The Effectiveness of Exercise Programs on Balance, Functional Ability, Quality of Life, and Depression in Progressive Supranuclear Palsy: A Case Study

Abstract

Progressive supranuclear palsy is a form of atypical Parkinsonism. People living with Progressive Supranuclear Palsy have various symptoms, such as movement and cognitive disorders, which mainly affect balance and functional ability with an increased risk of falls, dexterity, and dementia. The role of exercise at the early stage of progressive supranuclear palsy remains unclear. The aim of the present study was to examine the effectiveness of an exercise program at the early stage of progressive supranuclear palsy. A patient with a diagnosis of progressive supranuclear palsy within the past year followed a supervised 12-week exercise program (two times per week) by a physiotherapist, with a session lasting about 40 min at a private physiotherapy clinic. Functional status, balance, quality of life, anxiety, and depression were assessed four times with valid instruments and tests. The results from the timed-up-and-go test demonstrated an improvement in performance (MCID value = 3.4). Improvements were observed in the scores of the Parkinson’s Disease Questionnaire-39 (MCID value = 0.6). Finally, an improvement was reported in the score of the anxiety factor of the hospital anxiety and depression scale (MCID value = 1.5). Physiotherapy appears to improve functional capacity, quality of life, and mental health. Further research is needed to confirm these results with a large sample size in combination with other complementary therapies such as mental imagery.

1. Introduction

Progressive supranuclear palsy (PSP) is the most frequent form of atypical Parkinsonism, with a prevalence of 5–6 cases per 100,000 patients [1,2]. People living with PSP have various symptoms, such as movement disorders mainly affecting balance, functional inability with an increased risk of falls, and dexterity. Also, they demonstrate facial and cervical dystonia and oculomotor disorders [3,4]. Cognitive impairment, dementia, and depression are also associated with the overall progression of PSP [5,6]. Finally, they also often present with other comorbidities, such as cardiovascular, neurological, muscular, and urological disorders [7].

Early-stage PSP often manifests as behavioral changes, such as irritability and agitation, as well as subtle motor impairments, such as postural instability and falls, gait instability, and gaze abnormalities [8], which may affect an individual’s quality of life and functional independence. This early phase of the disease may present a critical window of opportunity for interventions that could potentially maintain or even improve functional abilities.

Few studies have investigated the role of exercise in PSP. Exercise is defined as a repetitive, planned, structured activity aimed at improving and maintaining muscle strength, function, and fitness [9]. Exercise interventions have been shown to play a crucial role in improving balance and gait in patients with PSP. A pilot study reported improvements on balance performance after a therapeutic exercise program in PSP patients within a short duration of 4 weeks [10]. Similarly, other studies have reported that a structured physical therapy program is thought to be beneficial for individuals living with PSP [11,12,13]. Moreover, a case report showed the effectiveness of long-term locomotor training, stretching and strengthening exercises in enhancing balance, slowing the rate of gait decline, preventing wheelchair dependence, and reducing falls in a patient with mixed PSP and corticobasal degeneration features [14]. Due to the initial symptoms of PSP resembling those of idiopathic Parkinson’s Disease (PD), physiotherapists often implement rehabilitation programs similar to those targeted at PD, focusing on increasing strength [15,16,17] and balance [18,19]. Commonly applied aerobic exercises for PD patients, such as cycling and dancing, may have potential applications for PSP as well [20,21]. However, the existing research is limited, and there is a need for further exploration of exercise-based approaches tailored to individuals with early-stage PSP.

The results of the present study provide a unique contribution to the field by examining the effects of a supervised exercise program on balance, functional ability, quality of life, and depression in an individual with early-stage of PSP. This approach contrasts with previous studies, which have predominantly focused on exercise interventions for individuals with moderate-to-advanced stages of the disease [10,22,23]. In contrast, the existing literature has tended to focus on single outcome measures, limiting the ability to capture the multifaceted impact of the disease and the diverse effects of exercise interventions [10].

Furthermore, the detailed description of an exercise program, encompassing warm-up, main exercises, and recovery components, provides valuable information for clinicians and researchers seeking to replicate or adapt successful exercise strategies for individuals with an early-stage PSP. This level of programmatic detail is often lacking in the current literature, hindering the translation of research findings into clinical practice.

