Effects of the agility boot camp with cognitive challenge (ABC-C) exercise program for Parkinson’s disease

Sensorimotor Network Segregation Predicts Long-Term Learning of Writing Skills in Parkinson's Disease

The prediction of motor learning in Parkinson's disease (PD) is vastly understudied. Here, we investigated which clinical and neural factors predict better long-term gains after an intensive 6-week motor learning program to ameliorate micrographia. We computed a composite score of learning through principal component analysis, reflecting better writing accuracy on a tablet in single and dual task conditions. Three endpoints were studied-acquisition (pre- to post-training), retention (post-training to 6-week follow-up), and overall learning (acquisition plus retention). Baseline writing, clinical characteristics, as well as resting-state network segregation were used as predictors. We included 28 patients with PD (13 freezers and 15 non-freezers), with an average disease duration of 7 (±3.9) years. We found that worse baseline writing accuracy predicted larger gains for acquisition and overall learning. After correcting for baseline writing accuracy, we found female sex to predict better acquisition, and shorter disease duration to help retention. Additionally, absence of FOG, less severe motor symptoms, female sex, better unimanual dexterity, and better sensorimotor network segregation impacted overall learning positively. Importantly, three factors were retained in a multivariable model predicting overall learning, namely baseline accuracy, female sex, and sensorimotor network segregation. Besides the room to improve and female sex, sensorimotor network segregation seems to be a valuable measure to predict long-term motor learning potential in PD.

Associations between baseline cognitive status and motor outcomes after treadmill training in people with Parkinson's disease: a pilot study

PURPOSE

To determine the effect of baseline cognition on gait outcomes after a treadmill training program for people with Parkinson's disease (PD).

METHODS

This pilot clinical trial involved people with PD who were classified as having no cognitive impairment (PD-NCI) or mild cognitive impairment (PD-MCI). Baseline executive function and memory were assessed. The intervention was a 10-week gait training program (twice-weekly treadmill sessions), with structured speed and distance progression and verbal cues for gait quality. Response to intervention was assessed by gait speed measured after week 2 (short-term) and week 10 (long-term).

RESULTS

Participants (n = 19; 12 PD-NCI, 7 PD-MCI) had a mean (standard deviation) age of 66.5 (6.3) years, disease duration of 8.8 (6.3) years, and MDS-UPDRS III score of 21.3 (10.7). Gait speed increased at short-term and long-term assessments. The response did not differ between PD-NCI and PD-MCI groups; however, better baseline memory performance and milder PD motor severity were independently associated with greater improvements in gait speed in unadjusted and adjusted models.

CONCLUSIONS

These findings suggest that memory impairments and more severe motor involvement can influence the response to gait rehabilitation in PD and highlight the need for treatments optimized for people with greater cognitive and motor impairment.IMPLICATIONS FOR REHABILITATIONCognitive deficits in Parkinson's disease (PD) could impact motor learning and gait rehabilitation, yet little is known about the effects of cognitive impairments on the response to rehabilitation in people with PD.This study demonstrates that the response to gait rehabilitation did not differ between people with PD who had no cognitive impairment and those with mild cognitive impairment.Across all participants, better baseline memory was associated with greater improvements in gait speed.Rehabilitation professionals should be mindful of PD severity, as those with more substantial memory and motor impairments may require additional dosing or support to maximize gait training benefits.

Clair KA, Toledo S, York MK, Todaro R, Yarab N, Wallock K. Delivering Multidisciplinary Rehabilitation Care in Parkinson's Disease: An International Consensus Statement

BACKGROUND

Parkinson's disease (PD) is a complex neurodegenerative disorder impacting everyday function and quality of life. Rehabilitation plays a crucial role in improving symptoms, function, and quality of life and reducing disability, particularly given the lack of disease-modifying agents and limitations of medications and surgical therapies. However, rehabilitative care is under-recognized and under-utilized in PD and often only utilized in later disease stages, despite research and guidelines demonstrating its positive effects. Currently, there is a lack of consensus regarding fundamental topics related to rehabilitative services in PD.

OBJECTIVE

The goal of the international Parkinson's Foundation Rehabilitation Medicine Task Force was to develop a consensus statement regarding the incorporation of rehabilitation in PD care.

METHODS

The Task Force, comprised of international multidisciplinary experts in PD and rehabilitation and people directly affected by PD, met virtually to discuss topics such as rehabilitative services, existing therapy guidelines and rehabilitation literature in PD, and gaps and needs. A systematic, interactive, and iterative process was used to develop consensus-based statements on core components of PD rehabilitation and discipline-specific interventions.

RESULTS

The expert-based consensus statement outlines key tenets of rehabilitative care including its multidisciplinary approach and discipline-specific guidance for occupational therapy, physical therapy, speech language pathology/therapy, and psychology/neuropsychology across all PD stages.

