Retropulsion in Parkinson Disease Improves With Exercise Program With Instruction

Parkinson’s disease, conceptual computer artwork.
Researchers sought to assess the utility of therapeutic exercise of ankle joint movement instructions for retropulsion in patients with moderate PD.

Retropulsion in patients with Parkinson disease (PD) improved with a 2-week therapeutic exercise program with instructions to land on the toes, according to a study published in Clinical Parkinsonism & Related Disorders.

Postural instability is a common challenge among patients with PD. Backwards falls can lead to femur fractures and increased risk for hospital admission. Prior research has indicated addressing balance dysfunction in therapeutic exercise can improve patients’ postural instability, but the research does not specify whether ankle joint movement patterns can be targeted in treating retropulsion.

Researchers of the current study sought to assess the utility of therapeutic exercise of ankle joint movement instructions for retropulsion in patients with moderate PD.

The researchers recruited 20 patients from a national hospital with idiopathic PD and postural instability who were clinically diagnosed by a neurologist and could walk independently. The patients completed a 2-week therapeutic exercise program on weekdays that involved repeated backward pulls on the shoulders. They could take a step backward to avoid falling. Ten randomly selected patients (INSTR group) received oral instructions from the therapist before and during the exercises to land on the toes.

Movement Disorder Society-sponsored revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS part III) scores improved significantly more among the INSTR group in the first week and the second week, but the instructions only induced improvement in subscores related to backward response (pull test analysis of covariance (ANCOVA) F=12.3, P =.003; axial ANCOVA, T0-T1; F=5.0, P =.040; T1-T2; F=16.9, P <.001). Both groups had group-dependent improvement in MDS-UPDRS part III scores.

Solely the INSTR group experienced significantly improved fast walking speed (Wilcoxon signed-rank test, P =.005). Both groups experienced significant improvements in timed up and go (TUG) test results and the Barthel Index.

No adverse effects or falls were reported.

The researchers said verbal instructions or cues that encourage attention to the therapy could strengthen cognitive engagement, bypassing PD patients’ abnormal anticipatory postural adjustments.

Study limitations included single center, largely homogenous group, adherence to treatment factors, and use of pull test.

The researchers stated “The results of this study support the notion that a therapeutic exercise that incorporates specific goal-directed motor learning improves backward response in PD and that this might be facilitated through cognitive engagement such as instruction … Our results suggest that providing instructions on toe landing may be an important component for treating retropulsion in PD.”


Taniuchi R, Harada T, Nagatani H, et al. The power of instruction on retropulsion: a pilot randomized controlled trial of therapeutic exercise focused on ankle joint movement in Parkinson’s disease. Clin Parkinsonism & Related Disorders. Published online July 1, 2022. doi: 10.1016/j.prdoa.2022.100151