Exercise for falls prevention in Parkinson disease: a randomized controlled trial

Ankle dorsiflexion range of motion is decreased in parkinson's disease patients with freezing of gait and high l-dopa equivalent daily dose

INTRODUCTION

The decrease in overall range of motion (ROM) of the joints in Parkinson's disease (PD) contributes to a functional decline. Ankle dorsiflexion required for activities such as walking, climbing, and descending stairs can be a clinically important outcome in this population as well as the presence of freezing of gait (FOG). However, there are no studies that consider this analysis in PD.

OBJECTIVE

To evaluate and to compare the ankle dorsiflexion ROM in PD patients classified into freezers and non-freezers as well as PD patients and healthy subjects.

METHODS

Cross-sectional study based on assessment protocols with qualitative and quantitative measures. Thirty-four individuals with PD were enrolled in this study. FOG questionnaire was adopted to classify patients into FOG and non-FOG (NFOG). Daily L-Dopa consumption was evaluated. MiniBESTest was used to assess balance. Ankle mobility for dorsiflexion was assessed by closed kinetic chain.

RESULTS

Individuals with FOG had lower dorsiflexion ROM compared to individuals with NFOG (FOG - right ROM: 5.99 ± 3.48 cm; left ROM: 5.96 ± 3.42 cm; NFOG - right ROM: 8.90 ± 4.23 cm; left ROM: 8.83 ± 4.12 cm).

CONCLUSION

Individuals with mild to moderate PD with FOG and high L-Dopa consumption had lower ankle dorsiflexion ROM compared to NFOG individuals.

Physiotherapy and Exercise in Parkinson's Disease

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

Effects of Cognitive Training on Balance and Motor Symptoms in Parkinson's Disease: An Exploratory Randomized Controlled Trial

BackgroundCognitive rehabilitation is a potential intervention for cognitive but also motor disorders in Parkinson's disease (PD).ObjectiveTo investigate the effects of cognitive rehabilitation on balance and motor symptoms in PD.MethodsA randomized controlled trial in a community setting, in people with mild-to-moderate PD (Hoehn and Yahr ≤ III) without cognitive impairment (MoCA ≥ 24) was conducted. Thirty-nine participants were randomly allocated to receive a cognitive intervention (Experimental Group, n = 20) or no intervention (Control Group, n = 19). The experimental protocol involved self-administered cognitive rehabilitation using the NeuronUP platform, focusing on sustained attention and information processing speed training (30 min/day, 3 days/week, 4 weeks). The Berg Balance Scale (BBS) was the main outcome. Motor variables included UPDRS-III, Percentage of Limits of Stability (%LOS) and Timed Up and Go Test (TUG). Neuropsychological variables included TMT-A, TMT-B, Processing Speed (Digit Symbol-Coding and Symbol Search) and Stroop test.ResultsAt post-intervention, marginal improvements were observed in BBS (Mean Difference = 2.23 points, 95%CI [-0.03, 4.49], p = 0.053) and significant improvements in the UPDRS-III (Mean Difference = -4.02 points, 95%CI [-7.82, -0.23], p = 0.039). No significant improvements were found in the rest of the motor and cognitive variables.ConclusionsSelf-administered cognitive training did not improve balance or cognition but significantly reduced motor symptom severity in PD. The effect of more intensive or in-person cognitive rehabilitation protocols on balance needs to be evaluated.

Cognitive measures predict falls in Parkinson's disease: Insights from the CYCLE-II cohort

BACKGROUND

Accurate prediction of falls in patients with Parkinson's disease (PWP) is crucial for effective prevention efforts. Historically, fall risk models have heavily relied on motor features, overlooking the vital cognitive-motor interplay essential for locomotion.

METHODS

Baseline assessments and year-long fall data from the CYClical Lower Extremity Exercise for Parkinson's disease II (CYCLE-II) trial's control group were utilized. A LASSO logistic regression model assessed thirty-seven demographic, motor, and cognitive variables to identify key fall predictors. To explore the practical implementation of predicting falls in a clinical setting, a second model was developed using a subset of nine candidate measures conducive for retrieval from electronic medical records. Models' accuracy was validated against Paul et al.'s 3-step fall prediction model.

RESULTS

Analysis included 123 participants (mean age 65.3 ± 8.3 years, 66 % males, mean disease duration 4.9 ± 4.1 years). Seventy-two participants (58.5 %) fell at least once; with 33.1 % occurring during walking, 34.4 % resulting in injuries. The initial model identified 8 predictors with an AUC of 0.68. The second model, incorporating disease duration and cognitive tests, achieved an AUC of 0.67, comparable to Paul et al.'s validation (AUC 0.66). Participants with poorer information processing and spatial memory were more prone to falling over the 12-month period.

CONCLUSIONS

Impaired cognitive performance and longer disease duration were powerful predictors in identifying a future fall in PWP. The link between cognitive performance and potential for falling reinforces the strong interplay between gait and cognition.

Feasibility of a Multidomain Intervention for Safe Mobility in People With Parkinson's Disease and Recurrent Falls

OBJECTIVE

Mobility limitations and falls are common in people with Parkinson's disease (PwP). Compared with exercise alone, a tailored, multidomain intervention has the potential to be more effective in improving mobility safety and preventing falls. This study aimed to explore the feasibility and potential effectiveness of a multidomain fall prevention intervention (Integrate) designed for PwP who experience frequent falls.

METHODS

The home-based intervention was delivered over a span of 6 months by occupational therapists and physiotherapists. The personalized intervention included home fall hazard reduction, exercise, and safer mobility behavior training. The participants received 8 to 12 home visits and were supported by care-partners (when necessary) to participate in the intervention.

RESULTS

Twenty-nine people (recruitment rate: 49%; drop-out rate: 10%) with moderate to advanced Parkinson's disease, a history of recurrent falls, and mild to moderate cognitive impairment participated in the study, with 26 people completing the study. A moderate-to-high adherence to the intervention was observed, and there were no adverse events related to the intervention. Twenty-one (81%) participants met or exceeded their safer mobility goal based on the Goal Attainment Scale. The participants exhibited a median 1.0-point clinically meaningful improvement according to the Short Physical Performance Battery. An exploratory analysis revealed that fall rates were reduced by almost 50% in the 6-month follow-up period (incidence rate ratio: 0.51; 95% confidence interval 0.28-0.92).

CONCLUSION

A multidomain occupational therapy and physiotherapy intervention for PwP experiencing recurrent falls was feasible and appeared to improve mobility safety. A randomized trial powered to detect the effects of the intervention on falls and mobility is warranted.

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.

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

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

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

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

Effect of Vestibular-Oriented Balance Training on Postural Control and Risk of Fall in Patients With Parkinson's Disease

Background: Parkinson's disease is a neurodegenerative disorder that affects balance and increases the risk of falling by compromising vestibular signal processing. Objectives: This study aims to assess the impact of vestibular-oriented balance training on postural control and fall risk among people in the middle stages of PD. Methods: Forty middle-stage individuals with PD were assigned to the vestibular-oriented balance training (study group) or the traditional balance training (control group). Outcome measures including Functional Gait Assessment (FGA) and modified Clinical Test of Sensory Interaction on Balance (mCTSIB) using the Biodex Balance System were measured before, immediately after and 4 weeks after treatment. Results: There was a significant group interaction by time for all outcome measures (p < 0.001). The results showed that the difference in the FGA and mCTSIB scores from baseline was significant between the two groups at all time points (p < 0.001). The study group showed significant sustained improvements in the FGA score overtime, while the control group had a significant improvement at Week 8 but that did not last to Week 12. In mCTSIB, the study group improved significantly in all test conditions (p < 0.001), while the control group showed significant improvement only in Conditions 1 and 2, without lasting effects at Week 12 (p > 0.05). Conclusions: The findings indicate that the implementation of vestibular-oriented balance training during the middle stage of PD might have a notable and lasting impact on both postural control and the risk of falls.

Modulating the cholinergic system-Novel targets for deep brain stimulation in Parkinson's disease

Parkinson's disease (PD) is the second-fastest growing neurodegenerative disease in the world. The major clinical symptoms rigor, tremor, and bradykinesia derive from the degeneration of the nigrostriatal pathway. However, PD is a multi-system disease, and neurodegeneration extends beyond the degradation of the dopaminergic pathway. Symptoms such as postural instability, freezing of gait, falls, and cognitive decline are predominantly caused by alterations of transmitter systems outside the classical dopaminergic axis. While levodopa and deep brain stimulation (DBS) of the subthalamic nucleus or globus pallidus internus effectively address PD primary motor symptoms, they often fall short in mitigating axial symptoms and cognitive impairment. Along these lines, the cholinergic system is increasingly recognized to play a crucial role in governing locomotion, postural stability, and cognitive function. Thus, there is a growing interest in bolstering the cholinergic tone by DBS of cholinergic targets such as the pedunculopontine nucleus (PPN) and nucleus basalis of Meynert (NBM), aiming to alleviate these debilitating symptoms resistant to traditional treatment strategies targeting the dopaminergic network. This review offers a comprehensive overview of the role of cholinergic dysfunction in PD. We discuss the impact of PPN and NBM DBS on the management of symptoms not readily accessible to established DBS targets and pharmacotherapy in PD and seek to provide guidance on patient selection, surgical approach, and stimulation paradigms.

