Participant expectations and experiences of a tailored physiotherapy intervention for people with Parkinson's and a history of falls

Improving recruitment and retention of people with Parkinson's disease to clinical studies: A scoping review

BackgroundTimely recruitment and effective retention of participants are challenging for clinical Parkinson's disease (PD) research studies. Not achieving this can affect delivery costs and bias results.ObjectiveTo identify successful recruitment and retention methodologies for clinical research studies in PD.MethodsWe conducted a systematic scoping review using a Population, Intervention, Comparator, Outcome and Study design (PICOS) framework to search and screen literature within five databases for published quantitative and mixed methods studies evaluating recruitment and retention strategies of interventional and observational trials in PD.ResultsSearches identified 4608 records, of which six papers covering eight studies were included in the review following screening for eligibility. No papers on retention strategies were found that met eligibility criteria. Effective strategies for rapid recruitment included research registries and trial finders (n = 3), digital marketing campaigns (n = 3), site recruitment support (n = 1) and multiple referral sources (n = 1). Recruitment diversity was increased by online campaigns, mandatory 10% minority targets set by funders and supplemental site funding.ConclusionsThis scoping review has identified methods that can be used to increase the rate and diversity of recruitment to PD clinical studies. Retention methodologies are under-researched.

Anticipation, agency and aging-conditions for making movement irresistible

This article describes an approach to developing and maintaining interpersonal agency through guided movement and responsive technologies. Making Movement Irresistible (MMI), considered conditions for developing a digital, online and wearable intervention that could make the act of movement irresistible for older residents in care, and encourage improvisational and social interactions. Working within a co-design framework, we combined making material objects and moving together as a method of examining the efficacy of human to human, and human to technology relationships to cultivate agency. Given that movement as performance is frequently not practiced or uncomfortable, we invited a variety of experts as our co-designers to notice the nuances of movement that interested them and to document these using drawing, writing and visuals. This documentation was gathered regularly in journals as the workshops progressed, leading to a coherent capture of data as it emerged. This data allowed us to attribute value to how simple actions could become a conduit for more ambitious, exploratory interactions. Our playful methods afforded the participation of co-designers, enabling us to situate our proposed intervention within a relational and social, rather than medical model, of ageing. Making movement do-able and relational, so that it can be shared and extended with a partner or carer, informed the idea to design a wearable device that could detect movement variability, resulting in a prototype, named emitts®. The device makes use of the hand as way in to accessing whole body interaction. Our work with responsiveness of visual feedback avoided deterministic targets, as with no two movements being identical, the reported problem of compliance with repetitive tasks could be reduced. The technology foregrounded movement that was capricious and improvisational, offering new modes of artistic practice and engagement through play and performance. The case we describe highlights the importance of understanding the conditions that augment social interaction, rather than specifying design criteria for determining interaction. The longer-term health benefits of our intervention have yet to be measured, however, our collaboration has revealed how interpersonal agency emerges when we socially, aesthetically, and physiologically stimulate movement, making it irresistible where there may otherwise be resistance.

Adherence to Non-Pharmacological Interventions in Parkinson's Disease: A Rapid Evidence Assessment of the Literature

Background

Low adherence to non-pharmacological interventions can impact treatment effectiveness. Yet, there is limited information on adherence barriers and facilitators to non-pharmacological interventions in Parkinson's disease (PD).

Objective

1) To examine the quality of adherence reporting and 2) to identify key determinants of adherence to PD non-pharmacological interventions.

Methods

A rapid evidence assessment was conducted, following PRISMA guidelines, that included controlled studies of exercise, physiotherapy, occupational therapy, speech-language therapy with explicit reporting of 'adherence' OR 'compliance', published in the last 15 years. Data extracted included: adherence rates, adherence outcomes, and factors associated with adherence. A collaborative thematic analysis was conducted to identify determinants of adherence.

Results

The search yielded 2,445 articles of which 114 met criteria for full screening with 45 studies meeting all inclusion criteria. High quality adherence data that aligned with the intervention goals were reported by 22.22%(N = 10) of studies, with the majority reporting attendance/attrition rates only 51.11%(N = 23). Four major themes (34 subthemes) emerged: disease and health, personal, program design, and system and environmental.

Conclusions

There has been limited progress in the quality of adherence reporting in PD non-pharmacological interventions over the last decade. Acknowledging this limitation, key determinants of adherence included: alignment with personal beliefs, attitudes, and expectations; the demands of the intervention and worsening disease symptoms and personal/time obligations; and accessibility and safety concerns. Program design elements found to facilitate adherence included: opportunities for social engagement and in-person offerings linked to higher levels of interventionist support, performative feedback, and social reinforcement.

