Physiotherapy Versus Physiotherapy Plus Cognitive Training on Cognition and Quality of Life in Parkinson Disease: Randomized Clinical Trial

Identification of Cognitive Training for Individuals with Parkinson's Disease: A Systematic Review

Background/Objectives: Parkinson's disease (PD) is a neurodegenerative disorder, characterised by cardinal motor features and a multitude of non-motor manifestations. Among them, cognitive impairment in PD has been recognised as a defined clinical entity, and it might lead to an increased risk of developing dementia. Consequently, the present review aimed to ascertain the available interventions for the training of cognitive abilities in persons with PD (PwPD). Methods: PRISMA guidelines were followed to select studies in the following databases: PubMed, PsycINFO, and Web of Science. Two independent reviewers conducted the different phases of the review, and a third expert was called in to address any doubts/conflicts. Randomised controlled trials and randomised clinical trials concerning cognitive training with cognitive outcomes in PwPD were selected. Results: A total of 28 articles were included. The considered studies applied various experimental interventions for the training of cognitive functions in PwPD: computer-based platforms, exergames, paper-and-pencil programmes, dual-task or treadmill training with action observation therapy, motor imagery, and virtual reality components, interventions targeting precise cognitive domain, tele-rehabilitation, transcranial direct current stimulation, structured cognitive training, and multimodal treatments. Cognitive functions were assessed employing neuropsychological tests, self-report questionnaires, and computerised batteries. Conclusions: Overall, the review reported better performances in the experimental groups compared to the control groups, in several cognitive domains. Structured cognitive training emerged as the most effective strategy to enhance cognitive functioning in PwPD. However, further studies are necessary to determine the most appropriate and useful training and to develop interventions that also consider patients' quality of life.

The feasibility of a visuo-cognitive training intervention using a mobile application and exercise with stroboscopic glasses in Parkinson's: Findings from a pilot randomised controlled trial

BACKGROUND

There is currently no pharmacological treatment for visuo-cognitive impairments in Parkinson's disease. Alternative strategies are needed to address these non-motor symptoms given their impact on quality of life. Novel technologies have potential to deliver multimodal rehabilitation of visuo-cognitive dysfunction, but more research is required to determine their feasibility in Parkinson's.

OBJECTIVE

To determine the feasibility and preliminary efficacy of a home-based, technological visuo-cognitive training (TVT) intervention using a mobile application and exercise with stroboscopic glasses compared to non-technological care in people with Parkinson's.

METHODS

This 18-month, parallel, two-arm pilot trial took place between July 2021-December 2022. Participants were community-dwelling individuals with a diagnosis of Parkinson's, aged over 50 years. Participants were randomly allocated to one of two active four-week interventions, TVT (n = 20) or standard care (SC) (n = 20). A physiotherapist delivered 8 home visits over 4 weeks, lasting 45-60 mins. Participants were evaluated at baseline and then on completion of the intervention. Primary outcomes were feasibility of the study design and intervention (recruitment/retention, adherence, assessment time scale, equipment and safety). Exploratory outcomes included assessments of cognitive, visual, clinical and motor function. (Blinding of participants was not possible due to the nature of the intervention).

RESULTS

The recruitment rate was 60% (40/67), and the retention rate was 98% (39/40). Adherence to both arms of the intervention was high, with participants attending 98% of visits in the TVT group and 96% of visits in the SC group. 35% (9/20) of participants in the TVT group experienced mild symptoms associated with use of the stroboscopic glasses which included dizziness, queasiness and unsteadiness. There were minimal between group differences, with both interventions having positive effects on a variety of clinical, cognitive, and physical performance outcomes.

CONCLUSIONS

Our findings suggest that home-based TVT with a physiotherapist is feasible in people with Parkinson's and could provide an alternative approach to addressing cognitive and motor dysfunction in this population. We make recommendations for future trials and invite ensuing studies to improve upon the design and utilise stroboscopic visual training and digital tools to investigate this emerging area of multimodal rehabilitation. This trial was prospectively registered at ISRCTN (registration number: ISRCTN46164906; https://doi.org/10.1186/ISRCTN46164906).

