.1 (17.3) !/0.467
1st month 50.8 (16.4) 54.6 (14.3) !/0.515
2nd month 52 (17.8) 63.1 (13.2) !/0.056
p-value (DEG) !/0.1546 B/0.001

Pace number in 10 m Baseline 19.6 (8.8) 21.2 (9.9) !/0.644
1st month 20.2 (8.1) 17.2 (4.1) !/0.199
2nd month 20.2 (8.9) 15.8 (3.1) !/0.512
p-value (DEG) !/0.6376 B/0.001

Time taken to turn around Baseline 10.3 (8.7) 8.53 (4.1) !/0.472
a chair (s) 1st month 12.2 (9.3) 7 (3.4) B/0.05
2nd month 12.6 (10.2) 5.53 (2.27) B/0.004
p-value !/0.0661 B/0.001

Nine Hole Peg Board test Baseline 44.6 (16.6) 42.8 (16.7) !/0.761
left (s) 1st month 45.4 (16.4) 36.5 (11.9) !/0.101
2nd month 45.1 (15.6) 33.8 (11.1) B/0.03
p-value (DEG) !/0.8899 B/0.001

Nine Hole Peg Board test Baseline 37.6 (13.4) 39.1 (10.6) !/0.742
right (s) 1st month 37.9 (13.4) 33 (9.1) !/0.254
2nd month 37.6 (12.1) 30 (8.3) B/0.053
p-value (DEG) !/0.9355 B/0.001

DBG, Difference between groups (Mann Á/Whitney U ); DEG, difference in each group (Kruskal Á/Wallis).

in 10-m (p B/0.029), 20-m walking time (p B/0.045) The differences were not statistically significant in
and time taken to turn around a chair (p B/0.05) at the second month when compared with the first
first month assessment. When the results of the month but were still significant when compared
second month assessments of the two group were with baseline (p B/0.0020 and p B/0.0028, respec-
compared, there were significant changes in all tively).
parameters except pace number in 10 m. Comparison of the groups showed that the
The difference seen in the parameters in two changes in IÁ/II, II Á/III and IÁ/III were significant
months were compared in the groups and the in first pace length (cm) (p B/0.0017, p B/0.0002
comparison of results of baseline to first month and p B/0.0000, respectively) and pace number in
(I Á/II), first month to second month (II Á/III) and 10 m (p B/0.0552, p B/0.0474, and p B/0.0331,
baseline to second month (I Á/III) evaluations are respectively).
shown in Table 3. Comparison of the groups showed that the
Comparison of the groups showed that the changes in II Á/III and IÁ/III were significant in
changes were significant in 10-m (p B/0.0053) and time taken to turn around a chair (p B/0.0344 and
20-m walking time (p B/0.0159) in the first month. p B/0.0110, respectively).


Table 3 Comparison of differences between assessments in two groups

Difference between Control group Exercise group p-valuea
assessments Mean (SD) Mean (SD)

10-m walking time (s) I Á/II (/1.93 (2.49) 3.27 (3.31) B/0.0053
II Á/III 0.93 (1.94) 0.87 (1.46) !/0.9162
I Á/III (/1 (2.77) 4.13 (3.70) B/0.0020

20-m walking time (s) I Á/II (/3.53 (4.12) 6.00 (7.80) B/0.0159
II Á/III 1.33 (4.27) 2.93 (3.20) !/0.2563
I Á/III (/2.2 (5.59) 8.93 (8.68) B/0.0028

First pace length (cm) I Á/II (/0.12 (3.82) (/8.62 (8.31) B/0.0017
II Á/III (/1.12 (4.94) (/8.92 (6.19) B/0.0002
I Á/III (/1.24 (7.01) (/17.5 (8.68) B/0.0001

Pace number in 10 m I Á/II (/0.67 (2.06) 4.00 (7.16) !/0.0552
II Á/III 0.07 (1.87) 1.40 (1.64) B/0.0474
I Á/III (/0.60 (2.38) 5.40 (7.44) B/0.0331

Time taken to turn around I Á/II (/1.53 (3.07) 1.53 (2.03) !/0.1201
a chair (s) II Á/III (/0.40 (2.10) 1.47 (1.41) B/0.0344
I Á/III (/1.93 (3.45) 3 (2.42) B/0.0110

Nine Hole Peg Board test I Á/II (/0.73 (4.37) 6.27 (7.54) B/0.0111
left (s) II Á/III 0.27 (2.79) 2.73 (2.58) B/0.0181
I Á/III (/0.47 (5.05) 9 (7.86) B/0.0011

Nine Hole Peg Board test I Á/II (/0.27 (4.61) 6.07 (7.27) B/0.0119
right (s) II Á/III 0.27 (4.95) 3.07 (3.33) !/0.0815
I Á/III 0 (4.22) 9.133 (6.59) B/0.0002

a
Student’s t-test.