Exercise and Sports Science Australia updated position statement on exercise for preventing falls in older people living in the community

BACKGROUNDS

Falls affect a significant number of older Australians and present a major challenge to health care providers and health systems with over 380 older Australians hospitalised for a fall each day.

OBJECTIVES

This statement seeks to inform and guide exercise practitioners and health professionals in safe and effective prescription of exercise to prevent falls amongst community-dwelling older people.

EXERCISE PRESCRIPTION TO PREVENT FALLS

Exercise is crucial for preventing falls in older age. Research evidence has identified that programmes which include functional balance and muscle strength training are the most effective in preventing falls. It is also important for exercise to be progressively challenging, ongoing and of sufficient dose to maximise its benefits in reducing falls. Additional (non-exercise) interventions are necessary for people with complex medical conditions, recent hospitalisation and/or particular risk factors not improved by exercise. People at a higher risk of falls may need greater support to undertake safe and effective fall prevention exercise.

SUMMARY

Global guidelines for fall prevention and management recommend that all older adults should receive advice about exercise to prevent falls. Qualified exercise professionals are well placed to prescribe and supervise functional balance and muscle strength training to older people with varied functional abilities, including those with co-morbidities.

Predictive Factors and the Predictive Scoring System for Falls in Acute Care Inpatients: Retrospective Cohort Study

Background

Falls in hospitalized patients are a serious problem, resulting in physical injury, secondary complications, impaired activities of daily living, prolonged hospital stays, and increased medical costs. Establishing a fall prediction scoring system to identify patients most likely to fall can help prevent falls among hospitalized patients.

objectives

This study aimed to identify predictive factors of falls in acute care hospital patients, develop a scoring system, and evaluate its validity.

Methods

This single-center, retrospective cohort study involved patients aged 20 years or older admitted to Shizuoka General Hospital between April 2019 and September 2020. Demographic data, candidate predictors at admission, and fall occurrence reports were collected from medical records. The outcome was the time from admission to a fall requiring medical resources. Two-thirds of cases were randomly selected as the training set for analysis, and univariable and multivariable Cox regression analyses were used to identify factors affecting fall risk. We scored the fall risk based on the estimated hazard ratios (HRs) and constructed a fall prediction scoring system. The remaining one-third of cases was used as the test set to evaluate the predictive performance of the new scoring system.

Results

A total of 13,725 individuals were included. During the study period, 2.4% (326/13,725) of patients experienced a fall. In the training dataset (n=9150), Cox regression analysis identified sex (male: HR 1.60, 95% CI 1.21-2.13), age (65 to <80 years: HR 2.26, 95% CI 1.48-3.44; ≥80 years: HR 2.50, 95% CI 1.60-3.92 vs 20-<65 years), BMI (18.5 to <25 kg/m²: HR 1.36, 95% CI 0.94-1.97; <18.5 kg/m²: HR 1.57, 95% CI 1.01-2.44 vs ≥25 kg/m²), independence degree of daily living for older adults with disabilities (bedriddenness rank A: HR 1.81, 95% CI 1.26-2.60; rank B: HR 2.03, 95% CI 1.31-3.14; rank C: HR 1.23, 95% CI 0.83-1.83 vs rank J), department (internal medicine: HR 1.23, 95% CI 0.92-1.64; emergency department: HR 1.81, 95% CI 1.26-2.60 vs department of surgery), and history of falls within 1 year (yes: HR 1.66, 95% CI 1.21-2.27) as predictors of falls. Using these factors, we developed a fall prediction scoring system categorizing patients into 3 risk groups: low risk (0-4 points), intermediate risk (5-9 points), and high risk (10-15 points). The c-index indicating predictive performance in the test set (n=4575) was 0.733 (95% CI 0.684-0.782).

Conclusions

We developed a new fall prediction scoring system for patients admitted to acute care hospitals by identifying predictors of falls in Japan. This system may be useful for preventive interventions in patient populations with a high likelihood of falling in acute care settings.

The effects of dance interventions on reducing the risk of falls in older adults: a network meta-analysis

Objective

The efficacy of dance in reducing fall risks among older adults highlights its potential for geriatric health, but the optimal dance style remains uncertain. The present study endeavors to systematically analyze the effects of various dance forms on reducing the risk of falls among older adult, with the aim of providing evidence-based insights into the most efficacious dance styles for this population.

Design

The network meta-analysis of the existing literature was conducted to synthesize the available evidence regarding the effectiveness of various dance interventions in reducing the risk of falls among older adults.

Methods

We searched seven databases for randomized controlled trials on dance interventions for fall prevention in older adults and used Stata 17.0 for network meta-analysis.

Results

Twenty-seven studies (n = 1,219 older adults) were included. Creative Dance (CD) significantly improved the Berg Balance Scale score in healthy older adults (p < 0.05) and ranked best. Folk Dance (FD), CD, and Ballroom Dance (BD) all significantly improved Timed Up and Go time compared to controls, with FD ranking best overall. In Parkinson's disease patients, both BD and FD significantly improved the Berg Balance Score, with FD again ranking best.

Conclusion

Creative dance, Folk dance, and Ballroom dance effectively reduce the risk of falls in older adults. Creative dance enhanced the Berg Balance Score the most among healthy older adults, while Folk dance improved the Timed Up and Go test performance the best. Similarly, among patients with Parkinson's disease, Folk dance exhibits the best effect in improving Berg Balance Scale scores.

Clinical trial registration

The protocol of this study was registered with the International Prospective Register of Systematic Review, PROSPERO, under the identification number CRD42022323426, and can be integrally assessed online (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022323426).

Balance and gait disorders in de novo Parkinson's disease: support for early rehabilitation

BACKGROUND

Postural instability is considered a late complication of Parkinson's disease (PD). However, growing evidence shows that balance and gait problems may occur early in the disease.

OBJECTIVE

To describe balance, gait, and falls/near falls in persons with newly diagnosed, untreated PD ("de novo"), and to compare this with persons with mild-moderate PD (Later PD). In addition, we evaluated differences relative to PD subtypes in de novo PD.

METHODS

De novo (n = 54) and Later (n = 58) PD were assessed regarding motor symptoms, balance, gait, and falls/near falls.

RESULTS

At least 25% of de novo PD had impaired reactive balance and/or comfortable gait speed ≤ 1.0 m/s. At least 50% had abnormal dynamic balance. A third reported balance problems during dual-tasking. Five persons (9%) reported falls/near falls. The median (q1-q3) motor symptom score was 21 (14-28) in de novo PD and 13.5 (9-20) in Later PD (p < 0.001). Later PD performed worse on more balance-demanding tests and a higher percentage of individuals reported falls/near falls (p ≤ 0.048). De novo PIGD PD (n = 10) exhibited worse motor symptoms, reactive and dynamic balance, gait speed, mobility, and freezing of gait as compared to the non-PIGD de novo PD (n = 37) (p ≤ 0.049).

CONCLUSION

Balance and gait were impaired in de novo PD and most pronounced in PIGD subtype. In addition, balance difficulties during dual-tasking and falls/near falls were evident during this early stage. The lower scores of motor symptoms in Later PD did not result in better mobility, balance, or less falls/near falls indicating that medications have less effect on these symptoms.

Deep learning-based detection of affected body parts in Parkinson's disease and freezing of gait using time-series imaging

We proposed a deep learning method using a convolutional neural network on time-series (TS) images to detect and differentiate affected body parts in people with Parkinson's disease (PD) and freezing of gait (FOG) during 360° turning tasks. The 360° turning task was performed by 90 participants (60 people with PD [30 freezers and 30 nonfreezers] and 30 age-matched older adults (controls) at their preferred speed. The position and acceleration underwent preprocessing. The analysis was expanded from temporal to visual data using TS imaging methods. According to the PD vs. controls classification, the right lower third of the lateral shank (RTIB) on the least affected side (LAS) and the right calcaneus (RHEE) on the LAS were the most relevant body segments in the position and acceleration TS images. The RHEE marker exhibited the highest accuracy in the acceleration TS images. The identified markers for the classification of freezers vs. nonfreezers vs. controls were the left lateral humeral epicondyle (LELB) on the more affected side and the left posterior superior iliac spine (LPSI). The LPSI marker in the acceleration TS images displayed the highest accuracy. This approach could be a useful supplementary tool for determining PD severity and FOG.

Exercise, Neuroprotective Exerkines, and Parkinson's Disease: A Narrative Review

Parkinson's disease (PD) is a prevalent neurodegenerative disease in which treatment often includes an exercise regimen. Exercise is neuroprotective in animal models of PD, and, more recently, human clinical studies have verified exercise's disease-modifying effect. Aerobic exercise and resistance training improve many of PD's motor and non-motor symptoms, while neuromotor therapy and stretching/flexibility exercises positively contribute to the quality of life in people with PD. Therefore, understanding the role of exercise in managing this complex disorder is crucial. Exerkines are bioactive substances that are synthesized and released during exercise and have been implicated in several positive health outcomes, including neuroprotection. Exerkines protect neuronal cells in vitro and rodent PD models in vivo. Aerobic exercise and resistance training both increase exerkine levels in the blood, suggesting a role for exerkines in the neuroprotective theory. Many exerkines demonstrate the potential for protecting the brain against pathological missteps caused by PD. Every person (people) with Parkinson's (PwP) needs a comprehensive exercise plan tailored to their unique needs and abilities. Here, we provide an exercise template to help PwP understand the importance of exercise for treating PD, describe barriers confronting many PwP in their attempt to exercise, provide suggestions for overcoming these barriers, and explore the role of exerkines in managing PD. In conclusion, exercise and exerkines together create a powerful neuroprotective system that should contribute to slowing the chronic progression of PD.

