Keywords: Parkinson 's disease ; Isokinetic ; Muscle strength ; Lower appendage
Parkinson 's disease ( PD ) is a common neurodegenerative status in which patients typically experience troubles such as awkwardness of motions ( bradykinesia ) , stiffness of the musculuss ( rigidness ) , shudder, balance perturbations, and progressive lessening in motor functions.1-3 When combined with multiple other factors, decreased musculus strength can take to falls among aged patients, doing breaks, joint disruptions, terrible soft tissue lesions, and caput trauma.4,5 As a back uping fact, the autumn rate is higher among those with PD compared to healthy aged persons, harmonizing to the clinical image of the disease.4,6
Muscle failing is one of the chief symptoms of PD.7 In recent clinical tests, decreased musculus strength has been observed in patients with PD.8-12 Kakinuma et al.12 measured the isokinetic musculus strength on articulatio genus extension and i¬‚exion, and they observed isokinetic strength decrease on the side that is more greatly affected by PD. In another survey, Nallegowda et al.9 tested the bole, hip, and ankle flexor and extensor musculuss ' strengths utilizing isokinetic measuring, and reported a lessening in strength in all the flexor and extensor musculus groups. Pedersen et al.10 obtained lower isokinetic homocentric torsion consequences compared to command topics on quantitative appraisal of dorsii¬‚exors. Inkster et al.11 observed that decreased strength at the hip muscles is an of import subscriber to the trouble in lifting from a chair among patients with PD. Finally, Nogaki et al.8,13 hypothesized that musculus failing in PD is likely to depend on motion speed.
In contrast to the isokinetic ratings mentioned supra, there are some surveies in which quantitative isotonic and isometric musculus strengths have been evaluated.7,14,15
So far, there has been no survey in the literature that evaluated the isokinetic strength of the hip, articulatio genus, and ankle articulations together. There are some limited surveies, nevertheless, that evaluated the musculus groups at different isokinetic speeds in the lower extremity13, every bit good as the correlativity between musculus strength, and clinical position and falls9 among patients with PD.
In this survey, we evaluate the lower appendage flexor and extensor isokinetic musculus strength at the hip, articulatio genus, and ankle articulations in patients with PD. We aim to happen out which musculus groups and motion speeds of the lower appendage are more greatly affected by the disease, and we seek to detect the relationship between musculus failing, and clinical position and falls.
2. Materials and Methods
This survey was designed as a cross-sectional, controlled survey. The patients included in this work were from the outpatient clinics of the Physical Medicine and Rehabilitation, and Neurology Departments, and were diagnosed with PD harmonizing to the United Kingdom Parkinson 's Disease Society Brain Bank criteria.9 The survey was approved by the local ethical commission at the Inonu University School of Medicine and carried out in conformity with the rules in the Declaration of Helsinki. Written consent was obtained from all the participants.
Twenty-five patients ( 17 males and 8 females ) were included in the survey. The average age of the patients was 62.1A±10.3 ( with a scope of 42-81 ) old ages. All patients were at Hoehn & A ; Yahr phase II or III, and were having intervention for PD. None of the patients had any serious orthopedic, neurological, vestibular, or ocular upset that could impact their musculus strength, and all of them could walk unsupported.
Twenty-four healthy voluntaries ( 13 males and 11 females ) with no orthopedic, neurological, or other diseases constituted the control group, which was age-matched with the patient group.
2.2.1. The Unified Parkinson 's Disease Rating Scale ( UPDRS ) and Hoehn & A ; Yahr presenting
Patients were assessed with the usage of the Unified Parkinson 's Disease Rating Scale ( UPDRS ) portion II 'activities of day-to-day populating ' ( UPDRS-ADL ) and portion III 'motor scrutiny ' ( UPDRS-ME ) 16, and Hoehn & A ; Yahr staging.17
2.2.2. Fall history
We used a standard definition for autumn, which is `` accidentally coming to rest on the land, floor, or other lower degree. `` 18 For the interest of coherence with the definition, coming to rest against furniture or a wall was non accepted as a autumn. The figure of falls was determined utilizing self-reported autumn events during the past 6 months.