By addressing these gaps in the existing literature, the results of the present study have the potential to inform the development of more effective, stage-appropriate exercise interventions for individuals with early-stage PSP, ultimately contributing to improved clinical outcomes and enhanced quality of life for this clinical population. Also, this study aimed to bridge the gap between the scarce literature available and clinical practice and to describe the effectiveness of a structured exercise program.

2. Materials and Methods

2.1. Participants

The inclusion criteria of the sample were as follows: (a) diagnosed with early-stage PSP, (b) understanding spoken and written language, (c) ambulatory, (d) no other serious health problems in the last month, and (e) willingness to take part in the study.

The exclusion criteria were: (a) moderate and severe stage PSP; (b) severe psychiatric problems; (c) serious health issues (e.g., medically significant cardiac or respiratory disease); and (d) inability to walk.

Three participants met the inclusion criteria, but finally one of them agreed to take part in the present study. The participant was a 78-year-old male diagnosed with PSP one year prior to the assessment. He demonstrated mild symmetrical limb Parkinsonism, voice change, and vertical gaze restriction, as well as balance problems, but has not yet used a walking aid. Other medical problems included arterial pressure and chronic obstructive pulmonary disease. Other demographic data are depicted in

Table 1. Characteristics of the participant.

Characteristics
Gender	Male
Age (years)	78
Duration of illness (years)	1
Height (cm)	176
Body mass (kg)	90
BMI 1 kg/m2	29.1

Abbreviations: ¹ ΒΜΙ: body mass index.

. A signed form was completed after being informed about the study’s procedure. This study received approval from the Ethics Committee of the University of Peloponnese (661/11-1-2023).

2.2. Measures and Instruments

Personal data were collected in the baseline assessment. Outcome measures were evaluated at four time points: (a) prior to the intervention (1st baseline assessment—E1), (b) at the 4th week of the intervention program—E2, (c) at the 8th week of the intervention program—E3, and (d) at the end of the exercise program at 12 weeks—E4. The outcome measures included:

• Balance

The timed-up-and-go (TUG) test examines mobility and balance in elderly people. The time required for the participant to stand up from the chair, walk a distance of three meters, turn, walk back to the chair, and sit in it is recorded. For the execution, the physiotherapist uses a chair (with back and arms), a tape measure, a tape, and a watch or stopwatch. From the chair, we measure and mark a distance of three meters. As soon as the patient is seated, the timing stops. The time required to perform the test is approximately 10–35 s. The test has good reliability for Parkinson’s disease [24].

2.

Functional ability

The five times sit-to-stand test (FTSST) assesses the functional ability of the lower limbs. It is simple and short and designed for elderly people. The test begins with the participant sitting with their back on the chair, feet shoulder-width apart and arms crossed at chest level. The participant stands up using only the lower limbs and returns to the sitting position without touching the back of the chair 5 times as fast as possible. The test has good reliability in patients with Parkinson’s Disease [25].

3.

Quality of life

The Parkinson’s disease questionnaire (PDQ-39) consists of 39 questions covering eight factors of patient’s health. The score ranges from 0–4. A higher score indicates a worse quality of life. It has good internal consistency (Cronbach α = 0.71–0.94) [26,27].

4.

Depression

The hospital anxiety and depression scale (HADS) consists of 14 questions, examining anxiety and depression, 7 questions each, through a 4-point Likert-type scale from 0 (not at all) to 3 (happens to me all the time/often). The total score ranges from 0 to 21 for each factor. Higher scores also indicate increased levels of anxiety-depression. The classification for each factor separately is: 8–10 (mild), 11–14 (moderate), and 15–21 (severe). A score below 8 indicates no clinical findings of anxiety-depression. The scale shows high internal consistency (Cronbach α = 0.884; anxiety factor 0.829, depression factor 0.840). Also, it has high test–retest reliability (ICC = 0.944) [28].

2.3. Procedure

The participant followed a 12-week intervention exercise program supervised by an experienced physiotherapist. The exercise program had a frequency of 2 times/week with 30–40 min duration per session. The customized exercises for this clinical population included three phases: the warm-up, the main part of the program, and the recovery (

Table 2. Description of the exercise program.

Variables	Warm Up	Main Program	Recovery
Duration	5–10 min	20–25 min	5–10 min
Exercises	Walking on the spot while simultaneously swinging the arms alternately	Rhythmic alternating movement of the lower limbs, with one limb always in contact with the ground	Cat–cow from a sitting position
	Neck turns	Light running	Vakrasana from a sitting position *
	Side bending of the head	Monopod support	Konasana *
	Shoulder lift	Jumping jack	Konasana from a sitting position
	Chest muscle stretching *	Big sideways steps	Vakrasana
	Hamstring stretch	Superman exercise *	Konasana 2 *
	Quadriceps stretch	Leg kicks
		Hips sideways

* Described in the Supplementary Materials (Appendix: Description of exercises).