Comparison of the groups showed that the programmes carried out in conjunction with drug
changes in I Á/II, II Á/III and I Á/III were signifi- therapy.1,15
cant in the Nine Hole Peg Board test left (s) Recently, a randomized and controlled study
(p B/0.0111, p B/0.0181 and p B/0.0011, respec- showed that multidisciplinary rehabilitation for
tively) and in I Á/II and IÁ/III in the Nine Hole patients with Parkinson’s disease may improve
Peg Board test right (s) (p B/0.0119 and p B/0.0002, mobility, and follow-up treatments may be needed
respectively). to maintain beneficial effects.18
Compliance was very high and patients dis- Some articles stated the benefits of short-term
played great care and attention in keeping the applied physiotherapy. In one, patients were in-
diary. They put ticks for every day for every structed by a physiotherapist at home, but it was
session. not a controlled study and the physiotherapy only
lasted a short time.10 In a second study, patients
were instructed by nursing students and the
investigators were mainly interested in nursing
Discussion parameters.12
More recent articles in the literature have also
The effects of physiotherapy and rehabilitation on described the use of home treatment for patients
patients with Parkinson’s disease have been re- with advanced Parkinson’s disease.9,11 Investiga-
searched by many investigators in the past.1,15 Á 17 tors stated that physiotherapy aimed at improving
The findings of these studies have showed the function in Parkinson’s disease is best provided in
benefits of physiotherapy and rehabilitation the home situation.11


The results of our present study suggest that if Significant improvement was found in walking
patients with Parkinson’s disease are taught in a controlled clinical trial done by Formisono
individualized and detailed home exercises by a et al. ,19 but the time taken to walk around a chair
physiotherapist, there is a statistically significant and Nine Hole Peg Board test completion time did
clinical improvement in their motor performance not change. In our trial we observed a highly
over an eight-week period. The benefits of a significant decrease (p B/0.01) in the time to walk
similar programme have also been shown in two around a chair, however there was an increase in
weeks in Parkinson’s disease as an outcome of an this time test in the control group. We think that
uncontrolled study in which home exercise was the main reason for this difference in patients in
instructed at home.10 However, our study showed the exercise group is that they had to walk around
that the improvement associated with physiother- the chair as a part of their home exercise pro-
apy continued for longer than two weeks and the gramme.
patients who were not referred to the exercise There was a significant decrease (p B/0.001) in
group for home exercise could not benefit from it. both left and right hand Nine Hole Peg Board test
Indeed, walking had deteriorated in control group completion times in the exercise group, which
patients over two months. Instructing exercise at reflects distal motor performance. The improve-
home may be feasible for patients, but it is not ment in the exercise group was due to the easily
feasible for the hospital staff if they do not have a performed hand exercises performed frequently by
special home therapy visiting team. This was why the patients.
we chose patients (grade I, II and III) who had Although the present study was based on a
no problems in transport, and we assessed and home programme, we believe the success in com-
instructed the patients at hospital. Since the pliance was primarily due to the motivational
patients agreed to come to hospital for three factor from the daily diary provided for comple-
visits at the beginning of the study, we did not tion by patients or relatives. Secondly, frequent
suffer from loss of patients. Patients in the visits to hospital and being assessed in detail
exercise and control groups had never been to a increased their interest in their treatment.
physiotherapist before. Our results showed that Another interesting finding was that the im-
patients who had difficulty in walking around a provement in most parameters was higher in the
chair also took longer for the 20-m walk test. We first month, but all continued to improve in the
concluded that these two parameters may be second month also. Some outcomes such as first
dependent to each other, since 20-m walking pace length and time taken to turn around a chair
time also has a ‘turn’ component. A highly improved similarly in the first and second months.
significant improvement was observed in the 10- These findings show the importance of follow-up
and 20-m walking time and time taken to turn visits to hospital by patients or to home by
around a chair for the patients in the exercise hospital staff in maintaining the useful outcomes
group. of physiotherapy.
As a result of their review, Deane et al. 13 Our study is a blinded and controlled study but
concluded that although 10 of the trials claimed our limitation is that group selection was done
a positive effect from physiotherapy, few outcomes with alternation of weeks. It is not a randomized
measured were statistically significant. Walking study.
velocity and stride length were the two parameters In addition, although it is a prospective and
increased significantly in two trials. Our present time-consuming study including training facilities
study also confirms that these parameters are and three assessments in two months, the number
affected by physiotherapy and is valuable in of patients was rather small and it would have been
showing the outcomes of motor performance. First better if we had reached a higher number of
pace length showed a significant improvement patients. On the other hand, the strength of the
(p B/0.001) and pace number in the 10-m walk study is that the doctor and physiotherapist
test decreased significantly (p B/0.001) in the assessing the patients were blind to the patient
exercise group. This provided an increase in the group selection, as well as the patients themselves
walking speed of these patients. being blind to selection of groups.


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