Effectiveness of home-based and remotely supervised aerobic exercise in Parkinson's disease: a double-blind, randomised controlled trial

Mediation effect of body mass index on the association between glycated albumin and 10-year atherosclerotic cardiovascular disease risk in Hunan residents of China: a retrospective cross-sectional study

OBJECTIVES

Glycated albumin (GA) and body mass index (BMI) are associated with the risk of atherosclerotic cardiovascular disease (ASCVD). However, the role of BMI in the association between GA and 10-year ASCVD risk is still not fully understood.

DESIGN

A retrospective cross-sectional study.

SETTING

In this retrospective cross-sectional study, 4646 healthy subjects who received a full health examination at the Health Management Medical Center, Third Xiangya Hospital of Central South University, from 1 January 2022 to 30 December 2023 were initially identified. According to the exclusion criteria, 2107 participants were included in the final analysis.

PARTICIPANTS

The inclusion criteria for this study included (a) age is ≥18 years old and (b) subjects were long-term residents of Hunan province.

PRIMARY AND SECONDARY OUTCOME MEASURES

The 10-year ASCVD risk was evaluated via the China-PAR equation. The link between GA and 10-year ASCVD risk was examined through a multivariable logistic regression model, and the dose-response relationship was demonstrated using the restricted cubic spline. The potential mediation effect of BMI on this association was explored, and the differences in this mediation effect across age and metabolic-associated fatty liver disease (MAFLD) subgroups were analysed.

RESULTS

Elevated GA levels were positively linked to an intensified 10-year ASCVD risk (OR=1.160, 95% CI 1.055 to 1.276). Additionally, BMI was negatively linked to GA and 10-year ASCVD risk. BMI mediated 13.9% of the connection between GA and 10-year ASCVD risk. Specifically, the mediating effect of BMI remained significant in the 40-60-year age subgroup and non-MAFLD subgroup, with mediation ratios of 43.7% and 8.5%, respectively.

CONCLUSIONS

GA is a key predictor of 10-year ASCVD risk, and BMI partially mediates this relationship in healthy populations. Therefore, targeted weight management is recommended to reduce the adverse effect of GA on 10-year ASCVD risk in different populations.

Intervention strategies for Parkinson's disease: the role of exercise and mitochondria

Parkinson's disease (PD), a progressive neurodegenerative disorder with complex pathogenic mechanisms, exhibiting rising prevalence alongside global population aging. Its pathological hallmarks include substantial loss of dopaminergic neurons in the substantia nigra pars compacta, leading to motor symptoms (e.g., bradykinesia, rigidity) and non-motor manifestations (e.g., cognitive impairment, sleep disorders). Accumulating evidence underscores mitochondrial dysfunction-encompassing reactive oxygen species (ROS) overproduction, defective mitophagy, and impaired biogenesis-as an important contributor to PD pathogenesis. Exercise, endorsed by leading medical and sports authorities as a non-pharmacological therapeutic strategy. While mitochondrial dysfunction impairs cellular energetics in PD patients, exercise can re-establish mitochondrial homeostasis through multiple pathways: stimulating neuroprotective exerkines, regulating mitochondrial ROS balance, modulating mitochondrial biogenesis and mitophagy, and enhancing brain-derived neurotrophic factor production. Many studies demonstrate that aerobic, resistance, and mind-body exercises demonstrably improve gait stability, postural control, and cognitive function in PD patients. However, standardized exercise prescriptions for PD prevention and treatment remain underutilized in clinical practice. This review synthesizes mitochondrial pathophysiology in PD progression, exercise-mediated regulatory mechanisms, and evidence-based exercise protocols, proposing accessible exercise regimens to support PD management. By integrating molecular insights with practical strategies, this work provides foundational evidence for utilizing exercise as a non-medical intervention against PD.

The prodromal individuals' perspective on active recruitment for early detection of α-synucleinopathies

Only the timely detection of individuals with incipient α-synucleinopathies can pave the way for developing disease-modifying therapies. Our aim was to explore the views of individuals with isolated REM sleep behavior disorder (iRBD), actively recruited from the general population, on the ethical justifiability of active recruitment and their experiences with risk disclosure. This mixed-methods study surveyed individuals with iRBD, confirmed by video-polysomnography, utilizing an interdisciplinary-developed online questionnaire. Of 99 invited individuals, 75 (75.8%) answered the survey. While 55.6% experienced the information on the increased risk as burdensome, 63.9% supported risk disclosure if consent had been obtained beforehand. Almost all individuals (96.2%) regarded our active recruitment method as appropriate, and 86.7% indicated they would participate again. Open-text responses indicated that key motivations included access to information and care, and contributing to research progress. This well-received recruitment strategy could serve as a model for future screening initiatives in α-synucleinopathy research.

Physiotherapy and Exercise in Parkinson's Disease

Physiotherapy is an important treatment strategy in Parkinson's disease. Guidelines recommend early and regular physiotherapy referrals, which may improve a variety of symptoms, including falls. There are multiple types of physiotherapy with different goals and benefits. Exercise as well can improve symptoms and may alter disease trajectory. Studies are limited by heterogenous interventions and outcome measures, and further research is needed in generating high-quality research and expanding physical therapy access.

Effect of an adapted physical activity program in Parkinson's disease: A randomized controlled study (APA-Park)

CONTEXT

Previous studies assessing adapted physical activity (APA) in Parkinson's disease (PD) have been very heterogeneous regarding methodology and intervention, and have generally not addressed the question of combining various types of physical activity with a long-term evaluation.

OBJECTIVES

To evaluate the immediate and long-term effect of a 3-month APA program, combining endurance, resistance training and stretching on motor symptoms, body composition, cardiorespiratory function and metabolic profile in PD patients.

METHODS

In this controlled trial, we randomly assigned forty-four PD patients in a 1:1 ratio to receive a 3-month APA program (APA + group, n = 22), or freely practice physical activity (APA- group, n = 22). The patients were evaluated for parkinsonian symptoms (UPDRS-III), body composition, cardiorespiratory function and metabolic profile at baseline, immediately after the end of the program (M3) and six months later (M9).

RESULTS

Between baseline and M3, the mean UPDRS-III score decreased in PD patients from the APA + group whereas it increased in the APA- group (-1.2 ± 6.6 vs. +1.9 ± 8.9; p = 0.04), regardless of age, sex, disease duration, dopaminergic treatment, UPDRS-III and axial score at baseline, but these between group differences waned at M9. No between group difference was observed regarding the evolution of body composition, metabolic profile or cardiorespiratory function between baseline, M3 and M9.

CONCLUSION

A 3-month APA program combining endurance and resistance training plus stretching is more efficient for improving motor symptoms in PD compared to an unstructured engagement in non-specific physical activities. However, the benefits fade away six months after discontinuation of the program.

STATISTICAL ANALYSIS CONDUCTED BY

LAMBERT Céline, CHU Clermont-Ferrand, DRCI, Biostatistics Unit, Clermont-Ferrand, FRANCE.

REGISTRATION NUMBER

clinicaltrials.gov number NCT02816619.

Disease-Modifying Therapies in Parkinson's Disease

A "disease-modifying" treatment is defined as an intervention capable of slowing the progressive worsening of clinical symptoms of a neurodegenerative disease. Over the last couple of decades, many efforts have been spent on disease-modifying compounds development in Parkinson's disease (PD). Herein, the authors present an overview of recent and ongoing clinical trials on PD disease-modifying therapies, stratified by mechanism of actions. Overall, several trials have been run to target alpha-synuclein in different ways, with disappointing results so far, despite preclinical positive findings. In the next few years, results on precision trials targeting genetic population or pathways (as β-glucocerebrosidase [GBA] or leucine-rich repeat kinase 2 mutations) are expected.

The effects of stretching in Parkinson's disease: A systematic review of randomized controlled trials

INTRODUCTION

Parkinson's disease (PD) is a progressive neurodegenerative disorder characterized by motor and non-motor symptoms. While incurable, exercise has shown therapeutic benefits. Stretching, an accessible and low-cost modality, may improve mobility, balance, and flexibility, warranting systematic evaluation for managing PD symptoms. This systematic review aimed to examine and critically analyze scientific evidence on the effects of stretching in people with Parkinson's disease.

METHODS

A search was conducted in four electronic databases (Scopus, Web of Science, PEDro, and MEDLINE/PubMed) from inception to November 2024. The methodological quality of included studies was assessed using the PEDro scale.

RESULTS

Twelve randomized controlled trials were analyzed. Stretching programs lasted 4 weeks to 6 months. Positive effects were observed in motor symptoms and functional mobility for people with PD, although these were generally less pronounced compared to interventions like Tai Chi or WuQinXi Qigong. In contrast, mixed results to no significant improvements were observed for balance, gait, strength, cardiorespiratory fitness, mental health, neurocognitive function, sleep quality, physical activity levels, and fatigue.

CONCLUSION

Stretching improves motor symptoms and mobility in people with PD, but its benefits for gait, motor function, and mental health are limited compared to other exercises. Further studies are needed to assess its impact on motor and neurocognitive functions.

Moderators of aerobic exercise effects on motor symptoms in patients with Parkinson's disease: A systematic review and meta-analysis

INTRODUCTION

Although growing evidence suggests that aerobic exercise has beneficial effects on motor symptoms in patients with Parkinson's disease (PD), it remains unclear which specific aerobic exercise regimen optimizes improvement in these symptoms. This study aimed to investigate the difference in the effects of aerobic exercise on motor function in patients with PD according to exercise intervention protocols.