2.2.3. Isokinetic musculus strength
Isokinetic musculus strength trials were administered in the forenoon before the patients took any medical specialty. Patients foremost warmed up for 10 proceedingss on a bike dynamometer with a burden of 1 W/kg. We used the Biodex System 3 Pro ( Biodex, Inc. , Shirley, NY, USA ) isokinetic ergometer for the isokinetic measurings. During the trials, the patients were stabilized with seat belts in order to supply joint stabilisation and to forestall them from falling off the trial chair. All trials were performed on both appendages. The isokinetic protocol consisted of trials at three angular motion speeds of 90, 120, and 150 degrees/sec at 10 revolutions per minute, with a 5-min remainder period between trials. We followed the same process for hip flexion-extension, knee flexion-extension, and ankle plantar/dorsiflexion. The articulatio genus and mortise joint trials were performed in a seated place, while a supine place was used to find hip flexure and extension strength. All trials were performed for homocentric musculus strength every bit good, where the maximal extremum torsion ( Nm ) was recorded at each angular velocity.9
2.3. Statistical analysis
We used the SPSS 16.0 package for statistical rating of the trial consequences ( SPSS, Chicago, IL, USA ) . The normalcy for uninterrupted variables in groups was determined by the Shapiro-Wilk trial. We used Student 's t-test or Mann-Whitney U trial for comparings, whereas Spearman 's rank correlativity trial was used for analysis of informations. For correlativity analysis, the mean musculus strength was calculated at 90, 120, and 150 degree/sec angular motion speeds over the entire values for the hip, articulatio genus, and ankle musculuss. A p value of less than 0.05 was taken as the degree of significance.
The descriptive features of the patient and control groups are presented in Table 1. It can be observed from the tabular array that there was no statistically important difference between the two groups in age, weight, and tallness. The average disease continuance was 5.6A±3.9 ( with a scope of 1-15 ) old ages. Fifteen patients ( 60 % ) were in Hoehn & A ; Yahr phase II, and 10 ( 40 % ) were in phase III. In the patient group, the UPDRS ME and ADL tonss were 26.3A±12 and 8.9A±5, severally.
During the last 6 months, the figure of lumbermans in the patient group was 12 ( 48 % ) , compared to merely 4 ( 16.7 % ) in the control group ( P & lt ; 0.05 ) . The mean figure of falls was found to be 0.9A±1.1 in the patient group and 0.2A±0.5 in the control group ( P & lt ; 0.001 ) .
The isokinetic musculus strength of the patient and control groups is shown in Table 2. At all speeds, the musculus strength of hip flexors ( P & lt ; 0.01 ) and extensors ( P & lt ; 0.05 ) was found to be significantly less in the patient group. Similarly, compared with the control group ( P & lt ; 0.05 ) , we observed a important lessening in the musculus strength of articulatio genus flexors and extensors in the patient group, irrespective of the speed. Furthermore, the isokinetic extremum torsions of ankle plantar- and dorsiflexor musculuss exhibited significantly smaller values at certain motion speeds in the patient group ( P & lt ; 0.05 ) .
We observed a considerable relationship between musculus strength and figure of falls ( P & lt ; 0.01 ) . The correlativity between musculus strength and Hoehn & A ; Yahr phase was statistically important. There was besides a strong correlativity between musculus strength and all UPDRS tonss ( P & lt ; 0.01 ) . However, there was no correlativity between musculus strength and disease continuance.
The lower appendage musculus strength is known to hold a outstanding consequence on mobility. So far, there have non been any surveies in the literature that evaluated the overall flexor and extensor musculus strength in the hip, articulatio genus, and ankle articulations in patients with PD, although several surveies have evaluated the musculus strength in merely one or two articulations separately10,12,13. In this survey, we assessed musculus strength with an isokinetic ergometer in an effort to find which musculus groups were more greatly affected, and at which of the evaluated motion speeds, and to measure their correlativity with clinical position and falls. While many surveies have evaluated isokinetic musculus strength before ( off province ) and after ( on province ) medicine, we chose to prove all the patients in the forenoon after backdown of medicine ( off province ) . The chief ground for this pick is to govern out the effects of medicine while measuring the musculus failing that exists as portion of the nature of PD. The positive effects of antiparkinsonian agents on musculus strength have already been shown in many studies9,19 and are outside the range of this survey.
Nallegowda et al.9 evaluated the isokinetic musculus strength at the bole, hip, and ankle flexor and extensor musculuss at 90, 120, and 150 degree/sec angular speeds, which are the same as the 1s used in our survey. They found a important difference in all musculus groups between patients who did non take medicine and the healthy control group. In contrast, we evaluated the articulatio genus flexor and extensor musculus strength alternatively of the bole flexor and extensor musculus strength. As a consequence, we observed a important failing in all hip and articulatio genus musculuss at all evaluated speeds, every bit good as in mortise joint musculuss at some certain speeds. There was besides pronounced musculus failing in the hip flexors compared to the other musculus groups. Hip flexors are the major gas pedals in the swing stage of the gait.20 The trouble in gait induction in patients with PD may lend to the apparent failing of the hip flexors. However, Bartels et al.21 suggested that freeze of pace was non correlated with bradykinesia. Alternatively, ankle musculus strength is more of import in forestalling falls and for proper pace. Less terrible mortise joint musculus failing than the other musculus groups demonstrates the importance of other factors like proprioception. Zia et al.22 pointed out the damage of joint place sense in patients with PD. These consequences suggest the possibility of different underlying diseased mechanisms.