Combinations of physical and cognitive training for subcortical neurodegenerative diseases with physical, cognitive and behavioral symptoms: a systematic review

BACKGROUND

The onset of the symptoms of subcortical NDs is due to a unique part of the brain which strengthens the idea of reciprocal influence of physical activity and cognitive training in improving clinical symptoms. Consequently, protocols combining the two stimulations are becoming increasingly popular in NDs. Our threefold aim was to (A) describe the different combinations of physical and cognitive training used to alleviate the motor and cognitive symptoms of patients with subcortical neurodegenerative disorders, (B) compare the effects of these different combinations (sequential, dual tasking, synergical) on symptoms, and (C) recommend approaches for further studies.

METHODS

We conducted literature searches of PubMed, BASE and ACM, to carry out a systematic review of randomized controlled trials and controlled trials of combined physical and cognitive training among patients with Huntington's disease, Parkinson's disease, amyotrophic lateral sclerosis, Lewy body dementia, spinocerebellar ataxia, Friedreich's ataxia, and progressive supranuclear palsy. Physical, neuropsychological, behavioral outcomes were considered. The Cochrane risk-of-bias tool was used to verify the critical appraisal.

RESULTS

Twenty-one studies focused on Parkinson's disease with 940 participants were included. Despites promising benefits on cognitive and physical function, our results revealed discrepant findings for research on combined training.

DISCUSSION

Inconsistencies were linked to the choice of tests, the functions that were targeted, disease progression, and trainings. There was a dearth of follow-up data.

CONCLUSIONS

Differences between combined training are unclear, particularly regarding the role of cognitive load. Future studies should focus on comparing the feasibility, tolerability, and effectiveness of different combinations of motor-cognitive training.

Towards multimodal cognition-based treatment for cognitive impairment in Parkinson's disease: drugs, exercise, non-invasive brain stimulation and technologies

PURPOSE OF REVIEW

Cognitive impairment is one of the most challenging non-motor symptoms of Parkinson's disease (PD) and may occur during all PD stages. There are no established pharmacological treatments for PD-related cognitive impairment, which may be improved by cognition-based interventions (i.e., cognitive stimulation, cognitive training, cognitive rehabilitation). Multimodal cognition-based interventions by adjunctive drugs, exercise, non-invasive brain stimulation and technologies may be effective in PD.

RECENT FINDINGS

Exercise combined with cognitive training may enhance global, memory, visuospatial and executive functioning, transcranial direct current stimulation delivered alongside cognitive training may improve attention and executive functioning, and exergames, semi-immersive virtual reality (VR) and telerehabilitation plus non-immersive VR combined with cognitive training may ameliorate global and executive functioning in PD patients.

SUMMARY

The evidence reviewed here, despite preliminary, is very encouraging and suggests strong rationale for combining pharmacological and non-pharmacological interventions with cognition-based treatments in PD. To overcome limitations of current studies, we propose some recommendations for future trials on drugs, exercise, non-invasive brain stimulation and technologies combined with cognition-based treatments for cognitive impairment in PD.

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.

Improving Healing: The Putative Effects of Low-Level Laser Therapy for Ulcer in Parkinson's Disease

The progressive nature of Parkinson's disease and its associated motor and non-motor symptoms can lead to various complications when patients experience immobilization, exacerbating existing motor impairments and potentially giving rise to secondary health issues. The variability, progression, and management of tremors in PD can be challenging. Due to low bone mass density, patients with Parkinson's disease are susceptible to vitamin D deficiency. The lack of movement can worsen muscle rigidity and stiffness, leading to contractures and a decreased range of motion in joints. Additionally, immobility may contribute to cardiovascular deconditioning, orthostatic hypotension, and an increased risk of pressure ulcers due to prolonged pressure on specific areas of the body. In this case report, we hereby report a case of Parkinson's disease further complicated by sinus discharge from the ulcer. This case report describes the putative effects of low-level laser therapy on discharging sinus from the wound secondary to a diabetic ulcer in idiopathic Parkinson's disease. Achieving an ideal level of functional independence and preventing problems associated with extended immobility are essential goals of structured physical therapy postoperative care. This may assist the patient in returning to their pre-injury position more quickly. Our patient underwent several interventions for wound healing, including proprioception training, tremor management, improving dynamic trunk balance, and pain control measures. Clinical outcome measures like the Barthel Index, lower extremity functional scale, and Visual-Analog Scale were used to assess the progress of the patient. Managing these interconnected conditions requires a multi-disciplinary approach.

