Effect of a Mat Pilates Program with TheraBand on Dynamic Balance in Patients with Parkinson's Disease: Feasibility Study and Randomized Controlled Trial

Abstract

The aim of this study was to assess the effect of a physical exercise program based on Mat Pilates (MP) with TheraBand^® on the dynamic balance of a sample population diagnosed with Parkinson's disease (PD). After random selection, 26 participants were allocated to a MP group or a control group where they performed calisthenics exercises. Both interventions lasted 12 weeks and involved 2 weekly sessions of 60 minutes. Assessments took place at baseline, 12 weeks after the intervention started and 4 weeks after the intervention was completed using the body mass index (BMI), the Timed Up and Go (TUG) test with Wiva^® sensors, the 30 Second Chair Stand test, and the Five Times Sit to Stand test. The group that completed the MP program presented significant improvements in BMI (F _1,21 = 3.986; p = 0.038), the 30 Second Chair Stand test (F _1,21 = 6.716; p = 0.014), the Five Times Sit to Stand test (F _1,21 = 5.213; p = 0.032), and the time required to complete the TUG dynamic balance test (F _1,21 = 5.035; p = 0.035). The MP program performed by a sample population with PD led to improvements in dynamic balance, and participants in the MP group showed increased strength in the lower limbs, but such improvements were not permanent after the activity ceased.

Introduction

Parkinson's disease (PD) is a neurodegenerative disorder that affects the central nervous system. Its progress is slow and asymmetric and, even though effective treatments are available today (drugs, multidisciplinary rehabilitation and sometimes surgery), there is still no cure. PD results in a premature, progressive, and irreversible degeneration in the pars compacta substantia nigra of dopaminergic neurons, which leads to a dopamine imbalance in the striatum following a rostrocaudal pattern.¹ This neurological disease causes numerous motor and nonmotor symptoms^2,3 and inclines patients toward a sedentary lifestyle, which has many deleterious consequences. The cardinal symptoms of PD are bradykinesia, rigidity, tremor and postural instability, which explain the patient's gradual loss of functional independence.^4,5

At present, the basic pillars of PD treatment include drug therapy and surgical techniques. Drug therapy is aimed at reestablishing the content of striatal dopamine in the patient's striatum administering levodopa, a precursor of dopamine, or dopaminergic agonists. Surgical techniques were introduced in the 1940s after researching the thalamus and the internal globus pallidus. Improved knowledge of the basal ganglia led to the exploration of new surgical targets, which, coupled with advanced neuroimaging and intraoperative neuromonitoring techniques, have triggered a surgical turn in PD.⁶ These treatments, however, do not make PD symptoms disappear. For this reason, over the past decade, physical therapy has been put forward as an alternative treatment that is low in cost and has no side effects, with the objective of maximizing the functional capacities of PD patients.

Systematic and controlled physical activity performance has positive effects on the development of conditional capacities, gait, balance, coordination, and the patient's emotional state, thus improving the quality of life of PD populations.^7

–10 New intervention proposals based on physical activity are currently being tested¹¹; however, these may not be applicable to the whole population. For this reason, feasibility studies and protocol validations are required to determine which strategy could be most appropriate for each specific pathology.

The Pilates Method of Exercise is a nonimpact activity adaptable to different physical conditions and health status, which is recommended for several different populations.¹² The floorwork exercises can be performed with specific apparatus (Equipment-based Pilates) or without them (Mat Pilates [MP]). MP is a form of physical exercise designed to improve strength, core balance, flexibility, muscular control, posture, and breathing,¹³ which contributes to the achievement of an optimal lumbopelvic stabilization necessary for daily life activities and functions.¹⁴ For the last few years, this exercise modality has experienced an upsurge among older adults, who have managed to enhance their physical condition, emotional state, and balance, as well as to reduce the risk of falling and improve their quality of life.^15

–18

Currently, the number of interventions featuring MP in populations with PD is very limited, although the results reported so far are generally positive, with an increase in flexibility levels and improvements in quality of life.^19

–22 The present study aims to measure the effect on dynamic balance of a MP program with TheraBand^® in a population diagnosed with PD.

Materials and Methods

Study design

This is a single-blind randomized controlled trial of an MP intervention with TheraBand. Assessments were carried out at baseline (week 0), at the end of the intervention (week 12), and as a follow-up, 4 weeks after the end of the intervention (week 17). All three assessment stages focused on the same variables.