Design of the STEPS trial: a phase II randomized controlled trial evaluating eHealth-supported motor-cognitive home training for Parkinson's disease

BACKGROUND

Electronic health (eHealth) technology offers the potential to support and motivate physical activity for symptom management in Parkinson's disease (PD). It is also recommended that motor exercise in PD be complemented with cognitive training aimed at attentional or executive functions. This paper describes the protocol for a double-blind randomized controlled trial to evaluate the effects of motor-cognitive training in the home environment, supported by eHealth.

METHODS/DESIGN

The Support for home Training using Ehealth in Parkinsons diseaSe (STEPS) is a double-blind single center randomized controlled trial. Two parallel groups will include in total 120 participants with mild to moderate PD who will receive either (i) the intervention (a progressive 10-week individualized motor-cognitive eHealth training with cognitive behavioral elements to increase physical activity levels) or (ii) an active control group (an individualized 10-week paper-based home exercise program). The active control group will not receive motor-cognitive exercises or cognitive behavioral approaches to increase physical activity level. The primary outcome is walking capacity assessed by the six-minute walk test (6MWT). Secondary outcomes will include gait performance during single and dual task conditions, gait speed, functional mobility and lower limb strength, balance, physical activity behavior and a range of patient reported outcome measures relevant in PD.

DISCUSSION

The STEPS trial will answer the question whether 10 weeks of eHealth supported motor-cognitive exercise in the home environment can improve walking capacity in PD when compared to a standard paper exercise program. Findings from this study will also strengthen the evidence concerning the efficacy of PD-specific eHealth interventions with a view meeting future health care demands by addressing issues of inaccessibility to specialized neurological rehabilitation in PD.

TRIAL REGISTRATION

ClinicalTrials.gov August 2022, NCT05510739.

Home-based exercise training by using a smartphone app in patients with Parkinson's disease: a feasibility study

Background

Parkinson's disease (PD) patients experience deterioration in mobility with consequent inactivity and worsened health and social status. Physical activity and physiotherapy can improve motor impairments, but several barriers dishearten PD patients to exercise regularly. Home-based approaches (e.g., via mobile apps) and remote monitoring, could help in facing this issue.

Objective

This study aimed at testing the feasibility, usability and training effects of a home-based exercise program using a customized version of Parkinson Rehab® application.

Methods

Twenty PD subjects participated in a two-month minimally supervised home-based training. Daily session consisted in performing PD-specific exercises plus a walking training. We measured: (i) feasibility (training adherence), usability and satisfaction (via an online survey); (ii) safety; (iii) training effects on PD severity, mobility, cognition, and mood. Evaluations were performed at: baseline, after 1-month of training, at the end of training (T2), and at 1-month follow-up (T3).

Results

Eighteen out of twenty participants completed the study without important adverse events. Participants' adherence was 91% ± 11.8 for exercise and 105.9% ± 30.6 for walking training. Usability and satisfaction survey scored 70.9 ± 7.7 out of 80. Improvements in PD severity, mobility and cognition were found at T2 and maintained at follow-up.

Conclusion

The home-based training was feasible, safe and seems to positively act on PD-related symptoms, mobility, and cognition in patients with mild to moderate stage of PD disease. Additionally, the results suggest that the use of a mobile app might increase the amount of daily physical activity in our study population. Remote monitoring and tailored exercise programs appear to be key elements for promoting exercise. Future studies in a large cohort of PD participants at different stages of disease are needed to confirm these findings.

Successful implementation of technology in the management of Parkinson's disease: Barriers and facilitators

Background

Parkinson's disease (PD) is a progressive neurodegenerative disease with a fast increasing prevalence. Several pharmacological and non-pharmacological interventions are available to alleviate symptoms. Technology can be used to improve the efficiency, accessibility and feasibility of these treatments. Although many technologies are available, only few are actually implemented in daily clinical practice.

Aim

Here, we study the barriers and facilitators, as experienced by patients, caregivers and/or healthcare providers, to successful implement technology for PD management.

Methods

We performed a systematic literature search in the PubMed and Embase databases until June 2022. Two independent raters screened the titles, abstracts and full texts on: 1) people with PD; 2) using technology for disease management; 3) qualitative research methods providing patients', caregivers and/or healthcare providers' perspective, and; 4) full text available in English or Dutch. Case studies, reviews and conference abstracts were excluded.

Results

We found 5420 unique articles of which 34 were included in this study. Five categories were made: cueing (n = 3), exergaming (n = 3), remote monitoring using wearable sensors (n = 10), telerehabilitation (n = 8) and remote consultation (n = 10). The main barriers reported across categories were unfamiliarity with technology, high costs, technical issues and (motor) symptoms hampering the use of some technologies. Facilitators included good usability, experiencing beneficial effects and feeling safe whilst using the technology.