). The warm-up exercises, lasting 5–10 min, aimed to promote circulation and prepare the body for the rest of the program. The participant mobilized his joints and stretched his muscles. The main part of the program consisted of muscle-strengthening exercises, endurance exercises, balance exercises, upper and lower extremity exercises, trunk twists, fast and slow-tempo exercises, and movements with a sudden change of direction [29]. This phase, lasting 20–25 min, included moderate to high aerobic exercise based on the rating of perceived exertion scale (RPE) [30]. Specifics regarding the number of repetitions or sets for each exercise were incorporated for optimal effectiveness. The recovery phase, lasting 5–10 min, included stretching of the core muscles and relaxing exercises [31]. Another physiotherapist undertook the assessment of balance, functional ability, quality of life, and depression 4 times: at the beginning, during, and at the end of the exercise program, using the instruments described above.

2.4. Statistical Analysis

Descriptive statistics, including mean and standard deviation, were calculated for the four assessments of the study. The study used the minimal clinically important differences (MCID) values. As MCID is defined as the smallest difference in score in any domain or outcome that patients can perceive as beneficial or harmful, it would possibly require a change in their health care approach. This analysis aimed to determine if there were any clinical changes in the treatment outcome resulting from the implementation of the exercise program. A literature review was conducted to acknowledge the MCIDv for the present study’s instruments. MCIDv is defined as the value of the MCID, which was used in the comparison with the reported differences (pre–post) of the participant’s assessments. There have been no studies reporting the MCIDv for the instruments used in populations with PSP. However, the MCIDv for the PDQ-39 and its factors were found from Peto et al. [32], in which they followed a distribution-based approach to estimate them. The MCIDv for the FTSTS were found in studies regarding vestibular disorders [33,34], for the TUG in studies regarding postoperative patients with degenerative discopathy [35], and for the HADS and its factors (HADS-A and HADS-D) in populations with cardiovascular disease [36]. Then a comparison was made between the MCIDv and the reported differences (pre–post) of the participant’s assessments. The MCIDv served as a threshold, identifying a reported difference (pre–post) as clinically important if its value exceeded the MCID [37].

3. Results

The participant demonstrated a high level of adherence, missing only one session throughout the entire 12-week intervention period, and that absence was due to personal reasons. The TUG and the FTSST were employed to assess participants’ balance and functional ability, respectively. Τhe HADS was used to assess depression and anxiety, and PQD-39 was used to evaluate the quality of life of the participant.

The MCIDv for TUG revealed an improvement in performance between E2-E1. However, threshold-based comparisons between MCID and reported differences in E3−E2 and E4−E3 showed no further differences since the difference value was lower than the MCIDv (

Table 3. Differences between the four assessments on functional ability, balance, quality of life, and depression of the participant.

	Baseline E1	4 Weeks E2	8 Weeks E3	12 Weeks E4	MCID |E2 − E1|	MCID |E3 − E2|	MCID |E4 − E3|	MCID Value
PDQ-39	5.12	7.5	5	5625	2.38 *	2.5 *	0.625 *	0.6
PDQ-39-Mobility	50	65	52.5	45	15 *	12.5 *	7.5 *	1.5
PDQ-39-ADL	29.1	29.1	20	20.8	-	9.1 *	0.8 *	0.7
PDQ-39-Emotional well-being	25	29.1	33.3	25	4.1 *	4.2 *	8.3 *	0.3
PDQ-39-Stigma	12.5	43.7	0	31.2	31.2 *	-	31.2 *	0.8
PDQ-39-Social support	0	8.3	0	16.6	8.3 *	-	16.6 *	1.2
PDQ-39-Cognition	18.7	37.5	6.2	31.25	18.8 *	31.3 *	25.05 *	0.4
PDQ-39-Communication	0	8.3	8.3	8.3	8.3 *	-	-	0.8
PDQ-39-Bodily discomfort	25	41.6	33.3	25	16.6 *	7.3 *	8.3 *	1.3
TUG	18	14	16	14	4 *	2	2	3.4
FTSST	17	14	21	17	3 *	7 *	4 *	2.3
HADS	20	22	14	16	2 *	7 *	2 *	1.7
HADS-Anxiety	14	10	10	11	4 *	-	1	1.5
HADS-Depression	6	12	4	5	6 *	8 *	1 *	0.5

Abbreviations: PDQ-39: The Parkinson’s Disease Questionnaire-39; ADL: activities of daily living; TUG: timed-up-and-go; FTSST: five times sit-to-stand test; HADS: hospital anxiety and depression scale. * p < 0.05.