Site and participant selection

The trial was designed and implemented by four experts in physical activity and neurodegenerative diseases from the University of Vigo in Spain. A sample of patients of both sexes diagnosed with idiopathic PD was recruited at “Asociación de Parkinson Provincial de Pontevedra,” according to the following inclusion criteria: (1) Hoehn & Yahr stage [H&Y] 1–3; (2) no clinical history of dementia, neurological deficits (e.g., the after-effects of a stroke or spinal injuries), or any other preexisting condition that could limit limb movement (as patients with a history of major surgical operations or wheelchair users), and; (3) no medical or surgical interventions that could interfere with the motor function. Before study, the trial was approved by the Research Ethics Committee of the Department of Health of the regional government and then assigned code number 2015/484. The trial followed both the ethics guidelines of the committee and the Declaration of Helsinki.

Recruitment

The recruitment phase spanned a period between December 2015 and January 2016, during which a meeting was held with the people in charge of “Asociación de Parkinson Provincial de Pontevedra” to share detailed information about the experimental study. The patients were evaluated by the lead researcher, who compiled a list of possible candidates after applying the inclusion criteria. All participants gave written informed consent.

Randomization

The lead researcher performed trial randomization once the initial evaluation had concluded. Taking sample size into account, a total of 26 PD patients met the inclusion criteria: 17 women and 9 men, who were randomly allocated with a 1:1 ratio to the MP intervention program group (MG) or to the control group (CG) (Fig. 1). Randomization was performed using IBM^® SPSS^® Statistics Software following the sequence: Data > Select Cases > Random sample of cases > Exactly 13 cases from the first 26 cases. The variables taken under consideration were age, gender, disease duration, H&Y scale ratings, and Unified Parkinson's Disease Rating Scale (UPDRS) motor score (Table 1).

FIG. 1.

Sample distribution flowchart.

Table 1.

Baseline Characteristics and Medication Use for All Participants

	MG	CG
	n = 13	n = 13
	Mean ± SD/%	Mean ± SD/%
Age (years)	62.85 ± 9.75	66.00 ± 13.14
Gender (% female)	61.50	69.20
Disease duration (years)	5.77 ± 3.39	5.69 ± 4.40
H&Y stage	2.08 ± 0.49	2.00 ± 0.82
Height (cm)	162.18 ± 6.43	162.46 ± 6.98
Weight (kg)	71.27 ± 10.13	76.46 ± 7.67
BMI (kg/m²)	27.05 ± 3.30	29.13 ± 4.01
UPDRS motor score	29.55 ± 11.26	31.54 ± 11.84
Parkinson's medication
Levodopa and carbidopa	92.30%	84.61%
Ropinirole	60.85%	53.16%
Rasagiline mesylate	30.09%	30.09%
Pramipexole	23.07%	13.38%
Rotigotine	23.07%	13.38%
Amantadine	7.69%	7.69%

BMI, body mass index; CG, control group; H&Y, Hoehn & Yahr; MG, Mat Pilates group; UPDRS, unified Parkinson's disease rating scale.

Intervention

Participants in both groups (MG and CG) completed 24 sessions at a rate of two nonconsecutive 60-minute sessions per week for 12 weeks (Table 2).

Table 2.

Mat Pilates Program

		Week
		1–3	4–6	7–9	10–12
Warm-up exercises (10 minutes)	Abdominal breathing	Abdominal breathing	Abdominal breathing	Abdominal breathing	Abdominal breathing
	Thoracic breathing	Thoracic breathing	Thoracic breathing	Thoracic breathing	Thoracic breathing
	Pelvic clock	Pelvic clock	Pelvic clock	Pelvic clock	Pelvic clock
Main part (45 minutes)	Arm arcs	Arm arcs	Arm arcs with adduction strap	Arm arcs with 0.5 kg wristbands	Arm arcs with straps and 0.5 kg wristbands
	Bridge	Bridge with straps, alternating legs (in bridge position, elevate one leg, then the other, then release)	Bridge with 0.5 kg ankle bands, alternating legs (in bridge position elevate one leg, then the other, then release)	Isometric bridge with straps, alternating legs	Isometric bridge with knee straps, alternating legs, and 0.5 kg ankle bands
	Curl ups	Curl ups with LL in triple flexion and 0.5 kg ankle bands	Curl ups with LL in diagonal pattern	Curl ups with LL in diagonal pattern and knee straps	Curl ups with LL in diagonal pattern and 0.5 kg ankle bands
	Leg circles	Leg circles with knee straps	Leg circles with knee straps	Leg circles with 0.5 kg ankle bands	Leg circles with 0.5 kg ankle bands
	Side leg	Side leg with 0.5 kg ankle bands	Side leg with ankle straps	Side leg with LL homolateral adduction and ankle straps	Side leg with 90° hip flexion and 0.5 kg ankle bands
	Superman	Superman with UL straps	Superman with UL straps and ankle bands	Superman with ankle and wristbands	Superman with ankle and wristbands
	Squats	In sitting position, alternating hip flexion with ankle straps	Squats with straps	Single leg stretch with straps	Single leg stretch with straps
Cooling-off exercises (5 minutes)	Thoracic breathing	Thoracic breathing	Thoracic breathing	Thoracic breathing	Thoracic breathing
Cooling-off exercises (5 minutes)	Abdominal breathing	Abdominal breathing	Abdominal breathing	Abdominal breathing	Abdominal breathing

LL, lower limbs; UL, upper limbs.