High-frequency multimodal training with a focus on Tai Chi in people with Parkinson's disease: a pilot study

Background and objectives

Cognitive decline is an important and common complication in patients with Parkinson's disease (PD) since it significantly reduces the quality of life. A breakthrough in treating and preventing cognitive decline in PD remains to be achieved. This study aimed to evaluate the effectiveness of high-frequency and intensive multimodal training in improving motor and cognitive function.

Methods

Twenty-eight patients diagnosed with idiopathic PD completed a comprehensive neuropsychological test battery and were neurologically examined. The patients of the intervention group (n = 15) underwent 2 weekly sessions of Tai Chi therapy over 4 weeks and participated in an individually tailored training program consisting of two modules (smartphone-based speech training and cognitive training). A matched control group consisted of n = 13 patients with PD who received computer-assisted cognitive training. The data were analyzed with repeated-measures ANOVA.

Results

Four weeks of high-frequency training showed significant effects on verbal and figural episodic memory and visuospatial function in the intervention group. Compared to the control group, the cognitive performance of the intervention group improved significantly in visuospatial function and figural episodic memory. A significant improvement was also shown in the intervention group in the Tinetti Mobility Test and the Epworth Sleepiness Scale. The significant effects in the Tinetti mobility test remained after the 6 months follow-up. After the intervention, the patients reported high motivation and satisfaction with the multimodal training.

Conclusion

In patients with PD, a multimodal training program not only improves gait and stability but may also contribute to improving cognition.

Clinical trial registration

ClinicalTrials.gov Identifier: NCT04103255; https://register.clinicaltrials.gov/prs/app/action/LoginUser?ts=1&cx=-jg9qo4.

Effects of LSVT-BIG via telerehabilitation on non-motor and motor symptoms and quality of life in Parkinson's disease

BACKGROUND

Parkinson's disease (PD) is a neurodegenerative disease with motor and non-motor symptoms affecting the quality of life. This study aimed to investigate the effects of the Lee Silverman Voice Therapy (LSVT)-BIG rehabilitation program via telerehabilitation on quality of life, motor and non-motor symptoms in people with Parkinson's disease (PwPD), and their correlation with each other.

METHODS

Fifteen patients with mild-to-moderate PD (Hoehn and Yahr stages 1-3) were included in the LSVT-BIG exercise program with remote access for 16 sessions over four weeks. Motor and non-motor experiences before and after the program were evaluated with MDS-UPDRS parts 1, 2, and 3 and quality of life with PDQ-39. The correlation between MDS-UPDRS parts and PDQ-39 subgroups was examined.

RESULTS

Following the application of the LSVT-BIG rehabilitation program with remote access, MDS-UPDRS parts 1, 2, and 3 scores and PDQ-39 summary index (PDQ-39 SI) and subgroup scores (excluding social support) were improved. A moderate-strong correlation was determined between MDS-UPDRS parts 1 and 2 and the PDQ-39 parameters of the patients.

CONCLUSION

Both motor and non-motor symptoms may be associated with the quality of life in PD. We have concluded that LSVT-BIG treatment via telerehabilitation can improve motor and non-motor symptoms along with the quality of life in PwPD.

Management of psychiatric and cognitive complications in Parkinson's disease

Neuropsychiatric symptoms (NPSs) such as affective disorders, psychosis, behavioral changes, and cognitive impairment are common in Parkinson's disease (PD). However, NPSs remain under-recognized and under-treated, often leading to adverse outcomes. Their epidemiology, presentation, risk factors, neural substrate, and management strategies are incompletely understood. While psychological and psychosocial factors may contribute, hallmark PD neuropathophysiological changes, plus the associations between exposure to dopaminergic medications and occurrence of some symptoms, suggest a neurobiological basis for many NPSs. A range of psychotropic medications, psychotherapeutic techniques, stimulation therapies, and other non-pharmacological treatments have been studied, are used clinically, and are beneficial for managing NPSs in PD. Appropriate management of NPSs is critical for comprehensive PD care, from recognizing their presentations and timing throughout the disease course, to the incorporation of different therapeutic strategies (ie, pharmacological and non-pharmacological) that utilize a multidisciplinary approach.