Conclusion

Although only few articles presented a qualitative evaluation of technologies, we found some important barriers and facilitators that may help to bridge the gap between the fast developing technological world and actual implementation in day-to-day living with PD.

Interventions for preventing falls in Parkinson's disease

BACKGROUND

Most people with Parkinson's disease (PD) experience at least one fall during the course of their disease. Several interventions designed to reduce falls have been studied. An up-to-date synthesis of evidence for interventions to reduce falls in people with PD will assist with informed decisions regarding fall-prevention interventions for people with PD.

OBJECTIVES

To assess the effects of interventions designed to reduce falls in people with PD.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, four other databases and two trials registers were searched on 16 July 2020, together with reference checking, citation searching and contact with study authors to identify additional studies. We also conducted a top-up search on 13 October 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of interventions that aimed to reduce falls in people with PD and reported the effect on falls. We excluded interventions that aimed to reduce falls due to syncope.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane Review procedures. Primary outcomes were rate of falls and number of people who fell at least once. Secondary outcomes were the number of people sustaining one or more fall-related fractures, quality of life, adverse events and economic outcomes. The certainty of the evidence was assessed using GRADE.

MAIN RESULTS

This review includes 32 studies with 3370 participants randomised. We included 25 studies of exercise interventions (2700 participants), three studies of medication interventions (242 participants), one study of fall-prevention education (53 participants) and three studies of exercise plus education (375 participants). Overall, participants in the exercise trials and the exercise plus education trials had mild to moderate PD, while participants in the medication trials included those with more advanced disease. All studies had a high or unclear risk of bias in one or more items. Illustrative risks demonstrating the absolute impact of each intervention are presented in the summary of findings tables. Twelve studies compared exercise (all types) with a control intervention (an intervention not thought to reduce falls, such as usual care or sham exercise) in people with mild to moderate PD. Exercise probably reduces the rate of falls by 26% (rate ratio (RaR) 0.74, 95% confidence interval (CI) 0.63 to 0.87; 1456 participants, 12 studies; moderate-certainty evidence). Exercise probably slightly reduces the number of people experiencing one or more falls by 10% (risk ratio (RR) 0.90, 95% CI 0.80 to 1.00; 932 participants, 9 studies; moderate-certainty evidence).  We are uncertain whether exercise makes little or no difference to the number of people experiencing one or more fall-related fractures (RR 0.57, 95% CI 0.28 to 1.17; 989 participants, 5 studies; very low-certainty evidence). Exercise may slightly improve health-related quality of life immediately following the intervention (standardised mean difference (SMD) -0.17, 95% CI -0.36 to 0.01; 951 participants, 5 studies; low-certainty evidence). We are uncertain whether exercise has an effect on adverse events or whether exercise is a cost-effective intervention for fall prevention. Three studies trialled a cholinesterase inhibitor (rivastigmine or donepezil). Cholinesterase inhibitors may reduce the rate of falls by 50% (RaR 0.50, 95% CI 0.44 to 0.58; 229 participants, 3 studies; low-certainty evidence). However, we are uncertain if this medication makes little or no difference to the number of people experiencing one or more falls (RR 1.01, 95% CI 0.90 to 1.14230 participants, 3 studies) and to health-related quality of life (EQ5D Thermometer mean difference (MD) 3.00, 95% CI -3.06 to 9.06; very low-certainty evidence). Cholinesterase inhibitors may increase the rate of non fall-related adverse events by 60% (RaR 1.60, 95% CI 1.28 to 2.01; 175 participants, 2 studies; low-certainty evidence). Most adverse events were mild and transient in nature.  No data was available regarding the cost-effectiveness of medication for fall prevention. We are uncertain of the effect of education compared to a control intervention on the number of people who fell at least once (RR 10.89, 95% CI 1.26 to 94.03; 53 participants, 1 study; very low-certainty evidence), and no data were available for the other outcomes of interest for this comparisonWe are also uncertain (very low-certainty evidence) whether exercise combined with education makes little or no difference to the number of falls (RaR 0.46, 95% CI 0.12 to 1.85; 320 participants, 2 studies), the number of people sustaining fall-related fractures (RR 1.45, 95% CI 0.40 to 5.32,320 participants, 2 studies), or health-related quality of life (PDQ39 MD 0.05, 95% CI -3.12 to 3.23, 305 participants, 2 studies). Exercise plus education may make little or no difference to the number of people experiencing one or more falls (RR 0.89, 95% CI 0.75 to 1.07; 352 participants, 3 studies; low-certainty evidence). We are uncertain whether exercise combined with education has an effect on adverse events or is a cost-effective intervention for fall prevention.  AUTHORS' CONCLUSIONS: Exercise interventions probably reduce the rate of falls, and probably slightly reduce the number of people falling in people with mild to moderate PD.  Cholinesterase inhibitors may reduce the rate of falls, but we are uncertain if they have an effect on the number of people falling. The decision to use these medications needs to be balanced against the risk of non fall-related adverse events, though these adverse events were predominantly mild or transient in nature. Further research in the form of large, high-quality RCTs are required to determine the relative impact of different types of exercise and different levels of supervision on falls, and how this could be influenced by disease severity. Further work is also needed to increase the certainty of the effects of medication and further explore falls prevention education interventions both delivered alone and in combination with exercise.

