Instrumental or Physical-Exercise Rehabilitation of Balance Improves Both Balance and Gait in Parkinson's Disease

Static Posture Instability as a Sensitive Biomarker for Motor Abnormalities in Pre-ataxic Spinocerebellar Ataxia Type 3 Patients

BACKGROUND

Spinocerebellar ataxia type 3 (SCA3) is a neurodegenerative disorder, with balance instability as a feature of the disease. Balance instability often manifests before the onset of obvious ataxic symptoms in patients. However, current clinical scales exhibit limited sensitivity in characterizing changes in pre-ataxic patients.

OBJECTIVES

Our research aims to identify appropriate postural characteristics for tracking motor changes in pre-ataxic patients with SCA3 over time.

METHODS

The posturographic platform assessed 102 participants (34 pre-ataxic SCA3 patients, 34 ataxic patients with SCA3, and 34 healthy controls) to measure their postural balance. Multivariate comparative analyses assessed the differential postural characteristics across the three groups. The Taiwanese formula was employed to estimate the age of onset for pre-ataxic patients. A Spearman's rho test was employed to assess correlations between postural characteristics and the time manifestation for pre-ataxic patients.

RESULTS

Compared to the healthy control group, we observed significant abnormalities in the static posture of pre-ataxic patients (P < 0.01). Compared to the pre-ataxic group, ataxic patients have significant abnormalities in all variables (P < 0.05). The sway range standard deviation (SD), total sway area, and limits of stability were positively correlated with the estimated time to onset. The total sway area is more closely associated with time to manifestation, whereas the sway range SD in the medial-lateral direction of the center of foot pressure is the most sensitive indicator of postural instability in pre-ataxic patients.

CONCLUSION

Static posture instability is a sensitive diagnostic parameter that may assist in capturing disease progression in the pre-ataxic stage of SCA3. © 2025 International Parkinson and Movement Disorder Society.

Balance exercise interventions in Parkinson's disease: A systematic mapping review of components, progression, and intensity

BACKGROUND

Rehabilitation in individuals with Parkinson's disease (PD) often includes balance training, but knowledge about optimal training content remains limited.

OBJECTIVES

To describe the design, content, delivery, and reporting of balance training for individuals with PD, and furthermore, to map the systematic use and reporting of methods monitoring intensity in balance training interventions for individuals with PD.

METHODS

Six databases were searched. Interventions with at least 50 % of exercises challenging balance control were included. Balance training types (exergaming, multi-modal, sensory-motor integrated, and task-oriented) were categorized based on specific balance exercise components: motor (limits of stability, anticipatory motor strategies, reactive motor strategies, and control of dynamics), sensory (vestibular, visual, and somatosensory systems), and cognitive (dual-tasking in motor or cognitive activities). Training Frequency, Intensity, Time, Type, Volume, and Progression (FITT-VP principles) were extracted.

RESULTS

In total, 114 studies (interventions n = 126) with 5335 participants (mean age: 67.5 years; mean PD duration: 6.8 years) were included. The highest mean number of balance components was found in the multi-modal (5.8), followed by sensory-motor (5.6), task-oriented (4.2), and exergaming (4.0). Intensity strategies were reported in 93 % of the exergaming interventions, which was superior to the other training types (multi-modal (18 %), sensory-motor (17 %), and task-oriented (6 %)).

CONCLUSIONS

Multi-modal and sensory-motor interventions had a greater focus on challenging balance components compared to other types of training, while exergaming interventions demonstrated superior reporting of intensity strategies. Future research is encouraged to prioritize implementing intensity strategies and aim to incorporate a broader range of balance components within balance training exercises.

Post-Physical Therapy 4-Month In-Home Dynamic Standing Protocol Maintains Physical Therapy Gains and Improves Mobility, Balance Confidence, Fear of Falling and Quality of Life in Parkinson's Disease: A Randomized Controlled Examiner-Blinded Feasibility Clinical Trial

Objective

Parkinson's patients will experience mobility disturbances with disease progression. Beneficial effects of physical therapy are short-lasting. Novel interventions are needed to maintain these benefits.

Methods

Fourteen Parkinson's patients (71±4.08 years) participated in a randomized controlled examiner-blinded feasibility clinical trial. After 12 physical therapy sessions, the intervention group received a height-adjustable desk that facilitates stepping while standing, for 4 months. Explorative outcome measures included MDS-UPDRS II, III, TUG, 8.5m walking test, PDQ-39, sABC, sFES, DEXA scans, and lower extremity strength.

Results

Post-physical-therapy, everyone significantly improved on the MDS-UPDRS II, III, TUG, and 8.5m walking test, and PDQ-39. (p<0.05) After 4 months, the control group regressed towards pre-physical-therapy values. In the intervention group, sedentary behavior decreased beyond desk use, indicating a carry-over effect. MDS-UPDRS II, PDQ-39, sFES, sABC, TUG, 8.5m walking test, activity time, sitting time, hip strength all improved with clinically relevant effect sizes.

Conclusion

Post-physical therapy in-home reduction of sedentary behavior was associated with maintenance of physical benefits and additional improvements in mobility, activity time, balance and quality of life.

Utilizing Machine Learning to Identify Biomarkers of Endoplasmic Reticulum Stress and Analyze Immune Cell Infiltration in Parkinson's Disease

The neurodegenerative disorder known as Parkinson's disease (PD) affects many people. The objective of this investigation was to examine the relationship between immune system infiltration, ATP-binding cassette transporter subfamily A member 7 (ABCA7) and TBL2 as well as potential therapeutic targets for the identification of PD associated to endoplasmic reticulum (ER) stress. First, we obtained PD data through GEO and divided it into two sets: a training set (GSE8397) plus a set for validation (GSE7621). Functional enrichment analysis was performed on a set of DEGs that overlapped with genes involved in endoplasmic reticulum stress. To identify genes of PD linked with endoplasmic reticulum stress, we employed random forest (RF) along with the least absolute shrinkage and selection operator (LASSO) logistic regression. Spearman's rank correlation analysis was then used to find associations among diagnostic markers with immune cell penetration. A grand total of 2 stress-related endoplasmic reticulum signature transcripts were identified. ABCA7 and TBL2 were shown to have diagnostic potential for PD and immune infiltrating cells have a role in the etiology of the disease. Additionally, resting CD4 memory, plasma cells, and NK cells overall exhibited positive associations with ABCA7, whereas triggered macrophages, T cells with active CD4 memory, activating NK cells, T cells with activated CD4 naive, engaged NK cells, and neutrophils all had adverse interactions with ABCA7. Overall, ABCA7 together with TBL2 have diagnostic utility for PD, and several types of immune cells, especially macrophages, may be involved in the development and progression of the disease.

Effects of a sequential square mat walking training program Fisior® on improving physical performance in older adults with Parkinson's disease: A pilot study

BACKGROUND

This study aimed to assess the efficacy of a 12-week functional walking training program utilizing a sequential square mat (Fisior® Mat) on the physical performance of older adults diagnosed with Parkinson's Disease (PD).

METHODS

Participants, aged over 60 and diagnosed with mild to moderate PD, underwent progressive resistance training sessions lasting 30-40 minutes, three times a week, using the Fisior® sequential square mat. A randomized clinical trial was conducted with participants from a patient association. Multiple linear regression models were employed to analyze physical performance variation between intervention and control groups.

RESULTS

Twenty-eight patients (14 in each group) participated, with improvements observed in total Short Physical Performance Battery (SPPB) score, chair test score, gait speed score, and balance test score. Participants in the intervention group showed significant improvement in chair and balance test scores compared to controls.

CONCLUSION

The Fisior® sequential square mat program, as an adjunct to conventional outpatient physiotherapy, effectively enhances physical performance in older adults with PD.

Amplitude of Lower Limb Muscle Activation in Different Phases of the Illinois Test in Parkinson's Disease Patients: A Pilot Study

Background: Parkinson's disease (PD) is a neurodegenerative disorder with high prevalence in men and is characterized by symptoms such as tremors and gait difficulties. This study aimed to determine muscle activation in patients with PD by considering sex differences. Methods: This pilot study used analytical, quantitative, observational, and case-control methods. Surface electromyography was used to assess muscle activity during a variant of the Illinois agility test. The study population comprised an experimental group of patients with PD (N = 30) and a control group of healthy individuals without the disease (N = 10). Results: The Illinois agility test revealed significant differences in completion times between the groups. The Parkinson's disease group took longer overall (p = 0.004), especially for standing up (p < 0.001) and sitting down (p = 0.002), than the control group. In the control group, sex influenced gastrocnemius muscle activation, with women showing higher activation (rs = -0.87). Women also had greater rectus femoris activation during standing and sitting, with higher activation on the right side when standing (rs = -0.66) and the left side when sitting (rs = -0.87). In the control group, men exhibited greater activation of the right biceps femoris (rs = 0.87). However, in the Parkinson's disease group, sex did not affect muscle activation. Conclusions: Patients with Parkinson's showed lower muscle activation than healthy individuals while standing up, sitting down, and walking.

