Current clinical literature is painfully lacking information regarding the efficacy of either physical rehabilitation or dietary intervention in the pathology of Parkinson’s Disease. The information in this article will pertain to the successes of a client under my supervision who has been following my training program for one year.
The significance of these positive results has the potential to heavily impact society’s perceptions on Parkinson’s Disease and the looming sense of inevitable decline that surrounds it.
Perhaps the most vital variable to keep in mind is that my client, Mary Lou, not only has diagnosed Parkinson’s Disease but was also clinically frail as defined by Fried’s Frailty Phenotype.[1] According to the Gross Motor Functioning Classification System (GMFCS),[2] Mary Lou was also classified as a Level II individual, primarily since she required periodic support when walking and was unable to run, jog, jump, or perform any accelerated locomotive skill. She was also a Stage III Parkinson’s sufferer based on criteria outlined in Hoehn and Yahr’s Staging of Parkinson’s Disease.[3] Schab and England Activities of Daily Living[4] scored her at a 70-80%, able to complete chores, but very slowly and with some unavoidable errors with reported issues with time required and physical fatigue.
It is worth noting that, in the case of Fried’s Frailty Phenotype, he omitted those with PD in fear it would mislead the metrics. For our purposes here, this scaling has still been used because of its worth as an assessment and identification tool.
I used a number of general assessment tests designed to specifically determine the approximate level of functionality. These include:
- 30 Second Sit-To-Stand
- Gait Speed Test
- Bar Hang Test
- Single-Leg Balance Test
- Farmer’s Walk Speed Test
- Farmer’s Walk Duration Test
- Timed Up-And-Go Test
Many of these tests are staples used in clinical environments. I included the farmer’s carry variations and the bar hang as a more accurate measurement of work capacity and upper body strength (as opposed to a bar curl test which only measures elbow flexion). The farmer’s carry also helps simulate common daily living; very often the task is not simply walking, but walking with some kind of load or over uneven terrain.
Mary Lou was also provided a personal nutritional consultation with me considering my sui generis Parkinson’s Polytherapeutic Protocol. This program provided a thorough outline of supplements, lifestyle changes, nutritional and dietary interventions, and uniquely designed physically rehabilitative training. She opted to not take any supplements with the exception of a whole-foods multivitamin. She also chose to follow a low-carb, high-fat, moderate-protein ketogenic diet as defined by Gasior et al.[i] Her adherence to this diet has been admittedly imperfect, but she still follows it close to 80%. This information was provided to me and further determined by me with access to daily food journals kept by Mary Lou.
All of the nutritional, nutraceutical, and physical training programs and curriculum followed according to the guidelines and clinical research provided in my Parkinson’s Polytherapeutic Protocol and heavily clinically supported throughout medical literature.
I will list each assessment test individually, introducing the first test as she started the program, her 6-month re-test, and the final one-year assessment. Pertinent notes will also be shared. To simply see the metric data from the various tests, see Table 1 at the end of this article.
About the Client
Mary Lou was diagnosed with Parkinson’s Disease (PD) shortly after she underwent chemotherapy and surgical intervention for breast cancer. She has been diagnosed with PD for approximately 18 years. Her Parkinsonian symptoms are controlled through the standard use of levodopa, a dopamine-mimicking drug. She is currently undergoing various techniques to avoid the use of the drug due to the potential long-term complications suffered by its continuous use.[5]
Clinically, Mary Lou was also frail according to the grading system used by Fried et al. This further complicated addressing Parkinson-centered rehabilitation and training since clinically frail individuals are already placed in a high-risk category. Prior to her cancer diagnosis and subsequent PD, Mary Lou had never engaged in any kind of physical training or athletic venture and lived an exclusively sedentary lifestyle.
Sit-To-Stand
For the sake of clarification, this test was repeated at all intervals on a chair that sat eighteen inches from the ground. This also serves as a worst-case-scenario approach since few sitting arrangements are at a lower height. This test was also conducted under a strict 30-second time limit.
On March 3, Mary Lou was able to stand from the seated position five times if allowed to place her palms onto her legs. When attempting to stand without the use of the arms, Mary Lou could not stand from the chair, even with significant torso movement. In the interest of having data to quantify improvements, the test was conducted instead with the client’s palms on her thighs.
