Treadmill Training Improves Gait in Patients With Parkinson's Disease

Deborah Brauser

January 28, 2010

January 28, 2010 — Treadmill training can lead to more improved gait parameters for patients with Parkinson's disease (PD) than for those who do not participate in exercise treatment, according to a new systematic review from Germany.

In fact, the training group showed increases in stride length, walking speed, and walking distance.

"Acceptability of treadmill training for study participants was also good and adverse events were rare," write Jan Mehrholz, MPH, professor at the Leiter Wissenschaftliches Institut at the Private Europaische Medizinische Akademie der Klinik Bavaria in Kreischa, Germany, and colleagues.

In an interview with Medscape Neurology, Dr. Mehrholz said that this is the first systematic review with a pooled estimate on the effects of this type of PD therapy. "Many patients with Parkinson's want to improve their gait movement, want to go faster, and it's strongly related to their quality of life. Treadmill training is a promising option for them."

This study was published in the first 2010 issue of the Cochrane Database of Systematic Reviews.

A Nonpharmaceutical Approach

Gait hypokinesia, characterized by slowness of movement, is one of the primary movement disorders associated with PD, according to the study authors. Currently, exercise is often incorporated into treatment regimens for these patients as a useful complement to traditional drug therapies, and past studies have looked at using electromechanical devices, such as treadmills, to facilitate gait rehabilitation.

"Small trials have shown improvements but have been inconclusive," said Dr. Mehrholz. "Therefore, we were interested in a systematic evaluation [that provided] strong evidence about this type of therapy to give clear advice going forward."

His team sought to compare the effects of treadmill training vs no treadmill training on the gait of patients with PD, as well as its acceptability and safety, by evaluating data on 203 patients (mean age, 66.25 years) from 8 randomized controlled and randomized controlled crossover trials from the Cochrane Library. They measured gait improvement by analyzing walking speed, stride length, number of steps per minute (cadence), and walking distance.

"We hoped that treadmill training as a nonpharmaceutical approach would lead to clear improvements of gait," explained Dr. Mehrholz.

Improvements in All Outcomes but Cadence

Results showed that the group receiving treadmill training had improvements in all gait parameter measurements except for cadence compared with those in the other group. The training also did not increase the risk of patients dropping out, signalling patient acceptability.

Table. Treadmill Training Effects on Gait Parameters

Measure Differences (95% CI) P Value
Walking speed (SMD) 0.50 (0.17 to 0.84) .003
Stride length (SMD) 0.42 (0.00 to 0.84) .05
Walking distance (MD), m 358 (289 to 426) <.0001
Cadence (MD) 1.06 (−4.32 to 6.44) .70
Patient dropout rate (RD) −0.07 (−0.18 to 0.05) .26

CI = confidence interval, MD = mean difference, RD = relative risk difference, SMD = standard mean difference

"Treadmill training appears to be a safe and effective way of improving gait in patients with [PD]," the study authors write. "Crucially, we saw very few adverse effects or drop outs ... given this type of rehabilitation therapy."

"If patients have gait problems due to [PD], even if they are very small, we would [recommend] using treadmills to train the movement," added Dr. Mehrholz. "Additionally, one should use higher treadmill speeds than usually used on the ground."

However, the study authors caution that these findings are based on only 8 small studies, and the persistence of the gait improvements is unknown. "Further research should address specific questions about duration of effect and frequency and duration of treadmill training. [For now], it is not clear if such devices should be applied in routine rehabilitation."

Dr. Mehrholz reported that his team hopes to follow up in 1 year on the individual patient data from the trials evaluated.

Encouraging Results, but More Studies Needed

"I thought [the investigators] did a detailed and meticulous job of summarizing the existing literature that is out there," said Jay Alberts, PhD, from the Center for Neurological Restoration at the Cleveland Clinic in Ohio, to Medscape Neurology. Although he was not involved with this study, Dr. Alberts recently presented a study (reported by Medscape) evaluating the effects of stationary bicycle use on patients with PD.

"Their conclusions in regards to treadmill training improving certain aspects of gait are encouraging," said Dr. Alberts. "I'm also encouraged that the data suggests that you can change motor function in a Parkinson's patient through some type of behavioral intervention, such as treadmill training."

However, he cautioned that these results shouldn't suggest that more studies aren't needed in this area. "We all know that exercise is good for us but we need more studies, and the authors stressed that, to really understand what types of exercise are good for individuals with [PD]. Maybe it's treadmill training, maybe it's stationary cycling, maybe it's forced exercise, maybe it's other types of interventions. But I think using the blanket statement that just says 'exercise is good for you' leaves people with neuromotor and neurocognitive dysfunction out in the cold, if you will."

"Hopefully, the conclusions from this study will keep people aware that we need to keep looking at exercise interventions on gait, as well as on postural stability, upper extremity function, and such," Dr. Alberts added.

He noted that the study's comments on not knowing how long the effects last should be kept in perspective. "Although we do want to develop interventions that are long-lasting, the effects of medications and the effects of deep brain stimulation are not long-lasting. So if we can develop a behavioral intervention that only lasts, say, 4 weeks after they stop doing it, I think that's a success."

Dr. Alberts said that in order to "break into the neurologists' offices" in terms of exercise and exercise interventions in the future, researchers will need to show that they can induce global improvements in motor functioning — and show that the effects go beyond the specific tasks that the individuals are practicing.

"If you can change motor function globally, it then points towards a central mechanism that may actually be changing the brain, and that is a whole new, exciting direction that isn't restricted to Parkinson's but includes other neurodegenerative and even neurocognitive disorders," he concluded.

This study was funded by the Klinik Bavaria Kreischa, the Faculty of Medicine at the Technical University of Dresden, and the SRH Fachhochschule Gera — all in Germany — and by the California State University in Long Beach. Although 2 of the study authors, including Dr. Mehrholz, were coauthors of one of the trials included in the analysis, they did not participate in its assessment. The other study authors and Dr. Alberts have disclosed no relevant financial relationships.

Cochrane Database Syst Rev. 2010:Issue 1.

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