LSVT® BIG versus progressive structured mobility training through synchronous telerehabilitation in Parkinson's disease: A randomized controlled trial

BACKGROUND

Parkinson's disease (PD) is a common neurodegenerative illness associated with motor symptoms.

AIM

The aim of study was to compare the effects of synchronous telerehabilitation-based Lee Silverman Voice Treatment® BIG (LSVT® BIG) protocol and progressive structured mobility training in patients with Parkinson's disease (PD).

METHODS

Thirty-two patients diagnosed with PD (aged 40-72 years, Hoehn-Yahr stage 1-3) were randomly allocated into LSVT® BIG (Group 1) and Progressive Structured Mobility Training (Group 2) groups. Exercises were performed in both groups for 60 min a day, 4 days a week, for 4 weeks under the supervision of a physiotherapist with synchronous online videoconference method. Dynamic balance was assessed with Mini-Balance Evaluation Systems Test (Mini-BESTest) as a primary outcome measure. The secondary outcome measurements were Timed Up and Go Test (TUG), spatiotemporal parameters of gait from Kinovea® software, and postural stability from the Biodex Balance System. Other outcome measures were Activity-Specific Balance Confidence Scale-Short Form (ABC-SF), Parkinson's Activity Scale (PAS), and Parkinson's Disease Quality of Life Questionnaire (PDQ-39).

RESULTS

This study showed significant group-by-time interactions on Mini-BEST (p = 0.042), ABC-SF (p = 0.029), and PAS (p = 0.022) in favor of group 1. Also, TUG (p < 0.01), spatiotemporal parameters of gait (p < 0.01), and PDQ-39 (p < 0.01) were improved in both groups.

CONCLUSION

Both synchronous telerehabilitation-based exercise protocols enhanced balance and gait, as well as activity level and quality of life in patients with PD. LSVT® BIG may be preferred to improve dynamic balance, balance confidence, and activity status in the early stages of PD. These results should be confirmed in future studies with more robust methodology.

TRIAL REGISTRATION

NCT04694872.

Vertical locomotion improves horizontal locomotion: effects of climbing on gait and other mobility aspects in Parkinson's disease. A secondary analysis from a randomized controlled trial

BACKGROUND

In the Climb Up! Head Up! trial, we showed that sport climbing reduces bradykinesia, tremor, and rigidity in mildly to moderately affected participants with Parkinson's disease. This secondary analysis aimed to evaluate the effects of sport climbing on gait and functional mobility in this cohort.

METHODS

Climb Up! Head Up! was a 1:1 randomized controlled trial. Forty-eight PD participants (Hoehn and Yahr stage 2-3) either participated in a 12-week, 90-min-per-week sport climbing course (intervention group) or were engaged in regular unsupervised physical activity (control group). Relevant outcome measures for this analysis were extracted from six inertial measurement units placed on the extremities, chest, and lower back, that were worn during supervised gait and functional mobility assessments before and after the intervention. Assessments included normal and fast walking, dual-tasking walking, Timed Up and Go test, Instrumented Stand and Walk test, and Five Times Sit to Stand test.

RESULTS

Compared to baseline, climbing improved gait speed during normal walking by 0.09 m/s (p = 0.005) and during fast walking by 0.1 m/s. Climbing also reduced the time spent in the stance phase during fast walking by 0.03 s. Climbing improved the walking speed in the 7-m- Timed Up and Go test by 0.1 m/s (p < 0.001) and the turning speed by 0.39 s (p = 0.052), the speed in the Instrumented Stand and Walk test by 0.1 m/s (p < 0.001), and the speed in the Five Times Sit to Stand test by 2.5 s (p = 0.014). There was no effect of sport climbing on gait speed or gait variables during dual-task walking.

CONCLUSIONS

Sport climbing improves gait speed during normal and fast walking, as well as functional mobility in people with Parkinson's disease. Trial registration This study was registered within the U.S. National Library of Medicine (No: NCT04569981, date of registration September 30th, 2020).

Intermittent theta-burst stimulation combined with physical therapy as an optimal rehabilitation in Parkinson's disease: study protocol for a randomised, double-blind, controlled trial

BACKGROUND

First-line rehabilitative strategies to improve motor deficits are based on functional training (physical or occupational therapy), which has been demonstrated to facilitate neural reorganisation. Accumulating evidence suggests that non-invasive brain stimulation techniques, such as repetitive TMS (rTMS), may enhance neuroplasticity, thereby facilitating neural reorganisation and recovery from Parkinson's disease. Evidence also shows that intermittent theta-burst stimulation (iTBS) can improve motor function and quality of life in patients by promoting the excitability and neural remodelling of cerebral cortex. We aimed to combine iTBS stimulation with physiotherapy to improve the rehabilitation effect compared to physiotherapy alone in patients with Parkinson's disease.

METHODS

This randomised, double-blind clinical trial will enrol 50 Parkinson's disease patients aged 45-70 years with Hoehn and Yahr scale scores of 1-3. Patients are randomly assigned to either the iTBS + physiotherapy or sham-iTBS + physiotherapy group. The trial consists of a 2-week double-blind treatment period and a 24-week follow-up period. iTBS and sham-iTBS will be administered twice daily for 10 days based on physiotherapy. The primary outcome will be the third part of Movement Disorders-Unified Parkinson's Disease Rating Scale (MDS-UPDRS III) from the baseline to the first 2 days following completion hospitalised intervention. The secondary outcome will be 39-item Parkinson's Disease Questionnaire (PDQ-39) at 4 weeks, 12 weeks and 24 weeks after intervention. Tertiary outcomes are clinical evaluations and mechanism study outcomes such as NMSS, 6MWD, 10MT, TUG, BBS, MRI, and EEG, the length of time between the drug needs to be adjusted when symptoms fluctuate.

DISCUSSION

The aim of this study is to demonstrate that iTBS can promote overall function and quality of life in Parkinson's disease patients using physiotherapy and that this efficacy may be associated with altered neuroplasticity in exercise-related brain regions. The iTBS combined with physiotherapy training model will be evaluated during a 6-month follow-up period. With significant improvement in quality of life and motor function, iTBS combined with physiotherapy can be considered as a first-line rehabilitation option for Parkinson's disease. The potential of iTBS to enhance neuroplasticity in the brain should have a more positive impact in increasing the generality and efficiency of physiotherapy, improving the quality of life and overall functional status of patients with Parkinson's disease.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200056581. Registered on 8 February 2022.

Effect of Pro-kin visual feedback balance training on balance function of individuals with early Parkinson's disease: a randomized controlled pilot trial

Background

Parkinson's disease (PD) is the second most common neurodegenerative disease. Patients often present with balance dysfunction. Several studies have applied visual feedback training to stroke patients and demonstrated significant improvement. However, the application of visual feedback balance training in PD patients has not been reported.

Objective

To observe the effects of visual feedback balance training combined with conventional rehabilitation training on the balance function of patients with early PD.

Methods

Fifty patients with early PD were randomly divided into control group and observation group. The control group received conventional rehabilitation training, including body position transfer, weight shifting, movement in all directions and gait training. The observation group were added with visual feedback balance training on the basis of the training above. All patients were trained 5 times per week for 4 weeks. Berg Balance Scale (BBS), Time Up-and-Go test (TUG) and Pro-Kin balance training instrument were used to evaluate the balance function of patients before and after treatment, and the balance function were compared between the two groups.

Results

The BBS and TUG scores of the observation group and the control group were improved significantly (P<0.01), and the BBS and TUG scores of the observation group were improved more obviously than control group (P<0.01). The length and area of eye open and closed condition in the observation group and the control group were significantly reduced compared with those before training (P<0.01), and the degree of reduction in the observation group was more obvious (P<0.01). The length and area of the observation group and the control group before and after training when eye open were smaller than those when eye closed (P<0.01).

Conclusion

The conventional rehabilitation therapy can improve the balance function of PD patients, but the combination of visual feedback balance training and conventional rehabilitation therapy can improve the balance function more significantly.