Parkinson's disease motor intervention patterns: a network meta-analysis based on patient motor function

Background

Parkinson's disease is characterized by symptoms such as bradykinesia and rigidity, which worsen as the disease progresses, significantly impacting patients' independence and quality of life. This study utilizes a network meta-analysis approach to quantify information gathered from randomized controlled trials (RCTs) regarding motor interventions that effectively improve the motor function of Parkinson's disease patients, aiming to provide evidence for selecting appropriate exercise intervention strategies for patients.

Methods

A systematic search strategy for randomized controlled trials (RCTs) restricted to English was constructed based on multiple biomedical databases. Databases searched included PubMed, Embase, Cochrane, Web of Science, CINAHL, CBM, China National Knowledge Infrastructure (CNKI), Wan fang, VIP, etc., with searches conducted from inception to July 9, 2023. Two authors screened all studies, extracted data, and used frequency domain analysis methods. Network meta-analysis was performed using STATA software version 18.0 to compare and rank exercises that could effectively improve the motor function of Parkinson's disease patients (measured by indicators such as MDS-UPDRS-III, TUG, BBS, Mini-BES Test, 6MWT scores). Additionally, a series of analyses and evaluations were conducted, such as assessing the methodological quality of included studies using the Cochrane risk of bias tool.

Results

The network meta-analysis included a total of 111 studies involving 5,358 participants, 133 intervention experiments, and 31 intervention measures. Although most exercise interventions showed effectiveness, cumulative ranking curves under the surface (SUCRA) values showed that archery exercise significantly improved patients' MDS-UPDRS-III scores (SUCRA = 95.6%), significantly superior to routine care [standardized mean difference (SMD = 16.92, 95%CI = -28.97, -4.87)]. High-intensity and agility exercise (High strength and agility) referred to as high-intensity exercise or agility training or a combination of both, collectively termed as high-intensity agility training, significantly improved patients' completion time for the time-up-and-go test (SUCRA = 99.7%), (SMD = -7.88, 95%CI = -9.47, -6.28). Dance and Tai Chi exercises significantly improved patients' balance abilities: Mini-Balance Evaluation Systems Test (SUCRA = 77.9%), (SMD = 5.25, 95%CI = -0.42, 10.92) for dance intervention and Berg Balance Scale (SUCRA = 94.7%), (SMD = 11.22, 95%CI = 3.26, 19.18) for Tai Chi intervention. Dance also significantly improved patients' walking ability in the 6-min walk test (SUCRA = 80.5%), (SMD = 71.31, 95%CI = 13.77, 128.84).

Conclusion

Compared to other exercises, archery, dance, Tai Chi, and high-intensity agility exercises demonstrate superior efficacy in improving the motor function of Parkinson's disease patients.

Reimagining Day Rehabilitation For Frailty and Neurodegenerative Conditions through the integrated Rehabilitation and EnAblement Program (iREAP)

Background

integrated Rehabilitation and EnAblement Program (iREAP) is an innovative redesign of the traditional day rehabilitation model, providing an anticipatory, early assessment and intervention program that manages care of community-dwelling older people with complex needs. It coordinates access to disciplines across medical, allied health and nursing, with a self-management focus, partnering with primary health in an integrated approach.

Objective

This observational study reviews the effectiveness of iREAP on frailty, patient activation, quality of life and physical outcome measures on older people at risk of, or experiencing falls and frailty, or with neurodegenerative conditions, including Parkinson's Disease.

Methods

99 participants completed the eight-week multidisciplinary program. Patient outcome measures included Rockwood Clinical Frailty Scale, quality of life measures, Patient Activation Measure, Timed Up and Go, 6 Minute Walk Test and Berg Balance Scale.

Results

On completion of iREAP, participants displayed improvements in their Rockwood Clinical Frailty Scores (mildly frail to vulnerable), 'patient activation' (55.08 to 60.61), quality of life (Parkinson's Disease Questionnaire-39, 49.93 to 47.16; WHO Quality of Life - Bref physical domain, 21 to 22.7) and physical measures including balance (44 to 49/56 Berg Balance scale) and mobility (294 m to 336 m, 6-minute walk test). Falls were not reduced at twelve months post-program (3.40 to 2.01).

Conclusion

iREAP is an interdisciplinary, early assessment and intervention program with the potential to reverse frailty and improve quality of life for complex older patients. This paper offers a platform for future research, given the paucity of evidence reviewing the efficacy of integrated anticipatory models of care in older adults with complex needs.

Generalization of In-Place Balance Perturbation Training in People With Parkinson Disease

BACKGROUND AND PURPOSE

Reactive balance training improves reactive postural control in people with Parkinson disease (PwPD). However, the extent to which reactive balance training generalizes to a novel, unpracticed reactive balance task is unknown. This study aimed to determine whether reactive training stepping through support surface translations can be generalized to an unpracticed, instrumented tether-release task.

METHODS

Twenty-five PwPD (70.52 years ± 7.15; Hoehn and Yahr range 1-3) completed a multiple baseline, open-label, uncontrolled pre-post intervention study. Stepping was trained through a 2-week (6-session) intervention with repeated support surface translations. Performance on an untrained tether-release task (generalization task) was measured at 2 baseline assessments (B1 and B2, 2 weeks apart), immediately after the intervention (P1), and 2 months after training (P2). The tether-release task outcomes were the anterior-posterior margin of stability (MOS), step length, and step latency during backward and forward steps.

RESULTS

After support surface translation practice, tether-release stepping performance improved in MOS, step length, and step latency for both backward and forward steps compared to baseline ( P < 0.05). Improvements in MOS and step length during backward and forward steps in the tether-release task, respectively, were related to stepping changes in the practiced task. However, the improvements in the generalization task were not retained for 2 months.

DISCUSSION AND CONCLUSIONS

These findings support short-term generalization from trained balance tasks to novel, untrained tasks. These findings contribute to our understanding of the effects and generalization of reactive step training in PwPD.

VIDEO ABSTRACT AVAILABLE

for more insights from the authors (see the Video, Supplemental Digital Content available at http://links.lww.com/JNPT/A465 ).

Survey of the Knowledge, Attitudes, and Practices of Neurologists Regarding Exercise in Parkinson's Disease

BACKGROUND AND PURPOSE

Exercise and physiotherapy can exert potentially beneficial effects on the motor and nonmotor features of Parkinson's disease (PD). We conducted an e-mail survey to assess the knowledge, attitudes, and practices of neurologists regarding exercise among patients with PD.

METHODS

A total of 222 neurologists from the Korean Movement Disorder Society and the Korean Society of Neurologists completed the survey and were classified into 4 clusters using the k-means clustering algorithm based on their institute types, the proportions of PD patients in their clinics, and the number of years working as neurologists.

RESULTS

Specialists working at referral hospitals (Clusters 1 and 2) were more confident than general neurologists (Clusters 3 and 4) about exercise improving the general motor features of PD. Specialists recommended more-frequent intense exercise compared with physicians not working at referral hospitals. The specialists in Cluster 1, representing >50% of PD patients in the clinics at referral hospitals, recommended exercise regardless of the disease stage, whereas the general neurologists in Clusters 3 and 4 recommended low-intensity exercise at an early stage of disease. Although most of the respondents agreed with the need for PD patients to exercise, less than half had prescribed rehabilitation or physiotherapy. More than 90% of the respondents answered that developing an exercise/physiotherapy protocol for PD would be helpful.

CONCLUSIONS

Specialists were more confident than general neurologists about the effect of exercise and recommended more-intense activities regardless of the disease stage. These results highlight the need to develop clinical practice guidelines and PD-specialized exercise protocols to provide optimal care for PD patients.

Exploring the experiences, priorities and preferences of people living with Parkinson's on exercise and physical activity promotion in the UK

BACKGROUND

People with Parkinson's (PwP) want access to timely, relevant, and specific exercise and physical activity (PA) information to enable them to manage their symptoms and maintain wellbeing and quality of life. Research that promotes exercise in this population group is limited. Little is also known about the clinical practice around PA promotion in this population, especially around the time of diagnosis.

OBJECTIVE

To explore the experiences, preferences, and priorities of PwP around exercise and PA promotion and assess their knowledge on these topics.

METHODS

A cross-sectional online survey for PwP in the United Kingdom was conducted from July to December 2021.

RESULTS

430 participants started the survey and 405 completed it. Participants had a mean age of 65.1 (±9.2) and had been living with Parkinson's for a varying time (up to 2 years = 38%, up to 6 years = 39% and for 7 or more years = 23%). Most participants reported they had not received an education (68%; n = 276) or exercise intervention (54%; n = 217) as part of their routine management by the National Health Service (NHS) since diagnosis and had sought services privately. Knowledge of the overall benefits of exercise was good, however participants lacked specific knowledge on the impact of Parkinson's Disease (PD) on posture, falls and muscle strength. 90% of participants reported they would participate in an exercise and PA education interventions.