Participants in MG followed a program based on Pilates floorwork exercises adapted for PD populations using Medium-Resistant TheraBand as well as 0.5 kg ankle and/or wristbands. The MG program consisted of seven exercises distributed in three sets of eight repetitions (Table 2). Workout intensity was measured using the Modified Borg Rating of Perceived Exertion²³ and then kept constant throughout the program at a rating of 7, adapting the specific tasks to each participant and adding extra resistance with the TheraBand, ankle, and/or wristbands. After finishing each exercise, participants were asked to rate their effort in the Modified Borg scale, so that the supervisors could adjust the workload appropriately.

Table 2 summarizes program structure. The first 10 minutes of every session (warm-up) focused on the stimulation of body awareness, emphasizing thoracic breathing, cervical spine alignment, neutral position of the pelvis, and activation of the transversus abdominis and pelvic floor musculature. The final 5 minutes of cool-down were devoted to deep breathing and stretching of diverse muscle groups.

Participants in CG followed a physical activity program based on calisthenics that combined aerobic exercises, such as different varieties of marching, with strength, flexibility, articular mobility, and coordination tasks. The sessions were organized according to the same schedule as MG, leaving 10 minutes for warm-up focused on articular mobility exercises and 5 minutes for cool-down and muscle group stretching.

It should be noted that MG performed all the exercises on the floor from a sitting position, while most CG exercises, which were performed from a standing position, required more intense movements.

Assessment

Participants were assessed at baseline (week 0), at the end of the intervention (week 12) and 4 weeks after the end of the intervention (week 17) to analyze possible residual effects. The variables under analysis were as follows.

Anthropometric measurements

The height (cm) and weight (kg) of the participants were registered while dressed in light clothing and without shoes. Their body mass index (BMI) was calculated with the formula, weight/height² (kg/m²). A Tanita TBF300 scale with a precision of 0.1 kg and a Handac stadiometer with a precision of 1.0 mm were used in the process.

Strength

Both the 30 Second Chair Stand and the Five Sit Up tests were used. The 30 Second Chair Stand is part of the Senior Fitness Test battery designed to evaluate the test takers' physical condition.²⁴ This test assesses the strength and resilience of their lower limbs considering the number of times they can sit down and stand up from a chair in 30 seconds. The Five Sit Up test, however, is part of the Short Physical Performance Battery,²⁵ measures the strength and speed of the lower body and requires the test-takers to sit and stand five times in the shortest possible span.

Dynamic balance

This variable was assessed using the Timed Up and Go (TUG) test with Wiva^® sensors,²⁶ a set of wireless inertial detection devices placed in the L4–L5 spinal segment. Wiva sensors include an accelerometer, a magnetometer and a gyroscope that allows professionals and practitioners to gather information about the angular velocities reached during TUG. In addition, Wiva records split time data in the early stages of TUG (Sit to Stand, Gait to Go, Turning, Gait Return, and Stand to Sit) and the total time required to complete the task. All this information was saved and sent to a PC via Bluetooth with Biomech Study 2011 v.1.1.

Motor scale

The “Unified Parkinson's Disease Rating Scale III” (UPDRS-Motor Scale) was used to evaluate bradykinesia, tremor, or rigidity.²⁷

Feasibility

The following data were gathered to evaluate feasibility in MG: recruitment rate (number of participants recruited vs. number of participants who met the inclusion criteria), participation rate (total completed hours of exercise vs. total possible hours of exercise), adherence (rate of patients with 80% participation or higher), dropout (number of participants who could not complete the program), and safety and tolerability (number of patients who suffered adverse effects derived from the intervention, such as pain, dizziness, vertigo, and falls).

All participants were assessed during their “activation” phase (1 to 1.5 hours after taking their PD medication). All pharmacological treatments and dosage were kept stable for the duration of the study (Table 1).

Safety for exercise

In the MP intervention program, participant safety was considered at the time of performing the battery of tasks proposed, particularly when sudden changes in position were involved, with the essential objective of preventing falls and/or dizziness. Special attention was also paid during the muscle awareness and breathing control stages in each session to prevent instances of hyperventilation.