CONCLUSIONS

Rehabilitative interventions should be an essential component in the comprehensive treatment of PD, from diagnosis to advanced disease. Greater education and awareness of the benefits of rehabilitative services for people with PD and their care partners, and further evidence-based and scientific study are encouraged.

Balance telerehabilitation and wearable technology for people with Parkinson's disease (TelePD trial)

BACKGROUND

Balance impairments, that lead to falls, are one of the main symptoms of Parkinson's disease (PD). Telerehabilitation is becoming more common for people with PD; however, balance is particularly challenging to assess and treat virtually. The feasibility and efficacy of virtual assessment and virtual treatment of balance in people with PD are unknown. The present study protocol has three aims: I) to determine if a virtual balance and gait assessment (instrumented L-shape mobility test) with wearable sensors can predict a gold-standard, in-person clinical assessment of balance, the Mini Balance Evaluation Systems Test (Mini-BESTest); II) to explore the effects of 12 sessions of balance telerehabilitation and unsupervised home exercises on balance, gait, executive function, and clinical scales; and III) to explore if improvements after balance telerehabilitation transfer to daily-life mobility, as measured by instrumented socks with inertial sensors worn for 7 days.

METHODS

The TelePD Trial is a prospective, single-center, parallel-group, single-blind, pilot, randomized, controlled trial. This trial will enroll 80 eligible people with PD. Participants will be randomized at a 1:1 ratio into receiving home-based balance exercises in either: 1) balance telerehabilitation (experimental group, n = 40) or 2) unsupervised exercises (control group, n = 40). Both groups will perform 12 sessions of exercise at home that are 60 min long. The primary outcome will be Mini-BESTest. The secondary outcomes will be upper and lower body gait metrics from a prescribed task (instrumented L-shape mobility test); daily-life mobility measures over 7 days with wearable sensors in socks, instrumented executive function tests, and clinical scales. Baseline testing and 7 days of daily-life mobility measurement will occur before and after the intervention period.

CONCLUSION

The TelePD Trial will be the first to explore the usefulness of using wearable sensor-based measures of balance and gait remotely to assess balance, the feasibility and efficacy of balance telerehabilitation in people with PD, and the translation of balance improvements after telerehabilitation to daily-life mobility. These results will help to develop a more effective home-based balance telerehabilitation and virtual assessment that can be used remotely in people with balance impairments.

TRIAL REGISTRATION

This trial was prospectively registered on ClinicalTrials.gov (NCT05680597).

Prevention of Falls in Parkinson's Disease: Guidelines and Gaps

Background

People living with Parkinson's disease (PD) have a high risk for falls.

Objective

To examine gaps in falls prevention targeting people with PD as part of the Task Force on Global Guidelines for Falls in Older Adults.

Methods

A Delphi consensus process was used to identify specific recommendations for falls in PD. The current narrative review was conducted as educational background with a view to identifying gaps in fall prevention.

Results

A recent Cochrane review recommended exercises and structured physical activities for PD; however, the types of exercises and activities to recommend and PD subgroups likely to benefit require further consideration. Freezing of gait, reduced gait speed, and a prior history of falls are risk factors for falls in PD and should be incorporated in assessments to identify fall risk and target interventions. Multimodal and multi-domain fall prevention interventions may be beneficial. With advanced or complex PD, balance and strength training should be administered under supervision. Medications, particularly cholinesterase inhibitors, show promise for falls prevention. Identifying how to engage people with PD, their families, and health professionals in falls education and implementation remains a challenge. Barriers to the prevention of falls occur at individual, environmental, policy, and health system levels.

Conclusion

Effective mitigation of fall risk requires specific targeting and strategies to reduce this debilitating and common problem in PD. While exercise is recommended, the types and modalities of exercise and how to combine them as interventions for different PD subgroups (cognitive impairment, freezing, advanced disease) need further study.

Digital measures of freezing of gait across the spectrum of normal, non-freezers, possible freezers and definite freezers

Over the course of the disease, freezing of gait (FoG) will gradually impact over 80% of people with Parkinson's disease (PD). Clinical decision-making and research design are often based on classification of patients as 'freezers' or 'non-freezers'. We derived an objective measure of FoG severity from inertial sensors on the legs to examine the continuum of FoG from absent to possible and severe in people with PD and in healthy controls. One hundred and forty-seven people with PD (Off-medication) and 83 healthy control subjects turned 360° in-place for 1 minute while wearing three wearable sensors used to calculate a novel Freezing Index. People with PD were classified as: 'definite freezers', new FoG questionnaire (NFOGQ) score > 0 and clinically observed FoG; 'non-freezers', NFOGQ = 0 and no clinically observed FoG; and 'possible freezers', either NFOGQ > 0 but no FoG observed or NFOGQ = 0 but FoG observed. Linear mixed models were used to investigate differences in participant characteristics among groups. The Freezing Index significantly increased from healthy controls to non-freezers to possible freezers and to definite freezers and showed, in average, excellent test-retest reliability (ICC = 0.89). Unlike the Freezing Index, sway, gait and turning impairments were similar across non-freezers, possible and definite freezers. The Freezing Index was significantly related to NFOG-Q, disease duration, severity, balance confidence, and the SCOPA-Cog (p < 0.01). An increase in the Freezing Index, objectively assessed with wearable sensors during a turning- in-place test, may help identify prodromal FoG in people with PD prior to clinically-observable or patient-perceived freezing. Future work should follow objective measures of FoG longitudinally.