METHODS

Through 28 qualified studies with randomized controlled trials, we assessed motor function using either the Unified PD Rating Scale (UPDRS) III or Movement Disorder Society-UPDRS III as an outcome measure. We employed random effects meta-analysis models to obtain standardized mean differences and 95 % confidence intervals (CIs). Moderator variable analyses were conducted based on exercise type (aerobic exercise vs. aerobic-based combined exercise), duration (<60 min vs. ≥60 min per session), frequency (

RESULTS

Aerobic exercise interventions demonstrated significant improvements in overall motor function. Although all categories were significantly effective in improving motor function, aerobic-based combined exercise had a greater effect size on motor symptoms compared to aerobic exercise alone. Additionally, ≥60 min per session showed a significantly increased effect size compared to <60 min per session. The impact of aerobic exercise did not differ based on exercise frequency, period, or intensity.

CONCLUSIONS

Our observations suggest that aerobic-based combined exercise and exercise sessions lasting 60 min or longer may be associated with greater improvements in motor symptoms in patients with PD.

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Key Words

• Aerobic
• Exercise
• Meta-analysis
• Motor
• Parkinson's disease

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MESH Headings

• Humans
• Exercise/physiology
• Exercise Therapy/methods
• Outcome Assessment, Health Care
• Parkinson Disease/physiopathology
• Parkinson Disease/therapy
• Parkinson Disease/rehabilitation
• Randomized Controlled Trials as Topic

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Affiliation(s)

Ryul Kim Department of Neurology, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, South Korea.
Nyeonju Kang Division of Sport Science, Sport Science Institute & Health Promotion Center, Incheon National University, Incheon, South Korea; Department of Human Movement Science, Incheon National University, Incheon, South Korea; Neuromechanical Rehabilitation Research Laboratory, Incheon National University, Incheon, South Korea.
Joon Ho Lee Division of Sport Science, Sport Science Institute & Health Promotion Center, Incheon National University, Incheon, South Korea; Department of Human Movement Science, Incheon National University, Incheon, South Korea
Hanall Lee Division of Sport Science, Sport Science Institute & Health Promotion Center, Incheon National University, Incheon, South Korea; Department of Human Movement Science, Incheon National University, Incheon, South Korea
Tae Lee Lee Division of Sport Science, Sport Science Institute & Health Promotion Center, Incheon National University, Incheon, South Korea; Department of Human Movement Science, Incheon National University, Incheon, South Korea
Do Kyung Ko Division of Sport Science, Sport Science Institute & Health Promotion Center, Incheon National University, Incheon, South Korea; Department of Human Movement Science, Incheon National University, Incheon, South Korea
Hajun Lee Division of Sport Science, Sport Science Institute & Health Promotion Center, Incheon National University, Incheon, South Korea; Department of Human Movement Science, Incheon National University, Incheon, South Korea
Kyeongho Byun Division of Sport Science, Sport Science Institute & Health Promotion Center, Incheon National University, Incheon, South Korea
Kiwon Park Department of Mechatronics Engineering, Incheon National University, Incheon, South Korea
Jee-Young Lee Department of Neurology, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, South Korea
Beomseok Jeon Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea

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Amplifying walking activity in Parkinson's disease through autonomous music-based rhythmic auditory stimulation: randomized controlled trial

Habitual moderate intensity walking has disease-modifying benefits in Parkinson's disease (PD). However, the lack of sustainable gait interventions that collectively promote sufficient intensity, daily amount, and quality of walking marks a critical gap in PD rehabilitation. In this randomized controlled trial (clinicaltrials.gov#: NCT05421624, registered on June 6, 2022), we demonstrate the effectiveness of a real-world walking intervention delivered using an autonomous music-based digital rhythmic auditory stimulation (RAS) system. In comparison to an active-control arm (N = 20) of moderately intense brisk walking, the autonomous RAS system used in the experimental arm (N = 21) amplified moderate-to-vigorous walking intensities, increased daily steps, and improved (reduced) gait variability. While regular engagement in real-world walking with or without RAS each cultivated habits for walking, only the RAS intervention yielded a combination of strengthened habits and improved gait outcomes. Findings from this study supported the use of a personalized, autonomous RAS gait intervention that is effective, habit-forming and translatable to real-world walking in individuals with PD.

Preparing for Parkinson's disease prevention trials: Current progress and future directions

In recent decades, numerous clinical trials have aimed to delay or prevent Parkinson's disease (PD) progression. Despite the theoretical promise and encouraging preclinical data, none have shown clear efficacy in slowing or preventing PD progression, related to several key limitations. Conventional motor and non-motor scales often fall short in detecting early disease changes, while the heterogeneity of PD phenotypes complicates treatment efficacy. The timing of interventions is also critical, as most trials target patients already in advanced stages of neurodegeneration. A deeper understanding of the preclinical phase and the emergence of new pathological frameworks have shifted the focus toward preventing the onset of clinical PD. Recent advances in biomarker research, including tissue, fluid, and imaging markers, are poised to transform PD research by improving patient selection, stratification, and disease progression monitoring. New biologically grounded frameworks for classifying synucleinopathies aim to distinguish biological subtypes from clinical phenotypes, enabling more targeted prevention trials. Successful PD prevention trials will require early enrollment of individuals at the highest risk, employing low-risk personalized interventions, with biomarkers or sensitive clinical markers as endpoints. Early involvement of key stakeholders will be essential to ensure that trials are timely, ethically sound, and aligned with the needs of the PD community.

Meta-analysis of the effect of cognitive stimulation therapy on cognitive function in patients with Alzheimer's disease

BACKGROUND

There is no effective treatment for Alzheimer's disease (AD), and pharmacological treatment of AD in clinical settings is expensive and prolonged, resulting in a huge psychological and economic burden on the patient's family and caregivers and society as a whole, AD is characterized by progressive, worsening cognitive impairment, and there are currently no drugs that can effectively reverse cognitive impairment. However, it is important to intervene early or delay cognitive impairment so that the condition can be delayed and, ultimately, the burden on patients and families can be reduced through maintenance treatment. It may be that non-pharmacological interventions such as cognitive stimulation therapy (CST) can help with cognitive dysfunction.

AIM

To provide a better treatment plan for AD patients and delay the deterioration of cognitive function, the effect of CST on cognitive function in AD was studied by Meta-analysis.

METHODS

Comprehensive search the Chinese and English databases were comprehensively searched by computer. Chinese databases: China Biomedical Literature Database (CBM), Wanfang Database, VIP Database, and China Periodicals Full-text Database (CNKI). The collection time limit is from July 21, 2010 to July 21, 2022 randomized controlled trials literature on the effects of CST on cognitive function in patients with AD. According to the inclusion and exclusion criteria, literature screening, data extraction, and quality evaluation were performed. Standardized mean difference (SMD) and 95%CI were used as evaluation criteria to evaluate the cognitive function of CST in AD patients. Sensitivity analysis and publication bias detection were performed on the results. Publication bias was assessed using funnel plots, and funnel plot symmetry was assessed with Eggr's test.

RESULTS

CST can not improve Mental State Examination Scale (MMSE) scores in AD patients. Meta-analysis of CST on MMSE scores showed that the heterogeneity was P = 0.14, I 2 = 35%. I 2 = 35% < 50%, and the Q test P > 0.1, choose the random effect model to integrate statistics, get SMD = 0.02, 95%CI: -0.37, 0.42, P > 0.05. Meta-analysis of CST on AD Cognitive Functioning Assessment Scale scores showed that the heterogeneity was P = 0.13, I 2 = 36%. I 2 = 36% < 50 choose a fixed effect model to integrate statistics, get SMD = -0.01, 95%CI: -0.40, 0.39, P > 0.05, the difference is not statistically significant. Meta-analysis of CST on the cognitive function indicators of patients showed that the heterogeneity was P = 0.17, I 2 = 31%. I 2 = 31% < 50%, the fixed effect model showed SMD = 0.01, 95%CI: -0.37, 0.38, P > 0.05, the difference was not statistically significant.

CONCLUSION

CST may not improve the cognitive function of AD patients, not improve the cognitive function of AD patients, not improve the ability of daily living, and not reduce mental behavior can improve the cognitive function of AD patients.

Advice to people with Parkinson's in my clinic: Get a cardiopulmonary exercise test

Aerobic (cardiopulmonary) exercise training improves fitness and limits the progression of motor signs in Parkinson's disease. Individualized development of exercise prescriptions relies upon accurately measured peak heart rate (HR). Cardiopulmonary exercise testing (CPET) is the only methodology to objectively confirm an individual's peak HR. This test is important in individuals who may have autonomic dysfunction, which may manifest as chronotropic incompetence. Without CPET's confirmation of maximal effort, there is no way of knowing whether exercise prescription in those with chronotropic incompetence is accurate. CPET also provides information regarding cardiorespiratory fitness, which can motivate patients to exercise to prolong health.

Is physical therapy recommended for people with parkinson's disease treated with subthalamic deep brain stimulation? a delphi consensus study

BACKGROUND

Although deep brain stimulation of the subthalamic nucleus (STN-DBS) induces motor benefits in people with Parkinson's disease (PwPD), its effect on motor axial symptoms (e.g., postural instability, trunk posture alterations) and gait impairments (e.g., freezing of gait) is still ambiguous. Physical therapy (PT) effectively complements pharmacological treatment to improve postural stability, gait performance, and other dopamine-resistant symptoms (e.g. freezing of gait) in the general population with PD. Despite the positive potential of combined PT and STN-DBS surgery, scientific results are still lacking. We therefore involved worldwide leading experts on DBS and motor rehabilitation in PwPD in a consensus Delphi panel to define the current level of PT recommendation following STN-DBS surgery.

METHODS

After summarizing the few available findings through a systematic scoping review, we identified clinically and academically experienced DBS clinicians (n = 21) to discuss the challenges related to PT following STN-DBS. A 5-point Likert scale questionnaire was used and based on the results of the systematic review, thirty-nine questions were designed and submitted to the panel-half related to general considerations on PT following STN-DBS, and half related to PT treatments.