Sample size

Sample size was calculated in accordance with the results obtained by Hirsch et al.²⁸ for the balance parameters (20% difference between the groups under analysis) considering the comparison between two mean values, a level of confidence of 85% (1-α), a statistical power of 60%, and expected losses of 20%. The application of these criteria resulted in a sample size of 26 subjects.

Statistical analysis

A descriptive analysis of the initial sample was carried out using central tendency and dispersion (mean and standard deviation) measures for each of the groups (MG and CG). Sample homogeneity was checked using Student's t test for unpaired samples, since the quantitative parameters met the normality criteria (Shapiro–Wilk test; p > 0.05).

To analyze the effect of the MP program with respect to the physical activity of CG, a two-way analysis of variance was performed (Group: MG and CG; Moment: Pre and Post; 2 × 2). Another two-way analysis of variance was applied to check the possible residual effects of the Pilates intervention on the PD collective (Group: MG and CG; Moment: Post and Follow-up; 2 × 2). IBM SPSS Statistics 20 statistical software was used for this analysis. Significance level was set at p < 0.05.

Results

A total of 36 people, older than the age of 60 years, diagnosed with PD were initially selected to take part in the experiment. The recruitment rate was 86.66%, as six patients did not meet the inclusion criteria, three declined, and one suffered physical problems. Consequently, the final sample was reduced to 26 participants (MG, n = 13; CG, n = 13), both groups being homogeneous, in accordance with the characteristics shown in Table 1. 11.53% of participants did not complete the experiment (MG, n = 1; CG, n = 2).

The participation rate in MG was 80.21%, with 231 hours of workout out of a possible 288 hours. Ten out of 12 participants in MG completed at least 80% of the sessions, which resulted in an adherence rate of 83.33%. The dropout rate was 7.69%, as one participant could not finish the program. The safety and tolerability rate was 100%, since no adverse effects derived from the program were attested.

The group of participants who were allocated to the MP program presented significant improvements in BMI (kg/m²), 30 Second Chair Stand (n), Five Sit Up (seconds), and TUG cinematic parameters such as PD range (m/s²), Gait Go (seconds), average angular velocity (°/s), peak angular velocity (°/s), Gait Return (seconds), turning peak angular velocity (°/s), peak flexion angle turning (°), peak angular velocity turning (°/s), time turning (seconds), and total time (Table 3). The group allocated to the calisthenics exercise program presented significant effects in the following TUG cinematic parameters: PD range (m/s²) and average angular velocity turning (°/s).

Table 3.

Inferential Analysis of Mat Pilates Program Effects in Patients with Parkinson's Disease

