ABSTRACT: Introduction: Parkinson's disease (also known as Parkinson disease or PD) is a degenerative disorder of the central nervous system that often impairs the sufferer's motor skills, speech, and other functions. It is characterized by muscle rigidity, tremor, a slowing of physical movement (bradykinesia) and, in extreme cases, a loss of physical movement (akinesia). The patients with PD are typically marked by reduced speed, shortened stride length and longer double support phase. The use of electromechanical devices such as treadmill training has been used in rehabilitation of patients with impaired gait .This study was done to assess the effect of treadmill training over the Gait and functional mobility in Parkinson’s patients.
Materials and Methods: This study was conducted at S.M.S Hospital Jaipur, Anisha Multispecialty Hospital Guntur, AP, Physiotherapy center, Punjabi Bagh, New Delhi and some other local referral clinics in Lucknow (2008-2010). The total study period was 2 years .The treatment for each subject was for a period of 8 weeks, 3 sessions a week with 20 minutes as a single session.
A total of 20 (n=20) patients who are diagnosed with PD by the Physician were randomly selected after taking consent for their participation in the study. The outcomes were measured by subjective assessment of PDQ-39, and objectively assessed by Gait speed and Stride length.
Results: In this study to evaluate the effectiveness of intensive treadmill training over the gait and functional mobility in Patients with Parkinson’s disease, all data was expressed as Mean+/- SD and was statistically analyzed by using Paired ‘t’ test .It is used to examine the changes in the dependent variables from baseline to after completion of intervention. The pretest mean value of PDQ-39 is 31.27(SD=4.69) and the post test mean is 21.25(SD=2.95). The pretest mean value of Gait speed is 1.03(SD=0.09) and the post test mean is 1.24(SD=0.09). The pretest mean value of stride length is 0.99(SD=0.09) and the post test mean is 1.19(SD=0.06) with p value <0.05 in all the parameters. Thus from the above statistical data of PDQ-39,Gait speed and Stride length ,the post test values are significantly different from pretest values with p<0.05,i.e 95% level of significance, hence the null hypothesis was rejected.
Conclusion: Intensive treadmill training is effective on Gait and Functional mobility in patients with Parkinson’s disease.
Key-words- Parkinson’s disease, Gait, PDQ-39, Stride length, Gait speed.

INTRODUCTION
Parkinson's disease (also known as Parkinson disease or PD) is a degenerative disorder of the central nervous system that often impairs the sufferer's motor skills, speech, and other functions.
It is a slowly progressing disease involving primarily a degeneration of cells in basal ganglia and substantia nigra leading to deficit of dopamine–a neurotransmitter which produces gradual weakness of the voluntary movement with muscular rigidity, tremors impairment in the balance and automatic reactions.
It is characterized by muscle rigidity, tremor, a slowing of physical movement (bradykinesia) and, in extreme cases, a loss of physical movement (akinesia).
The term Parkinsonism is used for symptoms of tremor, stiffness, and slowing of movement caused by loss of dopamine Parkinson's disease was first described in England in 1817 by James Parkinson. The condition was popularly known as shaking palsy derived from Latin word paralysis agitans. Prevalence and incidence of PD is the second most common neurodegenerative disorder. The incidence increases dramatically with increasing age. About 1% affected over the age of 65 and more than 4% of the population is affected by the age of 85 years¹. Approximately 13-33% of the patients present with postural instability and Gait disturbances as their initial motor symptoms and comprise a postural instability Gait disturbed (PIGD) group. Gait disturbances are also a common feature of late onset or advanced PD². The Patient with PD Demonstrates a number of significant Gait changes resulting from impoverished movement. The various gait disturbances found in PD are:

Shuffling gait: Gait is characterized by short steps, with feet barely leaving the ground. Small obstacles tend to cause the patient to trip. There is decreased arm-swing.

Turning "en bloc": rather than the usual twisting of the neck and trunk and pivoting on the toes, PD patients keep their neck and trunk rigid, requiring multiple small steps to accomplish a turn.

Festination: Because of a combination of stooped posture, imbalance, and short steps it results to a gait that gets progressively faster and faster, often ending in a fall.
The patients with PD are typically marked by reduced speed, shortened stride length and longer double support phase³.The mobility problems have a greater negative impact on patient’s quality of life and their mental well being4. Although modern methods of Medical and surgical care is available, patients develop progressive disability⁵. The use of electromechanical devices such as treadmill training has been used in rehabilitation of patients with impaired gait⁶.This study was done to assess the effect of treadmill training over the Gait and functional mobility in Parkinson’s patients.