), indicating a plateau in improvement over time.

The statistical analysis for FTSST demonstrated an initial improvement in performance speed, followed by a subsequent deterioration. Ultimately, the final performance was similar to the baseline (Table 3).

The PQD-39 was used to assess the quality of life. The overall score had changed in all the MCID comparisons of the questionnaire, i.e., mobility, emotional well-being, cognition and bodily discomfort. The ADL dimension did not show a difference at the comparison between E1 and E2. The communication dimension did not show a difference at the comparison between E3−E2 and E4−E3 (Table 3).

HADS was used to examine the participant’s anxiety and depression. The comparison between MCIDv and reported differences in E3−E2 and E4−E3 of the HADS-A revealed no change; only in E2−E1 appeared a reduction of anxiety. However, at the end of the program, differences were observed in the HADS-total score and in the HADS-D factor (Table 3).

4. Discussion

The purpose of the present study was to investigate the impact of an exercise program on balance, functional ability, quality of life, anxiety, and depression in an individual at an early stage of PSP. The results revealed some improvements in functional status and quality of life, as well as some reductions in anxiety and depression symptoms. However, the exercise program appeared to not have influenced balance.

The current case study found that a 12-week exercise program may not contribute to an improvement in balance; thus, more research with a larger group sample is needed. This finding appears to be in contrast with some previous research on the effects of exercise interventions in individuals with PSP. Several case studies and small trials, included in a systematic review [38], did report improvements in balance and functional mobility following exercise interventions [10,18,39,40]. The exercise programs’ duration and frequency of these four aforementioned studies were from 4 weeks to 3 years and from three to five times per week, respectively. The authors concluded that exercise therapy may help maintain or improve physical function, including balance, in people with PSP. However, the findings of the current case study are not entirely surprising, as the progressive nature of PSP presents significant challenges for rehabilitation. It is possible that the 12-week exercise program at the early stage of the PSP was not intensive or long-lasting enough to overcome the underlying neurological deficits contributing to the participant’s balance difficulties. Additionally, the single-case design of the current study limits the generalizability of the findings. Individual responses to exercise can vary greatly, especially in a complex neurodegenerative condition like PSP. Larger-scale studies with more participants would be needed to better understand the role of exercise in managing balance problems in this population.

The findings of this case study reported some improvements in functional ability after a 12-week exercise program. This finding is generally consistent with the existing literature on the benefits of exercise for individuals with PSP [14,40,41,42]. Steffen et al. [14] reported that a physiotherapy intervention including locomotor training and exercise programs improved balance, slowed the rate of gait decline, decreased wheelchair dependence, and decreased falls in a patient with mixed PSP. Similarly, Suteerawattananon et al. [40] showed improved gait, fall reduction, and enhanced balance following physical therapy in a person with PSP [40]. A systematic review by Slade et al. [38], aiming to assess the efficacy of exercise and physical activity interventions in the PSP, concluded that exercise training may be beneficial [42]. A series of three case reports examined the effects of physical therapy and exercise interventions for patients with PSP reporting improvements in physical functional status [39]. Other studies demonstrate that exercise programs targeting muscle strengthening, balance, and mobility could improve functional outcomes and quality of life in this population [23,43,44,45,46]. The mechanisms by which exercise may benefit functional ability in PSP likely involve improvements in muscular strength, postural control, and mobility—all of which are typically impaired in this neurodegenerative disorder [46,47].