	CG			MG
	n = 10			n = 12
	Pre	Post	Follow-up	Pre	Post	Follow-up	Factor moment (pre-post) × program	Factor moment (postfollow) × program
BMI (kg/m²)	29.03 ± 4.54	29.22 ± 4.61	29.10 ± 4.54	27.61 ± 3.36	27.27 ± 3.36^*	27.42 ± 3.49	F _1,21 = 3.986; p = 0.038	F _1,21 = 0.056; p = 0.814
H&Y	2.30 ± 0.67	2.50 ± 0.53	2.50 ± 0.53	1.92 ± 0.51	1.92 ± 0.51	1.92 ± 0.51	F _1,21 = 3.108; p = 0.087	F _1,21 = 0.001; p = 0.981
Sitting time (hours/week)
0–19	0.0%	0.0%	0.0%	0.0%	25.0%	0.0%	—	—
20–39	10.0%	20.0%	20.0%	25.0%	16.7%	27.3%	—	—
40–59	60.0%	50.0%	40.0%	41.7%	25.0%	54.5%	—	—
60–79	20.0%	30.0%	40.0%	33.3%	33.3%	18.2%	—	—
>80	10.0%	0.0%	0.0%	0.0%	0.0%	0.0%	—	—
30 Second Chair Stand (n)	13.90 ± 4.12	12.30 ± 5.06	12.20 ± 5.69	17.75 ± 6.36	23.83 ± 6.41^**	23.00 ± 6.91	F _1,21 = 6.716; p = 0.014	F _1,21 = 0.039; p = 0.845
Five Sit Ups (seconds)	10.71 ± 2.96	9.13 ± 4.07	9.35 ± 4.62	9.04 ± 4.01	5.78 ± 1.51^*	6.40 ± 1.59	F _1,21 = 5.213; p = 0.032	F _1,21 = 0.042; p = 0.838
UPDRS 3 (total)	35.00 ± 9.65	38.50 ± 10.81	37.60 ± 12.79	28.33 ± 12.09	27.92 ± 12.46	27.82 ± 15.87	F _1,21 = 0.453; p = 0.506	F _1,21 = 0.010; p = 0.921
Dynamic balance
TUG: Sit to Stand
Average angular velocity (°/s)	19.82 ± 8.36	17.70 ± 9.81	24.16 ± 5.96^#	23.99 ± 10.67	29.09 ± 19.06	16.19 ± 4.96^#	F _1,21 = 0.332; p = 0.569	F _1,21 = 6.108; p = 0.019
Peak angular velocity (°/s)	96.71 ± 38.97	79.91 ± 48.80	135.53 ± 88.22^#	121.63 ± 81.66	168.38 ± 174.38	64.56 ± 23.69^#	F _1,21 = 0.295; p = 0.591	F _1,21 = 6.516; p = 0.016
Peak flexion angle (°)	−12.41 ± 6.06	−12.95 ± 6.48	−10.86 ± 4.65	−14.40 ± 8.42	−10.90 ± 6.99	−13.79 ± 4.64	F _1,21 = 0.925; p = 0.343	F _1,21 = 0.490; p = 0.489
Peak extension angle (°)	3.26 ± 6.21	1.15 ± 2.63	3.26 ± 4.58	1.89 ± 3.76	4.54 ± 4.81	0.28 ± 0.70^#	F _1,21 = 4.444; p = 0.043	F _1,21 = 6.200; p = 0.018
AP range (m/s²)	7.55 ± 2.25	6.69 ± 1.13	7.53 ± 1.48	8.51 ± 2.47	8.42 ± 2.13	6.01 ± 1.47^##	F _1,21 = 0.453; p = 0.506	F _1,21 = 12.970; p = 0.001
PD range (m/s²)	5.98 ± 2.82	6.81 ± 2.62^*	7.61 ± 2.54	6.13 ± 1.34	7.98 ± 2.31^*	8.01 ± 1.80	F _1,21 = 2.546; p = 0.120	F _1,21 = 0.127; p = 0.724
ML range (m/s²)	2.63 ± 0.89	2.35 ± 0.81	2.75 ± 0.34	2.57 ± 0.82	2.80 ± 1.04	1.89 ± 0.58^#	F _1,21 = 0.113; p = 0.739	F _1,21 = 8.117; p = 0.007
Sit to Stand (seconds)	1.49 ± 0.43	1.54 ± 0.35	1.54 ± 0.41	1.38 ± 0.35	1.32 ± 0.74	1.99 ± 0.43^#	F _1,21 = 0.062; p = 0.805	F _1,21 = 4.931; p = 0.042
TUG: Go
Gait go (seconds)	2.27 ± 0.73	2.35 ± 0.78	2.64 ± 0.41	2.51 ± 2.31	1.78 ± 4.70^*	2.56 ± 3.23	F _1,21 = 6.001; p = 0.021	F _1,21 = 0.001; p = 0.983
TUG: turning
Average angular velocity (°/s)	91.60 ± 20.08	94.15 ± 21.29	93.05 ± 21.78	96.02 ± 29.24	110.76 ± 34.24^*	114.74 ± 35.56	F _1,21 = 3.153; p = 0.049	F _1,21 = 0.114; p = 0.738
Peak angular velocity (°/s)	178.02 ± 65.95	183.83 ± 37.20	192.40 ± 63.97	221.87 ± 103.14	328.40 ± 144.55^*	297.76 ± 109.35	F _1,21 = 3.921; p = 0.045	F _1,21 = 0.348; p = 0.559
Turning (seconds)	1.29 ± 0.45	1.21 ± 0.35	1.19 ± 0.29	1.18 ± 0.68	1.07 ± 0.36	0.93 ± 0.99	F _1,21 = 1.298; p = 0.263	F _1,21 = 0.087; p = 0.770
TUG: return
Gait return (seconds)	2.12 ± 0.58	2.17 ± 0.64	2.19 ± 0.59	2.59 ± 5.87	2.16 ± 4.66^*	2.65 ± 1.25^#	F _1,21 = 4.221; p = 0.041	F _1,21 = 4.197; p = 0.040
TUG: Stand to Sit
Turning peak angular velocity (°/s)	173.61 ± 49.49	188.83 ± 40.30	196.75 ± 70.29	297.24 ± 125.33	368.32 ± 137.58^*	311.87 ± 115.98	F _1,21 = 6.876; p = 0.010	F _1,21 = 0.657; p = 0.423
Peak flexion angle turning (°)	−26.31 ± 34.65	−11.73 ± 17.48	−11.03 ± 20.18	−25.93 ± 34.52	−21.84 ± 5.70^*	−21.66 ± 34.80	F _1,21 = 0.051; p = 0.822	F _1,21 = 0.052; p = 0.820
Peak extension angle turning (°)	61.00 ± 35.06	80.19 ± 8.36	76.95 ± 9.99	65.74 ± 31.39	82.69 ± 6.77	61.35 ± 33.27	F _1,21 = 0.401; p = 0.531	F _1,21 = 0.238; p = 0.629
Peak angular velocity turning (°/s)	173.61 ± 49.49	188.83 ± 40.30	196.75 ± 70.29	244.43 ± 83.64	368.32 ± 137.58^*	311.87 ± 115.98	F _1,21 = 8.876; p = 0.001	F _1,21 = 0.657; p = 0.423
Average angular velocity turning (°/s)	148.10 ± 62.18	135.50 ± 38.18^*	132.98 ± 31.42	184.53 ± 111.53	199.49 ± 74.35	191.73 ± 73.54	F _1,21 = 3.603; p = 0.043	F _1,21 = 0.147; p = 0.704
Time turning (seconds)	1.93 ± 1.36	1.95 ± 1.16	2.06 ± 0.54^#	1.69 ± 1.12	1.45 ± 0.75^*	1.54 ± 0.69^#	F _1,21 = 4.331; p = 0.047	F _1,21 = 5.007; p = 0.035
TUG: total
Total time (seconds)	9.10 ± 2.71	9.22 ± 2.49	9.62 ± 1.42	9.35 ± 2.43	7.78 ± 2.81^**	7.81 ± 5.64	F _1,21 = 5.035; p = 0.035	F _1,21 = 0.494; p = 0.488