MATERIALS AND METHODS
This study was conducted at S.M.S Hospital Jaipur, Anisha Multispeciality Hospital Guntur, A.P, Physiotherapy center, Punjabi Bagh, New Delhi and some other local referral clinics in Lucknow (2008-2010). The total study period was 2 years .The treatment for each subject was for a period of 8 weeks, 3 sessions a week with 20 minutes as a single session.
A total of 20 patients who are diagnosed with PD by the Physician were randomly selected after taking consent for their participation in the study. The inclusion criteria include the patients who are not demented, patients who were able to ambulate, Patients with a Grade I-III on Hoeh & Yahr scale. The patients with poor general condition, patients with compromised cardiovascular responses, age more than 75 years were not included in the study.

Technique: After taking informed consent from the patients and being satisfied by inclusion criteria, were selected randomly for treatment. The patients were explained about the total treatment protocol.
Initial assessment was taken before the starting of the treatment. The patients gait was assessed subjectively by Parkinson’s disease Questionnaire (PDQ-39). The objective assessment of the gait was done by Gait speed (m/sec) and Stride length in meters.
Patient was made to walk on motorized treadmill under close supervision of the therapist. The patient was made to wear a safety helmet and harness to prevent fall. The training programme consisted of a 20 minute session for 3 times a week for a total period of 8 weeks. Once a week over ground walking speed was reevaluated and treadmill speed was adjusted accordingly, hence there was a progressive increase in the gait speed. The settings on the initiation of the programme over the treadmill were described in Table 1.1.

Outcome measures: The outcome of the treatment was assessed pretest and post test by PDQ-39. It is a 39- items questionnaire on the subjective report of the impact of PD on daily life and addresses 8 health related quality of life dimensions (Mobility, ADL, Emotional well being, Stigma, Social support, Cognition, Communication and Bodily discomfort) A summary score (The Parkinson’s disease summary index (PDSI) can also be determined with the scores that range from 0 meaning perfect health and 100 meaning worst health. The gait speed was assessed by Measure and mark technique. This included marking a standard distance 5 meters and then the patient is asked to walk with comfortable pace. The patient is made to walk 3 repetitions and the average time is calculated. Then the speed of the gait is calculated by the formula:

Gait Speed =distance/time⁷
The stride length is calculated by the formula: Stride length =speed /no of steps per second

RESULT AND DATA ANALYSIS
In this study to evaluate the effectiveness of intensive treadmill training over the gait and functional mobility in Patients with Parkinson’s disease, all data was expressed as Mean+/- SD and was statistically analyzed by using Paired ‘t’ test .it is used to examine the changes in the dependent variables from baseline to after completion of intervention.
The pretest mean value of PDQ-39 is 31.27(SD=4.69) and the post test mean is 21.25(SD=2.95) with p value <0.05 which shows there is a significant difference between pre-test and post test mean value. (Table 1.2)
The pretest mean value of Gait speed is 1.03(SD=0.09) and the post test mean is 1.24(SD=0.09) with p value <0.05 which shows there is a significant difference between pre-test and post test mean value of gait speed. (Table 1.2) The pretest mean value of stride length is 0.99(SD=0.09) and the post test mean is 1.19(SD=0.06) with p value <0.05 which shows there is a significant difference between pre-test and post test mean value. (Table 1.2)

Table 1.1: Speed Settings for Treadmill training

S. No	Week	Speed
1	First week	70% of the subjects comfortable ambulatory speed
2	Second week	90% of the subjects comfortable ambulatory speed
3	Third week –eight week	Progressive increase in speed over the comfortable ambulatory speed of the patient

Table 1.2 Pre test and Post values

Measures	Pretest value		Post test value		P value
	Mean	S.D	Mean	S.D
PDQ 39	31.27	4.69	21.25	2.95	0.011
Gait speed(Meters/Sec)	1.03	0.09	1.24	0.09	0.015
Stride length (meters)	0.99	0.09	1.19	0.06	0.012

Graph 1: comparison of Pre test and Post test PDQ 39



Graph 2: Comparison of Pretest and Post test Gait speed



Graph 3: Comparison of Pretest and post test Stride length

Thus from the above statistical data of PDQ-39,Gait speed and Stride length ,the post test values are significantly different from pretest values with p<0.05,i.e 95% level of significance, hence we reject the null hypothesis.