Functional balance training in people with Parkinson's disease: a protocol of balanceHOME randomized control trial with crossover

Introduction

Balance disturbances in Parkinson's Disease (PD) are usually assessed in a single-task as well as standard balance physiotherapy is carried out in isolated environments. Conversely, daily activities are developed in highly challenging environments. Although functional balance training (FBT) is included in the latest protocols, several methodological issues have not yet been considered. In the proposed single-blinded randomized control trial with crossover (NCT04963894), the aims are (1) to quantify the effects achieved by domiciliary FBT (balanceHOME program) in participants with and without cognitive impairment, and (2) to compare them with the effects of a passive-control period and a conventional face-to-face physiotherapy program for PD.

Methods

The initial recruitment was estimated at 112 people with idiopathic PD. Two-thirds of the participants will be randomized to one of the two groups to make the crossover. In contrast, the other third will do a face-to-face group program only. The balanceHOME protocol consists of challenging balance exercises incorporated into functional daily tasks, developed in-home and conducted two times per week for 60-min over an 8-weeks period. The primary strategy will consist of splitting functional tasks of daily life into static and dynamic balance components, besides standardized facilitate and disturbing strategies to execution of each exercise. Biomechanics and clinical performance of balance and gait, perception of quality of life, cognitive and mental functioning, and severity of PD will be measured at baseline (T0), post-8 weeks training (T1), and follow-up (T2).

Results

The primary outcome of the study will be the center of pressure sway area. The secondary outcomes consist of biomechanics and clinical variables related to static and dynamic balance. Outcomes from biomechanical of gait, quality of life, cognitive and mental state, and severity of PD, represent the tertiary outcomes.

Discussion

The balanceHOME program standardizes the FBT in demanding and daily environments for people with PD who prefer individualized treatment from home. This is the first time that the effects of group versus individual balance rehabilitation have been compared in people with and without cognitive impairment and evaluated in complex environments. This still-to-be-finished study will open the possibility of new strategies according to changes in post-pandemic therapeutic approaches.

Effects of Therapeutic Intervention on Spatiotemporal Gait Parameters in Adults With Neurologic Disorder: Systematic Review and Meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to review and quantify the changes in gait parameters after therapeutic intervention in adults with neurologic disorders.

DATA SOURCES

A keyword search was performed in 4 databases: PubMed, CINAHL, Scopus, and Web of Science (01/2000-12/2021). We performed the search algorithm including all possible combinations of keywords. Full-text articles were examined further using forward/backward search methods.

STUDY SELECTION

Studies were thoroughly screened using the following inclusion criteria: Study design: randomized controlled trial; adults ≥55 years old with a neurologic disorder; therapeutic intervention; spatiotemporal gait characteristics; and language: English.

DATA EXTRACTION

A standardized data extraction form was used to collect the following methodological outcome variables from each of the included studies: author, year, population, age, sample size, and spatiotemporal gait parameters such as cadence, step length, step width, or double limb support. A meta-analysis was performed among trials presenting with similar characteristics, including study population and outcome measure. If heterogeneity was >50%, a random plot analysis was used; otherwise, a fixed plot analysis was done.

DATA SYNTHESIS

We included 25 out of 34 studies in our meta-analysis that examined gait in adults with neurologic disorders. All analyses used effect sizes and standard error and a P<.05(denoted by *) threshold was considered statistically significant. Overall, we found that sensory (SS) and electrical stimulation (ES) had the most significant effect on step length (SS: z=5.44*, ES: z=2.42*) and gait speed (SS: z=6.19*, ES: z=7.38*) in adults with Parkinson disease (PD). Although balance or physical activity interventions were not found to be effective in modifying step length in adults with PD, they showed a significant effect on gait speed. Further, physical activity had the most significant effect on cadence in adults with PD (z=2.84*) relative to sensory stimulation effect on cadence (z=2.59*). For stroke, conventional physical therapy had the most significant effect on step length (z=3.12*) and cadence (z=3.57*).

CONCLUSION

Sensory stimulation such as auditory and somatosensory stimulation while walking had the most significant effect on step length in adults with PD. We also found that conventional physical therapy did improve spatial gait parameters relative to other physical activity interventions in adults with PD and stroke.

Lisbon Intensive Falls Trampoline Training (LIFTT) Program for people with Parkinson's for balance, gait, and falls: study protocol for a randomized controlled trial

BACKGROUND

Falling and gait difficulties in people with Parkinson's disease (PD) are associated with impaired reactive postural adjustments and impairments in attentional resources. Combined intensive balance motor and cognitive exercise can be beneficial. However, uncertainties persist regarding the true effects and safety when applying such training. Using trampoline beds may be a favorable safe environment for a highly intensive, cognitive, and balancing training approach. The primary goal of this randomized controlled trial is to assess the effects of an intensive cognitive-motor training program in a safe trampoline environment in addition to usual care on balance impairment, gait, physical capacity, fear of falling, falls frequency and severity, cognition, and clinical impairments in people with mild or moderate PD.

METHODS

Sixty participants diagnosed with idiopathic PD, in stage 2-4 Hoehn and Yahr, with a clinical history of gait deficits and a fall history (at least one fall in the last 6 months) will be recruited and randomly allocated to an intervention group receiving cognitive-motor trampoline training or a control group undergoing their usual care. The intervention will consist of 8-week individual training sessions (1-h training, 3 days per week) led by specialized physiotherapists that will provide progressive, challenging training, and guarantee safety. Assessment will be conducted prior to and immediately after the 8-week intervention and at 3 months follow-up after participating in the study. Primary outcome measures will be balance performance (assessed using the Mini-BEST Test and nonlinear analysis) and change in gait parameters (Motor and Cognitive Timed-Up-Go and nonlinear analysis). Secondary outcomes will be change in clinical improvement (Movement Disorder Society Unified Parkinson's Disease Rating Scale), falls (falls weekly registry), fear of falling (assessed using the Falls Efficacy Scale), physical capacity (6-min walk test), and cognition (Montreal Cognitive Assessment).

DISCUSSION

This study will provide new evidence on the benefits of intensive cognitive-motor balance training on a trampoline for people living with PD. Better guidance on how professionals can apply safer dual-task balance and gait training in rehabilitation is needed.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN13160409 . Retrospectively registered on February 23, 2022.

The effect of Computer Assisted Rehabilitation Environment (CAREN) in cognitive impairment and coping strategies in Parkinson's disease: a preliminary study

Parkinson's disease is a neurodegenerative disorder characterized by different motor, vegetative, behavioral, and cognitive impairments, with worsening quality of life. Virtual reality devices have given promising results in neurorehabilitation as they can provide multisensory stimulation in a realistic environment. This study aims to test the efficacy of virtual reality training by using Computer Assisted Rehabilitation Environment in cognitive impairment in a sample of PD. 31 patients affected by PD were enrolled. All PD patients underwent 24 sessions of Computer Assisted Rehabilitation Environment training. The participants were assessed at baseline (T0) and after two months (T1). Our results suggested that Computer Assisted Rehabilitation Environment training may be effective in the cognitive and emotional domains, particularly by improving executive function, anxiety, and depressive symptoms. These changes have helped to improve self-efficacy and coping strategies. These results indicate greater cognitive and physical effort to overcome stressors. Our results show that Computer Assisted Rehabilitation Environment training was beneficial in improving cognitive functions. Longer duration training may be especially beneficial for patients with mild cognitive impairment. Our findings open the door to tailored personalized treatments based on the patient's motor and cognitive profiles.

Parkinson Symptom Severity and Use of Nutraceuticals

BACKGROUND

It is estimated that half of the individuals with Parkinson's disease (PD) use some form of over-the-counter vitamin, herbal supplement or nutraceutical. The goal of this study was to survey individuals with PD about their use of the nutraceuticals and evaluate the association of the nutraceutical with the severity of symptoms.

METHODS

Participants with self-reported idiopathic PD within the 2021 cohort (n = 1084) were included in a cross-sectional study to assess association of nutraceuticals with symptom severity via linear regression analysis. PD severity was measured using the patient-reported outcomes in PD, and supplement use reflected self-reported consistent use over the previous six months. All regression analyses adjusted for age, gender, income and years since diagnosis. The use of the term progression refers to PRO-PD scores adjusted for years since diagnosis.

RESULTS

The most frequently used supplements were vitamin D (71%), B12 (44%), vitamin C (38%) and fish oil (38%). None of the supplements being used were associated with statistically significant worse outcomes. Nutraceuticals associated with improved outcomes were Ginkgo biloba (GB), NAD+ or its precursors, 5-methyltetrahydrofolate, glutathione, mucuna, CoQ10, low dose lithium, curcumin, homocysteine factors, DHEA, coconut oil, vitamin C, and omega-3 fatty acids (fish oil).