Long-term Effect of Regular Physical Activity and Exercise Habits in Patients With Early Parkinson Disease

Background and Objectives

Owing to the lack of long-term observations or comprehensive adjustment for confounding factors, reliable conclusions regarding long-term effects of exercise and regular physical activity in Parkinson disease (PD) have yet to be drawn. Here, using data from the Parkinson's Progression Markers Initiative study that includes longitudinal and comprehensive evaluations of many clinical parameters, we examined the long-term effects of regular physical activity and exercise habits on the course of PD.

Methods

In this retrospective, observational cohort study, we primarily used the multivariate linear mixed-effects models to analyze the interaction effects of their regular physical activity and moderate to vigorous exercise levels, measured with the Physical Activity Scale for the Elderly questionnaire, on the progression of clinical parameters, after adjusting for age, sex, levodopa equivalent dose, and disease duration. We also calculated bootstrapping 95% confidence intervals (CIs) and conducted sensitivity analyses using the multiple imputation method and subgroup analyses using propensity score matching to match for all baseline background factors.

Results

Two hundred thirty-seven patients with early PD (median [interquartile range] age, 63.0 [56.0–70.0] years, male 69.2%, follow-up duration 5.0 [4.0–6.0] years) were included. Regular physical activity and moderate to vigorous exercise levels at baseline did not significantly affect the subsequent clinical progression of PD. However, average regular overall physical activity levels over time were significantly associated with slower deterioration of postural and gait stability (standardized fixed-effects coefficients of the interaction term [β_interaction] = −0.10 [95% CI −0.14 to −0.06]), activities of daily living (β_interaction = 0.08 [95% CI 0.04–0.12]), and processing speed (β_interaction = 0.05 [95% CI 0.03–0.08]) in patients with PD. Moderate to vigorous exercise levels were preferentially associated with slower decline of postural and gait stability (β_interaction = −0.09 [95% CI −0.13 to −0.05]), and work-related activity levels were primarily associated with slower deterioration of processing speed (β_interaction = 0.07 [95% CI 0.04–0.09]). Multiple imputation and propensity score matching confirmed the robustness of our results.

Discussion

In the long term, the maintenance of high regular physical activity levels and exercise habits was robustly associated with better clinical course of PD, with each type of physical activity having different effects.

Trial Registration Information

ClinicalTrials.gov Identifier: NCT01176565.

Classification of Evidence

This study provides Class II evidence that sustained increase in overall regular physical activity levels in patients with early PD was associated with slower decline of several clinical parameters.

Patient and Caregiver Experiences of Participating in Parkinson's Disease Clinical Trials: A Systematic Review of Qualitative Studies

Background

Older people experience multiple barriers to enrolment in clinical trials. Caregivers play an important role in supporting patients with Parkinson’s disease. Understanding the experiences of patients and caregivers who participate in trials is important to inform the design of future studies and identify problems with recruitment and retention.

Objective

To systematically review and synthesize qualitative studies exploring the experiences of participating in clinical trials from the perspectives of patients with Parkinson’s disease and their caregivers.

Methods

Two reviewers independently searched the following databases: MEDLINE, Embase, PsycInfo, Cochrane, and CINAHL. The reference lists of all selected papers were screened for additional studies. Articles meeting predefined eligibility criteria were included in the synthesis. Methodological quality of each study was assessed using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist. Included study findings were synthesized using the principles of thematic analysis.

Results

Eleven studies were included. Five key themes were identified: positive experiences of participating in research, assessment completion, motivators, enablers, and barriers. Positive experiences of participating in studies were linked to social interaction with other patients, building trust with the researchers, and expertise of the research team.

Conclusions

This review supports literature highlighting the important role of caregivers in supporting patients with Parkinson’s disease. Future studies are needed to further examine their perspectives on participating in research.