RESULTS

Despite the low-to-moderate quality of data, the few available rehabilitation studies suggested that PT could improve dynamic and static balance, gait performance and posture in the population with PD receiving STN-DBS. Similarly, the panellists strongly agreed that PT might help improve motor symptoms and quality of life, and it may be prescribed to maximize the effects of stimulation. The experts agreed that physical therapists could be part of the multidisciplinary team taking care of the patients. Also, they agreed that conventional PT, but not massage or manual therapy, should be prescribed because of the specificity of STN-DBS implantation.

CONCLUSIONS

Although RCT evidence is lacking, upon Delphi panel, PT for PwPD receiving STN-DBS can be potentially useful to maximize clinical improvement. However, more research is needed, with RCTs and well-designed studies. The rehabilitation and DBS community should expand this area of research to create guidelines for PT following STN-DBS.

MicroRNA-Targeted Gene Regulation in Salivary Gland Tissue of De Novo Parkinson's Disease Patients

Although α-synucleinopathy has been confirmed in the submandibular gland (SMG) tissue of Parkinson's disease (PD) patients, in-depth disease-related molecular research, such as tissue-specific transcriptional signals, has not been performed. In the present study, disease-relevant tissue-specific transcriptional signals in SMG tissue from PD patients were investigated to identify potential diagnostic, prognostic, and pathophysiologic biomarkers. Here, seven de novo drug-naïve PD patients and six age- and sex-matched individuals without neurological or psychological diseases were enrolled. Total RNA sequencing (RNA-seq) and total small RNA-seq (smRNA-seq) were performed on SMG tissue and blood samples, with 26 RNA-seq and 26 smRNA-seq samples used for the final analysis. Differentially expressed genes (DEGs) and microRNAs in SMG tissue and blood from PD patients were obtained and their functional integration and interaction network were analyzed. The Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis revealed that the DEGs interacted with cytokine-, inflammation-, and immune-related pathways. Synphilin-1 expression was significantly downregulated in SMG tissue of PD patients, and α-synuclein expression did not significantly differ between PD patients and controls in either SMG tissue or blood. Fifteen tissue-specific miRNA signals in SMG tissue were identified that showed better diagnostic ability compared with those in blood samples. The correlation between DEGs and environmental factors appeared altered in PD patients. The results indicated the DEGs and microRNA signatures identified in SMG tissue may be promising diagnostic and prognostic biomarkers. These molecular insights offer potential avenues for the development of novel therapeutic strategies targeting the underlying disease mechanisms in PD patients.

Management of freezing of gait - mechanism-based practical recommendations

Freezing of gait (FOG) is a debilitating motor symptom that commonly occurs in Parkinson disease, atypical parkinsonism and other neurodegenerative conditions. Management of FOG is complex and requires a multifaceted approach that includes pharmacological, surgical and non-pharmacological interventions. In this Expert Recommendation, we provide state-of-the-art practical recommendations for the management of FOG, based on the latest insights into the pathophysiology of the condition. We propose two complementary treatment flows, both of which are linked to the pathophysiology and tailored to specific FOG phenotypes. The first workflow focuses on the reduction of excessive inhibitory outflow from the basal ganglia through use of dopaminergic medication or advanced therapies such as deep brain stimulation and infusion therapy. The second workflow focuses on facilitation of processing across cerebral compensatory networks by use of non-pharmacological interventions. We also highlight interventions that have potential for FOG but are not supported by sufficient evidence to recommend for clinical application. Our updated recommendations are intended to enable effective symptomatic relief once FOG has developed, but we also consider potential targets for preventive approaches. The recommendations are based on scientific evidence where available, supplemented with practice-based evidence informed by our clinical experience.

Exergame-Based Program and Conventional Physiotherapy Based on Core Areas of the European Guideline Similarly Improve Gait and Cognition in People with Parkinson's Disease: Randomized Clinical Trial

Background: Gait impairments are among the most common and disabling symptoms of Parkinson's disease and are especially aggravated in dual-task conditions. Interventions with conventional physical therapy improve gait cadence and speed, cognition, fear of falling, and freezing of gait. However, exergames have attracted interest in the treatment of people with Parkinson's disease due to the characteristics of the training that benefit neuroplasticity and motor learning. Objective: The aim of this study was to analyze the effects of training based on Kinect exergames compared to conventional physiotherapeutic training based on core areas of the European physiotherapy guideline on functional mobility, gait, and cognitive functions. Materials and Methods: Thirty-eight people with idiopathic Parkinson's disease were randomized into two groups and underwent 14 intervention sessions, twice a week, for 60 minutes each. The primary outcome was postural stability in gait, which was evaluated using the Functional Gait Assessment. Secondary outcomes were functional mobility and impact of the dual task assessed using the Timed & Up and Go Test; gait speed by the 10-meter Walk Test in single and dual task; and cognitive functions assessed through the Montreal Cognitive Assessment. Results: After training, there was an improvement in the Functional Gait Assessment and Timed & Up and Go Test. Conclusion: Interventions based on Kinect AdventuresTM games and conventional physiotherapy based on the central areas of the European guideline promoted similar improvements in gait stability and functional mobility of people with Parkinson's disease, without differences between them. However, the benefits did not extend to cognitive function and other gait parameters.

Feasibility and acceptability of PDConnect, a multi-component intervention to support physical activity in people with Parkinson's disease: A mixed methods study

BackgroundPhysical activity (PA) is beneficial for people with Parkinson's (PwP); however, many are classed as sedentary. PDConnect is an online multicomponent intervention combining 1:1 physiotherapy and group-based PA combined with education, behavior change and self-management strategies, promoting PA and self-management among PwP.ObjectiveTo assess feasibility and acceptability of PDConnect.MethodsMixed methods study involving 31 PwP randomly allocated to: (i) usual care: physiotherapy once a week for six weeks, and (ii) PDConnect: physiotherapy once a week for six weeks, followed by 12 weekly sessions of group-based PA, followed by three monthly Teams calls to support engagement. Outcomes included intervention feasibility and acceptability (primary) assessed via survey and interviews; PA, motor, non-motor symptoms, and health and well-being (secondary) assessed at baseline, and at six, 18, and 30 weeks. Fidelity was accessed by post hoc video analysis.ResultsOnline delivery of PDConnect was feasible and safe. Participant retention was 74%. Response rate of self-reported measures was 97%. 95% of participants returned completed activity diaries. Attendance was high, with all participants recommending PDConnect. PDConnect participants reported improved flexibility, muscle strength, and endurance as well as increased PA confidence, PA levels and knowledge of Parkinson's disease. Half of PDConnect participants reported that they were much improved compared to 10% of usual care participants. Small to large effect sizes in PA (d = 0.03) and UPDRS (d = 0.96) ES) were reported, which warrant further exploration in an appropriately powered study.ConclusionsPDConnect is feasible and acceptable among PwP. A future large-scale trial is required to determine the effectiveness of PDConnect.

Integrating virtual reality into multidisciplinary care for Parkinson's disease: A narrative review

Parkinson's disease (PD) is a neurodegenerative disorder characterized by both motor and non-motor symptoms, significantly impacting patients' functionality and quality of life. Clinical exercise, as part of a multidisciplinary approach, is gaining a crucial role in PD management. Goal-based exercises, combining physical activity with cognitive tasks, external feedback and cues, motor sequencing strategies and dual-tasking may enhance motor learning processes and guide physiotherapy programs.Virtual reality (VR) and exergaming have also emerged as promising tools in PD rehabilitation, offering challenging activities in multisensory environments. They provide intensive and repetitive training, augmented feedback, and tailored exercises in highly interactive and enriched environments. Clinical studies have presented promising results in people with PD, supported by neuroimaging studies showing distinct brain activation patterns post-VR training. However, heterogeneity in study design and lack of standardized characterization of VR systems hinder further application in PD rehabilitation.In this review, we appraise the distinguishing features between different VR systems, highlight VR-related motor and cognitive training in PD and explore how VR interventions are aligned with principles of neuroplasticity and motor learning in PD.

Antiageing strategy for neurodegenerative diseases: from mechanisms to clinical advances

In the context of global ageing, the prevalence of neurodegenerative diseases and dementia, such as Alzheimer's disease (AD), is increasing. However, the current symptomatic and disease-modifying therapies have achieved limited benefits for neurodegenerative diseases in clinical settings. Halting the progress of neurodegeneration and cognitive decline or even improving impaired cognition and function are the clinically meaningful goals of treatments for neurodegenerative diseases. Ageing is the primary risk factor for neurodegenerative diseases and their associated comorbidities, such as vascular pathologies, in elderly individuals. Thus, we aim to elucidate the role of ageing in neurodegenerative diseases from the perspective of a complex system, in which the brain is the core and peripheral organs and tissues form a holistic network to support brain functions. During ageing, the progressive deterioration of the structure and function of the entire body hampers its active and adaptive responses to various stimuli, thereby rendering individuals more vulnerable to neurodegenerative diseases. Consequently, we propose that the prevention and treatment of neurodegenerative diseases should be grounded in holistic antiageing and rejuvenation means complemented by interventions targeting disease-specific pathogenic events. This integrated approach is a promising strategy to effectively prevent, pause or slow down the progression of neurodegenerative diseases.

Effects of MAO‑B inhibitors in life quality of Parkinson's disease patients: A systematic review and meta‑analysis

INTRODUCTION

Monoamine oxidase-B (MAO-B) inhibitors, as an add-on therapy to levodopa, are widely used in Parkinson's disease (PD). The effects of MAO-B inhibitors on quality of life remain unclear, and the aim of this systematic review and meta-analysis was to assess the efficacy and safety of MAO-B inhibitors on quality of life in different domains.

