McCracken, Sarah Jane
(2024)
Understanding the impact, accessibility and diversity of Nordic walking in people with Parkinson's Disease.
MPhil thesis, University of Nottingham.
Abstract
Background
Nordic Walking (NW) is an enhanced walking technique that uses special poles to increase the effort of the arms and legs. NW provides an all over body workout that is reported to improve posture and gait, strengthen the back and abdominal muscles, reduce the impact on joints and burn 20% more calories than walking without poles (British Nordic Walking, 2023b). There is a growing body of research supporting the use of NW as a means of regular, outdoor exercise for people of all ages and for those with a range of physical and mental health challenges. Research of NW shows promising outcomes for people with Parkinson’s (PwP), with significant improvements in walking speed and stride length, postural stability, gait, and in cognitive aspects of movement preparation (Ebersbach et al., 2014). However, the effectiveness and results of NW research in this population are inconsistent as there is heterogeneity of participants, various methodologies, no standardised model of NW delivery, and little data about the longer-term physical and psychological implications of NW.
This MPhil aimed to address this gap by exploring the impact of NW as a novel form of neurorehabilitation, taking the perspective of PwP on their quality of life/non-motor symptoms (NMS) into account, as well as measuring quantitative physical health outcomes. This study was conducted as society emerged from the Coronavirus (COVID-19) pandemic. PwP, with a diverse range of symptoms and backgrounds, were searching for safe ways to exercise outdoors, in a group, guided by an instructor with experience of Parkinson’s Disease (PD) and exercise. The data from this MPhil could inform new models of NW intervention, which might be suitable for larger effectiveness trials.
Aims
1. Explore the motor (physical) and non-motor (psychological and quality of life) impact of an eight-week programme of NW for PwP, by establishing the short-term and longer-term (after six months) impact of NW as a means of neurorehabilitation in this population.
2. Determine the feasibility and accessibility of the NW intervention for a diverse sample of PwP.
3. Understand the core components needed to implement a NW group intervention for PwP in a community rehabilitation setting.
Methods
A narrative literature review explored the impact and effectiveness of NW in PwP, with results presented in Chapter 1.
A quantitative repeated measures study is presented in Chapter 2. PwP were assigned to receive an eight-week course of NW intervention delivered by a trained NW instructor (NWI) who was also a Parkinson’s Disease Nurse Specialist (PDNS). Timed up and go (TUG), 10 metres and 20 metres walk tests (MWT), Tragus to wall distance (posture), Berg Balance (BB) and the Non-Motor Symptoms Scale (NMSS) questionnaires were recorded at baseline (T0), week eight (T1), and at month six (T2). Data were analysed using descriptive statistics and the mean change over time explored using two tailed paired t-tests. Field notes were written at the end of every NW session and were an adjunct to the main pre-post repeated measures study.
Three focus groups (FGs) were conducted to understand the core components and characteristics required to implement outdoor community NW rehabilitation groups for PwP (Chapter 3). Two FGs for PwP and one for NWIs and a walk leader (WL) were conducted. Participants were recruited from the first study, employing the same eligibility criteria. Participants were recruited via a research call from Parkinson’s UK, from local Parkinson’s Disease (PD) support groups, and via NHS colleagues. Data were analysed using thematic analysis (TA) methods and reviewed by a second researcher (Braun and Clarke, 2006). The Behaviour Change Wheel (Michie, 2011) was used as a theoretical framework for organising the themes and facilitated recommendations for future research, policy, and clinical practice. These recommendations were reported as core components.
Results
The literature review provided the following definition of NW: “An intensification of regular walking thanks to the active use of a pair of specially designed NW poles, whilst maintaining the characteristics of natural, bio-mechanically correct walking and appropriate posture,” (Mass, 2023), p33. Previously published studies confirmed the potential for NW as a novel form of neurorehabilitation (Cugusi et al., 2017., Silverberg and Prejserowicz, 2018., Salse‐Batán et al., 2022). Theories of rehabilitation for PwP were defined and explored, including a health psychological approach and practical exercise recommendations (Parkinson’s UK’s excellence network, (Ramaswamy et al., 2018)). Engagement (or lack thereof) with therapy programmes was examined, in the context of health psychology and behaviour change theories, such as Michie’s behaviour change wheel (BCW) (Michie et al., 2011).