Design issues in crossover trials involving patients with Parkinson's disease

Background and objectives

Crossover designs are frequently used to assess treatments for patients with Parkinson's disease. Typically, two-period two-treatment trials include a washout period between the 2 periods and assume that the washout period is sufficiently long to eliminate carryover effects. A complementary strategy might be to jointly model carryover and treatment effects, though this has rarely been done in Parkinson's disease crossover studies. The primary objective of this research is to demonstrate a modeling approach that assesses treatment and carryover effects in one unified mixed model analysis and to examine how it performs in a simulation study and a real data analysis example, as compared to other data analytic approaches used in Parkinson's disease crossover studies.

Methods

We examined how three different methods of analysis (standard crossover t-test, mixed model with a carryover term included in model statement, and mixed model with no carryover term) performed in a simulation study and illustrated the methods in a real data example in Parkinson's disease.

Results

The simulation study based on the presence of a carryover effect indicated that mixed models with a carryover term and an unstructured correlation matrix provided unbiased estimates of treatment effect and appropriate type I error. The methods are illustrated in a real data example involving Parkinson's disease. Our literature review revealed that a majority of crossover studies included a washout period but did not assess whether the washout was sufficiently long to eliminate the possibility of carryover.

Discussion

We recommend using a mixed model with a carryover term and an unstructured correlation matrix to obtain unbiased estimates of treatment effect.

Effects of motor-cognitive training on dual-task performance in people with Parkinson's disease: a systematic review and meta-analysis

Motor-cognitive training in Parkinson's disease (PD) can positively affect gait and balance, but whether motor-cognitive (dual-task) performance improves is unknown. This meta-analysis, therefore, aimed to establish the current evidence on the effects of motor-cognitive training on dual-task performance in PD. Systematic searches were conducted in five databases and 11 studies with a total of 597 people (mean age: 68.9 years; mean PD duration: 6.8 years) were included. We found a mean difference in dual-task gait speed (0.12 m/s (95% CI 0.08, 0.17)), dual-task cadence (2.91 steps/min (95% CI 0.08, 5.73)), dual-task stride length (10.12 cm (95% CI 4.86, 15.38)) and dual-task cost on gait speed (- 8.75% (95% CI - 14.57, - 2.92)) in favor of motor-cognitive training compared to controls. The GRADE analysis revealed that the findings were based on high certainty evidence. Thus, we can for the first time systematically show that people with PD can improve their dual-task ability through motor-cognitive training.

Multimodal Agility-Based Exercise Training for Persons With Multiple Sclerosis: A New Framework

INTRODUCTION

Multimodal agility-based exercise training (MAT) has been described as a framework for fall prevention in the elderly but might also be a valuable concept for exercise training in persons with Multiple Sclerosis (pwMS).

THE PROBLEM

Current recommendations advise pwMS to perform a multitude of different exercise training activities, as each of these has its separate evidence. However, pwMS struggle even more than the general population to be physically active. Additionally, Multiple Sclerosis often leads to co-occurring mobility and cognitive dysfunctions, for which simultaneous, time-efficient, and engaging training approaches are still limited in clinical practice and healthcare.

THE SOLUTION

The MAT framework has been developed to integratively improve cardiovascular, neuromuscular, and cognitive function by combining aspects of perception and orientation, change of direction, as well as stop-and-go patterns (ie, agility), in a group-training format. For pwMS, the MAT framework is conceptualized to include 3 Components: standing balance, dynamic balance (including functional leg strength), and agility-based exercises. Within these Components sensory, cognitive, and cardiovascular challenges can be adapted to individual needs.

RECOMMENDATIONS

We recommend investigating multimodal exercise interventions that go beyond easily standardized, unimodal types of exercise (eg, aerobic or resistance exercise), which could allow for time-efficient training, targeting multiple frequent symptoms of persons with mild disability at once. MAT should be compared to unimodal approaches, regarding sensor-based gait outcomes, fatigue-related outcomes, cognition, as well as neuroprotective, and (supportive) disease-modifying effects.