Nearly six months later, on August the 24th, we repeated the test with identical perimeters. Mary Lou was able to execute the full movement a total of twelve times in the thirty-second limit. This equates to an improvement of 240%. Of note, however, is the client’s continued dependence on pressing upon the thighs with her palms.
On her one-year assessment, On February the 17th, Mary Lou repeated the same test and was still able to perform twelve repetitions. Although there was no discernible improvement based on pure test metrics, a drastic change involved the use of her arms. In the first two tests, Mary Lou required the use of her arms as stabilizers, pushing her palms onto the tops of her legs. For her third test, her hands remained free. This reported a significant, although unquantifiable, improvement.
Mary Lou also expressed absolute contentment with her current level of functionality in this movement with no real desire to advance any further. Of particular note was the seeming lack of exertion Mary Lou reported at the conclusion of the test, which leads me to question if twelve repetitions represented her maximal output.
Gait Speed Test
Of particular concern to those suffering from Parkinson’s Disease is the prevalence of gait abnormalities.
This test consisted of a 37-foot long room. The client was cued with a simple “go” once the time started. The client walked to the end of the room. The time was stopped when she reached the far wall.
On her first assessment, Mary Lou walked the length of the room in 20.34 seconds. Her reassessment resulted in the same distance being traveled in 11.22 seconds, a reduction of 9.12 seconds, or an approximate 45% increase in gait speed.
On her one-year assessment, Mary Lou performed the same test in 10.22 seconds, a decrease of a solid second. Similar to her first test, Mary Lou expressed no desire to improve her gait speed and also was not even slightly fatigued. She finished the test clapping her hands together asking what was next.
Pull-Up Bar Hang Test
This test was executed on a standard straight pull-up bar. Mary Lou was provided a step stool so that she could comfortably reach and grip the bar while still allowing her feet to support her weight. When cued, she lifted her feet and suspended herself in the air, holding herself aloft on the bar.
On March 3rd, 2016, Mary Lou was unable to execute the test.
During her follow-up test on the 24th of August, Mary Lou was able to hold herself suspended for 14 seconds. This demonstrated an unquantifiable improvement.
On February 17th of the following year Mary Lou held herself aloft for 26.5 seconds. This demonstrated an 89% improvement from her previous assessment.
Single-Leg Balance Test (Flat Feet)
For this test, Mary Lou was asked to stand on one foot at a time with the foot staying flat. The other foot was kept aloft and not allowed to make contact with the ground, the standing leg, or any other object.
For her first test, Mary Lou was able to stand on her right leg for ten seconds. She was unable to perform the test with her left leg with any sureness and required a handle for stability, eliminating the validity of the test.
Her retest in February showed improved numbers. She was able to stand on her right leg for 24 seconds, demonstrating a 140% improvement. Mary Lou was also able to balance on her left leg for three seconds, demonstrating a 300% improvement from her previous inability to perform the test.
On her one-year assessment, Mary Lou was able to stand on her right leg for 48 seconds and her left leg for 8 seconds, demonstrating a 100% and 166% improvement, respectively. This equated to a total one-year improvement of 380% on her right leg and an 800% improvement on her left leg from her initial testing.
Farmer’s Walk Test, Endurance
This test utilized a set amount of weight for an undetermined amount of time to assess the client’s stamina under load. The farmer carry simulates movements performed in daily life very well; that is, moving under some form of load. We utilized two 15 pound dumbbells and a room that is 37 feet long. The client was cued when to start and instructed to simply turn and repeat the test in a back-and-forth motion until fatigue set in.
On the initial test, Mary Lou was able to walk with the dumbbells at her sides for 50 seconds. At her retest, she was able to perform the same movement and weight for 110 seconds, demonstrating a 120% improvement. For her final test, Mary Lou concluded her carry at the four-minute mark out of understandable boredom. A 240-second walk demonstrated a 118% improvement from her second test and a 380% overall improvement.