METHODS

We searched PubMed, Embass, and Cochrane Library databases for randomized controlled trials of PD patients who were administered MAO-B inhibitors. Outcomes were the change from baseline in the total score of life quality scales, change from baseline in domains of the Parkinson's Disease Questionnaire-39 (PDQ-39), and incidence of treatment-associated adverse events (TAEs).

RESULTS

Sixteen studies covering 4734 PD patients were included in the study. The PDQ-39 scores were lower with MAO-B inhibitors than with placebo (SMD: -0.26, 95 % CI: [-0.49, -0.04], P = 0.02). The European Quality of Life Questionnaire-5D (EQ-5D) scores were higher in the MAO-B inhibitor group. Patients treated with MAO-B inhibitors had better performance in the domains of mobility, activities of daily living, emotional well-being, stigma, communication, and bodily discomfort, except for social support and cognition. The incidence of TAEs was slightly higher in patients treated with MAO-B inhibitors.

CONCLUSIONS

Evidence has shown that MAO-B inhibitors, especially safinamide, are effective in improving the quality of life of PD patients, although with a slightly higher incidence of TAEs. The domains of quality of life were improved, except for cognition and social support, compared with placebo. Further studies are warranted to evaluate the effects of other MAO-B inhibitors on quality of life.

The Power of Exercise: Unlocking the Biological Mysteries of Peripheral-Central Crosstalk in Parkinson's Disease

BACKGROUND

Exercise is a widely recognized non-pharmacological treatment for Parkinson's Disease (PD). The bidirectional regulation between the brain and peripheral organs has emerged as a promising area of research, with the mechanisms by which exercise impacts PD closely linked to the interplay between peripheral signals and the central nervous system.

AIM OF REVIEW

This review aims to summarize the mechanisms by which exercise influences peripheral-central crosstalk to improve PD, discuss the molecular processes mediating these interactions, elucidate the pathways through which exercise may modulate PD pathophysiology, and identify directions for future research.

KEY SCIENTIFIC CONCEPTS OF REVIEW

This review examines how exercise-induced cytokine release promotes neuroprotection in PD. It discusses how exercise can stimulate cytokine secretion through various pathways, including the gut-brain, muscle-brain, liver-brain, adipose-brain, and bone-brain axes, thereby alleviating PD symptoms. Additionally, the potential contributions of the heart-brain, lung-brain, and spleen-brain axes, as well as multi-axis crosstalk-such as the brain-gut-muscle and brain-gut-bone axes-are explored in the context of exercise therapy. The study highlights the need for further research into peripheral-central crosstalk and outlines future directions to address challenges in clinical PD therapy.

Effects of 6 months of endurance exercise on motor function, exercise capacity, and autonomic function based on presence of autonomic dysfunction in individuals with early Parkinson's disease

BackgroundEndurance exercise improves aerobic capacity (VO2peak) and motor symptoms in people with early Parkinson's disease (PD). Some people with PD exhibit signs of chronotropic incompetence (CI), which may impact exercise-induced benefits.ObjectiveWe investigated whether CI in people with early PD influences the change in motor signs, VO2peak, and peak heart rate (HR) following 6 months of endurance exercise.MethodsWe performed secondary analyses of the Study in Parkinson's Disease of Exercise (SPARX), which randomized people with early PD into a high-intensity endurance exercise [80-85% of peak HR], moderate-intensity endurance exercise [60-65% of peak HR], or usual care group. MDS-UDPRS Part 3 score, VO2peak, and heart rate (HR) response to maximal cardiopulmonary exercise testing (CPET) were analyzed at baseline and following 6 months of exercise. Participants were divided into three groups: 1) normal chronotropic response at baseline, 2) CI at baseline, and 3) taking medications with a known negative chronotropic effect regardless of CI status.ResultsData from 119 individuals (64.0 ± 9.0 years, 57.1% male, 0.3 years since diagnosis [median]) were analyzed. There were no differences among the groups in change in MDS-UPDRS motor score (p = 0.953), VO2peak (p = 0.965), or peak HR (p = 0.388). People randomized into the high-intensity group improved VO2peak compared to usual care (p < 0.001adj) regardless of CI status.ConclusionsBaseline CI did not alter responses to endurance exercise in those with early PD, suggesting that the beneficial effects of endurance exercise on disease progression and VO2peak in people with early PD apply equally to people with CI.

Effects of exercise interventions on cognition, physical function and quality of life among older adults with cognitive frailty: A systematic review and meta-analysis

OBJECTIVES

To explore the effects of exercise interventions on cognition, physical function, and quality of life among older adults with cognitive frailty.

METHODS

A systematic review and meta-analysis were conducted (PROSPERO [CRD42024532608]). PubMed, Web of Science, Cochrane Library, Embase, CNKI, WanFang, VIP, and SinoMed databases were searched from inception until December 18, 2023.

RESULTS

We found exercise improved overall cognition, physical frailty, walking ability, gait speed, and so on among older adults with cognitive frailty, but the effect on physical fitness and quality of life was insignificant. Subgroup analysis revealed exercise conducted ≥3 times per week, each session lasting ≤45 min and cycle≤12 weeks, had better-improved cognition. Traditional mind-body exercises like Baduanjin were more effective than resistance training for enhancing cognition.

CONCLUSIONS

Exercise intervention benefits overall cognition and most physical functions, but its impact on physical fitness and quality of life remains to be confirmed by future studies.

Insomnia in Parkinson's Disease: Causes, Consequences, and Therapeutic Approaches

Sleep disorders represent prevalent non-motor symptoms in Parkinson's disease (PD), affecting over 90% of the PD population. Insomnia, characterized by difficulties in initiating and maintaining sleep, emerges as the most frequently reported sleep disorder in PD, with prevalence rates reported from 27 to 80% across studies. Insomnia not only significantly impacts the quality of life of PD patients but is also associated with cognitive impairment, motor disabilities, and emotional deterioration. This comprehensive review aims to delve into the mechanisms underlying insomnia in PD, including neurodegenerative changes, basal ganglia beta oscillations, and circadian rhythms, to gain insights into the neural pathways involved. Additionally, the review explores the risk factors and comorbidities associated with insomnia in PD, providing valuable insights into its management. Special attention is given to the challenges faced by healthcare providers in delivering care to PD patients and the impact of caregiving roles on patients' quality of life. Overall, this review provides a comprehensive understanding of insomnia in PD and highlights the importance of addressing this common sleep disorder in PD patients.

Enhancing sleep quality in synucleinopathies through physical exercise

During sleep, several crucial processes for brain homeostasis occur, including the rearrangement of synaptic connections, which is essential for memory formation and updating. Sleep also facilitates the removal of neurotoxic waste products, the accumulation of which plays a key role in neurodegeneration. Various neural components and environmental factors regulate and influence the physiological transition between wakefulness and sleep. Disruptions in this complex system form the basis of sleep disorders, as commonly observed in synucleinopathies. Synucleinopathies are neurodegenerative disorders characterized by abnormal build-up of α-synuclein protein aggregates in the brain. This accumulation in different brain regions leads to a spectrum of clinical manifestations, including hypokinesia, cognitive impairment, psychiatric symptoms, and neurovegetative disturbances. Sleep disorders are highly prevalent in individuals with synucleinopathies, and they not only affect the overall well-being of patients but also directly contribute to disease severity and progression. Therefore, it is crucial to develop effective therapeutic strategies to improve sleep quality in these patients. Adequate sleep is vital for brain health, and the role of synucleinopathies in disrupting sleep patterns must be taken into account. In this context, it is essential to explore the role of physical exercise as a potential non-pharmacological intervention to manage sleep disorders in individuals with synucleinopathies. The current evidence on the efficacy of exercise programs to enhance sleep quality in this patient population is discussed.

A 4-Week Mobile App-Based Telerehabilitation Program vs Conventional In-Person Rehabilitation in Older Adults With Sarcopenia: Randomized Controlled Trial

BACKGROUND

Sarcopenia is closely associated with a poor quality of life and mortality, and its prevention and treatment represent a critical area of research. Resistance training is an effective treatment for older adults with sarcopenia. However, they often face challenges when receiving traditional rehabilitation treatments at hospitals.

OBJECTIVE

We aimed to compare the effects of a digital rehabilitation program with those of traditional therapist-supervised rehabilitation training on older adults with sarcopenia.

METHODS

In total, 58 older adults with sarcopenia were recruited offline and randomized (1:1) into 2 groups: the telerehabilitation group (TRG, n=29, 50%) and the in-person rehabilitation group (IRG, n=29, 50%). Both groups underwent 4-week resistance training targeting 6 major muscle groups. The TRG received exercise guidance via a mobile app, while the IRG received in-person training from a therapist. Offline assessments of body composition, grip strength, and balance using the 30-Second Arm Curl Test (30SACT), 30-Second Sitting-to-Rising Test (30SSRT), quadriceps femoris extension peak torque (EPT) and extension total power (ETP), Berg Balance Scale (BBS), Timed Up-and-Go Test (TUGT), 6-Minute Walk Test (6MWT), and Instrumental Activities of Daily Living (IADL) scale, were conducted before and after the intervention.