TURN-IT: a novel turning intervention program to improve quality of turning in daily life in people with Parkinson's disease

BACKGROUND

People with Parkinson's disease (PD) have a high fall rate and many falls are associated with turns. Despite this, there is minimal research on effects of rehabilitation on the quality of turns. Further, quantifying turns in the home may have broader implications since rehabilitation of turns would ideally improve turning in real world mobility.

METHODS

Sixty people with PD and a history of falls will be randomized to receive either a novel TURNing InTervention (TURN-IT) or no intervention (control group). The TURN-IT group will be seen for 6 weeks (18 visits) for an individualized, progressive program that is based on the specific constraints of turning in PD. Wearable sensors will be used to measure 7 days of mobility, including turns, before and after intervention or control period. In addition, blinded assessments of gait, mobility and turns will occur before and after intervention for both groups and falls will be monitored for twelve months post intervention with bimonthly email questionnaires.

DISCUSSION

This study has the potential to change how we rehabilitate and assess turning in people with PD and falls. There are several novel aspects to our study including a comprehensive turning-focused intervention that is tailored to the underlying constraints that impair turning in people with PD. Further, our outcome measure of turning quality during 7 days of daily life is novel and has implications for determining real-life changes after rehabilitation. The ultimate goal of this rehabilitation intervention is to improve how patients turn in daily life and to reduce falls.

TRIALS REGISTRATION

This protocol is registered at clinicaltrials.gov; #NCT04897256; https://clinicaltrials.gov/ct2/show/NCT04897256?term=Horak&cond=Parkinson+Disease&draw=2&rank=4 .

Effects of dual task training on dual task gait performance and cognitive function in individuals with Parkinson's disease: A meta-analysis and meta-regression

OBJECTIVE

To explore the effects of dual task (DT) training on DT gait performance and cognitive function in individuals with Parkinson's disease (PD) and to examine factors that might influence the effects of DT training.

DATA SOURCES

PubMed, Wiley Online Library, Cochrane Library, CINAHL, and Medline were searched for articles published from January 2006 to December 2021.

STUDY SELECTION

Randomized controlled trials comparing DT training with usual care or general exercise were included.

DATA EXTRACTION

The outcomes studied were DT gait parameters including speed, step and stride length, cadence, step and stride time variability, dual task cost on gait speed, and Trail Making Tests (TMT) presented as standardized mean differences. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to evaluate the quality of evidence.

DATA SYNTHESIS

Ten randomized controlled trials with 466 participants were included in the meta-analysis. The included studies presented, in general, with a low to high risk of bias. Meta-analyses used a random-effects model for all analysis. The meta-analysis showed the DT training effects on DT gait speed (SMD=0.825, p=0.012), DT step and stride length (SMD=0.400, p=0.015), TMT-A (SMD=0.533, p=0.010) and TMT-B (SMD=0.516, p=0.012) compared to the control group. Only the effect on TMT-A was maintained at the follow-up assessment. The results of meta-regression showed that participants with slower initial single task gait speed improved more after DT training on DT step and stride length.

CONCLUSIONS

The DT training improved more in DT gait speed with moderate-quality evidence as compared with usual care or conventional physical training in individuals with PD. The beneficial effects of DT training on DT step and stride length, attention and executive function were also demonstrated in this meta-analysis. Furthermore, the improvement in the DT walking step and stride length was related to the participant's initial single task gait speed.

Cognitive dual-task cost depends on the complexity of the cognitive task, but not on age and disease

Introduction

Dual-tasking (DT) while walking is common in daily life and can affect both gait and cognitive performance depending on age, attention prioritization, task complexity and medical condition. The aim of the present study was to investigate the effects of DT on cognitive DT cost (DTC) (i) in a dataset including participants of different age groups, with different neurological disorders and chronic low-back pain (cLBP) (ii) at different levels of cognitive task complexity, and (iii) in the context of a setting relevant to daily life, such as combined straight walking and turning.

Materials and methods

Ninety-one participants including healthy younger and older participants and patients with Parkinson's disease, Multiple Sclerosis, Stroke and cLBP performed a simple reaction time (SRT) task and three numerical Stroop tasks under the conditions congruent (StC), neutral (StN) and incongruent (StI). The tasks were performed both standing (single task, ST) and walking (DT), and DTC was calculated. Mixed ANOVAs were used to determine the effect of group and task complexity on cognitive DTC.

Results

A longer response time in DT than in ST was observed during SRT. However, the response time was shorter in DT during StI. DTC decreased with increasing complexity of the cognitive task. There was no significant effect of age and group on cognitive DTC.

Conclusion

Our results suggest that regardless of age and disease group, simple cognitive tasks show the largest and most stable cognitive effects during DT. This may be relevant to the design of future observational studies, clinical trials and for clinical routine.