DISCUSSION
In this study to evaluate the effect of intensive treadmill training over the gait and functional mobility in Patients with Parkinson’s disease, there was statistical difference in the pre and post test values, hence thereby we reject null hypothesis.
This randomized controlled trail evaluated the efficiency of the treadmill training on the gait and functional mobility of Parkinson’s patients.
The participants in the study were the patients with mild to moderate PD, who obtained benefit from a gait training intervention. The ability of a patient to walk after suffering PD is often hindered by rigidity, reduced muscle torque, Loss of available Range of motion, weakness or decreased Muscle power. Treadmill training is beneficial for the patients as it provides an opportunity for extensive practice of the whole task of walking in presence of muscle weakness and poor balance control.
Treadmill training is the new innovation to improve gait in patients with various Neurological dysfunction. Miyai et.al in his study in 2000 has proved that treadmill walking is effective than that of conventional PD gait training programme⁸.
Phol et.al in his study in 2003 examined the immediate effects of a single treadmill session in a crossover, 4 consecutive day trail in 17 patients with early PD. Their results suggest that gait speed and stride length can be improved through a single intervention of treadmill but not through conventional gait training⁹.
Protas et.al in their study in 2005 assessed the benefits of gait and step training in PD and found that walking on a treadmill at a greater speed resulted in a reduction in falls and improvement in gait and dynamic balance in a small group of patients¹⁰.
Fiatarone et al showed that high intensity, progressive resistive training is highly efficacious, even among frail adults¹¹.
The mechanism whereby treadmill training works in PD remains to be fully determined. One of the explained possibilities is that the treadmill acts as a external cue by setting the walking patterns, reinforcing neural circuits which are meant for normal gait pacing. The improvement in Gait can also be attributed to the principles of motor learning. VanHedel et.al evaluated the acquisition and performance of a high precision locomotor task in patients with PD compared with healthy subject12. He founded that initially PD patients performed poorer and after task repletion, the groups performed similarly, indicating that adequate training can improve locomotor behavior in PD patients.
Thus, the treadmill protocol described here would achieve short term and long term goals in gait performance in patients with PD.

CONCLUSIONS
The following conclusion is drawn from the present study. Intensive treadmill training is effective on Gait and Functional mobility in patients with Parkinson’s disease.

ACKNOWLEDGMENT
I would like to extend my gratitude to my teachers who has guided me in this study. I also thank all the physicians who have referred the cases. I would also like to thank all the subjects who have actively participated in this study.

REFERENCES

1. De Rijk MC, Launer LJ, Berger K, et al. Prevalence of Parkinson's disease in Europe: a collaborative study of population-based cohorts. Neurologic Diseases in the Elderly Research Group. Neurology.2000; 54 (11 suppl 5):S21–S23.
2. Morris ME, Iansek R, Matyas TA, Summers JJ. Stride length regulation in Parkinson’s disease. Normalization strategies and underlying mechanisms. Brain 1996; 119 (Pt 2): 551–68.
3. Ebersbach G, Sojer M, Valldeoriola F, Wissel J, Muller J, Tolosa E, Poewe W (1999) Comparative analysis of gait in Parkinson’s disease, cerebellar ataxia and subcortical arteriosclerotic encephalopathy. Brain 122(7):1349–1355.
4. De Boer AG, Wijker W, Speelman JD, de Haes JC (1996) Quality of life in patients with Parkinson’s disease: development of a questionnaire. J Neurol Neurosurg Psychiatry 61:70–74.
5. Deane KH, Jones D, Playford ED, Ben-Shlomo Y, Clarke CE. Physiotherapy for patients with Parkinson’s disease: a comparison of techniques. Cochrane Database of Systematic Reviews 2001, Issue 3 [DOI: 10.1002/14651858.CD002815].
6. Moseley AM, Stark A, Cameron IS, Pollock, A. Treadmill training and body weight support for walking after stroke. Cochrane Database of Systematic Reviews 2005:4. [DOI: 10.1002/ 14651858.CD002840.pub2.b2].
7. Fritz S. Lusardi M. (2010). White Paper: Walking Speed: the Sixth Vital Sign. Journal of Geriatric Physical Therapy 32(2): 2-5.
8. Miyai I et.al (2002), Long term effect of body weight supported treadmill training in Parkinson’s disease: A randomized control trail, Arch Phys.Med.Rehabili.2002oct;83(10):1370-3.
9. Pohl M, Rockstroh G, Rückriem S, Mrass G, Mehrholz J. Immediate effects of speed-dependent treadmill training on gait parameters in early Parkinson’s disease. Archives of Physical Medicine and Rehabilitation 2003; Vol. 84:1760–6.
10. Protas EJ, Mitchell K, Williams A, Qureshy H, Caroline K, Lai EC. Gait and step training to reduce falls in Parkinson’s disease. Neuro Rehabilitation 2005; Vol. 20, issue 3:183–90.
11. Fiatarone et al (1990),High intensity Strength training in Nonagenarians Effects on skeletal Muscle, JAMA, June13, 1990-vol263, No. 22.
12. VanHedel et.al (2006), Learning a high precision locomotor task in patients with Parkinson’s disease, Movement Disorders 21(3):406-11, March 2006.

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