The study’s findings may indicate improvements in participant scores in HADS-D due to an exercise intervention in individuals with PSP. Regarding the effect of exercise on depression in people with PSP, this study is unique and innovative as there are no other studies studying this topic; however, these findings are supported by a body of evidence exploring the mechanisms by which physical activity can influence psychological well-being in chronic neurologic disorders [48,49,50]. A systematic review reported that exercise programs targeting balance, gait, and physical functioning often resulted in improvements in measures of depression and quality of life [50]. These positive changes may be attributed to psychological mechanisms that influence the participant’s self-image [51]. Exercise plays a role in removing the patient from negative thoughts enhancing self-esteem through the theory of self-efficacy and self-mastery [52]. From a neurobiological perspective, exercise has been shown to increase the production and release of neurotransmitters such as serotonin, dopamine, and endorphins, which can have mood-enhancing effects and contribute to the reduction of anxiety and depressive symptoms [53,54]. Additionally, physical activity can modulate the hypothalamic–pituitary–adrenal (HPA) axis, leading to decreased cortisol levels and improved regulation of the stress response system, which is often dysregulated in mood disorders [55]. Furthermore, exercise has been associated with increased hippocampal volume, enhanced neurogenesis, and improved connectivity in brain regions involved in emotional regulation, such as the prefrontal cortex and limbic system, all of which can contribute to the observed psychological benefits [56,57].

This study found an improvement in the quality of life of the participant. This result is in agreement with the limited existing research on the potential benefits of exercise for quality of life in individuals with PSP. A systematic review [58] provided preliminary evidence that exercise programs may improve quality of life in different studies with a small sample of PSP patients [23,43,59,60]. The current case study builds upon these findings, demonstrating that a 12-week exercise intervention targeting muscular strength, endurance, balance, and flexibility can lead to meaningful improvements in self-reported quality of life for an individual with early stage PSP.

Exercise has been demonstrated to influence a variety of neurobiological mechanisms that can have profound impacts on neurological health and function. One of the key processes is neuroplasticity, which refers to the brain’s ability to reorganize and adapt its connections and function in response to changes in behavior, environment, or neural processes [61]. Turning to the specific case of PSP, these exercise-induced neurobiological changes could have therapeutic implications. PSP is a rare and debilitating neurodegenerative disorder characterized by progressive impairment of balance, gait, eye movements, and cognitive function [62]. The neurodegeneration in PSP is thought to involve excessive oxidative stress, mitochondrial dysfunction, and impaired neuroplasticity [6,63]. By enhancing neuroplasticity, promoting neurogenesis, and bolstering antioxidant defenses, exercise may help offset the neurological decline associated with PSP and potentially improve functional outcomes and quality of life for patients [64].

The exercise program, which included aerobic exercise in its main part, may prove effective in improving motor condition and functional ability. It targeted the most basic motor symptoms, resulting in some improvements. In the early stages of idiopathic Parkinson’s disease, high-intensity interval training and progressive resistive strength training combined with movement strategies and education have been found to be effective for both motor symptoms such as gait and balance and falls rates [65,66]. The rehabilitation program followed by PSP patients often is similar to that of idiopathic Parkinson’s disease’s because initial symptoms or difficulty with function and activity limitations can appear similar [11,67]. As PSP progresses, the exercise programs often need to be adjusted to account for the changing functional abilities of the patient.

However, as the disease advances and balance, gait, and physical function decline, more targeted exercise strategies may be required. Restorative exercise approaches, such as those incorporating core stabilization, postural control, and compensatory movement patterns, might be beneficial. Additionally, exercise programs may need to be adapted to the specific stage of the disease. In the later stages of PSP, when mobility is severely impaired, exercises focusing on maintenance of range of motion, seated exercises, and activities to promote respiratory function may be more appropriate.

One limitation of the present study was the challenge in reaching general conclusions. Also, the use of TUG as the only tool to assess balance is a limitation of this study. However, the study’s strength and differentiation was the use of MCIDv in the PSP population. To the best of our knowledge, no other study has demonstrated MCIDv in this clinical population until now. It is essential to acknowledge that MCIDv for various assessments, such as the FTSST in vestibular system disorders [33,34], the TUG in postoperative patients with degenerative disc disease [35], and the HADS in cardiovascular disease [36], have been reported in different contexts. Future research using larger sample sizes should be conducted to assess the effect of exercise programs, particularly at early stages, on PSP with more specific measurement tools like the progressive supranuclear palsy quality of life scale.

5. Conclusions

Participants with PSP commonly experience cognitive, emotional, and functional challenges. Therapeutic interventions for PSP often incorporate exercise programs. This study demonstrated that such exercise programs may have positive effects, improving patients’ functional status, quality of life, anxiety, and depression at the early stage of PSP. While additional research is warranted to validate and strengthen the findings of the present study, those suggest that an exercise program may help mitigate the debilitating effects of this neurodegenerative disorder on patient wellbeing and daily functioning.