CONCLUSIONS

PwP want exercise and PA education interventions that provide knowledge, skills and access to opportunities that enable participation. For the majority, these interventions have not been provided as part of their routine care pathway. To align with the priorities and preferences of PwP, interventions should be offered around the time of diagnosis, include content that is relevant and specific to how exercise and PA can mitigate symptoms of PD and should be delivered in person or online in a group setting.

Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis

BACKGROUND

Physical exercise is effective in managing Parkinson's disease (PD), but the relative benefit of different exercise types remains unclear.

OBJECTIVES

To compare the effects of different types of physical exercise in adults with PD on the severity of motor signs, quality of life (QoL), and the occurrence of adverse events, and to generate a clinically meaningful treatment ranking using network meta-analyses (NMAs).

SEARCH METHODS

An experienced information specialist performed a systematic search for relevant articles in CENTRAL, MEDLINE, Embase, and five other databases to 17 May 2021. We also searched trial registries, conference proceedings, and reference lists of identified studies up to this date.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing one type of physical exercise for adults with PD to another type of exercise, a control group, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. A third author was involved in case of disagreements. We categorized the interventions and analyzed their effects on the severity of motor signs, QoL, freezing of gait, and functional mobility and balance up to six weeks after the intervention using NMAs. Two review authors independently assessed the risk of bias using the risk of bias 2 (RoB 2) tool and rated the confidence in the evidence using the CINeMA approach for results on the severity of motor signs and QoL. We consulted a third review author to resolve any disagreements. Due to heterogeneous reporting of adverse events, we summarized safety data narratively and rated our confidence in the evidence using the GRADE approach.

MAIN RESULTS

We included 154 RCTs with a total of 7837 participants with mostly mild to moderate disease and no major cognitive impairment. The number of participants per study was small (mean 51, range from 10 to 474). The NMAs on the severity of motor signs and QoL included data from 60 (2721 participants), and 48 (3029 participants) trials, respectively. Eighty-five studies (5192 participants) provided safety data. Here, we present the main results. We observed evidence of beneficial effects for most types of physical exercise included in our review compared to a passive control group. The effects on the severity of motor signs and QoL are expressed as scores on the motor scale of the Unified Parkinson's Disease Rating Scale (UPDRS-M) and the Parkinson's Disease Questionnaire 39 (PDQ-39), respectively. For both scales, higher scores denote higher symptom burden. Therefore, negative estimates reflect improvement (minimum clinically important difference: -2.5 for UPDRS-M and -4.72 for PDQ-39). Severity of motor signs The evidence from the NMA (60 studies; 2721 participants) suggests that dance and gait/balance/functional training probably have a moderate beneficial effect on the severity of motor signs (dance: mean difference (MD) -10.18, 95% confidence interval (CI) -14.87 to -5.36; gait/balance/functional training: MD -7.50, 95% CI -11.39 to -3.48; moderate confidence), and multi-domain training probably has a small beneficial effect on the severity of motor signs (MD -5.90, 95% CI -9.11 to -2.68; moderate confidence). The evidence also suggests that endurance, aqua-based, strength/resistance, and mind-body training might have a small beneficial effect on the severity of motor signs (endurance training: MD -5.76, 95% CI -9.78 to -1.74; aqua-based training: MD -5.09, 95% CI -10.45 to 0.40; strength/resistance training: MD -4.96, 95% CI -9.51 to -0.40; mind-body training: MD -3.62, 95% CI -7.24 to 0.00; low confidence). The evidence is very uncertain about the effects of "Lee Silverman Voice training BIG" (LSVT BIG) and flexibility training on the severity of motor signs (LSVT BIG: MD -6.70, 95% CI -16.48 to 3.08; flexibility training: MD 4.20, 95% CI -1.61 to 9.92; very low confidence). Quality of life The evidence from the NMA (48 studies; 3029 participants) suggests that aqua-based training probably has a large beneficial effect on QoL (MD -15.15, 95% CI -23.43 to -6.87; moderate confidence). The evidence also suggests that mind-body, gait/balance/functional, and multi-domain training and dance might have a small beneficial effect on QoL (mind-body training: MD -7.22, 95% CI -13.57 to -0.70; gait/balance/functional training: MD -6.17, 95% CI -10.75 to -1.59; multi-domain training: MD -5.29, 95% CI -9.51 to -1.06; dance: MD -3.88, 95% CI -10.92 to 3.00; low confidence). The evidence is very uncertain about the effects of gaming, strength/resistance, endurance, and flexibility training on QoL (gaming: MD -8.99, 95% CI -23.43 to 5.46; strength/resistance training: MD -6.70, 95% CI -12.86 to -0.35; endurance training: MD -6.52, 95% CI -13.74 to 0.88; flexibility training: MD 1.94, 95% CI -10.40 to 14.27; very low confidence). Adverse events Only 85 studies (5192 participants) provided some kind of safety data, mostly only for the intervention groups. No adverse events (AEs) occurred in 40 studies and no serious AEs occurred in four studies. AEs occurred in 28 studies. The most frequently reported events were falls (18 studies) and pain (10 studies). The evidence is very uncertain about the effect of physical exercise on the risk of adverse events (very low confidence). Across outcomes, we observed little evidence of differences between exercise types.

AUTHORS' CONCLUSIONS

We found evidence of beneficial effects on the severity of motor signs and QoL for most types of physical exercise for people with PD included in this review, but little evidence of differences between these interventions. Thus, our review highlights the importance of physical exercise regarding our primary outcomes severity of motor signs and QoL, while the exact exercise type might be secondary. Notably, this conclusion is consistent with the possibility that specific motor symptoms may be treated most effectively by PD-specific programs. Although the evidence is very uncertain about the effect of exercise on the risk of adverse events, the interventions included in our review were described as relatively safe. Larger, well-conducted studies are needed to increase confidence in the evidence. Additional studies recruiting people with advanced disease severity and cognitive impairment might help extend the generalizability of our findings to a broader range of people with PD.

A systematic review of Behaviour Change Interventions to improve exercise self-efficacy and adherence in people with Parkinson's disease using the Theoretical Domains Framework

Physical activity and exercise can limit the development of sarcopenia in Parkinson's Disease. This review aims to evaluate the potential effects of behavioural change (BC) interventions on exercise self-efficacy and adherence in people with Parkinson's. We searched nine databases and included randomised and non-randomised studies reporting exercise self-efficacy, quality of life (QoL), physical function and/or exercise adherence. Two reviewers independently screened, data extracted, and assessed risk of bias and certainty of evidence. The interventions were mapped to the Theoretical Domains Framework. Eleven studies (n=901) were included. Four were randomised trials and risk of bias was mixed. Most interventions were multi-component, including education, behavioural techniques, and support groups. The most effective domains appear to be Behavioural regulation, Belief about Capabilities, Social influences, Reinforcement and Goals. Future research should examine multi-component BC interventions encompassing the five most effective TDF domains.

Exercise and physical activity promotion for people newly diagnosed with Parkinson's disease: a UK survey exploring current practice and the views of healthcare professionals

OBJECTIVES

Exercise and physical activity (PA) are increasingly recognized as important components in the management of Parkinson's disease (PD). Their promotion at diagnosis is essential for better management of symptoms and overall well-being. Healthcare professionals (HCPs) are pivotal to the promotion of exercise and PA, but there is limited guidance on the content of such interventions. This study describes current practice, and explores views of HCPs around PA and exercise promotion at diagnosis for people with PD (PwP) DESIGN: A cross-sectional study using an anonymous online survey.

PARTICIPANTS

HCPs working with PwP in the UK.

RESULTS

Twenty-nine doctors, 17 nurses and 106 physiotherapists completed the survey. All nurses, 99% of physiotherapists and 72% of doctors reported that they always promote exercise and PA during clinic appointments. HCPs identified how PA impacts PD symptoms, evidence on the role of exercise, and signposting to support groups as core topics in PA promotion for PwP. However, these topics are mainly addressed during physiotherapy appointments. Referrals to physiotherapy occur most frequently when PwP experience falls or mobility issues, rather than at diagnosis. HCPs (52% doctors and 41% of nurses) identified lack of confidence as a barrier to prescribing exercise to PwP.

CONCLUSION

The importance of promoting PA at diagnosis is widely acknowledged by HCPs. There are variations between disciplines in terms of the tools used, and the timing and duration of interventions. Previously identified barriers to exercise promotion were also found in this study, and should be explored further in order to aid the implementation of effective interventions.

A Novel Home-Based Telerehabilitation Program Targeting Fall Prevention in Parkinson Disease: A Preliminary Trial

Background and Objectives

Falls in a person with Parkinson disease (PwP) are frequent, consequential, and only partially prevented by current therapeutic options. Notably, most falls in PwPs occur in the home or its immediate surroundings; however, our current strategies for fall prevention are clinic-centered. The primary objective of this nonrandomized pilot trial was to investigate the feasibility and preliminary efficacy of the novel implementation of home-based PD telerehabilitation (tele-physical/occupational therapy) focusing on fall risk reduction and home-safety modification.