CONCLUSIONS

These data suggest that in a real-world setting, some over-the-counter supplements are associated with fewer patient-reported symptoms. Supplements with significant associations with fewer symptoms have biological plausibility and future clinical trials should be explored.

Proprioceptive Focal Stimulation (Equistasi®) for gait and postural balance rehabilitation in patients with Parkinson's disease: A systematic review

Gait and postural deficits are the most common impairments in patients with Parkinson's Disease (PD). These impairments often reduce patients' quality of life. Equistasi^® is a wearable proprioceptive stabilizer that converts body thermic energy into mechanical vibration. No systematic reviews have been published investigating the influences of Equistasi^® on gait and postural control in patients with PD. This review aimed to examine the effects of proprioceptive focal stimulation (Equistasi^®) on gait deficits and postural instability in patients with PD. PubMed, Scopus, PEDro, REHABDATA, web of science, CHAINAL, EMBASE, and MEDLINE were searched from inception to July 2021. The methodological quality of the selected studies was evaluated using the Physiotherapy Evidence Database (PEDro) scale. Five studies met the eligibility criteria. The scores on the PEDro scale ranged from 3 to 8, with a median score of 8. The results showed evidence for the benefits of the proprioceptive focal stimulation (Equistasi^®) on gait and postural stability in individuals with PD. Proprioceptive focal stimulation (Equistasi^®) appears to be safe and well-tolerated in patients with PD. Proprioceptive focal stimulation (Equistasi^®) may improve gait ability and postural stability in patients with PD. Further high-quality studies with long-term follow-ups are strongly needed to clarify the long-term effects of proprioceptive focal stimulation (Equistasi^®) in patients with PD.

[Postural stability and walking in Parkinson's disease]

The article is of an overview nature and is devoted to movement disorders in Parkinson's disease. The article discusses the existing problems according to the latest literature data, a review on the treatment and rehabilitation of postural instability. Special attention in the article is paid to dopamine receptor agonists - namely, piribedil, prescribed for the correction of these disorders.

Rehabilitation clinicians' perspectives of reactive balance training

PURPOSE

Reactive balance training (RBT) aims to improve reactive balance control. However, because RBT involves clients losing balance, clinicians may view that it is unsafe or not feasible for some clients. We aimed to explore how clinicians implement RBT to treat balance and mobility issues.

MATERIALS AND METHODS

Physiotherapists and kinesiologists across Canada who reported that they include RBT in their practices were invited to complete telephone interviews about their experiences with RBT. Interviews were transcribed verbatim, and analysed using a deductive thematic analysis.

RESULTS

Ten participants completed telephone interviews, which lasted between 30-60 min. Participants primarily worked in a hospital setting (inpatient rehabilitation (n = 3); outpatient rehabilitation (n = 2)), and were treated clients with neurological conditions (n = 5). Four main themes were identified: 1) there is variability in RBT approaches; 2) knowledge can be a barrier and facilitator to RBT; 3) reactive balance control is viewed as an advanced skill; and 4) RBT experience builds confidence.

CONCLUSIONS

Our findings suggest a need for resources to make clinical implementation of RBT more feasible.Implications for rehabilitationTrust between the therapist and client improves self-efficacy and feelings of apprehension/fear when conducting reactive balance training.Being creative and improvising with equipment that is readily available in clinics enables reactive balance training, without the need for high-tech equipment.Clinicians should consider using standardized tools with reactive balance control components, such as the Balance Evaluation Systems Test or Performance Oriented Mobility Assessment, to assess balance control.

System Comparison for Gait and Balance Monitoring Used for the Evaluation of a Home-Based Training

There are currently no standard methods for evaluating gait and balance performance at home. Smartphones include acceleration sensors and may represent a promising and easily accessible tool for this purpose. We performed an interventional feasibility study and compared a smartphone-based approach with two standard gait analysis systems (force plate and motion capturing systems). Healthy adults (n = 25, 44.1 ± 18.4 years) completed two laboratory evaluations before and after a three-week gait and balance training at home. There was an excellent agreement between all systems for stride time and cadence during normal, tandem and backward gait, whereas correlations for gait velocity were lower. Balance variables of both standard systems were moderately intercorrelated across all stance tasks, but only few correlated with the corresponding smartphone measures. Significant differences over time were found for several force plate and mocap system-obtained gait variables of normal, backward and tandem gait. Changes in balance variables over time were more heterogeneous and not significant for any system. The smartphone seems to be a suitable method to measure cadence and stride time of different gait, but not balance, tasks in healthy adults. Additional optimizations in data evaluation and processing may further improve the agreement between the analysis systems.

Research-Driven Guidelines for Delivering Group Exercise Programs via Videoconferencing to Older Adults

Telehealth holds much potential for supporting older adults' physical and social health. In particular, telewellness interventions to support the physical and social wellness of older adults are needed to overcome participation barriers with in-person programs. This paper presents guidelines for delivering telewellness interventions to older adults, which were informed by a human factors approach to developing a Tele Tai Chi intervention for older adults with mobility disabilities, including reviewing user needs literature and conducting user-centered needs assessment research. From these findings, we developed a protocol and support materials for delivering a telewellness intervention and conducted a feasibility study. We also established an adaptation committee to provide recommendations on the intervention. The outcome of our human factors approach was the establishment of research-driven design guidelines for delivering group exercise programs to older adults using videoconferencing. The guidelines provide direction for designing a telewellness protocol, supporting remote participation, and promoting socialization and engagement. These guidelines can be used to deliver interventions that increase access to socially-engaging, physical activity programs for older adults, which can ultimately help support their physical health, mental health, and quality of life.

Association Between Mitochondrial Function and Rehabilitation of Parkinson's Disease: Revealed by Exosomal mRNA and lncRNA Expression Profiles

Rehabilitation has been proposed as a valid measure complementary to the management of Parkinson's disease (PD). However, the mechanism underlying is not clear yet. The differential expressions of exosomal messenger RNA (mRNA) and long noncoding RNAs (lncRNAs) may play a critical role in PD progression and rehabilitation. To compare the differential expressions of exosomal mRNAs and lncRNAs, patients with PD (PWPs, Hoehn and Yahr stages 1.5-2.5, n = 6) and age- and sex-matched healthy controls (HCs, n = 6) were included in this study. All PWPs received a 2-week rehabilitation treatment in the hospital, which seemingly led to improvement in both the motor and non-motor functions. A set of differentially expressed mRNAs (DEmRNAs) and differentially expressed lncRNAs (DElncRNAs) extracted from exosomes in blood samples via next-generation sequencing (NGS) was screened out. Compared to HCs, 2,337 vs. 701 mRNAs and 1,278 vs. 445 lncRNAs were significantly upregulated and significantly downregulated, respectively, in pre-rehabilitation (pre-rehab) PWPs; 2,490 vs. 629 mRNAs and 1,561 vs. 370 lncRNAs were significantly upregulated and significantly downregulated, respectively, in post-rehabilitation (post-rehab) PWPs. Compared to pre-rehab PWPs, 606 vs. 1,056 mRNAs and 593 vs. 1,136 lncRNAs were significantly upregulated and significantly downregulated, respectively, in post-rehab PWPs. Overall, 14 differentially expressed mRNAs (DEmRNAs) and 73 differentially expressed lncRNAs (DElncRNAs) were expressed in the blood exosomes of HCs, pre- and post-rehab PWPs, simultaneously. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses identified 243 significantly co-expressed lncRNA-mRNA pairs. One DEmRNA of interest (ENSG00000099795, NDUFB7) and three corresponding DElncRNAs (ENST00000564683, ENST00000570408, and ENST00000628340) were positively related. Quantitative real-time polymerase chain reaction (qRT-PCR) validated that the expression levels of NDUFB7 mRNA and the 3 DElncRNAs increased significantly in pre-rehab PWPs, but decreased significantly in post-rehab PWPs compared to HCs. NDUFB7 mRNA is a marker related to mitochondrial respiration. It is reasonably believed that mitochondrial function is associated with PD rehabilitation, and the mitochondrial pathway may involve in the pathogenesis of 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.