The Effect of Dual-Task Motor-Cognitive Training in Adults with Neurological Diseases Who Are at Risk of Falling

Falls are common in patients with neurological diseases and can be very problematic. Recently, there has been an increase in fall prevention research in people with neurological diseases; however, these studies are usually condition-specific (e.g., only MS, PD or stroke). Here, our aim was to evaluate and compare the efficacy of an advanced and innovative dual-task, motor-cognitive rehabilitation program in individuals with different neurological diseases who are at risk of falling. We recruited 95 consecutive adults with neurological diseases who are at risk of falling and divided them into four groups: 31 with cerebrovascular disease (CVD), 20 with Parkinson’s disease (PD), 23 with traumatic brain injury (TBI) and 21 with other neurological diseases (OND). Each patient completed a dual-task, motor-cognitive training program and underwent two test evaluations to assess balance, gait, fear of falling and walking performance at the pre-and post-intervention. We found that our experimental motor-cognitive, dual-task rehabilitation program was an effective method for improving walking balance, gait, walking endurance and speed, and fear of falling, and that it reduced the risk of falls in patients with different neurological diseases. This study presents an alternative approach for people with chronic neurological diseases and provides innovative data for managing this population.

A Literature Review of High-Tech Physiotherapy Interventions in the Elderly with Neurological Disorders

Neurological physiotherapy adopts a problem-based approach for each patient as determined by a thorough evaluation of the patient’s physical and mental well-being. Τhis work aims to provide a literature review of physical therapy interventions in the elderly with neurological diseases (NDs) and discuss physiotherapy procedures and methods that utilize cutting-edge technologies for which clinical studies are available. Hence, the review focuses on acute NDs (stroke), deteriorating NDs (Parkinson’s disease), and age-related cognitive impairment. The most used physiotherapy procedures on which clinical data are available are balance and gait training (robot-assisted or not), occupational therapy, classical physiotherapy, walking and treadmill training, and upper limb robot-assisted therapy. Respectively, the most often-used equipment are types of treadmills, robotic-assisted equipment (Lokomat^® and Gait Trainer GT1), and portable walkway systems (GAITRite^®), along with state-of-the-art technologies of virtual reality, virtual assistants, and smartphones. The findings of this work summarize the core standard tools and procedures, but more importantly, provide a glimpse of the new era in physiotherapy with the utilization of innovative equipment tools for advanced patient monitoring and empowerment.

Multidisciplinary Rehabilitation for People with Parkinson’s Disease: A Systematic Review and Meta-Analysis

Introduction

Guidelines endorse to implement an integrated and multidisciplinary team approach in the management of people with Parkinson's disease (PD). However, there is no net and clear finding that shows the supremacy of multidisciplinary team interventions over conventional interventions for people with PD. Therefore, we perform a systematic review and meta-analysis to determine the supremacy of multidisciplinary interventions for people with PD.

Methods

A systematic review and meta-analysis of randomized controlled trials were conducted. PubMed, Physiotherapy Evidence Database, Cochrane Library, and Google Scholar were searched from inception until May 2021. Randomized controlled trials comparing multidisciplinary intervention with conventional physiotherapy were included. The outcome measures were gait balance, disability status, quality of life, and depression level. The PEDro scale was used to systematically appraise methodological quality. Two reviewers screened, extracted, and performed a quality assessment of included studies independently. Review Manager V.5.4 (Cochrane Collaboration) software was used for statistical analysis. Heterogeneity was analyzed using I² statistics, and a standardized mean difference with 95% CI and Pvalue was used to calculate the treatment effect for outcome variables.

Results

A total of 6 studies with 1260 participants were included. The average PEDro methodological quality score was 6.67. No statistically significant difference between multidisciplinary and conventional rehabilitation on functional capacity (SMD: 0.69; 95% CI: −0.13, 1.51; P=0.10), disability status (SMD: 0.65; 95% CI: −0.16, 1.46; P=0.11), and quality of life (SMD: 0.28; 95% CI: −0.31, 0.59; P=0.08) was found. However, there is a statistically significant improvement in caregivers' anxiety levels in the multidisciplinary group (SMD: 0.39; 95% CI 0.06, 1.73; P=0.02).