Pretest–Posttest significant difference: ^* p < 0.05; ^** p < 0.001; posttest-follow-up significant difference: ^# p < 0.05; ^## p < 0.001.

AP, anteroposterior; MG, Mat Pilates group; ML, mediolateral; PD, Parkinson's disease; TUG, Timed Up and Go.

Table 3 indicates that 4 weeks after the intervention ended (follow-up), several TUG cinematic parameters experienced a significant worsening in MG: average angular velocity (°/s), peak angular velocity (°/s), peak extension angle (°), anteroposterior range (m/s²), mediolateral range (m/s²), Sit to Stand (seconds), Gait Return (seconds), and time turning (seconds). In the case of CG, average angular velocity (°/s) and peak angular velocity (°/s) declined.

The analysis of the changes experienced by MG and CG is presented in Table 3. Considering these results, it could be stated that the MP program led to significant differences with respect to the program based on calisthenics in terms of BMI (kg/m²), 30 Second Chair Stand (n), Five Sit Up (seconds), as well as the following TUG cinematic parameters: peak extension angle (°), Gait Go (seconds), average angular velocity turning (°/s), peak angular velocity turning (°/s), Gait Return (seconds), turning peak angular velocity (°/s), time turning (seconds), and total time (seconds).

Discussion

The alteration of dynamic balance in PD populations is one of the most characteristic symptoms of the disease. In this randomized controlled trial, the group allocated to the MP program obtained significant improvements with respect to CG in parameters such as lower body strength and dynamic balance. The results obtained in MG are in line with the conclusions presented in previous trials,^19
–21 where both programs based on Pilates in PD populations led to an improvement in the levels of lower body strength and dynamic balance, as indicated by the reduction in TUG test completion time. These results complement previous experiences with PD populations,^7

–10 where physical exercise performance had positive effects on physical abilities.

The physical program based on calisthenics that CG carried out did not lead to significant gains in strength, which, in turn, might have positive repercussions in the core balance, muscular control, and balance dynamic.¹³ The analysis of the data provided by UPDRS III (Motor Score) points to the existence of differences between the two groups. These results are in line with those presented by Li et al.²⁹ However, different results, show inverse trends for MG and CG, which should be verified and contrasted with future research, given the impossibility of such comparison at present. Therefore, it could be hypothesized that the intensity levels of the calisthenics program were not appropriate to produce the changes that were initially expected.

The analysis of TUG dynamic balance revealed that participants in MG attested improvements in the Go, Return, and Stand to Sit phases, while CG did not register such enhancements, apart from Stand to Sit. These results indicate that the inclusion of strength work in MP might explain such increases, which are connected to higher levels of functional independence in PD patients.³⁰

Pilates training could be considered a form of physical exercise focused on the improvement of strength, core stability, flexibility, muscular control, posture, and breathing.¹³ Studies by Hageman and Thomas³¹ and Thomas and Hageman,³² where the intervention program involved the use of TheraBand, did not report lower TUG total times, which is not consistent with the results presented here. However, the age and level of dependence in this sample might have had an impact on these figures.

When both programs were completed, after the 4-week follow-up, the improvements achieved were not maintained, which suggests that continued and scheduled practice adjusting the intensity of the workout is an essential factor to increase functional independence and keep strength at an adequate level.