Effect of Intensive Rehabilitation Program in Thermal Water on a Group of People with Parkinson's Disease: A Retrospective Longitudinal Study

The main objective of this study is to test the effect of thermal aquatic exercise on motor symptoms and quality of life in people with Parkinson's Disease (PD). Fourteen participants with diagnosis of idiopathic PD completed the whole rehabilitation session and evaluation protocol (Hoehn and Yahr in OFF state: 2-3; Mini Mental State Examination >24; stable pharmacological treatment in the 3 months prior participating in the study). Cognitive and motor status, functional abilities and quality of life were assessed at baseline and after an intensive rehabilitation program in thermal water (12 sessions of 45 min in a 1.4 m depth pool at 32-36 ∘C). The Mini Balance Evaluation System Test (Mini-BESTest) and the PD Quality of Life Questionnaire (PDQ-39) were considered as main outcomes. Secondary assessment measures evaluated motor symptoms and quality of life and psychological well-being. Participants kept good cognitive and functional status after treatment. Balance of all the participants significantly improved (Mini-BESTest: p<0.01). The PDQ-39 significantly improved after rehabilitation (p=0.038), with significance being driven by dimensions strongly related to motor status. Thermal aquatic exercise may represent a promising rehabilitation tool to prevent the impact of motor symptoms on daily-life activities of people with PD. PDQ-39 improvement foreshows good effects of the intervention on quality of life and psychological well-being.

Stabilometric Analysis of Parkinson's Disease Patients

Parkinson's disease (PD) is considered a movement disease; it is a progressive and degenerative neurological disorder, causing disabling motor dysfunctions. Investigate the body instability of PD patients through the stabilometry test is the aim of this study. A sample of 40 participants with PD were staged between the stages of the disease using Hoehn and Yahr Modified Scale 1.5 to 3.0 in static posture with eyes open and closed to assess stabilometry in the distance from the center of pressure (CoP), as well as anteroposterior (AP) and mediolateral axis (ML). There were found no differences in the body oscillation variables on the AP and ML axis. There was a difference in CoP displacement and oscillation speed between stage 1.5 to 3.0. It was concluded that participants with PD in stage 3.0 had greater distances from the CoP and greater speed of body sway, and that these instabilities become more evident with the progression of the disease.

A pathophysiological model of gait captures the details of the impairment of pace/rhythm, variability and asymmetry in Parkinsonian patients at distinct stages of the disease

Locomotion in people with Parkinson' disease (pwPD) worsens with the progression of disease, affecting independence and quality of life. At present, clinical practice guidelines recommend a basic evaluation of gait, even though the variables (gait speed, cadence, step length) may not be satisfactory for assessing the evolution of locomotion over the course of the disease. Collecting variables into factors of a conceptual model enhances the clinical assessment of disease severity. Our aim is to evaluate if factors highlight gait differences between pwPD and healthy subjects (HS) and do it at earlier stages of disease compared to single variables. Gait characteristics of 298 pwPD and 84 HS able to walk without assistance were assessed using a baropodometric walkway (GAITRite®). According to the structure of a model previously validated in pwPD, eight spatiotemporal variables were grouped in three factors: pace/rhythm, variability and asymmetry. The model, created from the combination of three factor scores, proved to outperform the single variables or the factors in discriminating pwPD from HS. When considering the pwPD split into the different Hoehn and Yahr (H&Y) stages, the spatiotemporal variables, factor scores and the model showed that multiple impairments of gait appear at H&Y stage 2.5, with the greatest difference from HS at stage 4. A contrasting behavior was found for the asymmetry variables and factor, which showed differences from the HS already in the early stages of PD. Our findings support the use of factor scores and of the model with respect to the single variables in gait staging in PD.

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.

Changes of biomechanics induced by Equistasi® in Parkinson's disease: coupling between balance and lower limb joints kinematics

Axial disorders, including postural deformities, postural instability, and gait disturbances, are among the most disabling symptoms of Parkinson's disease (PD). Equistasi®, a wearable proprioceptive stabilizer device, has been proposed as neurological rehabilitative device for this set of symptoms. To investigate the effects of the device on gait and balance, 24 participants affected by PD were enrolled in this crossover double-dummy, randomized, controlled study. Subjects were assessed four times before and after 8 weeks treatment with either active or placebo device; one-month wash-out was taken between treatments, in a 20-week timeframe. Gait analysis and instrumented Romberg test were performed with the aid of a sterofotogrammetric system and two force plates. Joint kinematics, spatiotemporal parameters of gait and center of pressure parameters were extracted. Paired T-test (p < 0.05) was adopted after evidence of normality to compare the variables across different acquisition sessions; Wilcoxon was adopted for non-normal distributions. Before and after the treatment with the active device, statistically significant improvements were observed in trunk flexion extension and in the ankle dorsi-plantarflexion. Regarding balance assessment, significant improvements were reported at the frequencies corresponding to vestibular system. These findings may open new possibilities on PD's rehabilitative interventions. Research question, tailored design of the study, experimental acquisition overview, main findings, and conclusions.

Comparison of the effect of whole-body vibration therapy versus conventional therapy on functional balance of patients with Parkinson's disease: adding a mixed group

OBJECTIVE

Assess the effect of Whole-Body Vibration (WBV) therapy in functional balance status of Parkinson's disease (PD) patients and compare this to conventional and combined therapy.

INTRODUCTION

PD patients experience a decreased mobility, inactivity, and loss of independence as consequence of disturbances in gait, posture, and balance. Rehabilitation therapy is a non-pharmacological way of improving functionality. One of the most studied modalities is WBV, with multiple studies showing improvement in motor function. However, results in this manner are inconsistent.

METHODS

Forty-five patients were enrolled in a non-randomized controlled trial and divided into three groups. Group 1 received conventional therapy (thermotherapy, stretching, strengthening, coordination and balance). Group 2 received WBV therapy, and group 3 patients underwent a combined therapy protocol. A total of 20 sessions (3 per week) were conducted, assessing Berg Balance Scale (BBS) before initial and after final session.

RESULTS

The 3 intervention groups showed significant improvement in BBS scores after concluding the 20-session trial compared to initial assessment. When comparing mean change in BBS score from initial to final assessment, the combined therapy group had a greater increase compared to conventional therapy, but no significant differences were observed comparing to WBV group. Mean change in BBS score showed no significant difference between conventional therapy and WBV therapy group.

CONCLUSIONS

WBV therapy is a useful tool as co-adjuvant in conventional therapy. The combination of both therapies is a significant therapeutic alternative for the improvement of functional balance status in PD patients compared to conventional therapy alone.

Pedobarography in Physiotherapy: A Narrative Review on Current Knowledge

Pedobarography is a modern technology enabling the assessment of the locomotor system based on the plantar pressure distribution. The technic is useful in the rehabilitation of various types of dysfunction of body movement. This chapter aims to describe the application of pedobarography in clinical therapy. The qualitative analysis is based on a review of articles in English, French, German, Polish, Portuguese, Spanish, Turkish, and Chinese in Medline/PubMed, Cochrane Library, Embase, and PEDro databases. The search covered the articles on clinical trials, randomized controlled trials, meta-analyses, and reviews published over 1984-2020. The literature shows that pedobarography is a safe non-invasive method that is useful for the examination of foot biomechanics with a reference to the entire musculoskeletal system. A pedobarographic examination enables insight into a motion disorder, its plausible relation to a systemic pathology, and monitoring the course of treatment and rehabilitation.

Effectiveness of robotic balance training on postural instability in patients with mild Parkinson's disease: A pilot, single blind, randomized controlled trial

OBJECTIVE

To examine whether tailored robotic platform training could improve postural stability compared with conventional balance treatment in patients with mild Parkinson's disease.  Design: Randomized single-blind pilot study.

SUBJECTS

Twenty-two patients with mild Parkinson's disease (Hoehn and Yahr scale; HandY 1-2).

METHODS

Patients were randomly assigned to an experimental group for robotic balance training and to a control group for conventional balance training. Each patient received 20 treatments (45 min/session, 5 times/week). Blinded evaluations were conducted before and after the treatment and 1 month post-treatment. Primary outcome measures were Mini BESTest, and Berg Balance Scale; secondary outcome measures were 10-Meter Walk Test, Five Times Sit to Stand Test, and Parkinson's Disease Questionnaire 39.

RESULTS

Primary outcome measures in patients in both the experimental and control groups improved significantly after the balance treatment. Similar results were found for all the secondary outcome measures. The experimental group performed significantly better than the control group at both post-intervention and follow-up evaluation in the primary outcomes (p < 0.05). No significant differences be-tween groups were found in secondary outcomes.

CONCLUSION

Robot-assisted balance training may be a promising tool to improve postural stability in patients with mild Parkinson's disease.

Highly challenging balance and gait training for individuals with Parkinson's disease improves pace, rhythm and variability domains of gait - A secondary analysis from a randomized controlled trial

OBJECTIVE

Evaluate immediate and long-term effects of highly challenging balance and gait training on pace-, rhythm-, variability-, asymmetry-, and postural control domains of gait for individuals with Parkinson's disease (PD).