Pedersen et al.10 evaluated the mortise joint dorsiflexor isokinetic musculus strength both concentrically and eccentrically, and found significantly lower values for the homocentric musculus strength at all motion speeds compared to the control group, while the bizarre musculus strength was different from the control group merely in male patients. Kakinuma et al.12 separated the topics into two groups harmonizing to their holding more- or less-affected appendage, and found that the isokinetic musculus strength decreased at both the slow and fast motion speeds during the early period of the disease. They besides observed that the difference in musculus strength between the more- and the less-affected appendages decreased in the advanced phase of the disease. Our survey and the surveies mentioned above 9,10,12 demonstrated no relation between the reduced musculus strength and the motion speeds. Nogaki et al.13 found a important lessening in the peak torsion of the isokinetic musculus strength compared to the less-affected appendage at high motion speeds but no difference between the two appendages at lower motion speeds. Therefore, the observation of increased musculus failing at higher motion speeds, which was proposed in the survey by Nogaki et al.13, is comparable with the determination in our survey.
Although Corcos et al.23 indicated an asymmetric distribution of musculus failing, our survey has shown the common musculus failing in patients with PD to be similar to those found in the survey by Nallegowda et al.9 In some studies9,13, the importance of the cardinal consequence on musculus failing was emphasized, but the consequence of immobilisation was non considered in patients with PD. The effects of immobilisation on musculus failing should be noted, particularly in aged patients with PD.
Assorted surveies reported the hazard of falling in those with PD to run from 38 to 70 % 2,4,9. Our consequences sing the per centum of patients who have suffered from falls were similar. There was a important relationship between falling and musculus strength, but we have non come across any surveies on the association of musculus strength with falls in patients with PD. Some authors24,25 have observed musculus failing at lower appendage as a hazard factor for falling. Therefore, the hazard of falling may be examined in connexion with lower appendage isokinetic musculus strength in patients with PD.
We found a pronounced correlativity between musculus strength, and UPDRS ME and ADL tonss. Since the UPDRS ME and ADL tonss are related to clinical position, we had already expected to happen such correlativity between these parametric quantities and musculus strength. The UPDRS is a often used measuring for measuring the clinical state of affairs of patients with PD.26 Given the important correlativity between musculus strength and the UPDRS, isokinetic musculus strength may be used to measure clinical position of patients.
Disease patterned advance in PD was evaluated utilizing Hoehn & A ; Yahr presenting. Increased disease badness ( a‰?stage III ) leads to more pronounced locomotor system abnormality.27 Most of our patients were in Hoehn & A ; Yahr phase II. As can be seen in Table 3, there appeared a important correlativity between isokinetic musculus strength and Hoehn & A ; Yahr phase. Muscle failing in our patients was non outstanding, as they were at an early phase of PD. It seems musculus failing is related to clinical badness instead than disease continuance.
The chief restrictions of our survey are the unequal figure of patients and the absence of lower speeds, such as 60 degrees/sec, at which isokinetic musculus strength could be evaluated.
In drumhead, we found a important lessening in bilateral hip, articulatio genus, and ankle flexor and extensor isokinetic musculus strength, which was particularly outstanding in the hip muscles at 90, 120, and 150 degree/sec angular motion speeds. In add-on, we detected a relationship between disease badness and musculus failing. Furthermore, a important correlativity was besides present between musculus strength, and UPDRS ME and ADL tonss. Finally, there was a pronounced association between musculus strength and figure of falls.
Taking the consequences of our survey into consideration, we have shown that although musculus strength decreased in the lower appendage, particularly in the hip and articulatio genus, musculus failing was non associated with the speeds at which it was evaluated in this survey. We have demonstrated that the rating of musculus failing degree may be a utile tool for the appraisal of clinical badness and autumn hazard in patients with PD. It should be noted, nevertheless, that conflicting old consequences and the deficiency of specific criterions necessitate farther surveies.
The writers would wish to thank Associate Professor Saim Yologlu ( Department of Statistics, Inonu University School of Medicine ) for his sort part to this survey.