The repeated measures study recruited 49 PwP and of this sample, 40 PwP (n=27 males) completed eight weeks of NW intervention. PwP ranged from 47 to 83 years, mean age 66. Mean Hoehn and Yahr (H&Y) stage of PD was 2.20, (range 1-4). Thirty-nine PwP (n=24 males) completed eight-week follow-up physical assessments and 34 (n=19 males) returned for six month follow up data collection. The return rate for NMSS questionnaires at baseline was (n=24, 61.5%), at week eight (n=13, 33.3%) and month six (n=20, 51.3%). Of 39 PwP who completed the intervention and assessments, statistically significant improvements were observed in the following motor assessments: 10 MWT and 20 MWT (gait speed and cadence), TUG, Tragus, all with p values <0.001. The mean change in Tragus was -2.03 cm after eight weeks and this improved six months post intervention (-2.73 cm). These improvements (p <0.001) indicated continued benefits of a NW programme after the period of intervention. Improvements were recorded in NMS, especially dimensions of sleep and fatigue, mood and cognition and some urinary symptoms. All motor and some of the non-motor improvements persisted after six months. Data from nine participants who did not complete eight-weeks of NW intervention (NMSS and field notes) were analysed and explored. There was a mean reduction in the total NMSS of -10.08 points after eight weeks of NW (p value 0.03). This sample of PwP appeared to have improved NMSS across all domains and most notably sleep and fatigue (p value 0.006), cognition and mood (p value 0.77), and urinary symptoms (p value 0.24). These improved quality of life dimensions were substantiated in the field notes. This was a diverse sample and some participants had high baseline scores for cognition, mood, and urinary symptoms. An unanticipated result was a general improvement in reported urinary symptoms after the intervention (-2.46), (p value 0.25), which could have clinical implications if NW was found to positively impact core stability and pelvic floor musculature. This warrants further exploration in the literature and additional studies. Combined with improvements in speed of walking, posture and confidence, this sample of PwP articulated a reduced fear of falls, which they attributed to NW. There were no adverse events.
Fifteen participants were recruited into the three FGs, including 11 PwP (n=6 males), three British Nordic Walking Instructors (BNWI) (n=1 male) and one walk leader (WL, n=0 male). PwP ranged in age from 51 to 80 (median 72) years. Analysis of the FG data highlighted six main themes: physical benefits, social interaction, core practical components, qualities and characteristics of the NWI, risk management and safety, and other facilitators for delivering community NW groups. PwP reported physical and psychological benefits from participating in an eight-week programme of NW. Optimising safety was an important theme, utilising COVID-19 screening tests and health screening risk assessments (PARQa) for PD and complex comorbidities. Core components required to deliver community PD rehabilitation groups include practical facilitators: parking, public transport (access), toilets and café (amenities), an instructor with knowledge and experience of PD, and effective partnerships with PUK and BNW. Opportunities to NW with friends and family at groups and parkrun may promote a change in behaviour or lifestyle that has a longer-term impact. Within this study, PwP enjoyed peer support and appreciated NW outside in the park.
Conclusion
These studies suggest that an eight-week programme of NW improves mobility, upright posture, NMS domains including cognition, mood, sleep, fatigue, and some urinary symptoms in PwP. Results from the repeated measures study indicate that further trials are needed to explore NW effectiveness and implementation in the NHS. Future studies could employ a randomised controlled trial (RCT) design comparing NW to routine care or to specialist, supervised community exercise or physical activity-based interventions. Results from both studies demonstrate that the aims of the MPhil were fulfilled, and recommendations were made for future research and practice. Future NW community rehabilitation groups for PwP could seek NHS, social values funding, social prescribing (NHS England), or third-party sources, in partnership with BNW and PUK.
Key words. Nordic Walking, Parkinson’s, Parkinson’s Disease, motor symptoms, non-motor symptoms, repeated measures, focus group, community rehabilitation.
Ethical considerations. Ethical approval was granted in September 2021, by the University of Nottingham, Faculty of Medicine Research Ethics Committee. REC ref: FMHS 331-0821.
| Item Type: |
Thesis (University of Nottingham only)
(MPhil)
|
| Supervisors: |
Booth, Vicky
Logan, Pip
Allen, Fran |
| Keywords: |
Nordic Walking, Parkinson’s, Parkinson’s Disease, motor symptoms, non-motor symptoms, repeated measures, focus group, community rehabilitation |
| Subjects: |
W Medicine and related subjects (NLM Classification) > WL Nervous system |
| Faculties/Schools: |
UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine |
| Item ID: |
77963 |
| Depositing User: |
McCracken, Sarah
|
| Date Deposited: |
17 Jul 2024 04:40 |
| Last Modified: |
17 Jul 2024 04:40 |
| URI: |
https://eprints.nottingham.ac.uk/id/eprint/77963 |
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