DESIGN

Randomized controlled trial - a secondary analysis.

SETTING

University hospital setting.

PARTICIPANTS

One-hundred older adults with mild to moderate PD (Hoehn & Yahr 2 and 3).

INTERVENTION

Training group (n = 51): 10 weeks (3 times/week) of intensive balance and gait training, incorporating dual tasks. Control group (n = 49): care as usual.

MAIN OUTCOME MEASURES

Spatiotemporal gait variables collected during normal and fast walking on a pressure-sensitive mat. A linear mixed model was used to evaluate training effects post intervention and at the 6 and 12 month follow-up.

RESULTS

Immediate training effects in the pace domain of gait were increased step velocity (normal speed: 8.2 cm/s, P = 0.04; fast: 10.8 cm/s, P < 0.01), increased step length (normal speed: 3 cm, P = 0.05; fast: 2.3 cm, P = 0.05) and reduced swing time variability (fast speed: -2.5 ms, P = 0.02). In the rhythm domain reduced step time (fast speed: -19.3 ms, P = 0.02), stance time (normal: -24.3 ms, P = 0.01; fast: -29.6 ms, P = 0.02) and swing time (fast speed: -8.7 ms, P = 0.04) was seen. Relative to the variability domain, the training decreased step time variability (fast: -2.8 ms, P = 0.02) and stance time variability (fast: -3.9 ms, P = 0.02). No training effects were retained at 6 months.

CONCLUSIONS

Highly challenging balance and gait training improved pace, rhythm and variability aspects of PD gait in the short-term, but effects are not retained long-term.

TRIAL REGISTRATION NUMBER

NCT01417598.

Adaptation of balancing behaviour during continuous perturbations of stance. Supra-postural visual tasks and platform translation frequency modulate adaptation rate

When humans are administered continuous and predictable perturbations of stance, an adaptation period precedes the steady state of balancing behaviour. Little information is available on the modulation of adaptation by vision and perturbation frequency. Moreover, performance of supra-postural tasks may modulate adaptation in as yet unidentified ways. Our purpose was to identify differences in adaptation associated to distinct visual tasks and perturbation frequencies. Twenty non-disabled adult volunteers stood on a platform translating 10 cm in antero-posterior (AP) direction at low (LF, 0.18 Hz) and high frequency (HF, 0.56 Hz) with eyes open (EO) and closed (EC). Additional conditions were reading a text fixed to platform (EO-TP) and reading a text stationary on ground (EO-TG). Peak-to-peak (PP) displacement amplitude and AP position of head and pelvis markers were computed for each of 27 continuous perturbation cycles. The time constant and extent of head and pelvis adaptation and the cross-correlation coefficients between head and pelvis were compared across visual conditions and frequencies. Head and pelvis mean positions in space varied little across conditions and perturbation cycles but the mean head PP displacements changed over time. On average, at LF, the PP displacement of the head and pelvis increased progressively. Adaptation was rapid or ineffective with EO, but slower with EO-TG, EO-TP, EC. At HF, the head PP displacement amplitude decreased progressively with fast adaptation rates, while the pelvis adaptation was not apparent. The results show that visual tasks can modulate the adaptation rate, highlight the effect of the perturbation frequency on adaptation and provide evidence of priority assigned to pelvis stabilization over visual tasks at HF. The effects of perturbation frequency and optic flow and their interaction with other sensory inputs and cognitive tasks on the adaptation strategies should be investigated in impaired individuals and considered in the design of rehabilitation protocols.

Quickcard-Based Approach to Guiding Specific Nonpharmacological Treatments in a German Parkinson's Network

Interdisciplinary care has been shown to be effective at optimizing the treatment of patients with Parkinson's disease. An optimized collaboration between the various healthcare providers involved in the treatment process facilitates successful care. One of the main shortcomings in the German healthcare system is the limited and unstandardized communication between practitioners. The Parkinson's network Münsterland+ (PNM+) is an interdisciplinary network of medical and non-medical experts involved in the treatment of Parkinson's patients: neurologists, physiotherapists, occupational therapists, speech therapists, psychologists, Parkinson's nurses, pharmacists, patients, and relatives. The PNM+ elaborates guideline-based therapy recommendations, provided as so-called "Quickcards". Thereby, the communication of the treating neurologist and therapists is based on a coordinated feedback system and suggestions to adequately select and, if necessary, adjust the therapy. In the German healthcare system, with its fragmented structures, the PNM+ and its activities have been shown to enhance integration of the healthcare providers and thereby optimize the care of Parkinson's disease patients. Future research should evaluate the effects and cost-effectiveness.

Responsiveness and minimal clinically important difference of the Mini-BESTest in patients with Parkinson's disease

BACKGROUND

Balance problems in Parkinson's Disease (PD) require appropriate evaluation. While the Mini-BESTest is commonly used to assess dynamic balance, some of its psychometric properties have not yet been addressed.

RESEARCH QUESTION

What is the responsiveness and the Minimal Clinically Important Difference (MCID) of the Mini-BESTest in patients with PD?

METHODS

One-hundred forty-eight patients with PD underwent a treatment specific for balance skills (1-h session, three times/week for four weeks). All patients were initially evaluated with the Mini-BESTest and Activities-Specific Balance Confidence scale 5-levels (ABC-5L). Post-treatment, patients were assessed with the Mini-BESTest, ABC-5L and Global Rating of Change (GRC, both patient- and physiotherapist-rated). Responsiveness to treatment and MCID were calculated with distribution and anchor-based methods: effect size, area under the curve (AUC) of receiver operating characteristics (ROC), and correlations between evaluations (change in score of Mini-BESTest, ABC-5L, GRC). Eleven a priori hypotheses were formulated for testing responsiveness.

RESULTS

The effect size of treatment measured with the Mini-BESTest was 0.44, revealing moderate responsiveness. AUCs were 0.75, 0.82 and 0.59 for the patient-rated GRC, physiotherapist-rated GRC and ABC-5L, respectively. There was a moderate correlation between changes in the Mini-BESTest and patient-rated (r_s = 0.42) or physiotherapist-rated (r_s = 0.62) GRC scores. Conversely, a low correlation (r_s = 0.17) was found between changes in the Mini-BESTest and ABC-5L. Consequently, 72.7% of hypotheses were met. The Mini-BESTest MCID was between 3.4 and 4.0 when calculated with distribution and anchor-based methods, respectively.

SIGNIFICANCE

The Mini-BESTest showed moderate responsiveness for detecting treatment-related improvement in dynamic balance. A 4.0-point MCID value is useful to identify clinical effects of balance rehabilitation in a single patient with PD. Values ranging from 3.4 and 4.0 are recommended for interpretation of results at a group level.

Mechanical Plantar Foot Stimulation in Parkinson's Disease: A Scoping Review

BACKGROUND

Parkinson's disease (PD) is the second most prevalent neurodegenerative disease in older individuals. Neurorehabilitation-based interventions such as those improving gait are crucial for a holistic approach and to limit falls. Several studies have recently shown that mechanical plantar foot stimulation is a beneficial intervention for improving gait impairment in PD patients. The objective of this scoping review is to evaluate the beneficial effects of this stimulation on gait parameters, and to analyse protocols of foot stimulation and other effects in non-motor symptoms. Relevant articles were searched in the Medline database using Pubmed and Scopus, using the primary search terms 'foot stimulation' OR 'plantar stimulation' AND 'Parkinson's disease*'. Several protocols have been used for mechanical plantar foot stimulation (ranging from medical devices to textured insoles). The gait parameters that have been shown to be improved are stride length and walking speed. The beneficial effects are achieved after both acute and repeated plantar foot stimulation. Beneficial effects are observed in other organs and systems, such as muscle activation, brain connectivity, cardiovascular control in the central nervous system, and the release of brain-derived neurotrophic factor and cortisol in blood added evidence about this intervention's impact on brain function. Mechanical plantar foot stimulation is a safe and effective add-on treatment able for improving gait impairments in PD patients during the L-dopa off state. Randomized and controlled clinical trials to study its eventual potentiating effect with different pharmacotherapy regimens are warranted.