Effects of a Cognitively Challenging Agility Boot Camp Program on Balance and Gait in People With Parkinson's Disease: Does Freezing of Gait Status Matter?

BACKGROUND AND AIM

Individuals with Parkinson's disease (PD) with and without freezing of Gait (FoG) may respond differently to exercise interventions for several reasons, including disease duration. This study aimed to determine whether both people with and without FoG benefit from the Agility Boot Camp with Cognitive Challenges (ABC-C) program.

METHODS

This secondary analysis of our ABC-C trial included 86 PD subjects: 44 without FoG (PD-FoG) and 42 with FoG (PD + FoG). We collected measures of standing sway balance, anticipatory postural adjustments, postural responses, and a 2-minute walk with and without a cognitive task. Two-way repeated analysis of variance, with disease duration as covariate, was used to investigate the effects of ABC-C program. Effect sizes were calculated using standardized response mean (SRM) for PD-FoG and PD + FoG, separately.

RESULTS

The ABC-C program was effective in improving gait performance in both PD-FoG and PD + FoG, even after controlling for disease duration. Specifically, dual-task gait speed (P < .0001), dual-cost stride length (P = .012), and these single-task measures: arm range of motion (P < .0001), toe-off angle (P = .005), gait cycle duration variability (P = .019), trunk coronal range of motion (P = .042), and stance time (P = .046) improved in both PD-FoG and PD + FoG. There was no interaction effect between time (before and after exercise) and group (PD-FoG/PD + FoG) in all 24 objective measures of balance and gait. Dual-task gait speed improved the most in PD + FoG (SRM = 1.01), whereas single-task arm range of motion improved the most in PD-FoG (SRM = 1.01).

CONCLUSION

The ABC-C program was similarly effective in improving gait (and not balance) performance in both PD-FoG and PD + FoG.

Resting state functional networks predict different aspects of postural control in Parkinson's disease

BACKGROUND

Parkinson's disease (PD) is a neurodegenerative disorder causing postural control impairments. Postural control involves multiple domains, such as control of postural sway in stance, automatic postural responses (APRs) and anticipatory postural adjustments (APAs). We hypothesize that impairments in each postural domain is associated with resting-state functional connectivity (rsFC), accounted by predictive modeling and that cortical and cerebellar networks would predict postural control in people with PD (PwPD).

OBJECTIVE

To determine whether rsFC can predict three domains of postural control independently in PwPD and older adults (OA) based on predictive accuracy of models.

METHODS

The cohort consisted of 65 PwPD (67.7 +8.1 age) tested in their OFF-state and 42 OA (69.7 +8.2 age). Six body-worn, inertial sensors measured postural sway area while standing on foam, step length of APRs to a backward push-and-release perturbation, and magnitude of lateral APAs prior to voluntary gait initiation. Resting state-fMRI data was reported on 384 regions of interest that were grouped into 13 functional brain networks. Associations between rsFC and postural metrics were characterized using predictive modeling, with an independent training (n = 67) and validation (n = 40) dataset. Models were trained in the training sample and performance of the best model was validated in the independent test dataset.

RESULTS

rsFC of different brain networks predicted each domain of postural control in PD: Frontoparietal and Ventral Attention rsFC for APAs; Cerebellar-Subcortical and Visual rsFC and Auditory and Cerebellar-Subcortical rsFC for APRs; Ventral Attention and Ventral Multimodal rsFC for postural sway. In OA, CinguloOpercular and Somatomotor rsFC predicted APAs.

CONCLUSIONS

Our findings suggest that cortical networks predict postural control in PD and there is little overlap in brain network connectivities that predict different domains of postural control, given the rsFC methodology used. PwPD use different cortical networks for APAs compared to OA.

Patients with Parkinson's disease and a history of falls have decreased cerebellar grey matter volumes in the cognitive cerebellum

The objective of this study was to determine if cerebellar gray matter (GM) structure differs between fallers and non-fallers with Parkinson's disease (PD) and their respective association to cognitive function. A total of 48 fallers and 63 non-fallers with PD were identified from the Parkinson's Progression Markers Initiative database. Fallers were categorized as those who self-reported a fall within the past year. Unified Parkinson's Disease Rating Scale-III (UPDRS-III), Montreal Cognitive Assessment (MoCA), Trail Making Test parts A (TMT-A) and B (TMT-B) scores were collected for each patient. Cerebellar GM volumes were derived from magnetic resonance imaging data. Analyses of covariance were used to compare group differences. Partial Pearson's correlations were used to assess the relationship between cerebellar GM volumes to UPDRS-III and cognitive outcomes. Significance was set at P ≤ 0.01. Fallers had significantly decreased GM volumes in lobules V, Crus-1, Crus-2, and VIIb (P<0.01). Cerebellar GM volumes in non-fallers demonstrated little-to-no relationship with UPDRS-III, MoCA, and TMT-B (P>0.01). However, TMT-A performance demonstrated significant, fair association to GM volumes in lobules I-IV, V, VI, Crus-1, and Crus-2 (r=-0.44 - -0.34, P<0.01) in non-fallers. Patients with PD and a history of falls have significantly decreased GM volumes in cerebellar lobules associated with cognitive functions. However, these lobule volumes become disassociated with cognitive function compared to non-fallers.