RESULTS

Of the 58 patients, 51 (88%; TRG: n=24, 47%; IRG: n=27, 53%) completed the trial. After 4 weeks of intervention, the mean grip strength increased from 18.10 (SD 5.56) to 19.92 (SD 5.90) kg in the TRG (P=.02) and from 18.59 (SD 5.95) to 19.59 (SD 6.11) kg in the IRG (P=.01). The 30SACT and 30SSRT scores increased from 12.48 (SD 2.68) to 14.94 (SD 3.68) times (P=.01) and from 15.16 (SD 7.23) to 16.58 (SD 8.42) times (P=.045), respectively, in the TRG and from 12.25 (SD 4.19) to 14.68 (SD 4.36) times (P=.003) and from 14.31 (SD 4.04) to 16.25 (SD 4.91) times (P=.01), respectively, in the IRG. The quadriceps femoris EPT increased from 26.19 (SD 10.26) to 35.00 (SD 13.74) Nm (P=.004) in the TRG and from 26.95 (SD 11.81) to 32.74 (SD 12.33) Nm (P=.003) in the IRG. The BBS scores significantly improved in both groups (P<.001), with the mean TRG score increasing by 3.19 (SD 2.86) points and the mean IRG score by 3.06 (SD 2.44) points. Neither group exhibited significant within-group changes on the TUGT or the 6MWT. Both groups reported significant improvements in the IADL (TRG: P=.04; IRG: P=.02). Between-group comparisons revealed no significant differences in changes in all indicators.

CONCLUSIONS

A 4-week remote resistance training program is effective in improving strength, balance, and the IADL in older adults with sarcopenia, with effects comparable to rehabilitation supervised by a physical therapist. Telerehabilitation may be a convenient and effective alternative for older adults with sarcopenia who have limited access to rehabilitation resources.

TRIAL REGISTRATION

ChiCTR 2300071648; https://www.chictr.org.cn/showprojEN.html?proj=196313.

Gait ecological assessment in persons with Parkinson's disease engaged in a synchronized musical rehabilitation program

Data on gait parameters during real-life activities and home rehabilitation programs for Persons with Parkinson's disease (PwPDs) are scarce. Although cueing has been shown to improve their gait in laboratory conditions, few studies have applied this technique in at-home rehabilitation programs. Our study aimed to explore the use of a real-time synchronized beat-step music program for at-home rehabilitation. We conducted a 1-month outdoor gait rehabilitation program called BeatPark (30 min/day, 5 days/week), with 25 PwPDs, using real-time synchronized, cued, music, and measurements through the BeatMove application. We demonstrated that real-world walking with BeatMove exhibited improved gait parameters both within and across sessions. These improvements were further confirmed by the Six-Minute Walk Test conducted in silence in the laboratory before and after the program. Measures in real life are unique tools to enhance rehabilitation programs. Future research incorporating a control group will be essential to fully validate these encouraging findings.

Safety of Immersive Virtual Reality for the Management of Parkinson's Disease

Virtual reality (VR) has been used in research and clinical practice in the management of Parkinson's disease (PD), potentially enhancing physiotherapy. Adverse events (AEs) associated with VR applications in PD have been poorly explored. We conducted a randomized controlled trial to compare two 12-week interventions using physiotherapy and immersive VR, and analyzed the frequency and type of AEs occurring in 30 people with PD. We reported 144 AEs (8.4% of the sessions), predominantly classified as mild and unrelated to the interventions. Two were serious AEs, one leading to study discontinuation. Notably, discomfort/pain, motor fluctuations, and falls were the most frequently reported, accounting for 63% of the total AEs. Five falls were definitely associated with the 'sense of presence' provided by the fully immersive VR system, which underscores the necessity for careful game selection when designing interventions for PD. Motor fluctuations may have been associated with various factors, which merit further investigation. We also explored the role of SSQ as a measure of cybersickness in PD. In conclusion, it is important to closely monitor and characterize AEs to ensure safety and efficacy in clinical practice as AEs may be more common than previously recognized in VR interventions in PD.

Video game-based application for fall risk assessment: a proof-of-concept cohort study

Background

Fall(s) are a significant cause of morbidity and mortality especially amongst elderly with polyneuropathy and cognitive decline. Conventional fall risk assessment tools are prone to low predictive values and do not address specific vulnerabilities. This study seeks to advance the development of an innovative, engaging fall prediction tool for a high-risk cohort diagnosed with diabetes.

Methods

In this proof-of-concept cohort study, between July 01, 2020, and May 31, 2022, 152 participants with diabetes performed clinical examinations to estimate individual risks of fall (timed "up and go" (TUG) test, dynamic gait index (DGI), Berg-Balance-Scale (BBS)) and participated in a video game-based fall risk assessment with sensor-equipped insoles as steering units. The participants engaged in four distinct video games, each designed to address capabilities pertinent to prevent fall(s): skillfulness, reaction time, sensation, endurance, balance, and muscle strength. Data were collected during both, seated and standing gaming sessions. By data analyses using binary machine learning models a classification of participants was achieved and compared with actual fall events reported for the past 24 months.

Findings

Overall 22 out of 152 participants (14.5%) underwent at least one episode of fall during the past 24 months. Adjusted risk classification accuracies of TUG, DGI, and BBS reached 58.7%, 58.3%, and 47.5%, respectively. Data analyses from gaming sessions in seated and standing positions yielded two models with six predictors from the four games with accuracies of 82.8% and 88.6% (area under the receiver-operating-characteristic curve 0.84 (95% confidence interval (CI): 0.77-0.91) and 0.91 (95% CI: 0.85-0.97), respectively). Key capabilities that were distinctly different between the groups related to endurance (0.6 ± 0.1 vs. 0.5 ± 0.2; p = 0.03) and balance (0.7 ± 0.2 vs. 0.6 ± 0.2; p = 0.05). The AI-driven analysis allowed to extract a list of game features that showed highly significant predictive values, e.g., reaction times in specific task, deviation from ideal steering routes in parcours and pressure-related parameters.

Interpretation

Thus, video game-based assessment of fall risk surpasses traditional clinical assessment tools and scores (e.g., TUG, DGI, and BBS) and may open a novel resource for patient evaluation in the future. Further research with larger, heterogeneous cohorts is needed to validate these findings and especially predict future fall risk probabilities in clinical as well as outpatient settings.

Funding

This project was funded by the Ministry of Science, Economics, and Digitalization of the State of Saxony-Anhalt and the European Fund for Regional Development under the Autonomy in Old Age Program (Funding No: ZS/2016/05/78615, ZS/2018/12/95325) and Healthy Cognition and Nerve function (HeyCoNer, ZS/2023/12/183088).

Long-term aerobic exercise improves learning memory capacity and effects on oxidative stress levels and Keap1/Nrf2/GPX4 pathway in the hippocampus of APP/PS1 mice

Objective

To examine the effects of long-term aerobic exercise on oxidative stress and learning memory ability of APP/PS1 mice, focusing on the hippocampal Keap1, Nrf2, HO-1, and GPX4 proteins.

Methods

Thirty APP/PS1 double transgenic AD mice were randomly divided into three groups: model group, short-term exercise group, and long-term exercise group, with 10 mice in each group. Male non-transgenic mice of the same age served as the control group. The groups underwent swimming training for 6 weeks and 12 weeks, respectively. After the intervention, cognitive abilities were assessed using the Morris water maze test. Hippocampal tissue samples were analyzed for changes in superoxide dismutase (SOD) activity and malondialdehyde (MDA) content. ROS expression was observed using dihydroethidium probe, and Keap1, Nrf2, HO-1, and GPX4 protein levels were detected by Western blot analysis.

Results

Aerobic exercise significantly reduced the escape latency and increased both the time spent in the target quadrant and the number crossing the platform compared to the model group (p < 0.05). In the hippocampus, aerobic exercise significantly reduced the MDA content, while significantly increased SOD activity (p < 0.05). The level of ROS in the hippocampal region was significantly reduced by aerobic exercise (p < 0.05), with decreased Keap1 protein expression of and increased Nrf2, HO-1, GPX4 protein expression (p < 0.05).

Conclusion

Aerobic exercise enhances memory and learning abilities, improves cognitive function, and reduces the oxidative stress levels in the hippocampus of AD mice, which involves in the activation of Keap1/Nrf2/GPX4 pathway.

Home physical therapy versus telerehabilitation in improving motor function and quality of life in Parkinson's disease: a randomized controlled trial

BACKGROUND

Over the past few years, the development of telerehabilitation has advanced rapidly. Patients with Parkinson's disease (PwPD) often have difficulty with mobility, making it challenging for them to perform centre-based exercise.This study aims to compare the effectiveness and adherence of home physical therapy (HPT) and telerehabilitation (TR) in mitigating motor symptoms and improving the quality of life in patients with mild to moderate Parkinson's disease.

METHODS

This randomized controlled trial included a total of 190 patients who underwent in-person eligibility assessment, with 100 allocated to the HPT group and 90 to the TR group. Both interventions consisted of home-based training sessions lasting 40-60 min and were conducted five times a week for 4 weeks. The primary outcome was the Unified Parkinson's Disease Rating Scale motor section (UPDRS3) score. Secondary outcomes included balance function, assessed using the Berg Balance Scale (BBS); risk of fall, evaluated through the Timed Up-and-Go test (TUG) and the Five Times Sit-to-Stand test (FTSST); gait, measured using the Freezing of Gait Questionnaire (FOGQ) and IDEEA activity monitor; muscle strength, evaluated using the isokinetic dynamometry; motor aspects of experiences of daily living (UPDRS2); and quality of life, assessed by Parkinson's Disease Questionnaire-39 (PDQ-39).

RESULTS

There was a significant difference in the UPDRS3, BBS, TUG, FTSST, FOGQ,step length, step velocity,preswing angle, UPDRS2 and PDQ-39 between baseline and 4 weeks in both groups. The decrease in the UPDRS3 score was significantly greater in the HPT group (-3.38 points) than in the RE group (-1.45 points) in the older age group (P = 0.021), but there was no significant between-group difference in the younger age group (P = 0.416). Similar changes favouring the HPT group were observed in the BBS, TUG, step velocity, and extension average torque. 7 (7%) patients in the HPT group and 12 (13%) patients in the TR group did not complete their daily exercise plan.