Clinical experience of comprehensive treatment on the balance function of Parkinson's disease

To investigate the effect of multi-disciplinary teamwork on balance performance of Parkinson's disease (PD).Sixteen primary Parkinson's disease patients (8 male, 8 female) treated with bilateral subthalamic nucleus deep brain stimulation (STN-DBS) were included in the study. The median age of patients was 60.5 years; all patients were in the Hoehn&Yahr (H&Y) 3 stage; the median PD duration of the disease was 9 years. For each patient, multi-disciplinary teamwork treatment including DBS, medication, physical therapy and psychotherapy proceeded. levodopa equivalent daily dose (LEDD, mg/day), life quality (PDQ-39), Motor disability (MDS-UPDRSIII) and balance performance (MDS-UPDRS 3.12, Berg Balance Scale BBS, Limits of Stability LoS) were assessed in different time and status respectively: preoperation (Med-off, Med-on), postoperation (Stim-Off/Med-Off, Stim-On/Med-Off, Stim-On/Med-On), 6 months postoperation (Stim-On/ Med-Off, Stim-On/Med-On) and 12 months postoperation (Stim-On/Med-Off, Stim-On/Med-On).The LEDD, life quality (PDQ-39) continued to improve during the follow-up, statistical difference were found in both 6 months postoperation and 12 months postoperation compared with preoperation. The Motor disability (MDS-UPDRSIII), balance performance (MDS-UPDRS 3.12, BBS) and the LoS (target acquisition percentage, trunk swing angle standard deviation, time) showed significant improvement in Stim-On/med-Off 6 months postoperation and 12 months postoperation separately compared with Med-Off preoperation.Multi-disciplinary teamwork for PD patients with STN-DBS could improve balance performance.

Effects of a community-based exercise program on mobility, balance, cognition, sleep, activities of daily living, and quality of life in PD: a pilot study

Aim: The primary objective of the study was to evaluate the effects of a community-based exercise program for adults with Parkinson's disease (PD). Patients & methods: This one-group pretest and post-test design involved 22 participants with PD who participated in two to three exercise sessions per week for 8 weeks. Outcomes assessed for statistical significance included balance, mobility, cognition, activities of daily living, sleep and quality of life. Results: Although exercise is positively correlated with improvements in function, this short-duration study did not demonstrate this. Qualitative themes revealed an increase in self-perceived socialization, coordination and motivation to continue exercise. Conclusion: This community-based exercise study showed improvements in socialization, self-reported coordination and motivation to exercise. Further research is needed to assess community exercise interventions for PD.

Human Balance in Response to Continuous, Predictable Translations of the Support Base: Integration of Sensory Information, Adaptation to Perturbations, and the Effect of Age, Neuropathy and Parkinson’s Disease

This short narrative review article moves from early papers that described the behaviour of healthy subjects balancing on a motorized platform continuously translating in the antero-posterior direction. Research from the laboratories of two of the authors and related investigations on dynamic balancing behaviour are briefly summarized. More recent findings challenging time-honoured views are considered, such as the statement that vision plays a head-in-space stabilizing role. The time interval to integrate vision or its withdrawal in the balancing pattern is mentioned as well. Similarities and differences between ageing subjects and patients with peripheral or central disorders are concisely reported. The muscle activities recorded during the translation cycles suggest that vision and amplitude changes of the anticipatory postural activities play a predominant role in controlling dynamic balance during prolonged administration of the predictable perturbation. The potential of this paradigm for rehabilitation of balance problems is discussed.

The effects of exercise interventions on Parkinson's disease: A Bayesian network meta-analysis

OBJECTIVE

This work aimed to assess effects of different exercise intervention on Parkinson's disease (PD) treatment via a network meta-analysis.

METHODS

Eligible literatures were retrieved from three databases (PubMed, EMBASE and Cochrane Library) up to March 5, 2019 and screened based on established selection criteria. Afterwards, relevant data was extracted and heterogeneity tests were conducted to select appropriate effect models according to chi-square test and I2 statistics. Publication bias of included studies was also performed. Finally, the pairwise and network meta-analyses were carried out to evaluate the efficacy of different exercise training on PD management.

RESULTS

Overall, 19 studies encompassing 920 PD patients were identified to explore effects of interventions such as dance, Qigong, tango, resistance training (RT), Taichi and yoga on PD in terms of six indicators including six-minute walk, gait velocity, UPDRS III, PD questionnaire-39 (PDQ-39), timed up and go (TUG) and Berg balance test (BBT). The direct meta-analysis revealed that RT and dance altered the gait velocity and PDR-39 indicator of PD patients. And there was a statistical difference in RT and Tango regarding UPDRS III. Besides, significant differences were also detected among multiple comparisons based on TUG and BBT, containing RT vs control, Tai Chi vs control and Tango vs control for TUG, and dance vs control for BBT. Finally, results of network meta-analysis implied that tango was a good exercise for PD patients according to six different outcome measures.

CONCLUSION

Tango was an optimal and effective option for improving functional mobility of PD patients.

Is the Brief-BESTest Brief Enough? Suggested Modifications Based on Structural Validity and Internal Consistency

BACKGROUND

The Brief Balance Evaluation Systems Test (Brief-BESTest) could be a useful tool for balance assessment. Although some psychometric characteristics have been examined, others still need to be clarified.

OBJECTIVE

The objective was to assess the structural validity, convergent validity, discriminant validity, and internal consistency of the Brief-BESTest in neurological patients.

DESIGN

This was a cross-sectional study.

METHODS

Data were from 416 patients with neurological disease and related balance disorders. Patients were assessed with the 5-levels Activities-Specific Balance Confidence Scale (ABC 5-levels), Brief-BESTest, and some simple balance tests (ie, 1-leg stance, Timed "Up & Go" test, functional reach, and a fall history questionnaire). Three Brief-BESTest models were examined through confirmatory factor analysis, and the following indexes were calculated: Comparative Fit Index, Tucker-Lewis Index, and root-mean-square error of approximation. Convergent validity was assessed by calculating the correlation between Brief-BESTest and ABC 5-levels total scores. Receiver operating characteristics assessed the ability of each model to differentiate between people with falls and those without falls. Internal consistency was measured with Cronbach α and coefficient ω.

RESULTS

Confirmatory factor analysis showed model 3 (Comparative Fit Index = 0.97; Tucker-Lewis Index = 0.95; root-mean-square error of approximation = 0.05), with item 1 removed and error covariance between items 3 and 4 and between items 5 and 6, to have a significantly better structure than models 1 and 2. The correlation between Brief-BESTest and ABC 5-levels was 0.61 (Spearman ρ) for all 3 models. The area under the curve of the receiver operating characteristics showed an acceptable accuracy (0.72) in distinguishing patients with a history of falls from those without a history of falls (95% confidence interval = 0.66-0.78) for all models and was superior to the areas under the curve of other simple balance tests (1-leg stance, Timed "Up & Go" test, functional reach). Cronbach α was good for Brief-BESTest models 1 (0.92) and 3 (0.92), but ω was greater than 0.80 only for model 3.

LIMITATIONS

The sample was heterogeneous.

CONCLUSIONS

The Brief-BESTest, after some changes, shows good validity and internal consistency in patients affected by different balance disorders.

Study on Effect of Striatal mGluR2/3 in Alleviating Motor Dysfunction in Rat PD Model Treated by Exercise Therapy