Methods

Persons with mild-to-moderate PD who were identified as being at risk of falls by their movement disorders neurologist were recruited from a tertiary movement disorders clinic. After an initial in-person evaluation by the study physical and occupational therapists, 15 patients with PD (Hoehn and Yahr Stage 2 (n = 8) and Stage 3 (n = 7)) participated in 4 biweekly PT/OT televisits with care partner supervision over the course of 10 weeks. The Goal Attainment Scale (GAS) was implemented to assess progress toward individualized PT/OT goals established at baseline. Outcomes were assessed at the end of the intervention at 10 weeks and at a six-month follow-up.

Results

Participants completed all 120 protocol-defined televisits without dropouts and adverse events. At 10 weeks, mean composite PT and OT-GAS scores showed significant improvement from baseline (PT: p < 0.001, OT: p < 0.008), which continued at 6 months (PT: p < 0.0005, OT: p < 0.0005). Home-modification recommendations made through novel virtual home-safety tours were cumulatively met by participants at 87% at 10 weeks and 91% at 6 months.

Discussion

Home-based telerehabilitation is a promising new strategy toward fall prevention in PD. The GAS has the potential to serve as an effective and patient-driven primary outcome variable for rehabilitation interventions for heterogeneous PwPs to assess progress toward personalized goals.

Trial Registration Information

ClinicalTrial.gov identifier: NCT04600011.

Coproduction and Usability of a Smartphone App for Falls Reporting in Parkinson Disease

OBJECTIVE

The purpose of this study was to coproduce a smart-phone application for digital falls reporting in people with Parkinson disease (PD) and to determine usability using an explanatory mixed-methods approach.

METHODS

This study was undertaken in 3 phases. Phase 1 was the development phase, in which people with PD were recruited as co-researchers to the project. The researchers, alongside a project advisory group, coproduced the app over 6 months. Phase 2 was the implementation phase, in which 15 people with PD were invited to test the usability of the app. Phase 3 was the evaluation phase, in which usability was assessed using the systems usability scale by 2 focus groups with 10 people with PD from phase 2.

RESULTS

A prototype was successfully developed by researchers and the project advisory group. The usability of the app was determined as good (75.8%) by people with PD when rating using the systems usability scale. Two focus groups (n = 5 per group) identified themes of 1) usability, 2) enhancing and understanding management of falls, and 3) recommendations and future developments.

CONCLUSIONS

A successful prototype of the iFall app was developed and deemed easy to use by people with PD. The iFall app has potential use as a self-management tool for people with PD alongside integration into clinical care and research studies.

IMPACT

This is the first digital outcome tool to offer reporting of falls and near-miss fall events. The app may benefit people with PD by supporting self-management, aiding clinical decisions in practice, and providing an accurate and reliable outcome measure for future research.

LAY SUMMARY

A smartphone application designed in collaboration with people who have PD to record their falls was acceptable and easy to use by people with PD.

Medical, surgical, and physical treatments for Parkinson's disease

Although dopamine replacement therapy remains a core component of Parkinson's disease treatment, the onset of motor fluctuations and dyskinetic movements might require a range of medical and surgical approaches from a multidisciplinary team, and important new approaches in the delivery of dopamine replacement are becoming available. The more challenging, wide range of non-motor symptoms can also have a major impact on the quality of life of a patient with Parkinson's disease, and requires careful multidisciplinary management using evidence-based knowledge, as well as appropriately tailored strategies according to the individual patient's needs. Disease-modifying therapies are urgently needed to prevent the development of the most disabling refractory symptoms, including gait and balance difficulties, cognitive impairment and dementia, and speech and swallowing impairments. In the third paper in this Series, we present the latest evidence supporting the optimal treatment of Parkinson's disease, and describe an expert approach to many aspects of treatment choice where an evidence base is insufficient.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Walking to Prevent Fear of Falling Among Community-Dwelling Older Adults: A Scoping Review

The current review sought to identify and synthesize the evidence on available interventions that include walking and their impact on fear of falling (FOF) among community-dwelling older adults without cognitive impairment. A 10-year search was conducted (January 2012 to January 2022) in two peer-reviewed databases. A total of 116 articles were identified, and 22 articles were reviewed. Most studies included multicomponent walking interventions, such as walking and another type of intervention or exercise. Among the different questionnaires to assess FOF, the Falls Efficacy Scale-International was the most used in 77.3% (n = 17) of studies. In addition to walking, interventions to reduce FOF mainly included balance training, lower extremity strengthening, cardio or aerobic exercises, or a combination of these exercises. Further research is needed to evaluate the impact of unidimensional walking interventions, as well as those that incorporate psychological and technological elements targeted to FOF prevention and management. [Journal of Gerontological Nursing, 50(1), 15-21.].

Emergency department visits in Parkinson's disease: The impact of comorbid conditions

INTRODUCTION

Older adults have complex, often overlapping, medical conditions requiring careful management that may lead to increased emergency department usage compared to younger adults. Parkinson's disease (PD), a progressive neurodegenerative disorder characterized by distinct motor and nonmotor features, frequently occurs with additional comorbid disease. Classifying comorbid conditions into clinical subgroups allows for further understanding of the heterogeneity in outcomes in patients with PD. The current study examines the reasons for emergency department (ED) visits in a cohort of patients with PD and identifies comorbidities that are potential risk factors for specific ED presenting conditions.

METHODS

Using data from Optum's de-identified Integrated Claims-Clinical dataset years 2010-2018, patients with PD were identified based on ICD-9/10 diagnosis codes. We identified all ED visits occurring after the first observed diagnosis code for PD. Comorbid conditions were classified using the AHRQ Clinical Classification Software (CCS). We classified patients using Latent Class Analysis (LCA) and conducted multiple logistic regression models with the outcome of reason-for-visit to examine the associations with comorbidity-profile class, patient demographics, and socio-economic characteristics.

RESULTS

The most common reasons for ED admission were injuries such as fractures and contusions, diseases of the circulatory system, and general signs and symptoms, including abdominal pain, malaise, and fatigue. Comorbid medical conditions often observed in this patient population include depression, diabetes mellitus, and chronic pulmonary disease. Patients in the "Poorest Health" classification of the LCA had greater odds for ED admission for diseases related to the gastrointestinal system, musculoskeletal system, and injury/poisoning categories and reduced odds for admission for diseases of the circulatory system.

DISCUSSION

Patients with PD who present to the emergency department with injuries are more likely to be in poor health overall with a high comorbidity burden. Clarifying the complex medical needs of patients with PD is the first step to further individualize care, which may reduce ED visits in this population, improve quality of life, and lessen the footprint on the healthcare system.

Stability Changes in Fall-Prone Individuals With Parkinson Disease Following Reactive Step Training

BACKGROUND AND PURPOSE

Poor reactive steps may lead to falls in people with Parkinson disease (PwPD). However, whether reactive steps can be improved in PwPD at risk for falls or whether step training reduces falls remains unclear. This study aimed to determine whether 2 weeks of reactive step training result in (1) immediate and retained improvements in stepping and (2) fewer prospective falls in PwPD at fall risk.

METHODS

Twenty-five PwPD (70.52 years ± 7.15; Hoehn & Yahr range 1-3) at risk for falls completed a multiple baseline, open-label, uncontrolled pre-/postintervention study. Stepping performance was assessed at 2 baseline assessments (B1 and B2) followed by a 2-week, 6-session training protocol. Stepping was assessed immediately (P1) and 2 months after training (P2). Primary outcomes were anterior-posterior margin of stability (MOS), step length, and step latency during backward stepping. Fall frequency was measured for 2 months before and after training.

RESULTS

MOS during backward steps was significantly larger (better) after training ( P < 0.001, d = 0.83), and improvements were retained for 2 months ( P = 0.04, d = 0.66). Step length was not statistically significant different after training ( P = 0.13, d = 0.46) or at follow-up ( P = 0.08, d = 0.62), although effect sizes were medium and large, respectively. Step latency improved after initial exposure ( P = 0.01, d = 0.60) but not following training ( P = 0.43, d = 0.35). Twelve participants experienced fewer falls after training than before (10 = no change, 5 = increase; P = 0.12). Greater improvements in MOS were related to fewer falls ( P = 0.04).

DISCUSSION AND CONCLUSIONS

Two weeks of reactive step training resulted in immediate and retained improvements in some reactive stepping outcomes in PwPD at risk for falls and may reduce fall risk. Reactive step training may be a viable approach to reduce falls in PwPD.

The effect of home-based exercise on motor symptoms, quality of life and functional performance in Parkinson's disease: a systematic review and meta-analysis

BACKGROUND

Faced with the lack of physical activity caused by mandatory home isolation during special periods and patients' inconvenience in carrying out professionally supervised exercise, many home-based exercise programs have been developed. This systematic review and meta-analysis aimed to examine the effects of home-based exercise on measures of motor symptoms, quality of life and functional performance in Parkinson's disease (PD) patients.

METHODS

We performed a systematic review and meta-analysis, and searched PubMed, MEDLINE, Embase, Cochrane library, and Web of Science from their inception date to April 1, 2023. The quality of the literature was assessed using PEDro's quality scale. The data was pooled using R software. Results are presented as pooled standardized mean difference (SMD) with 95% confidence interval (CI).