Conclusion

This systematic review and meta-analysis show no significant difference between multidisciplinary and conventional rehabilitation on functionality, disability, and quality of life. Caregivers' anxiety levels show improvement following multidisciplinary interventions. However, large-scale studies with long-term follow-up were required for concrete and clinical recommendations.

Effect of Dual-Task Motor-Cognitive Training in Preventing Falls in Vulnerable Elderly Cerebrovascular Patients: A Pilot Study

Falling is a frequent and major clinical problem among older adults, as well as in patients with chronic cerebrovascular diseases (CVD). At present, sequential (mixed) and simultaneously (dual-task) motor-cognitive trainings are the best approaches to affording patients more autonomy in their everyday motor independence while reducing fall risks and consequences. The objective of this study was to evaluate the efficacy of an advanced and innovative dual-task motor-cognitive rehabilitation program on fall risks in vulnerable older persons with chronic CVD. To this purpose, 26 consecutive older fallers with chronic CVD were recruited, and completed a mixed motor-cognitive or a dual-task motor-cognitive training program. Each patient also underwent two test evaluations to assess balance, gait, fear of falling, and walking performance at pre-and post-intervention. We found that our experimental motor-cognitive dual-task rehabilitation program could be an effective method to improve walking balance, gait, walking speed, and fear of falling, while reducing the risk of falls in older people with chronic CVD. Furthermore, results show that the simultaneous motor-cognitive training is more effective than the sequential motor-cognitive training. Therefore, our study brings innovative data, which can contribute positively to the management of this population.

Dual-task intervention based on trail making test: Effects on Parkinson's disease

OBJECTIVE

To evaluate the effectiveness of an intervention with dual task based on trail making test on gait, cognition and daily activities execution in individuals with Parkinson's disease.

DESIGN

Randomized controlled trial.

METHODOLOGY

10 individuals with Parkinson's Disease (PD) were divided into dual task group (DTG) and control group (CG). Were realized 16 dual task (DT) training sessions based on the Trail Making Test (TMT) for DTG and a conventional training protocol for CG. Pre and post intervention assessments used the 6 minute walk test (T6), TMT, Katz Index and Falls Efficacy Scale (FES).

RESULTS

Comparing the difference between pre and post intervention values between groups, there was no significant difference for T6 (p=0,36). In TMT there was a significant difference (p=0,03), showing shorter times for DTG. The tests used for time values in the Katz index tasks showed an important difference for the DTG (P=0,02). As for the results of the FES, they did not show pre and post changes in the DTG (0,45) and in the CG (p= 0,29) and not even between the groups (p=0,45).

CONCLUSION

The proposed intervention was able to promote improvements in the performance of daily life activities, learning adaptations and retention of motor and cognitive aspects, which may reflect positively in the daily lives of patients with PD and, consequently, greater autonomy to perform these types of activities.

Physiotherapy versus Consecutive Physiotherapy and Cognitive Treatment in People with Parkinson's Disease: A Pilot Randomized Cross-Over Study

Background: Parkinson’s disease (PD) is characterized by motor and cognitive dysfunctions that can usually be treated by physiotherapy or cognitive training, respectively. The effects of consecutive physiotherapy and cognitive rehabilitation programs on PD deficits are less investigated. Objective: We investigated the effects of 3 months of physiotherapy (physiotherapy treatment group) or consecutive physiotherapy and cognitive (physiotherapy and cognitive treatment group) rehabilitation programs on cognitive, motor, and psychological aspects in 20 PD patients. Methods: The two groups switched programs and continued rehabilitation for another 3 months. The outcomes were score improvement on cognitive (Montreal Cognitive Assessment, Frontal Assessment Battery, Trail Making Test, Verbal Phonemic Fluency, Digit Span, and Rey Auditory Verbal Learning), motor (Unified Parkinson’s Disease Rating Scale-III, Berg Balance Scale, Two-Minute Walking Test, and Time Up and Go), and psychological (Beck Depression Inventory and State-Trait Anxiety Inventory) scales. Results: Between-group comparison revealed a significant difference in functional mobility between the two rehabilitation programs. Improvements in walking abilities were noted after both interventions, but only the patients treated with consecutive training showed better performance on functional mobility and memory tasks. Conclusion: Our findings support the hypothesis that consecutive physiotherapy plus cognitive rehabilitation may have a greater benefit than physiotherapy alone in patients with PD.