Background: Exercise therapy has been widely applied in clinical rehabilitation as an important practical and side effect-free adjuvant therapy, with a significant effect in alleviating motor dysfunction of patients with Parkinson's disease (PD) or animal PD models. This study focuses on the effect of exercise therapy in reducing the concentration of extracellular glutamate (Glu) in the striatum in a rat PD model by upregulating the expression of group II metabotropic Glu receptor (mGluR2/3), so as to alleviate motor dysfunction in the rat PD model. Methods: Neurotoxin 6-hydroxydopamine (6-OHDA) was injected into the right medial forebrain bundle (MFB) of the rats to establish the semi-lateral cerebral damage PD model. The sham-operated group was given an equal amount of normal saline at the same site and taken as the control group. The apomorphine (APO)-induced rotational behavior test combined with immunohistochemical staining with tyrosine hydroxylase (TH) in the substantia nigra (SNc) and striatum was performed to assess the reliability of the model. The exercise group was given treadmill exercise intervention for 4 weeks (11 m/min, 30 min/day, 5 days/week) 1 week after the operation. The open field test (OFT) was performed to assess the locomotor activity of the rats; the Western blot technique was used to detect SNc TH and striatal mGluR2/3 protein expressions; real-time polymerase chain reaction (RT-PCR) was applied to detect striatal mGluR2 and mGluR3 mRNA expressions; the microdialysis-high-performance liquid chromatography (HPLC) method was adopted to detect the concentration of extracellular Glu in striatal neurons. Results: Compared with the control group, the number of rotations of each model group at the first week was significantly increased (P < 0.01); compared with the PD group, the number of rotations of the PD + exercise group at the third week and the fifth week was significantly decreased (P < 0.05, P < 0.01). Compared with the control group, the total movement distance, the total movement time, and the mean velocity of each model group at the first week were significantly reduced (P < 0.05); compared with the PD group, the total movement distance, the total movement time, and the mean velocity of the PD + exercise group at the third week and the fifth week were significantly increased (P < 0.01). Compared with the control group, the count of immunopositive cells and protein expression of SNc TH, and the content of immunopositive fiber terminals in the striatal TH of each model group significantly declined (P < 0.01). Compared with the PD group, the striatal mGluR2/3 protein expression of the PD + exercise group significantly rose (P < 0.01). Compared with the control group, the concentration of extracellular Glu in striatal neurons of each model group at the first week significantly grew (P < 0.05); compared with the PD group, the concentration of extracellular Glu in striatal neurons of the PD + exercise group at the third week and the fifth week was significantly decreased (P < 0.01); compared with the PD + exercise group, the concentration of extracellular Glu in striatal neurons of the group injected with mGluR2/3 antagonist (RS)-1-amino-5-phosphonoindan-1-carboxylic acid (APICA) into the striatum at the third week and the fifth week was significantly increased (P < 0.05, P < 0.01). Compared with the control group, the striatal mGluR2/3 protein expression of the PD group was significantly downregulated (P < 0.01); compared with the PD group, the striatal mGluR2/3 protein expression of the PD + exercise group was significantly upregulated (P < 0.05); compared with the control group, the striatal mGluR3 mRNA expression of the PD group was significantly downregulated (P < 0.01); compared with the PD group, the striatal mGluR3 mRNA expression of the PD + exercise group was significantly upregulated (P < 0.01); 6-OHDA damage and exercise intervention had no significant effect on the striatal mGluR2 mRNA expression (P > 0.05). Compared with the PD + exercise group, the total movement distance, the total movement time, and the mean velocity of the PD + exercise + APICA group were significantly decreased (P < 0.05); compared with the PD group, the PD + exercise + APICA group had no significant change in the total movement distance, the total movement time, and the mean velocity (P > 0.05). Conclusion: These data collectively demonstrate that the mGluR2/3-mediated glutamatergic transmission in the striatum is sensitive to dopamine (DA) depletion and may serve as a target of exercise intervention for mediating the therapeutic effect of exercise intervention in a rat model of PD.

Vision Does Not Necessarily Stabilize the Head in Space During Continuous Postural Perturbations

Vision favors head stabilization in space during perturbations of standing balance. This is particularly obvious under conditions of continuous predictable perturbations as during sinusoidal antero-posterior (A-P) translations of the supporting platform. We tested here the hypothesis that under this condition the head can instead undergo large A-P oscillations, when a precision visual task is concurrently performed. We compared the head oscillations across four conditions while standing on a continuously translating platform. Eyes open (EO, no visual task), EO while reading a text fixed to the moving platform (EO-TP), EO while reading a text fixed to earth-ground (EO-TG), eyes-closed (EC). The platform translated at 0.2 and 0.6 Hz. Participants were young adult subjects, who received no particular instruction except reading the text aloud when required. Markers fixed on head, platform and text-sheet were captured by an optoelectronic device. We found that head oscillations were larger with EC than under all EO conditions. The oscillations were the least with EO and EO-TG, and intermediate with EO-TP. This was true under both low and high translation frequency, in spite of broadly smaller head oscillations at high frequency, common to all visual conditions. The distance between the head and the text was quite constant with EO-TP but fluctuated with EO-TG. The basic whole-body coordination features were moderately similar under all conditions, as assessed by the head-platform correlation coefficients and time lags. It appears that vision does not produce head stabilization in space when a concurrent visual task requiring focusing on a reading-text moving with the platform is performed. Contrary to traditional views centered on the stabilizing effect of vision under both static and dynamic conditions, the results show that head stabilization, normally ensuring a reference for inertial guidance for body balance, can be revoked by the CNS to allow performance of a non-postural task. This novel paradigm can shift long-standing views on the effect of vision on equilibrium control and be considered a potential exercise treatment for enhancing the multisensory integration process in people with balance problems.

Proposal of a new conceptual gait model for patients with Parkinson's disease based on factor analysis

BACKGROUND

Gait impairment is a risk factor for falls in patients with Parkinson's disease (PD). Gait can be conveniently assessed by electronic walkways, but there is need to select which spatiotemporal gait variables are useful for assessing gait in PD. Existing models for gait variables developed in healthy subjects and patients with PD show some methodological shortcomings in their validation through exploratory factor analysis (EFA), and were never confirmed by confirmatory factor analysis (CFA). The aims of this study were (1) to create a new model of gait for PD through EFA, (2) to analyze the factorial structure of our new model and compare it with existing models through CFA.

RESULTS

From the 37 variables initially considered in 250 patients with PD, 10 did not show good-to-excellent reliability and were eliminated, while further 19 were eliminated after correlation matrix and Kaiser-Meyer-Olkin measure. The remaining eight variables underwent EFA and three factors emerged: pace/rhythm, variability, and asymmetry. Structural validity of our new model was then examined with CFA, using the structural equation modeling. After some modifications, suggested by the Modification Indices, we obtained a final model that showed an excellent fit. In contrast, when the structure of previous models of gait was analyzed, no model achieved convergence with our sample of patients.

CONCLUSIONS

Our model for spatiotemporal gait variables of patients with PD is the first to be developed through an accurate EFA and confirmed by CFA. It contains eight gait variables divided into three factors and shows an excellent fit. Reasons for the non-convergence of other models could be their inclusion of highly inter-correlated or low-reliability variables or could be possibly due to the fact that they did not use more recent methods for determining the number of factors to extract.

Walking Along Curved Trajectories. Changes With Age and Parkinson's Disease. Hints to Rehabilitation

In this review, we briefly recall the fundamental processes allowing us to change locomotion trajectory and keep walking along a curved path and provide a review of contemporary literature on turning in older adults and people with Parkinson's Disease (PD). The first part briefly summarizes the way the body exploits the physical laws to produce a curved walking trajectory. Then, the changes in muscle and brain activation underpinning this task, and the promoting role of proprioception, are briefly considered. Another section is devoted to the gait changes occurring in curved walking and steering with aging. Further, freezing during turning and rehabilitation of curved walking in patients with PD is mentioned in the last part. Obviously, as the research on body steering while walking or turning has boomed in the last 10 years, the relevant critical issues have been tackled and ways to improve this locomotor task proposed. Rationale and evidences for successful training procedures are available, to potentially reduce the risk of falling in both older adults and patients with PD. A better understanding of the pathophysiology of steering, of the subtle but vital interaction between posture, balance, and progression along non-linear trajectories, and of the residual motor learning capacities in these cohorts may provide solid bases for new rehabilitative approaches.

Abnormal gait pattern emerges during curved trajectories in high-functioning Parkinsonian patients walking in line at normal speed

Background

Several patients with Parkinson´s disease (PD) can walk normally along straight trajectories, and impairment in their stride length and cadence may not be easily discernible. Do obvious abnormalities occur in these high-functioning patients when more challenging trajectories are travelled, such as circular paths, which normally implicate a graded modulation in the duration of the interlimb gait cycle phases?

Methods

We compared a cohort of well-treated mildly to moderately affected PD patients to a group of age-matched healthy subjects (HS), by deliberately including HS spontaneously walking at the same speed of the patients with PD. All participants performed, in random order: linear and circular walking (clockwise and counter-clockwise) at self-selected speed. By means of pressure-sensitive insoles, we recorded walking speed, cadence, duration of single support, double support, swing phase, and stride time. Stride length-cadence relationships were built for linear and curved walking. Stride-to-stride variability of temporal gait parameters was also estimated.

Results

Walking speed, cadence or stride length were not different between PD and HS during linear walking. Speed, cadence and stride length diminished during curved walking in both groups, stride length more in PD than HS. In PD compared to HS, the stride length-cadence relationship was altered during curved walking. Duration of the double-support phase was also increased during curved walking, as was variability of the single support, swing phase and double support phase.

Conclusion

The spatio-temporal gait pattern and variability are significantly modified in well-treated, high-functioning patients with PD walking along circular trajectories, even when they exhibit no changes in speed in straight-line walking. The increased variability of the gait phases during curved walking is an identifying characteristic of PD. We discuss our findings in term of interplay between control of balance and of locomotor progression: the former is challenged by curved trajectories even in high-functioning patients, while the latter may not be critically affected.