RESULTS

A total of 20 studies involving 1885 PD patients were included. Meta-analysis results showed that home-based exercise had a small effect in relieving overall motor symptoms in PD patients (SMD = -0.29 [-0.45, -0.13]; P < 0.0001), improving quality of life (SMD = 0.20 [0.08, 0.32]; P < 0.0001), walking speed (SMD = 0.26 [0.05, 0.48]; P = 0.005), balance ability (SMD = 0.23 [0.10, 0.36]; P < 0.0001), finger dexterity (SMD = 0.28 [0.10, 0.46]; P = 0.003) and decreasing fear of falling (SMD = -0.29 [-0.49, -0.08]; P = 0.001). However, home-based exercise did not significantly relieve the overall motor symptoms of PD patients when the training period was less than 8 weeks and the total number of sessions was less than 30.

CONCLUSION

During times of limited physical activity due to pandemics such as COVID-19, home-based exercise is an alternative to maintain and improve motor symptoms in PD patients. In addition, for the minimum dose of home-based exercise, we recommend that the exercise period is no less than 8 weeks and the total number of sessions is no less than 30 times.

TRIAL REGISTRATION

PROSPERO registration number: CRD42022329780.

Physiotherapy case reports on three people with progressive supranuclear palsy

Introduction

Progressive supranuclear palsy (PSP) is a neurodegenerative brain disease that affects patient's functionality and quality of life. Physiotherapy should be recommended at the time of diagnosis to slow the progression of disability and enhance the quality of life of these patients.

Clinical presentation

Here, we describe three cases of patients with PSP, outlining their motor and non-motor symptoms and examining their clinical progression with physiotherapy intervention. During the initial intervention years, a reduction in the number of falls was achieved, along with improvements in gait and balance.

Conclusion

Exercise and physiotherapy appear to be beneficial for patients with PSP by enhancing their functionality and quality of life. Controlling or reducing the number of falls should be the primary goal of any intervention for patients with PSP.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Association between regular physical activity and biomarker changes in early Parkinson's disease patients

INTRODUCTION

Physical activity benefits patients with Parkinson's disease (PD) and is assumed to possess disease-modifying potential. PD-related biomarkers, such as dopamine transporter (DAT) imaging and cerebrospinal fluid (CSF) α-synuclein (α-syn) and amyloid β (Aβ), correlate with disease severity and, to some extent, reflect disease progression and pathology. However, the association between regular physical activity and PD biomarker changes remains unknown. This study aimed to investigate the association between physical activity and longitudinal trajectories of PD biomarkers.

METHODS

This retrospective study included 444 patients with a median follow-up time of 5 years from the Parkinson's Progression Markers Initiative cohort. Data collection included physical activity as scaled by the Physical Activity Scale for the Elderly questionnaire, dopamine transporter imaging, CSF assessment, and serum biomarkers. We analyzed the data using a linear mixed regression model.

RESULTS

Regular physical activity was associated with a slower decline of DAT uptake in the caudate (β = 0.063, p = 0.011) and the putamen (β = 0.062, p = 0.023). No association was detected between regular physical activity and CSF, as well as serum biomarkers.

CONCLUSION

Regular physical activity is associated with favorable PD biomarker progression, indicating a potential disease-modifying effect.

Effects of Exercise-Based Interventions on Physical Activity Levels in Persons With Parkinson's Disease: A Systematic Review With Meta-analysis

BACKGROUND AND PURPOSE

Parkinson's disease (PD) is the most common neurodegenerative movement disorder. Symptom severity leads to devastating consequences such as falls, immobility, impaired quality of life, and reduced general activity. Adopting a sedentary lifestyle creates a vicious circle, as physical inactivity can negatively affect the clinical domains of PD. Despite the recognition of the disease-modifying potential of physical activity (PA), achieving adequate exercise levels can be challenging for individuals with PD. This study aimed to investigate the repercussions of exercise-based interventions to improve PA levels in persons with PD through a systematic review with meta-analysis.

METHODS

A search was conducted from database inception to February 2021 across 3 databases: PubMed, Web of Science, and Scopus. Randomized controlled trials were included if they involved persons with PD, outcome measures associated with PA levels, and an exercise-based intervention. Two reviewers performed independent data extraction and methodologic quality assessment of the studies using the Downs and Black quality checklist.

RESULTS

A total of 6 studies were included in the study (1251 persons with PD). Four intervention types were identified: balance, strength, aerobic, and multimodal exercise (combination of several types of exercise programs). The meta-analysis showed that exercise interventions have a positive effect on PA (standard mean difference = 0.50, 95% CI =-0.02, 1.00; P = .06). The risk of bias was generally low.

CONCLUSIONS

The findings support the use of exercise-based interventions (aerobic exercise, balance exercise, strength exercise, and/or multimodal exercise) to improve PA levels. However, the limited number of studies and the heterogeneity of the interventions do not allow us to draw a definitive conclusion.

Effects of three physical exercise modalities on respiratory function of older adults with Parkinson's disease: A randomized clinical trial

INTRODUCTION

Deficits in respiratory function of patients with Parkinson's disease contribute to aspiration pneumonia, one of the main causes of mortality in this population. The aim of this study was to evaluate the effects of functional training, bicycle exercise, and exergaming on respiratory function of elderly with Parkinson's disease.

METHODS

A randomized clinical trial with single blinding was conducted in a public reference outpatient clinic for the elderly. The participants were randomly assigned to three groups. Group 1 was submitted to functional training (n = 18); group 2 performed bicycle exercise (n = 20), and group 3 trained with Kinect Adventures exergames (n = 20). The sessions performed lasted 8 weeks with a frequency of three 50-min sessions per week. The primary outcome was the forced expiratory volume in the first second; and the secondary outcomes were forced vital capacity, peak expiratory flow, and maximum inspiratory and expiratory pressures.

RESULTS

The interventions performed did not improve the forced expiratory volume in the first second, forced vital capacity, and peak expiratory flow. However, group 2 improved (p = 0.03) maximum expiratory pressure (from 65.5cmH2O to 73.1cmH2O) (effect size 0.47), and group 3 increased (p = 0.03) maximum inspiratory pressure (from -61.3cmH2O to -71.6cmH2O) (effect size 0.53).

CONCLUSIONS

No effect was found on lung volume, forced respiratory flow and capacity of the participants with Parkinson's disease submitted to three different modalities of motor training. However, bicycle exercise and exergaming have improved expiratory and inspiratory muscle strength, respectively. NCT02622737.

Effect of Physiotherapy Interventions on Motor Symptoms in People With Parkinson's Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the effectiveness of different types of physiotherapy interventions in people with Parkinson's disease (PD).

DESIGN

Systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

Five databases (PubMed, Embase, Cochrane Library, CINAHL and Web of Science Core Collection) were searched for relevant RCTs published from database inception to July 14, 2022. Reviewers independently screened the literature, extracted data, and assessed the literature quality according to the Cochrane Collaboration Risk of Bias Tool and PEDro Scale. This meta-analysis was conducted using RevMan 5.4.1 and reported in compliance with the PRISMA statement.

RESULTS

Forty-two RCTs with 2,530 participants were included. Across all types of physiotherapy, strength training, mind-body exercise, aerobic exercise, and non-invasive brain stimulation (NiBS) were effective in improving motor symptoms as measured by the (Movement Disorders Society-) Unified PD Scale, whereas balance and gait training (BGT) and acupuncture were not. The pooled results showed that the change in mind-body exercise (MD = -5.36, 95% CI [-7.97 to -2.74], p < .01, I2 = 68%) and NiBS (MD = -4.59, 95% CI [-8.59 to -0.59], p = .02, I2 = 78%) reached clinical threshold, indicating clinically meaningful improvements. Considering the effectiveness of the interventions on motor symptoms, balance, gait and functional mobility, mind-body exercise was recommended the most.

CONCLUSIONS

Exercise appears to be a better form of physiotherapy than NiBS and acupuncture for improving motor function. Mind-body exercise showed beneficial effects on motor symptoms, balance, gait and functional mobility in people with PD, and is worthy of being promoted.

The effect of rehabilitation interventions on freezing of gait in people with Parkinson's disease is unclear: a systematic review and meta-analyses

PURPOSE

To summarize the effects of rehabilitation interventions to reduce freezing of gait (FOG) in people with Parkinson's disease.

METHODS

A systematic review with meta-analyses of randomized trials of rehabilitation interventions that reported a FOG outcome was conducted. Quality of included studies and certainty of FOG outcome were assessed using the PEDro scale and GRADE framework.

RESULTS

Sixty-five studies were eligible, with 62 trialing physical therapy/exercise, and five trialing cognitive and/or behavioral therapies. All meta-analyses produced very low-certainty evidence. Physical therapy/exercise had a small effect on reducing FOG post-intervention compared to control (Hedges' g= -0.26, 95% CI= -0.38 to -0.14, 95% prediction interval (PI)= -0.38 to -0.14). We are uncertain of the effects on FOG post-intervention when comparing: exercise with cueing to without cueing (Hedges' g= -0.58, 95% CI= -0.86 to -0.29, 95% PI= -1.23 to 0.08); action observation training plus movement strategy practice to practice alone (Hedges' g= -0.56, 95% CI= -1.16 to 0.05); and dance to multimodal exercises (Hedges' g= -0.64, 95% CI= -1.53 to 0.25).

