Parkinson's disease (PD) is a chronic, progressive neurologic condition that results in numerous motor and nonmotor symptoms that can be impacted by physical therapy. In this issue of JNPT, King et al1 provide the results from their most recent study on the Ability Boot Camp (ABC) program. In 2009, an article by King and Horak2 described the development and elements of this novel sensorimotor agility program that aims to prevent or reduce the motor symptoms common in PD. The program consists of 6 exercise group intervals, including tai chi, kayaking, agility course, boxing, lunges, and prepilates. For each interval, specific actions/movements are described, as are methods to progress the plan of care. One study published to date provides evidence of the effectiveness of the ABC program.3

In the current study by King et al,1 the aim was to determine the effectiveness of the ABC when administered via individualized physical therapy sessions, group therapy, and a home exercise program (HEP). They also sought to determine whether comorbidities impact the success of the intervention provided. These are important questions for a number of reasons. We know that intensive task-specific training, wherein the patient is an active participant, is important to improving functional performance. However, little evidence exists to inform our decision making in regard to how to structure therapy. At the same time, clinicians increasingly face challenges that are altering how care is delivered. For example, because of productivity expectations, it is increasingly common to deliver care in a group session. In addition, financial constraints often limit the number of visits, increasing the need for the patient to take personal responsibility for carrying out the therapeutic plan, a goal that is often accomplished via an HEP. Learning to regain balance requires opportunities to practice the use of motor and sensory strategies during various tasks, under differing conditions. Given the fall risks associated with balance activities, balance retraining done in a group setting or via an HEP presents unique challenges. This study provides beneficial information to help us understand the impact of various forms of delivering care when using the ABC program in persons with PD.

Subjects in the King et al1 study had idiopathic PD, were 40 to 80 years old, had at least 1 PD or age-related comorbidity, and were able to walk unassisted. They were randomized into 1 of the 3 intervention groups. Each subject's intervention was progressed as deemed appropriate. Subjects randomized to the HEP group received a written program consisting of exercises that could be safely completed in the home. Each performed the HEP on his/her own over the trial, and no attempt was made to progress the program. Regardless of assignment, the exercise program was to be completed in 1-hour sessions 3 days per week for four weeks. Compliance was measured based on the percentage of assigned exercise sessions where exercises occurred. The primary outcome measure used was the 7-item Physical Performance Test (PPT). Multiple other measures were used to assess intervention-related changes in a number of constructs important to people with PD (eg, balance, gait, balance confidence, quality of life, among others) and comorbidities.

Results of this study showed that only those receiving individual physical therapy improved on the PPT; this group also showed the most improvements in other functional and balance measures. Those receiving group therapy improved the most on the gait measures. Subjects assigned to the HEP showed the least improvement across all measures.

This study helps answer important clinical questions regarding the setting in which we provide services, and the amount of supervision provided to our patients. First and foremost, individuals receiving physical therapy in a clinic setting, whether participating in individualized or group physical therapy, are more likely to have better outcomes as compared with those performing an HEP without supervision. This is useful knowledge and supports, to some degree, the use of group therapy as it is less costly than individual therapy. However, it is important to note that the best overall improvements were found in those receiving individualized physical therapy. In addition, those receiving group care improved in gait, but not balance. Perhaps this is due to the need to sufficiently challenge a patient's balance, which may be difficult in a group setting.

One area that is not fully described in the article, but which may have impacted the outcomes, is that the subjects receiving individualized physical therapy may have received more practice trials and cuing, compared with those in group care where the physical therapist's attention to subjects was likely divided. Subjects in the HEP arm of this study benefitted least from the intervention. Although they did have slightly lower compliance rates as compared with the other groups, we believe the lack of supervision, external cues, and program progression were the main factors limiting improvement. As with group therapy, it is possible that limitation in the ability of subjects to maximally challenge their own balance was likely constrained because of lack of supervision.

For clinicians using the ABC program for patients with PD, there are a number of important factors that would be valuable to keep in mind. If the patient's goals pertain to both balance and function, providing individualized care is likely to achieve the best outcome. Patients participating in group physical therapy should also receive individualized physical therapy that includes challenging balance tasks. The lack of progress in the HEP group strongly suggests that patients need supervision, and plans of care must be progressed regularly. This is particularly true for patients with greater physical and cognitive impairments. Patients may benefit from videos of the exercises (for external cueing), in addition to a written HEP. Lastly, multiple outcome instruments are necessary because, as was shown with the subjects receiving group care, patients sometimes improve in some measures but not in others. Failure to use relevant measures could lead to an erroneous conclusion that there was no improvement, when in fact this conclusion simply reflects the selection of measurement tools.

In summary, the study by King et al1 supports the use of the ABC program when administered in individual and group settings. The photographs published in the online supplement to the article are helpful; however, a video depicting the ABC exercises would be valuable to clinicians and patients with PD. Regarding recommendations for future research, it would be clinically meaningful for studies to compare various trial durations, and to assess the effect of the ABC program administered, supervised, and progressed through telerehabilitation.

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