CONCLUSIONS

Both HPT and TR have demonstrated effectiveness, safety, and feasibility in PwPD. However, the HPT program exhibited greater effectiveness among older patients and higher patient compliance compared to TR.

TRIAL REGISTRATION

Chictr.org.cn, ChiCTR2300071648. Registered on 22 May 2023-retrospectively registered, https://www.chictr.org.cn/showproj.html?proj=196313 .

Dementia and Video Games: Systematic and Bibliographic Review

BACKGROUND/OBJECTIVES

This systematic and bibliographic review examines publications in the field of dementia and video game research from 2004 to 2023. The main objective is to assess developments and trends in video game technology for dementia care and detection.

METHODS

The PubMed database was the primary source for publications. PRISMA guidelines were applied to structure this review. Ten variables were defined, investigated, and split into three main categories: bibliographic, medical, and technical.

RESULTS

The results were synthesized using a quantitative approach to reduce bias through interpretation. Of 209 initial results, 77 publications have been included in the investigation. More studies focus on rehabilitation over assessment and detection of dementia. Clinical trials are typically conducted with limited participants. The most populated trials rarely enrol over 300 subjects. On average, around 38 subjects were enrolled in the trials. These studies are commonly supervised by a trainer or technology specialist, suggesting a technology gap in familiarity in the trial demographic.

CONCLUSIONS

Most interventions assessed were custom-designed applications with a specific outcome, focusing on physical activity and cognitive exercises. As the first of its kind, this publication focuses on the technical aspects of applied technologies and development methods. Using video games to treat and detect patients with cognitive impairments like dementia can benefit healthcare professionals, caretakers, and patients.

Adverse events associated with the delivery of telerehabilitation across rehabilitation populations: A scoping review

OBJECTIVE

This scoping review aimed to map existing research on adverse events encountered during telerehabilitation delivery, across rehabilitation populations. This includes identifying characteristics of adverse events (frequency/physical/non-physical, relatedness, severity) and examining adverse events by different modes of telerehabilitation delivery and disease states.

INTRODUCTION

Telerehabilitation, a subset of telemedicine, has gained traction during the COVID-19 pandemic for remote service delivery. However, no prior scoping review, systematic review, or meta-analysis has identified and summarized the current primary research on adverse events in telerehabilitation. Understanding adverse events, such as falls during physiotherapy or aspiration pneumonia during speech therapy, is crucial for identifying limitations and optimizing delivery through risk mitigation and quality indicators. This understanding could also help to improve the uptake of telerehabilitation among clinicians and patients. This review addresses this gap by summarizing published literature on adverse events during telerehabilitation.

METHODS

The review followed the Joanna Briggs Institute framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. The review protocol was registered and published on Open Science Framework. A comprehensive search across multiple databases (MEDLINE ALL/EMBASE/APA PsycINFO/CENTRAL/CINAHL) was conducted. Screening, extraction, and synthesis were performed in duplicate and independently. Data extraction followed the Template for Intervention Description and Replication framework and also involved extraction on authors, publication year (pre- or post-COVID), population, sample size, and modes of telerehabilitation delivery (asynchronous, synchronous, hybrid). For synthesis, data were summarized quantitatively using numerical counts and qualitatively via content analysis. The data were grouped by intervention type and by type of adverse event.

INCLUSION CRITERIA

This scoping review included qualitative and quantitative studies published between 2013-2023, written in English, and conducted in any geographic area. All modes of telerehabilitation delivery were included. Systematic reviews, meta-analyses, commentaries, protocols, opinion pieces, conference abstracts, and case series with fewer than five participants were excluded.

RESULTS

The search identified 11,863 references, and 81 studies were included in this review with a total of 3,057 participants (mean age:59.3 years; females:44.6%). Modes of telerehabilitation delivery (whether asynchronous, synchronous or hybrid) used in the studies included videoconferencing (52), phone calls (25), text messaging (4), email (6), mobile apps (10), and internet-based virtual reality systems (3). A total of 295 adverse events occurred during 84,534 sessions (0.3%), with the majority being physical (e.g., falls or musculoskeletal pain), non-serious/non-severe/mild, and unrelated to (i.e., not caused by) to the telerehabilitation provided.

CONCLUSIONS

From the 81 included studies, telerehabilitation was delivered with related adverse events being rare, and mostly characterized as mild/non-severe. A comparable occurrence of adverse events (~30%) was found between asynchronous and synchronous telerehabilitation studies. When categorized by disease type, cardiac telerehabilitation studies had the most frequent adverse events. Detailed reporting of telerehabilitation interventions and adverse event characteristics is recommended for future studies (i.e., use of TIDieR reporting guidelines). Telerehabilitation has the potential to make rehabilitation services more accessible to patients; however, more evidence on the safety of telerehabilitation is needed.

Online training program maintains motor functions and quality of life in patients with Parkinson's disease

Objective

Several systematic reviews have shown that physical exercise positively affects motor function (MF) and quality of life (QoL) in patients with Parkinson's disease (PD). After the coronavirus disease (COVID-19) pandemic, numerous studies were conducted to reveal the effects of telerehabilitation for patients with PD. However, only a few empirical results of online programs for PD patients have been reported. Therefore, this study aimed to determine the effects of an online physical and cognitive training program on MF and QoL in patients with PD.

Methods

We evaluated the impact of our online program on the QoL and MF of patients with PD by comparing data at baseline and after six months of intervention. For the QoL assessment, we used the Schwab and England Activities of Daily Living scale and Parkinson's Disease Questionnaire (PDQ-39), whereas, for MF, we measured movement status using the modified 20-m walk test and timed up-and-go (TUG) test.

Results

We enrolled 20 patients for QoL and 19 for MF in this study. For PDQ-39, social support (p = 0.046, δ = 0.320) and cognitions (p = 0.028, δ = 0.268) significantly improved. Additionally, cadence (p = 0.032, g = -0.377) in the modified 20-m walk and exam duration (p = 0.003, δ = 0.296) and forward gait (p = 0.003, δ = 0.341) in the TUG test showed significant differences before and after the intervention.

Conclusion

Our results suggest that online physical and cognitive training programs positively affect MF and QoL in individuals with PD.

A single-blind, randomised control trial on the effectiveness of a structured multi component training module for family caregiver of persons with Parkinson's disease: A study protocol

INTRODUCTION

Parkinson disease (PD), a neurodegenerative disorder that progresses over time, is steadily growing in number and prevalence worldwide. PD in Malaysia is expected to increase five-fold by 2040 from the existing estimate of 20,000 patients in 2018. Treatment program of PD in Malaysia is rather unstructured, and there is no known comprehensive PD family caregiver training program available to date. To ensure the quality of a program, it must be tested for feasibility, effectiveness and sustainability. This paper describes the protocol of a study that evaluates the effectiveness of a structured, comprehensive training program of family caregiver to persons with PD in comparison to usual care.

MATERIALS AND METHODS–STUDY PROTOCOL

A total of 60 pairs of persons with PD of stage II and III, and their primary family caregiver will be recruited and allocated into either an experimental or a control group for 12 weeks of intervention. The experimental group will undergo initial training from multi-disciplinary healthcare providers and will be given a physical module containing weekly tasks that must be practised at home. While the control group will receive a usual care. Both groups will be assessed in terms of physical functions, functional mobility, quality of life (QoL), caregiver burden and knowledge using standardised assessment tools namely Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS), Timed Up and Go (TUG) test, Parkinson's Disease Questionnaire (PDQ-39), European Quality of Life five-dimensions (EQ-5D), Malay version of Zarit Burden Interview (MZBI) and Knowledge of Parkinson Disease Questionnaire (KPDQ). In addition, the feasibility and sustainability of the interventions will be evaluated, alongside its cost-effectiveness based on the average and incremental cost effectiveness ratio. All data will be analysed using descriptive and inferential statistics, particularly mixed model ANOVA.

DISCUSSION

There is a significant gap in the literature pertaining family caregiver training programs for people with PD. Documented programs are lacking in term of comprehensiveness of content, application approach and the measurement of training outcomes including the program cost-effectiveness. The feasibility and effectiveness of such training program in a Malaysian setting also requires investigation due to differences in living environment, support system and population's perception. This study will assist to fulfil the existing literature gap and demonstrate the potential benefit of caregiver involvement in mediating the care and therapy for PD in the home setting. Optimum knowledge and skills gained through the training are expected to enhance the confidence and ability of the family caregivers and may possibly reduce their perceived caregiving burden.

PROTOCOL REGISTRATION

The protocol of this study is registered in the Australian-New Zealand Clinical Trial Registry (ANZCTR) with a registration number ACTRN12623000336684.

Assessment of Personalized Exercise Prescriptions Issued by ChatGPT 4.0 and Intelligent Health Promotion Systems for Patients with Hypertension Comorbidities Based on the Transtheoretical Model: A Comparative Analysis

Purpose

Exercise is a vital adjunct therapy for patients with hypertension comorbidities. However, medical personnel and patients face significant obstacles in implementing exercise prescription recommendations. AI has been developed as a beneficial tool in the healthcare field. The performance of intelligent tools such as ChatGPT 4.0 and Intelligent Health Promotion Systems (IHPS) in issuing exercise prescriptions for patients with hypertension comorbidities remains to be verified.

Patients and Methods

After collecting patient information through IHPS hardware and questionnaire systems, the data were input into the software terminals of ChatGPT 4.0 and IHPS according to the five stages of the Transtheoretical Model, resulting in exercise prescriptions. Subsequently, experts from various fields scored the accuracy, comprehensiveness, and applicability of each prescription, along with providing professional recommendations based on their expertise. By comparing the performance of both systems, their capability to serve this specific group was evaluated.