CONCLUSIONS

We are uncertain if physical therapy/exercise, cognitive or behavioral therapies, are effective at reducing FOG.Implications for rehabilitationFOG leads to impaired mobility and falls, but the effect of rehabilitation interventions (including physical therapy/exercise and cognitive/behavioral therapies) on FOG is small and uncertain.Until more robust evidence is generated, clinicians should assess FOG using both self-report and physical measures, as well as other related impairments such as cognition, anxiety, and fear of falling.Interventions for FOG should be personalized based on the individual's triggers and form part of a broader exercise program addressing gait, balance, and falls prevention.Interventions should continue over the long term and be closely monitored and adjusted as individual circumstances change.

Association between regular physical activity and biomarker changes in early Parkinson's disease patients

INTRODUCTION

Physical activity benefits patients with Parkinson's disease (PD) and is assumed to possess disease-modifying potential. PD-related biomarkers, such as dopamine transporter (DAT) imaging and cerebrospinal fluid (CSF) α-synuclein (α-syn) and amyloid β (Aβ), correlate with disease severity and, to some extent, reflect disease progression and pathology. However, the association between regular physical activity and PD biomarker changes remains unknown. This study aimed to investigate the association between physical activity and longitudinal trajectories of PD biomarkers.

METHODS

This retrospective study included 444 patients with a median follow-up time of 5 years from the Parkinson's Progression Markers Initiative cohort. Data collection included physical activity as scaled by the Physical Activity Scale for the Elderly questionnaire, dopamine transporter imaging, CSF assessment, and serum biomarkers. We analyzed the data using a linear mixed regression model.

RESULTS

Regular physical activity was associated with a slower decline of DAT uptake in the caudate (β = 0.063, p = 0.011) and the putamen (β = 0.062, p = 0.023). No association was detected between regular physical activity and CSF, as well as serum biomarkers.

CONCLUSION

Regular physical activity is associated with favorable PD biomarker progression, indicating a potential disease-modifying effect.

Exercise for prevention of falls and fall-related injuries in neurodegenerative diseases and aging-related risk conditions: a meta-analysis

Introduction

Neurodegenerative diseases often cause motor and cognitive deterioration that leads to postural instability and motor impairment, while aging-associated frailty frequently results in reduced muscle mass, balance, and mobility. These conditions increase the risk of falls and injuries in these populations. This study aimed to determine the effects of exercise on falls and consequent injuries among individuals with neurodegenerative diseases and frail aging people.

Methods

Electronic database searches were conducted in PubMed, Cochrane Library, SportDiscus, and Web of Science up to 1 January 2023. Randomized controlled trials that reported the effects of exercise on falls and fall-related injuries in neurodegenerative disease and frail aging people were eligible for inclusion. The intervention effects for falls, fractures, and injuries were evaluated by calculating the rate ratio (RaR) or risk ratio (RR) with 95% confidence interval (CI).

Results

Sixty-four studies with 13,241 participants met the inclusion criteria. Exercise is effective in reducing falls for frail aging people (RaR, 0.75; 95% CI, 0.68-0.82) and participants with ND (0.53, 0.43-0.65) [dementia (0.64, 0.51-0.82), Parkinson's disease (0.49, 0.39-0.69), and stroke survivors (0.40, 0.27-0.57)]. Exercise also reduced fall-related injuries in ND patients (RR, 0.66; 95% CI, 0.48-0.90) and decreased fractures (0.63, 0.41-0.95) and fall-related injuries (0.89, 0.84-0.95) among frail aging people. For fall prevention, balance and combined exercise protocols are both effective, and either short-, moderate-, or long-term intervention duration is beneficial. More importantly, exercise only induced a very low injury rate per participant year (0.007%; 95% CI, 0-0.016) and show relatively good compliance with exercise (74.8; 95% CI, 69.7%-79.9%).

Discussion

Exercise is effective in reducing neurodegenerative disease- and aging-associated falls and consequent injuries, suggesting that exercise is an effective and feasible strategy for the prevention of falls.

Differences in fall-related characteristics across cognitive disorders

Approximately 40-60% of falls in the elderly lead to injuries, resulting in disability and loss of independence. Despite the higher prevalence of falls and morbidity rates in cognitively impaired individuals, most fall risk assessments fail to account for mental status. In addition, successful fall prevention programmes in cognitively normal adults have generally failed in patients with cognitive impairment. Identifying the role of pathological aging on fall characteristics can improve the sensitivity and specificity of fall prevention approaches. This literature review provides a thorough investigation into fall prevalence and fall risk factors, the accuracy of fall risk assessments, and the efficacy of fall prevention strategies in individuals with diverse cognitive profiles. We show that fall-related characteristics differ between cognitive disorders and fall risk assessment tools as well as fall prevention strategies should critically consider each patient's cognitive status to facilitate the identification of fallers at an earlier stage and support clinical decision-making.

Physical Exercise Interventions on Quality of Life in Parkinson Disease: A Network Meta-analysis

BACKGROUND AND PURPOSE

Physical exercise is considered an effective intervention for maintaining or improving quality of life (QoL) in patients with Parkinson disease (PD), but there is no evidence showing which type of physical exercise intervention has more positive effects. This systematic review and meta-analysis aimed to synthesize the evidence regarding the effectiveness of exercise interventions on improving QoL in patients with PD, comparing different types of exercise interventions.

METHODS

A literature search was conducted through January 2022. The methodological quality of the trials was assessed using the Cochrane risk of bias tool RoB2. For the meta-analysis, physical exercise interventions were classified into 5 training categories: resistance, endurance, alternative exercises, dance, and sensorimotor interventions. A standard meta-analysis and network meta-analysis were carried out to evaluate the efficacy of the different types of physical exercise interventions.

RESULTS

The search retrieved 2451 studies, 48 of which were included in this network meta-analysis with a total of 2977 patients with PD. The indirect effects of the network meta-analysis showed positive results for alternative exercises (-0.46; 95% confidence interval [CI]: -0.76, -0.16), dance (-0.63; 95% CI: -1.08, -0.17), and sensorimotor interventions (-0.23; 95% CI: -0.40, -0.07) versus control comparisons.

DISCUSSION AND CONCLUSIONS

More research is needed to determine the types of physical exercise interventions that are most beneficial and for which conditions of the disease they have the most positive effects.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A398 ).

Utilising telehealth to support exercise and physical activity in people with Parkinson disease: a program evaluation using mixed methods

BACKGROUND

Physical activity and exercise play a key role in managing Parkinson disease. This study aimed to: 1) determine if physiotherapy supported by telehealth helped people with Parkinson disease (PwP) to adhere to a home-based exercise program and maintain their physical activity; and 2) understand their experiences of using telehealth during the COVID-19 pandemic.

METHODS

A mixed methods program evaluation involving a retrospective file audit from a student-run physiotherapy clinic and semi-structured interviews exploring participants' experiences of telehealth. Ninety-six people with mild to moderate disease received home-based telehealth physiotherapy for 21 weeks. The primary outcome was adherence to the prescribed exercise program. Secondary outcomes were measures of physical activity. Interviews were conducted with 13 clients and seven students and analysed thematically.

RESULTS

Adherence to the prescribed exercise program was high. The mean (SD) proportion of prescribed sessions completed was 108% (46%). On average clients spent 29 (12) minutes per session, and 101 (55) minutes per week exercising. Physical activity levels were maintained, with clients taking 11,226 (4,832) steps per day on entry to telehealth, and 11,305 (4,390) steps per day on exit from telehealth. The semi-structured interviews identified important features of a telehealth service required to support exercise; a flexible approach of clients and therapists, empowerment, feedback, a therapeutic relationship, and mode of delivery.

CONCLUSIONS

PwP were able to continue exercising at home and maintain their physical activity when physiotherapy was provided via telehealth. The flexible approach of both the client and the service was imperative.

Dancing for Parkinson's Disease Online: Clinical Trial Process Evaluation

Background: Dancing is an engaging physical activity for people living with Parkinson's disease (PD). We conducted a process evaluation for a PD trial on online dancing. Methods: "ParkinDANCE Online" was co-produced by people with PD, healthcare professionals, dance instructors, and a PD organisation. The evaluation mapped the following inputs: (i) stakeholder steering group to oversee program design, processes, and outcomes; (ii) co-design of online classes, based on a research evidence synthesis, expert advice, and stakeholder recommendations; (iii) trial fidelity. The key activities were (i) the co-design of classes and instruction manuals, (ii) the education of dance teachers, (iii) fidelity checking, (iv) online surveys, (v) and post-trial focus groups and interviews with participants. The outputs pertained to: (i) recruitment, (ii) retention, (iii) adverse events, (iv) fidelity, (v) protocol variations, and (vi) participant feedback. Results: Twelve people with PD, four dance instructors and two physiotherapists, participated in a 6-week online dance program. There was no attrition, nor were there any adverse events. Program fidelity was strong with few protocol variations. Classes were delivered as planned, with 100% attendance. Dancers valued skills mastery. Dance teachers found digital delivery to be engaging and practical. The safety of online testing was facilitated by careful screening and a home safety checklist. Conclusions: It is feasible to deliver online dancing to people with early PD.

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.

Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis

BACKGROUND

Physical exercise is effective in managing Parkinson's disease (PD), but the relative benefit of different exercise types remains unclear.