Behavioural and neuroplastic effects of a double-blind randomised controlled balance exercise trial in people with Parkinson's disease

Balance dysfunction is a disabling symptom in people with Parkinson's disease (PD). Evidence suggests that exercise can improve balance performance and induce neuroplastic effects. We hypothesised that a 10-week balance intervention (HiBalance) would improve balance, other motor and cognitive symptoms, and alter task-evoked brain activity in people with PD. We performed a double-blind randomised controlled trial (RCT) where 95 participants with PD were randomised to either HiBalance (n = 48) or a control group (n = 47). We found no significant group by time effect on balance performance (b = 0.4 95% CI [-1, 1.9], p = 0.57) or on our secondary outcomes, including the measures of task-evoked brain activity. The findings of this well-powered, double-blind RCT contrast previous studies of the HiBalance programme but are congruent with other double-blind RCTs of physical exercise in PD. The divergent results raise important questions on how to optimise physical exercise interventions for people with PD.Preregistration clinicaltrials.gov: NCT03213873.

Relationship Between Brain Volumes and Objective Balance and Gait Measures in Parkinson's Disease

BACKGROUND

Instrumented measures of balance and gait measure more specific balance and gait impairments than clinical rating scales. No prior studies have used objective balance/gait measures to examine associations with ventricular and brain volumes in people with Parkinson's disease (PD).

OBJECTIVE

To test the hypothesis that larger ventricular and smaller cortical and subcortical volumes are associated with impaired balance and gait in people with PD.

METHODS

Regional volumes from structural brain images were included from 96 PD and 50 control subjects. Wearable inertial sensors quantified gait, anticipatory postural adjustments prior to step initiation (APAs), postural responses to a manual push, and standing postural sway on a foam surface. Multiple linear regression models assessed the relationship between brain volumes and balance/gait and their interactions in PD and controls, controlling for sex, age and corrected for multiple comparisons.

RESULTS

Smaller brainstem and subcortical gray matter volumes were associated with larger sway area in people with PD, but not healthy controls. In contrast, larger ventricle volume was associated with smaller APAs in healthy controls, but not in people with PD. A sub-analysis in PD showed significant interactions between freezers and non-freezers, in several subcortical areas with stride time variability, gait speed and step initiation.

CONCLUSION

Our models indicate that smaller subcortical and brainstem volumes may be indicators of standing balance dysfunction in people with PD whereas enlarged ventricles may be related to step initiation difficulties in healthy aging. Also, multiple subcortical region atrophy may be associated with freezing of gait in PD.

Gamified Dual-Task Training for Individuals with Parkinson Disease: An Exploratory Study on Feasibility, Safety, and Efficacy

Objectives: The feasibility and safety of the use of neurorehabilitation technology (SMARTfit^® Trainer system) by physical therapists in implementing a gamified physical-cognitive dual-task training (DTT) paradigm for individuals with Parkinson disease (IWPD) was examined. Additionally, the efficacy of this gamified DTT was compared to physical single-task training (STT), both of which were optimized using physio-motivational factors, on changes in motor and cognitive outcomes, and self-assessed disability in activities of daily living. Methods: Using a cross-over study design, eight participants with mild-to-moderate idiopathic PD (including one with mild cognitive impairment) completed both training conditions (i.e., gamified DTT and STT). For each training condition, the participants attended 2–3 sessions per week over 8.8 weeks on average, with the total amount of training being equivalent to 24 1 h sessions. A washout period averaging 11.5 weeks was inserted between training conditions. STT consisted of task-oriented training involving the practice of functional tasks, whereas for gamified DTT, the same task-oriented training was implemented simultaneously with varied cognitive games using an interactive training system (SMARTfit^®). Both training conditions were optimized through continual adaptation to ensure the use of challenging tasks and to provide autonomy support. Training hours, heart rate, and adverse events were measured to assess the feasibility and safety of the gamified DTT protocol. Motor and cognitive function as well as perceived disability were assessed before and after each training condition. Results: Gamified DTT was feasible and safe for this cohort. Across participants, significant improvements were achieved in more outcome measures after gamified DTT than they were after STT. Individually, participants with specific demographic and clinical characteristics responded differently to the two training conditions. Conclusion: Physical therapists’ utilization of technology with versatile hardware configurations and customizable software application selections was feasible and safe for implementing a tailor-made intervention and for adapting it in real-time to meet the individualized, evolving training needs of IWPD. Specifically in comparison to optimized STT, there was a preliminary signal of efficacy for gamified DTT in improving motor and cognitive function as well as perceived disability in IWPD.