Farmer’s Walk Test, Gait Speed Under Load
We repeated the same test as above, only instead of going for maximum time, the client performed the same weight for a limited distance to assess speed under load. This mimics ADL patterns very accurately. Loaded carries are also a strong indicator of an individual’s total muscular strength, coordination, balance, and muscular balance.
We utilized two 15-pound dumbbells just as above, and a room that was 37 feet long.
In her initial test, Mary Lou was able to perform the carry in 28 seconds.
In her retest she was able to carry the same load for the same distance in 16 seconds, a 43% improvement. In the final, one-year reassessment, Mary Lou completed the same task in 11 seconds, a 31% improvement from her previous score. This equates to a total improvement of 61% from baseline. To turn a phrase, Mary Lou was able to perform the same loaded carry in less than half the time of baseline.
Of particular note is that Mary Lou was able to perform the same gait speed under a thirty-pound load as without. This reveals a potential weakness in the farmer carry as an assessment tool due to maximum measurement potential.
Time Up-and-Go Test
For this test we utilized the same 18’’ seat. The distance traveled was 3 meters. The client was cued to start, then she would rise from the seated position and move across a line drawn 3 meters from her toes.
On March 3 Mary Lou completed the test in 17.3 seconds. For her second test, Mary Lou completed the test in 11 seconds, an improvement of 6.3 seconds, or 36%. Similar to the sit-to-stand test, Mary Lou completed the Timed Up-and-Go Test in the same amount of time on her final assessment, resulting in a finalized improvement of 6.3 seconds, or 36%, from baseline. When questioned, client again expressed absolute contentment at her current gait speed and desired no further improvement.
Parkinson’s and Frailty Reclassification
Mary Lou also redefined both her Parkinson’s and Frailty classifications. Due to her massive improvements, she is no longer clinically frail as defined by Fried et al. Her GMFCS classification also improved to a I/II, constrained by her inability to run or jog. Similarly, she is a Stage III/II Parkinson’s as determined by Hoehn and Yahr Staging of Parkinson’s Disease. At her current level of improvement, she will be firmly classified as a category II within six months.
Summary
Unfortunately, these testing methods still do not account for other improvements that are mentioned or witnessed in other avenues, such as the client’s confidence climbing bleachers at her grandson’s football game or the complimentary words of her girlfriends over coffee on Friday afternoons. However, even limited as it is to simple metrics and data, drastic improvements are easily noticed.
Working with Mary Lou has been a crowning experience and I look forward to continuing to help her cement her independence and freedom in the future.
Table 1: Summary of Assessment Tests
| Test Name | 3 March 2016 | 24 August 2016 | 17 Feb 2017 | Total Improvement |
| Sit-To-Stand | 5 Repetitions | 12 Repetitions | 12 Repetitions | 140% |
| Gait Speed | 20.34 Seconds | 11.22 Seconds | 10.22 Seconds | 50% |
| Bar Hangs | N/A | 14 Seconds | 26.5 Seconds | 89% |
| Single-Leg Bal. | R: 10 L: N/A | R: 24 L: 3 Seconds | R: 48 L: 8 Seconds | R: 380% L: 800% |
| Farmer C, Time | 50 Seconds | 110 Seconds | 240 Seconds | 380% |
| Farmer C, Gait | 28 Seconds | 16 Seconds | 11 Seconds | 61% |
| Up-and-Go | 17.3 Seconds | 11 Seconds | 11 Seconds | 36.4% |
Shane Caraway CHN, CPT, PTSP, uses his education, experience, and credentials as a certified personal trainer and nutritionist to help others recapture the primitive mystique, strength, and beauty that their body is capable of. His greatest pleasure comes from the successes of his clients, no matter how mundane or simple each small victory may be. Always in pursuit of various techniques, compounds, nutrients, herbs, and other means to help support the body against disease, Shane finds the challenge of combating chronic disease to be the pinnacle of his work, especially with diseases and conditions that otherwise cause clients to surrender.
References:
[1] https://www.ncbi.nlm.nih.gov/pubmed/11253156
[2] https://www.cerebralpalsy.org.au/what-is-cerebral-palsy/severity-of-cerebral-palsy/gross-motor-function-classification-system/
[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897716/
[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897716/