OBJECTIVES

To compare the effects of different types of physical exercise in adults with PD on the severity of motor signs, quality of life (QoL), and the occurrence of adverse events, and to generate a clinically meaningful treatment ranking using network meta-analyses (NMAs).

SEARCH METHODS

An experienced information specialist performed a systematic search for relevant articles in CENTRAL, MEDLINE, Embase, and five other databases to 17 May 2021. We also searched trial registries, conference proceedings, and reference lists of identified studies up to this date.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing one type of physical exercise for adults with PD to another type of exercise, a control group, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. A third author was involved in case of disagreements.  We categorized the interventions and analyzed their effects on the severity of motor signs, QoL, freezing of gait, and functional mobility and balance up to six weeks after the intervention using NMAs. Two review authors independently assessed the risk of bias using the risk of bias 2 (RoB 2) tool and rated the confidence in the evidence using the CINeMA approach for results on the severity of motor signs and QoL. We consulted a third review author to resolve any disagreements. Due to heterogeneous reporting of adverse events, we summarized safety data narratively and rated our confidence in the evidence using the GRADE approach.

MAIN RESULTS

We included 156 RCTs with a total of 7939 participants with mostly mild to moderate disease and no major cognitive impairment. The number of participants per study was small (mean 51, range from 10 to 474). The NMAs on the severity of motor signs and QoL included data from 71 (3196 participants), and 55 (3283 participants) trials, respectively. Eighty-five studies (5192 participants) provided safety data. Here, we present the main results. We observed evidence of beneficial effects for most types of physical exercise included in our review compared to a passive control group. The effects on the severity of motor signs and QoL are expressed as scores on the motor scale of the Unified Parkinson Disease Rating Scale (UPDRS-M) and the Parkinson's Disease Questionnaire 39 (PDQ-39), respectively. For both scales, higher scores denote higher symptom burden. Therefore, negative estimates reflect improvement (minimum clinically important difference: -2.5 for UPDRS-M and -4.72 for PDQ-39). Severity of motor signs The evidence from the NMA (71 studies; 3196 participants) suggests that dance has a moderate beneficial effect on the severity of motor signs (mean difference (MD) -10.32, 95% confidence interval (CI) -15.54 to -4.96; high confidence), and aqua-based, gait/balance/functional, and multi-domain training might have a moderate beneficial effect on the severity of motor signs (aqua-based: MD -7.77, 95% CI -13.27 to -2.28; gait/balance/functional: MD -7.37, 95% CI -11.39 to -3.35; multi-domain: MD -6.97, 95% CI -10.32 to -3.62; low confidence). The evidence also suggests that mind-body training and endurance training might have a small beneficial effect on the severity of motor signs (mind-body: MD -6.57, 95% CI -10.18 to -2.81; endurance: MD -6.43, 95% CI -10.72 to -2.28; low confidence). Flexibility training might have a trivial or no effect on the severity of motor signs (MD 2.01, 95% CI -4.82 to 8.98; low confidence). The evidence is very uncertain about the effects of strength/resistance training and "Lee Silverman Voice training BIG" (LSVT BIG) on the severity of motor signs (strength/resistance: MD -6.97, 95% CI -11.93 to -2.01; LSVT BIG: MD -5.49, 95% CI -14.74 to 3.62; very low confidence). Quality of life The evidence from the NMA (55 studies; 3283 participants) suggests that aqua-based training probably has a large beneficial effect on QoL (MD -14.98, 95% CI -23.26 to -6.52; moderate confidence). The evidence also suggests that endurance training might have a moderate beneficial effect, and that gait/balance/functional and multi-domain training might have a small beneficial effect on QoL (endurance: MD -9.16, 95% CI -15.68 to -2.82; gait/balance/functional: MD -5.64, 95% CI -10.04 to -1.23; multi-domain: MD -5.29, 95% CI -9.34 to -1.06; low confidence). The evidence is very uncertain about the effects of mind-body training, gaming, strength/resistance training, dance, LSVT BIG, and flexibility training on QoL (mind-body: MD -8.81, 95% CI -14.62 to -3.00; gaming: MD -7.05, 95% CI -18.50 to 4.41; strength/resistance: MD -6.34, 95% CI -12.33 to -0.35; dance: MD -4.05, 95% CI -11.28 to 3.00; LSVT BIG: MD 2.29, 95% CI -16.03 to 20.44; flexibility: MD 1.23, 95% CI -11.45 to 13.92; very low confidence). Adverse events Only 85 studies (5192 participants) provided some kind of safety data, mostly only for the intervention groups. No adverse events (AEs) occurred in 40 studies and no serious AEs occurred in four studies. AEs occurred in 28 studies. The most frequently reported events were falls (18 studies) and pain (10 studies). The evidence is very uncertain about the effect of physical exercise on the risk of adverse events (very low confidence). Across outcomes, we observed little evidence of differences between exercise types.

AUTHORS' CONCLUSIONS

We found evidence of beneficial effects on the severity of motor signs and QoL for most types of physical exercise for people with PD included in this review, but little evidence of differences between these interventions. Thus, our review highlights the importance of physical exercise regarding our primary outcomes severity of motor signs and QoL, while the exact exercise type might be secondary. Notably, this conclusion is consistent with the possibility that specific motor symptoms may be treated most effectively by PD-specific programs. Although the evidence is very uncertain about the effect of exercise on the risk of adverse events, the interventions included in our review were described as relatively safe. Larger, well-conducted studies are needed to increase confidence in the evidence. Additional studies recruiting people with advanced disease severity and cognitive impairment might help extend the generalizability of our findings to a broader range of people with PD.

Do dance style and intervention duration matter in improving balance among people with Parkinson's disease? A systematic review with meta-analysis

INTRODUCTION

Impaired balance is a common symptom that increases fall risk in people with Parkinson's disease (PwPD). Although previous meta-analyses concluded that dance-based interventions could improve balance in PwPD, they have limitations, such as small samples and low rigor. Another overlooked issue is whether the effects of dance-based interventions depend on dance style and training duration. The primary purpose of this meta-analysis was to further examine the efficacy of dance-based interventions in improving balance in PwPD. The secondary goals were to compare the intervention efficacy of different dance styles and durations.

METHODS

Fourteen randomized controlled trials (RCT) examining the effect of dance-based treatment on improving balance among 612 PwPD were included. Effect size (ES) was calculated as the standardized mean difference. Meta-analyses (one primary analysis and three subgroup analyses) were completed using random-effects models.

RESULTS

Results showed a medium overall ES of 0.57 (95% confidence interval or CI: [0.29,0.84], p < 0.0001) in favor of dance versus control on improving balance in PwPD. The subgroup analysis of six dance styles revealed various ES ranging 0.40-2.00. Balance was significantly improved with dance compared to control group for 12+ week interventions (ES = 0.72, 95%CI: [0.37,1.08], p < 0.0001). Interventions with 60- and 90-min classes produced similar ES for improving PwPD's balance (60-min ES = 0.54; 90-min ES = 0.68).

CONCLUSION

Dance-based interventions (particularly of 12+ weeks) could effectively improve balance among PwPD. More high-quality RCT are needed to determine the most beneficial dance styles and session lengths. These findings could inform future studies for designing/deploying effective dance-based balance training and fall prevention programs for PwPD.

Vitamin D (VD3) Intensifies the Effects of Exercise and Prevents Alterations of Behavior, Brain Oxidative Stress, and Neuroinflammation, in Hemiparkinsonian Rats

In the present study, we investigated the effects of physical exercise in the presence of Vitamin D3 (VD3), on 6-hydroxydopamine (6-OHDA)-lesioned hemiparkinsonian rats. The animals were divided into sham-operated (SO), 6-OHDA-lesioned, and 6-OHDA-lesioned plus VD3 (1 µg/kg, 21 days), in the absence (no exercise, NE) and presence (with exercise, WE) of physical exercise on a treadmill (30 min, speed of 20 cm/s, once a day/21 days). This procedure started, 24 h after the stereotaxic surgery (injections of 6-OHDA into the right striatum). The animals were then subjected to behavioral (rotarod, open field, and apomorphine tests) and their brain areas were dissected for neurochemical, dopamine (DA), 3,4-dihydroxyphenylacetic acid (DOPAC) determinations, and immunohistochemical studies for tyrosine hydroxylase (TH), dopamine transporter (DAT), and vitamin D receptor (VD3R). The effects on the brain oxidative stress: nitrite/nitrate, glutathione (GSH), and malondialdehyde (MDA) measurements were also evaluated. Behavioral changes of the 6-OHDA lesioned group were improved by exercise plus VD3. Similar results were observed in dopamine (DA) and 3,4-dihydroxyphenylacetic acid (DOPAC) concentrations increased by exercise and VD3, compared with SO groups. Additionally, tyrosine hydroxylase (TH) and dopamine transporter (DAT) immunoexpressions were decreased in the 6-OHDA-lesioned groups, with values normalized after exercise and VD3. The VD3 receptor immunoexpression decreased in the 6-OHDA (NE) group, and this was attenuated by exercise, especially after VD3. While 6-OHDA lesions increased, VD3 supplementation decreased the oxidative stress, which was intensified by exercise. VD3 showed neuroprotective properties that were intensified by physical exercise. These VD3 actions on hemiparkinsonian rats are possibly related to its antioxidant and anti-inflammatory effects.