Relating Global Cognition With Upper-Extremity Motor Skill Retention in Individuals With Mild-to-Moderate Parkinson's Disease

Background and Purpose: Cognition has been linked to rehabilitation outcomes in stroke populations, but this remains unexplored in individuals with Parkinson's disease (PD). The purpose of this secondary data analysis from a recent clinical trial (NCT02600858) was to determine if global cognition was related to skill performance after motor training in individuals with PD. Methods: Twenty-three participants with idiopathic PD completed 3 days of training on an upper-extremity task. For the purposes of the original clinical trial, participants trained either "on" or "off" their dopamine replacement medication. Baseline, training, and 48-h retention data have been previously published. Global cognition was evaluated using the Montreal Cognitive Assessment (MoCA). Linear regression examined whether MoCA score predicted longer-term retention at nine-day follow-up; baseline motor task performance, age, PD severity, depressive symptoms, and group (medication "on"/"off") were included as covariates. Baseline and follow-up motor task performance were assessed for all participants while "on" their medication. Results: MoCA score was positively related to follow-up motor task performance, such that individuals with better cognition were faster than those with poorer cognition. Baseline task performance, age, PD severity, depressive symptoms, and medication status were unrelated to follow-up performance. Discussion and Conclusions: Results of this secondary analysis align with previous work that suggest cognitive impairment may interfere with motor learning in PD and support the premise that cognitive training prior to or concurrent with motor training may enhance rehabilitative outcomes for individuals with PD. Findings also suggest that assessing cognition in individuals with PD could provide prognostic information about their responsiveness to motor rehabilitation.

Effects of a Highly Challenging Balance Training Program on Motor Function and Brain Structure in Parkinson's Disease

Background:

Parkinson’s disease (PD) is characterized by motor deficits and brain alterations having a detrimental impact on balance, gait, and cognition. Intensive physical exercise can induce changes in the neural system, potentially counteracting neurodegeneration in PD and improving clinical symptoms.

Objective:

This randomized controlled trial investigated effects of a highly challenging, cognitively demanding, balance and gait training (HiBalance) program in participants with PD on brain structure.

Methods:

95 participants were assigned to either the HiBalance or an active control speech training program. The group-based interventions were performed in 1-hour sessions, twice per week over a 10-week period. Participants underwent balance, gait, cognitive function, and structural magnetic resonance imaging assessments before and after the interventions. Voxel-based morphometry was analyzed in 34 HiBalance and 31 active controls. Additionally, structural covariance networks were assessed.

Results:

There was no significant time by group interaction between the HiBalance and control training in balance, gait, or brain volume. Within-HiBalance-group analyses showed higher left putamen volumes post-training. In repeated measures correlation a positive linear, non-significant relationship between gait speed and putamen volume was revealed. In the HiBalance group we found community structure changes and stronger thalamic-cerebellar connectivity in structural covariance networks. Neither brain volume changes nor topology changes were found for the active controls after the training.

Conclusion:

Thus, subtle structural brain changes occur after balance and gait training. Future studies need to determine whether training modifications or other assessment methods lead to stronger effects.

The Role of Exercise in Parkinson's Disease

Parkinson's disease (PD) is a progressive, neurodegenerative disorder of the central nervous system. While it primarily affects motor function, patients eventually develop non-motor symptoms including depression, anxiety, and eventually dementia. Although there is currently no cure, treatment is aimed largely at improving quality of life though medication or surgical techniques to reduce motor symptoms. However, there is vast evidence of the benefits of physical activity as adjunct therapy for Parkinson's disease. In this review, we analyze 31 studies or reviews and highlight the role of exercise and rehabilitation in PD treatment. This study serves to provide clinicians with a comprehensive resource of the wide variety of exercises with proven benefit for patients affected by Parkinson's disease. Specifically, patients report significant improvements in motor function, cognition, mood and sleep habits.

Functional limits of stability and standing balance in people with Parkinson's disease with and without freezing of gait using wearable sensors

BACKGROUND

People with from Parkinson's disease (PD) and freezing of gait (FoG) have more frequent falls compared to those who do not freeze but there is no consensus on which, specific objective measures of postural instability are worse in freezers (PD + FoG) than non-freezers (PD-FoG).

RESEARCH QUESTION

Are functional limits of stability (fLoS) or postural sway during stance measured with wearable inertial sensors different between PD + FoG versus PD-FoG, as well as between PD versus healthy control subjects (HC)?