Results

In most cases, ChatGPT scored significantly higher than IHPS in terms of accuracy, comprehensiveness, and applicability. However, when patients exhibited certain functional movement disorders, GPT's exercise prescriptions involved higher health risks, whereas the more conservative approach of IHPS was advantageous.

Conclusion

The path of generating exercise prescriptions using artificial intelligence, whether via ChatGPT or IHPS, cannot achieve a completely satisfactory state.But can serve as a supplementary tool for professionals issuing exercise prescriptions to patients with hypertension comorbidities, especially in alleviating the financial burden of consulting costs. Future research could further explore the performance of AI in issuing exercise prescriptions, harmonize it with physiological indicators and phased feedback, and develop an interactive user experience.

Causal Mediation Analysis of Factors Influencing Physical Activity and Community Access Among People With Mild-to-Moderate Parkinson Disease

OBJECTIVE

To examine how known causal factors (exercise self-efficacy, balance, walking capacity) affect outcomes (moderate-intensity physical activity, community access) in people with Parkinson disease (PD): through a direct pathway, indirectly through potential mediators (nonmotor impairments), or through combined direct and mediated paths.

DESIGN

Causal mediation analyses using baseline and three-month data from pooled treatment groups in a randomized controlled trial.

SETTING

Data were collected at 2 university clinical research centers.

PARTICIPANTS

One hundred thirty-eight people with PD.

INTERVENTIONS

Home and community-based walking and strength exercise program.

MAIN OUTCOME MEASURE(S)

Exposures were exercise self-efficacy, walking capacity, and balance. Potential mediators included pain, fatigue, mood (anxiety, depression, affect, apathy), stigma, and cognition (executive function and cognitive flexibility). The outcomes were physical activity and community access behavior at follow-up 3 months later. Separate models were developed for each causal factor-mediator-outcome combination. To minimize bias, all models were adjusted for known confounders (comorbidities, freezing of gait, severity of motor impairment, and/or age) and baseline values of the outcomes.

RESULTS

Self-efficacy of walking duration had a causal relationship with moderate-intensity physical activity through direct and combined paths (P<.001). Walking capacity had a causal relationship with community access through direct (P=.03-.04) and combined (P=.02-.03) paths. Balance did not affect community access (P>.05). There were no significant mediation effects through indirect pathways for either outcome.

CONCLUSIONS

The effect of known causal factors on physical activity and community access was not mediated by nonmotor impairments. Walking self-efficacy and walking capacity remain the primary intervention targets for improving physical activity and community access, respectively, in people with PD.

LRE-MMF: A novel multi-modal fusion algorithm for detecting neurodegeneration in Parkinson's disease among the geriatric population

Parkinson's disease (PD) is a prevalent neurological disorder characterized by progressive dopaminergic neuron loss, leading to both motor and non-motor symptoms. Early and accurate diagnosis is challenging due to the subtle and variable nature of early symptoms. This study aims to address these diagnostic challenges by proposing a novel method, Localized Region Extraction and Multi-Modal Fusion (LRE-MMF), designed to enhance diagnostic accuracy through the integration of structural MRI (sMRI) and resting-state functional MRI (rs-fMRI) data. The LRE-MMF method utilizes the complementary strengths of sMRI and rs-fMRI: sMRI provides detailed anatomical information, while rs-fMRI captures functional connectivity patterns. We applied this approach to a dataset consisting of 20 PD patients and 20 healthy controls (HC), all scanned with a 3 T MRI. The primary objective was to determine whether the integration of sMRI and rs-fMRI through the LRE-MMF method improves the classification accuracy between PD and HC subjects. LRE-MMF involves the division of imaging data into localized regions, followed by feature extraction and dimensionality reduction using Principal Component Analysis (PCA). The resulting features were fused and processed through a neural network to learn high-level representations. The model achieved an accuracy of 75 %, with a precision of 0.8125, recall of 0.65, and an AUC of 0.8875. The validation accuracy curves indicated good generalization, with significant brain regions identified, including the caudate, putamen, thalamus, supplementary motor area, and precuneus, as per the AAL atlas. These results demonstrate the potential of the LRE-MMF method for improving early diagnosis and understanding of PD by effectively utilizing both sMRI and rs-fMRI data. This approach could contribute to the development of more accurate diagnostic tools.

The effect of multi-component exercise intervention in older people with Parkinson's disease and mild cognitive impairment: A randomized controlled study

A multimodal exercise training program might be the best way to improve motor and cognitive function in patients with Parkinson's disease (PD), but this has yet to be fully proven in PD patients with mild cognitive impairment (MCI). This study aims to examine the feasibility and effectiveness of a theory-based, multi-component exercise intervention in older people with PD-MCI. Participants were randomized into an intervention group (n=23) and an active control group (n=23), receiving the theory-based multi-component exercise intervention and Parkinson's health exercises, respectively. All participants performed 60-minute exercise training sessions three times a week over a 12-week period. The retention rate at post-intervention was 95.7% (42/46) for the entire cohort. The attendance rates were 99.6% in the intervention group and 99.5% in the control group. No adverse events occurred. The intervention group showed significantly greater improvements than the control group in global cognitive function, executive function, physical motor function, balance and gait, depression, and quality of life. This study indicates that the theory-based multi-component exercise intervention demonstrates high feasibility in promoting exercise adherence and is an effective treatment option for older adults with PD-MCI.

Festination-like steps during forward and backward gait while playing tennis

Festination is an episodic gait disorder which is often a precursor of freezing of gait episodes in Parkinson's disease patients. We discuss what lessons can be learned from a patient who had to quit playing tennis as he repeatedly fell due to backward festination-like steps.

Physical Exercise for Treating the Anxiety and Depression Symptoms of Parkinson's Disease: Systematic Review and Meta-Analysis

BACKGROUND

Depression and anxiety are non-motor symptoms of Parkinson's disease (PD). Physical exercise is a promising approach to reducing neuropsychological burden. We aimed to comprehensively synthesize evidence regarding the use of exercise for treating depression and anxiety symptoms in PD.

METHODS

Systematic review and meta-analysis following PRISMA recommendations. Searches on PubMed, Cochrane Library, Scopus, Web of Science, Embase, and Physiotherapy Evidence Database (PEDro) was conducted. The random-effects model was employed for all analyses with the standardized mean difference as the effect estimate.

RESULTS

Fifty records were retrieved, but only 17 studies met the criteria for the meta-analyses. A moderate to large effect was observed for depression (-.71 [95% CI = -.96 to -.46], 11 studies, 728 individuals), and a small to moderate effect for anxiety (-.39 [95% CI = -.65 to -.14], 6 studies, 241 individuals), when comparing exercise to non-exercise controls. Subgroup analysis revealed significant effects from aerobic (-.95 [95% CI = -1.60, -.31]), mind-body (-1.85 [95% CI = -2.63, -1.07]), and resistance modalities (-1.61 [95% CI = -2.40, -.83]) for depression, and from mind-body (-.67 [95% CI = -1.19 to -.15]) and resistance exercises (-1.00 [95% CI = -1.70 to -.30]) for anxiety.

CONCLUSION

Physical exercise has a relevant clinical impact on depression and anxiety in PD. We discuss the level of the evidence, the methodological limitations of the studies, and give recommendations.

The Acoustic Voice Quality Index (AVQI) in People with Parkinson's Disease Before and After Intensive Voice and Articulation Therapies: Secondary Outcome of a Randomized Controlled Trial

OBJECTIVES

The majority of individuals with Parkinson's disease (PD) experience voice and speech problems during the course of the disease. Despite the importance of voice quality in communication and the documented disordered voice quality in PD, few studies have explored the effects of speech treatment on this variable.

STUDY DESIGN/METHODS

A parallel arm, unblinded randomized controlled trial (RCT) was conducted with two active comparators, LSVT LOUD (n = 23) and LSVT ARTIC (n = 20), and an inactive comparator group of untreated individuals with PD (n = 22). A group of 20 healthy adults was also included for pre-treatment analysis. Voice recordings were obtained pre-treatment, immediately post-treatment and at 6-month follow-up. The acoustic voice quality index (AVQI) is reported here as a secondary outcome measure of the RCT. Linear mixed-effects regression analysis was performed with AVQI and sound pressure level (SPL) as dependent variables. Pearson correlation coefficient analysis was also conducted to explore the relationship between voice quality and SPL.

RESULTS

Statistically significant improvements in AVQI and SPL from pre-treatment to post-treatment and follow-up were only observed in the LSVT LOUD group. Voice quality significantly improved only from pre-treatment to follow-up in the LSVT ARTIC group, whilst significant improvements in SPL were observed during maximum phonation only immediately post-treatment. No significant changes were observed in the untreated group.

DISCUSSION

This study investigated the effects of intensive speech treatment targeting voice or targeting articulation on voice quality, as measured by the AVQI, in individuals with PD. Findings indicate that voice-focused treatment leads to greater improvements in voice quality in this population.

"There is only one motive … fun." Perspectives of participants and providers of physical exercise for people with Parkinson's disease

PURPOSE

To explore the perspectives of people with Parkinson's disease (PD) and exercise providers regarding facilitating factors, barriers, needs, and demands relating to physical exercise for people with PD.

MATERIALS AND METHODS

Focus group discussions or telephone interviews of 30 people with PD (with or without an active sports history) and 13 providers were conducted and analyzed using structuring content analysis.

RESULTS

Factors facilitating participation in physical exercise included motivation-enhancing elements (enjoyment, group training environment) and providers with sufficient qualifications in PD-specific training demands. Identified barriers were lack of motivation, physical limitations, poor service accessibility, and inadequate matching of intervention groups based on capability or age. Providers found it difficult to design and conduct group trainings for people with PD with varying physical limitations. Having an active sports history before PD-onset was described as generally beneficial, though a competitive mindset could lead to frustration. People with PD reported needing their physicians to provide better education regarding physical exercise.