Impact of cognitive intervention on cognitive symptoms and quality of life in idiopathic Parkinson's disease: a randomized and controlled study

Pharmacological treatments for mild cognitive impairment (MCI), are lacking, and alternative approaches have been implemented, including cognitive training (CT).

Objective

To determine the impact of CT on cognitive and quality of life measures in patients with Parkinson's disease (PD) who were seen a hospital neurorehabilitation program.

Methods

Thirty-nine individuals with MCI-PD, according to the Movement Disorder Society, were randomly distributed into two groups: experimental and control group, matched for demographic and clinical characteristics. Both groups were assessed for cognition and quality of life at the beginning of the study and at the end of the intervention protocol. The following instruments were used to assess cognition and quality of life: Addenbrooke's Cognitive Examination III, Digit Span, Trail Making Test (TMT, A and B) and Parkinson disease quality of life questionnaire. The experimental group (EG) engaged in CT, whereas the control group (CG) underwent activities of the general rehabilitation program.

Results

No baseline evaluation differences were found. Intergroup analysis showed differences in measures, such as total score (1.977, p=0.0480) and visuospatial domain (-2.636, p=0.0084) of the ACE-III, with the EG performing better, in addition to better performance in TMT-B mistakes (-1.928, p=0.0439). Intragroup analysis revealed that the EG showed significant improvement in almost all the cognitive variables, well as in self-reported quality of life (total score and mobility, activities of daily living, body discomfort dimensions).

Conclusions

Engagement in cognitive activities was associated with better cognitive abilities in PD-MCI. Future studies should consider the long-term effect of this type of intervention and impact on functional activities.

Spanish version of the mini-BESTest: a translation, transcultural adaptation and validation study in patients with Parkinson's disease

Balance is affected in numerous neurologic disorders, like stroke, multiple sclerosis and Parkinson's disease contributing to falls, and diminishing quality of life and functionality. The mini-BESTest is one of the most recommended scales to detect balance disorders in people with Parkinson's disease, which has solid psychometric properties. Unfortunately, this scale has not been validated in Chile and there are no other validated scales that can determine balance disorders in patients with Parkinson's disease to date. The study objective was to validate the mini-BESTest scale in Chilean Parkinson's disease patients. The translation and adaptation to Chilean Spanish of the mini-BESTest scale were made following a cross-cultural adaptation process, to then obtain face and content validity by an expert committee. Afterwards, the demographic data and psychometric properties of internal consistency and ceiling and floor effects were measured with a sample of 50 subjects with Parkinson's disease. Furthermore, 10 subjects of the sample were evaluated with the purpose of measuring inter rater reliability. The scale presented a good internal consistency (Cronbach's alpha = 0.845), and an excellent inter rater reliability (intraclass correlation coefficient = 0.97), no ceiling or floor effects were found. The results of the face and content validity and psychometric properties are adequate, achieving the validation of the mini-BESTest scale for balance in Chilean people with Parkinson's disease.

Non-pharmacological management of cognitive impairment in Parkinson's disease

We evaluated the therapeutic effects of non-pharmacological interventions (cognitive training, physical activity, and non-invasive brain stimulation) on cognitive symptoms in Parkinson's disease. A comprehensive literature search for non-pharmacological intervention randomized controlled trials was performed and effect sizes were calculated for each suitable study intervention approach and cognitive domain. Despite the heterogeneity of the study results, we report level B evidence for the probable efficacy of cognitive training in improving or maintaining attention/working memory and memory domains. Level C (possible efficacy) evidence was found for specific physical training types with respect to enhancing executive functions. Non-invasive brain stimulation techniques and combinatorial approaches show preliminary but promising results. Prediction markers evaluating distinct treatment responses should be identified that would help to choose the best candidates for specific treatment strategies and cognitive symptoms. Future directions and recommendations are discussed.