METHODS

Sixty-four PD subjects with FoG (MDS-UPDRS Part III: 45.9 ± 12.5) and 80 PD subjects without FoG (MDS-UPDRS Part III: 36.2 ± 10.9) were tested Off medication and compared with 79 HC. Balance was quantified with inertial sensors worn on the lumbar spine while performing the following balance tasks: 1) fLoS as defined by the maximum displacement in the forward and backward directions and 2) postural sway area while standing with eyes open on a firm and foam surface. An ANOVA, controlling for disease duration, compared postural control between groups.

RESULTS

PD + FoG had significantly smaller fLoS compared to PD-FoG (p =  0.004) and to healthy controls (p <  0.001). However, PD-FoG showed similar fLoS compared to healthy controls (p =  0.48). Both PD+FoG and PD-FoG showed larger postural sway on a foam surface compared to healthy controls (p =  0.001) but there was no significant difference in postural sway between PD+FoG and PD-FoG.

SIGNIFICANCE

People with PD and FoG showed task-specific, postural impairments with smaller fLoS compared to non-freezers, even when controlling for disease duration. However, individuals with PD with or without FoG had similar difficulties standing quietly on an unreliable surface compared to healthy controls. Wearable inertial sensors can reveal worse fLoS in freezers than non-freezers that may contribute to FoG and help explain their more frequent falls.

Rehabilitation of Falls in Parkinson's Disease: Self-Perception vs. Objective Measures of Fall Risk

Falls are an important cause of injury and increased hospital/long-term care facility stays and has been reported in 70% of people with Parkinson’s disease (PD), yet there is limited effectiveness of medications for reducing falls. As an adjunct, many exercise therapies succeed in objectively reducing the number of falls, but this may not translate to improved quality of life (QOL). Importantly, self-perceived fall risk has a greater influence on activities of daily living and QOL, making it important to evaluate in the rehabilitation of PD. The purpose of this study was to examine the influence of a 10-week exercise intervention (PD SAFE × TM) on self-perceived (according to balance confidence measures) and objective measures of gait that are commonly linked to fall risk in PD. Participants (N = 44) with PD completed PD SAFE × TM. Pre-/post-assessment involved the Activities-specific Balance Confidence Scale (perception), objective falls characteristics (stride time, stride width, stride length, and stride variability), and symptom severity (Unified Parkinson’s Disease Rating Scale motor subsection III (UPDRS-III)) after participants were stratified into a mild (no-balance impairment) vs. severe (balance impairment) groups. Overall disease severity (F (1, 43) = 8.75, p < 0.003) and all objective fall parameters improved (p < 0.05) in both groups, yet self-perceived fall risk improved in only the severe PD group F (1, 43) = 9.86, p < 0.022. Given that self-perceived fall risk and objective fall risk both play a role in the quality of life, identifying strategies to improve both aspects may be important in improving the overall quality of life.

Responsiveness of Objective vs. Clinical Balance Domain Outcomes for Exercise Intervention in Parkinson's Disease

Background: Balance deficits in people with Parkinson's disease (PD) are often not helped by pharmacological or surgical treatment. Although balance exercise intervention has been shown to improve clinical measures of balance, the efficacy of exercise on different, objective balance domains is still unknown.

Objective: To compare the sensitivity to change in objective and clinical measures of several different domains of balance and gait following an Agility Boot Camp with Cognitive Challenges (ABC-C) intervention.

Methods: In this cross-over, randomized design, 86 individuals with PD participated in 6-week (3×/week) ABC-C exercise classes and 6-week education classes, consisting of 3–6 individuals. Blinded examiners tested people in their practical off state. Objective outcome measures from wearable sensors quantified four domains of balance: sway in standing balance, anticipatory postural adjustments (APAs) during step initiation, postural responses to the push-and-release test, and a 2-min natural speed walk with and without a cognitive task. Clinical outcome measures included the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) Part III, the Mini Balance Evaluation Systems Test (Mini-BESTest), the Activities of Balance Confidence (ABC), and the Parkinson's Disease Questionnaire (PDQ-39). The standardized response means (SRM) of the differences between before and after each intervention compared responsiveness of outcomes to intervention. A linear mixed model compared effects of exercise with the active control—education intervention.

Results: The most responsive outcome measures to exercise intervention with an SRM > 0.5 were objective measures of gait and APAs, specifically arm range of motion, gait speed during a dual-task walk, trunk coronal range of motion, foot strike angle, and first-step length at step initiation. The most responsive clinical outcome measure was the patient-reported PDQ-39 activities daily living subscore, but all clinical measures had SRMs <0.5.

Conclusions: The objective measures were more sensitive to change after exercise intervention compared to the clinical measures. Spatiotemporal parameters of gait, including gait speed with a dual task, and APAs were the most sensitive objective measures, and perceived functional independence was the most sensitive clinical measure to change after the ABC-C exercise intervention. Future exercise intervention to improve gait and balance in PD should include objective outcome measures.