CONCLUSION

Enjoyment of physical exercise is a key aspect of maintaining physical activity engagement, which should be considered more in research and clinical practice. Developing qualifications for providers could help to broaden and enhance the dissemination of PD-specific exercise approaches. Physicians should be trained to encourage physical exercise.Implications for rehabilitationPhysicians should highlight the benefits and be knowledgeable regarding the availability of physical exercise interventions for people with PD.Additional physical exercise providers should become qualified to work with people with PD.The joyfulness of physical exercise interventions is a key aspect of maintaining physical activity engagement for people with PD.

Exercise Habits in People with Parkinson's: A Multinational Survey

BACKGROUND

Exercise has been demonstrated to result in improvements in physical function, cognition, and quality of life in People with Parkinson's (PwP) but its adoption is variable.

OBJECTIVES

To investigate exercise preferences, levels, influencing factors among a diverse Parkinson's disease (PD) population, to understand exercise adoption patterns and plan informed interventions.

METHODS

A cross-sectional survey collected data through online platforms and paper-based methods. The Exercise Index (ExI) calculated exercise level based on frequency and duration.

RESULTS

Of 2976 PwP, 40.6% exercised regularly, 38.3% occasionally, and 21.2% did not exercise. The overall mean ExI was 18.99 ± 12.37. Factors associated with high exercise levels included exercising in groups (ExI 24-26), weightlifting (ExI 27 (highest)), using muscle-building equipment (ExI 25-26), and exercising at home following an app (ExI 26). A positive trend between ExI and varied exercise groups, locations, types, and equipment was observed. No expected benefit from exercise achieved the lowest ExI (8). Having at least two exercise-promoting factors, a bachelor's degree or higher, receiving exercise advice at initial visits, and aged ≤40 years at PD onset were strong predictors of exercise (adjust OR = 7.814; 6.981; 4.170; 3.565). Falls and "other" most troublesome PD symptoms were negative predictors (aOR = 0.359; 0.466). Barriers to exercise did not predict the odds of exercise.

CONCLUSIONS

The study shows that PwP's exercise behavior is influenced by their exercise belief, age at PD onset, doctor's advice at initial visits, education level, symptoms, and exercise-promoting factors. High exercise levels were associated with certain types of exercises and exercising in groups.

Investigating the effects of a daily multidisciplinary intensive outpatient rehabilitation program on innovative biomarkers in people with Parkinson's disease: Study protocol for a phase III randomized controlled clinical trial

BACKGROUND

To date, there has been no medication that has prevented the progression of Parkinson's disease (PD). Many benefits of intensive and multidisciplinary rehabilitation program for PD are supported by clinical, epidemiological, and experimental data. The main question is whether high-intensity motor and cognitive exercises have an effect on the disease's biological mechanisms.

OBJECTIVE

This study protocol is a Randomized Controlled Trial (RCT) designed to determine the efficacy of an experimental, intensive, and multidisciplinary treatment in comparison to a home-based self-treatment in improving biomolecular and functional parameters in PD.

METHODS

A total of 72 participants will be randomly allocated to two different groups, experimental (n = 36) and control group (n = 36). The rehabilitation program will last 6 consecutive weeks and will involve the execution of a total of 30 sessions, one for each day of the week from Monday to Friday. Participants allocated to the control group will carry out a home-based self-treatment program that includes muscle-stretching and active mobilization exercises for 40'/day for 6 consecutive weeks. The primary outcome measure is the effects of both treatments on a new set of molecular biomarkers such as oligomeric alpha-synuclein and neurotrophic factors measured in peripheral neural derived extracellular vesicles (NDEVs). Secondary outcomes will include changes of motor and non-motor symptoms, balance and gait performance and cognitive functioning. This RCT has been registered as "Intensive Multidisciplinary Rehabilitation and Biomarkers in Parkinson's Disease" on 30 May, 2022 to ClinicalTrials.gov with the Study ID number: NCT05452655.

DISCUSSION

This rehabilitation program is believed to be crucial in modifying biomolecular and functional parameters in people with PD. We expect that this study will provide additional evidence to understand the impact of an aerobic and intensive rehabilitation program on brain plasticity in patients with PD.

Exercise as medicine in Parkinson's disease

Parkinson's disease (PD) is an incurable and progressive neurological disorder leading to deleterious motor and non-motor consequences. Presently, no pharmacological agents can prevent PD evolution or progression, while pharmacological symptomatic treatments have limited effects in certain domains and cause side effects. Identification of interventions that prevent, slow, halt or mitigate the disease is therefore pivotal. Exercise is safe and represents a cornerstone in PD rehabilitation, but exercise may have even more fundamental benefits that could change clinical practice. In PD, the existing knowledge base supports exercise as (1) a protective lifestyle factor preventing the disease (ie, primary prevention), (2) a potential disease-modifying therapy (ie, secondary prevention) and (3) an effective symptomatic treatment (ie, tertiary prevention). Based on current evidence, a paradigm shift is proposed, stating that exercise should be individually prescribed as medicine to persons with PD at an early disease stage, alongside conventional medical treatment.

Distinct Clinical Implications of Patient- Versus Clinician-Rated Motor Symptoms in Parkinson's Disease

BACKGROUND

Patient-rated motor symptoms (PRMS) and clinician-rated motor symptoms (CRMS) often differ in Parkinson's disease (PD).

OBJECTIVE

Our goal was to investigate the determinants and clinical implications of PRMS compared with CRMS in PD.

METHODS

This retrospective, observational cohort study analyzed the cross-sectional associations and longitudinal impacts of PRMS as assessed by the Movement Disorders Society-sponsored Unified PD Rating Scale (MDS-UPDRS) part 2, while controlling for CRMS measured by MDS-UPDRS part 3. Longitudinal analyses used Cox proportional hazards models and multiple linear mixed-effects random intercepts/slope models, adjusting for many clinical predictors. We conducted propensity score matching (PSM) to reinforce our analyses' robustness and surface-based morphometry to investigate neural correlates.

RESULTS

We enrolled 442 patients with early-stage PD. At baseline, regardless of CRMS, PRMS were associated with the severity of postural instability and gait disturbance (PIGD). Notably, PRMS independently and more accurately predicted faster long-term deterioration in motor function than CRMS (Hoehn and Yahr 4, adjusted hazard ratio per +1 point = 1.19 [95% confidence intervals, 1.08-1.32]), particularly in PIGD (PIGD subscore, β-interaction = 0.052 [95% confidence intervals, 0.018-0.086]). PSM confirmed these findings' robustness. Surface-based morphometry suggested that enhanced sensory processing was distinctively associated with PRMS.

CONCLUSIONS

In early-stage PD, PRMS weighed different aspects of symptoms and more effectively predicted motor deterioration compared to CRMS, with distinctive brain structural characteristics. The superior sensitivity of PRMS to subtle declines in drug-refractory symptoms like PIGD likely underlie our results, highlighting the importance of understanding the differential clinical implications of PRMS to prevent long-term motor deterioration. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Game-Based Assessment of Peripheral Neuropathy Combining Sensor-Equipped Insoles, Video Games, and AI: Proof-of-Concept Study

BACKGROUND

Detecting peripheral neuropathy (PNP) is crucial in preventing complications such as foot ulceration. Clinical examinations for PNP are infrequently provided to patients at high risk due to restrictions on facilities, care providers, or time. A gamified health assessment approach combining wearable sensors holds the potential to address these challenges and provide individuals with instantaneous feedback on their health status.

OBJECTIVE

We aimed to develop and evaluate an application that assesses PNP through video games controlled by pressure sensor-equipped insoles.

METHODS

In the proof-of-concept exploratory cohort study, a complete game-based framework that allowed the study participant to play 4 video games solely by modulating plantar pressure values was established in an outpatient clinic setting. Foot plantar pressures were measured by the sensor-equipped insole and transferred via Bluetooth to an Android tablet for game control in real time. Game results and sensor data were delivered to the study server for visualization and analysis. Each session lasted about 15 minutes. In total, 299 patients with diabetes mellitus and 30 with metabolic syndrome were tested using the game application. Patients' game performance was initially assessed by hypothesis-driven key capabilities that consisted of reaction time, sensation, skillfulness, balance, endurance, and muscle strength. Subsequently, specific game features were extracted from gaming data sets and compared with nerve conduction study findings, neuropathy symptoms, or disability scores. Multiple machine learning algorithms were applied to 70% (n=122) of acquired data to train predictive models for PNP, while the remaining data were held out for final model evaluation.

RESULTS

Overall, clinically evident PNP was present in 247 of 329 (75.1%) participants, with 88 (26.7%) individuals showing asymmetric nerve deficits. In a subcohort (n=37) undergoing nerve conduction study as the gold standard, sensory and motor nerve conduction velocities and nerve amplitudes in lower extremities significantly correlated with 79 game features (|R|>0.4, highest R value +0.65; P<.001; adjusted R2=0.36). Within another subcohort (n=173) with normal cognition and matched covariates (age, sex, BMI, etc), hypothesis-driven key capabilities and specific game features were significantly correlated with the presence of PNP. Predictive models using selected game features achieved 76.1% (left) and 81.7% (right foot) accuracy for PNP detection. Multiclass models yielded an area under the receiver operating characteristic curve of 0.76 (left foot) and 0.72 (right foot) for assessing nerve damage patterns (small, large, or mixed nerve fiber damage).

CONCLUSIONS

The game-based application presents a promising avenue for PNP screening and classification. Evaluation in expanded cohorts may iteratively optimize artificial intelligence model efficacy. The integration of engaging motivational elements and automated data interpretation will support acceptance as a telemedical application.