The TUG cinematic analysis revealed that the mean value of the angle of hip flexion was lower in MG than in CG at the end of the intervention, but higher at follow-up, even though such differences were not significant. Future studies should control these variables more closely, as the increase in angular velocity could have been due to an improvement in strength and, consequently, balance. The TUG Sit to Stand, Turning, and Stand to Sit figures in MG confirm the assumption that one of the objectives of MP is to improve coordination and core muscle control, leading to the optimal lumbopelvic stabilization needed for daily life activities and functions.¹⁶

In summary, the promising results obtained in safety and feasibility suggest that the MP program with TheraBand is appropriate for PD populations. The intervention led to improvements in dynamic balance and significant gains in lower body strength, even though such benefits were not maintained 4 weeks after the experiment concluded.

Limitations and future directions

The first limitation that should be made explicit involves the low statistical power (60%) of sample size estimation, which may have affected the probability of identifying program effects.

The unavailability of a CG which did not exercise represents the second limitation of the present study; had there been a CG with no physical activity, the effect of the Pilates intervention could have been clearer.

The third limitation is related to the heterogeneity of the sample (age, sex, and H&Y stage) that makes it difficult to draw adequate comparisons and extrapolate useful data. Future research should aim to stratify the sample according to age, sex, and H&Y stage with the objective of identifying program effects in more homogeneous groups.

The fourth limitation derives from the design of the experiment, which is not double-blind, as would have been desirable. The researchers were aware of participant allocation in MG and CG.

The fifth and last limitation to be reported is connected to the cinematic analysis performed on dynamic balance: TUG with Wiva sensors is rare, because there are still no articles where they use it, which has been an obstacle at the time of contrasting the results obtained. Further research studies should be conducted with these analyses.

Footnotes

Acknowledgment

The authors thank the Parkinson Pontevedra Association for its participation in the study.

Author Disclosure Statement

No competing financial interests exist.

References

Lang

, Lozano

. Parkinson's disease: First of two parts. N Engl J Med, 1998; 339:1044–1053.

Shastry

. Parkinson disease: Etiology, pathogenesis and future of gene therapy. Neurosci Res, 2001; 41:5–12.

Jellinger

. How close are we to revealing the etiology of Parkinson's disease?. Expert Rev Neurother, 2015; 15:1105–1107.

Morris

, Iansek

, Matyas

, Summers

. The pathogenesis of gait hypokinesia in Parkinson's disease. Brain, 1994; 117 (Pt 5):1169–1181.

Speelman

, Van De Warrenburg

, Van Nimwegen

, Petzinger

, Munneke

, Bloem

. How might physical activity benefit patients with Parkinson disease?. Nat Rev Neurol, 2011; 7:528–534.

Volkmann

. Deep brain stimulation for the treatment of Parkinson's disease. J Clin Neurophysiol, 2004; 21:6–17.

Crizzle

, Newhouse

. Is physical exercise beneficial for persons with Parkinson's disease?. Clin J Sport Med, 2006; 16:422–425.

Rodrigues de Paula

, Teixeira-Salmela

, Coelho de Morais Faria

, Rocha de Brito

, Cardoso

. Impact of an exercise program on physical, emotional, and social aspects of quality of life of individuals with Parkinson's disease. Mov Disord, 2006; 21:1073–1077.

Van der Kolk

, King

. Effects of exercise on mobility in people with Parkinson's Disease. Mov Disord, 2013; 28:1587–1596.

10.

Ayán

, Cancela

, Gutiérrez-Santiago

, Prieto

. Effects of two different exercise programs on gait parameters in individuals with Parkinson's disease: A pilot study. Gait Posture, 2014; 39:648–651.

11.

Pérez-de la Cruz

, Luengo

, Lambeck

. Efectos de un programa de prevención de caídas con Tai Chi acuático en pacientes diagnosticados de parkinson. Neurología, 2015; 31:176–182.

12.

Hita-Contreras

, Martínez-Amat

, Cruz-Díaz

, Pérez-López

. Fall prevention in postmenopausal women: The role of Pilates exercise training. Climacteric, 2016; 19:229–233.

13.

Wells

, Kolt

, Bialocerkowski

. Defining Pilates exercise: A systematic review. Complement Ther Med, 2012; 20:253–262.

14.

Queiroz

, Cagliari

, Amorim

, Sacco

. Muscle activation during four Pilates core stability exercise in quadruped position. Arch Phys Med Rehabil, 2010; 91:86–92.

15.

Cancela

, Oliveira

, Rodríguez-Fuentes

. Effects of Pilates method in physical fitness on older adults. A systematic review. Eur Rev Aging Phys Act, 2014; 11:81.

16.

Pata

, Lord

, Lamb

. The effect of Pilates based exercise on mobility, postural stability, and balance in order to decrease fall risk in older adults. J Bodyw Mov Ther, 2014; 18:361–367.

17.

Rodríguez-Fuentes

, Oliveira

, Ogando-Berea

, Otero-Gargamala

. An observational study on the effects of Pilates on quality of life in women during menopause. Eur J Integr Med, 2014; 6:631–636.

18.

Bullo

, Bergamin

, Gobbo

, Sieverdes

, Zaccaria

, Neunhaeuserer

, Ermolao

. The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: A systematic review for future exercise prescription. Prev Med, 2015; 75:1–11.

19.

Johnson

, Putrino

, James

, Rodrigues

, Stell

, Thickbroom

, Mastaglia

. The effects of a supervised Pilates training program on balance in Parkinson's disease. Adv Park Dis, 2013; 2:58–61.

20.

Mollinedo

, Rodríguez-Fuentes

, Cancela-Carral

. El método Pilates como técnica innovadora para la mejora de la calidad de vida en población parkinsoniana femenina, In: Pérez-Fuentes

, Molero

, Gázquez

, Barragán

, Martos

, Pérez-Esteban

(eds.). Cuidados, aspectos psicológicos y actividad física en relación con la salud, ASUNIVEP, Almería, Spain, 2016, pp. 469–476.

21.

Cancela

, Mollinedo

, Ayán

, Machado

. Feasibility and Efficacy of Mat Pilates on people with mild to moderate Parkinson's disease: A preliminary study. Rejuvenantion Res, 2017 [Epub ahead of print]; DOI: 10.1089/rej.2017.1969.

22.

Mollinedo

, Cancela-Carral

, Rodríguez-Fuentes

. [Modifications in the levels of flexibility in a parkinsonian population over 65 years after participating in a physical program based on the Pilates Method.] In: Pérez-Fuentes

, Molero

, Gázquez

, Barragán

, Martos

, Pérez-Esteban

(eds). Care, psychological aspects and physical activity in relation to health, ASUNIVEP, Almería, Spain, 2016, pp. 477–482. [In Spanish].

23.

Penko

, Barkley

, Koop

, Alberts

. Borg scale is valid for ratings of perceived exertion for individuals with Parkinson's disease. Int J Exerc Sci, 2017; 10:76–86.

24.

Cancela

, Ayán

, Gutiérrez-Santiago

, Prieto

, Varela

. The senior fitness test as a functional measure in Parkinson's disease: A pilot study. Parkinsonism Relat Disord, 2012; 18:170–173.

25.

Guralnik

, Ferrucci

, Pieper

, Leveille

, Markides

, Ostir

, Studenski

, Berkman

, Wallace

. Lower extremity function and subsequent disability: Consistency across studies, predictive models, and value of gait speed alone compared with the short physical performance battery. J Gerontol A Biol Sci Med Sci, 2000; 55:M221–M231.

26.

Cancela

, Pallín

, Orbegozo

, Ayán

. Effects of three diferent chair-based exercise programs on people older than 80 years. Rejuvenation Res, 2017 [Epub ahead of print]; DOI: 10.1089/rej.2017.1924.

27.

Ramaker

, Marinus

, Stiggelbout

, Van Hilten

. Systematic evaluation of rating scales for impairment and disability in Parkinson's disease. Mov Disord, 2002; 17:867–876.

28.

Hirsch

, Toole

, Maitland

, Rider

. The effects of balance training and high-intensity resistance training on persons with idiopathic Parkinson's disease. Arch Phys Med Rehabil, 2003; 84:1109–1117.

29.

, Harmer

, Fitzgerald

, Eckstrom

, Stock

, Galver

, Maddalozzo

, Batya

. Tai chi and postural stability in patients with Parkinson's disease. N Engl J Med, 2012; 366:511–519.

30.

Chen

, Chen

, Chang

, Cheng

, Huang

. Elastic band exercises improved activities of daily living and functional fitness of wheelchair-bound older adults with cognitive impairment: A cluster randomized controlled trial. Am J Phys Med Rehabil, 2016; 95:789–799.

31.

Hageman

, Thomas

. Gait performance in dementia: The effects of a 6-week resistance training program in an adult day-care setting. Int J Geriatr Psychiatry, 2002; 17:329–334.

32.

Thomas

, Hageman

. Can neuromuscular strength and function in people with dementia be rehabilitated using resistance-exercise training? Results from a preliminary intervention study. J Gerontol A Biol Sci Med Sci, 2003; 58:M746–M751.