Client and therapist views on exercise programmes for early-mid stage Parkinson's disease and Huntington's disease

Supporting physical activity engagement in people with Huntington's disease (ENGAGE-HD): study protocol for a randomized controlled feasibility trial

Background

Huntington’s disease (HD) is a complex, single-gene inherited neurodegenerative condition resulting in symptoms that occur across a wide range of neurological domains, including cognitive, behavioral and motor. The benefits of regular physical activity for people with HD are widely recognized. However, a number of factors can prohibit sustained exercise and activity. The purpose of this trial is to explore the feasibility, acceptability and effectiveness of a physical activity intervention program targeted for people with early- to mid-stage HD.

Methods/Design

The proposed trial is a single blind, multisite, exploratory, randomized controlled feasibility trial of a physical activity intervention. A total of 62 participants with genetically confirmed HD will be recruited. Each participant will be involved in the trial for 26 weeks. Participants will be randomized immediately following the baseline assessment into either a physical activity intervention or a social contact control intervention. The physical activity intervention is framed around self-determination theory placed within a broader behaviour change wheel framework. An HD-specific workbook and individual goal setting will be utilized over six 1:1 sessions, with interim telephone calls. All participants will be reassessed at 16 weeks following the baseline assessment, and then again at a final follow-up assessment 26 weeks later. At the end of the study, all participants will be offered a brief version of the alternative intervention, with one home visit and one follow-up telephone call.

Discussion

Engaging and supporting people with HD in a regular physical activity program raises a number of challenges. The physical activity intervention and the comparator social interaction intervention have been developed following consultation with people with HD and their families. Each are individually tailored and determined on individual needs and goals. The results from this trial will provide guidance for the development of definitive trials.

Trial registration

The trial was registered with ISRCTN ( http://www.isrctn.com/ISRCTN65378754) on 13 March 2014.

Effects of a Two-Year Intensive Multidisciplinary Rehabilitation Program for Patients with Huntington's Disease: a Prospective Intervention Study

Objective: To assess effects of a two year intensive, multidisciplinary rehabilitation program for patients with early- to mid-stage Huntington’s disease. Design: A prospective intervention study. Setting: One inpatient rehabilitation center in Norway. Subjects: 10 patients, with early- to mid-stage Huntington’s disease. Interventions: A two year rehabilitation program, consisting of six admissions of three weeks each, and two evaluation stays approximately three months after the third and sixth rehabilitation admission. The program focused on physical exercise, social activities, and group/teaching sessions. Main outcome measures: Standard measures for motor function, including gait and balance, cognitive function, including MMSE and UHDRS cognitive assessment, anxiety and depression, activities of daily living (ADL), health related quality of life (QoL) and Body Mass Index (BMI). Results: Six out of ten patients completed the full program. Slight, but non-significant, decline was observed for gait and balance from baseline to the evaluation stay after two years. Non-significant improvements were observed in physical QoL, anxiety and depression, and BMI. ADL-function remained stable with no significant decline. None of the cognitive measures showed a significant decline. An analysis of individual cases revealed that four out of the six participants who completed the program sustained or improved their motor function, while motor function declined in two participants. All the six patients who completed the program reported improved or stable QoL throughout the study period. Conclusion: Our findings suggest that participation in an intensive rehabilitation program is well tolerated among motivated patients with early to mid-stage HD. The findings should be interpreted with caution due to the small sample size in this study.

Participants', caregivers', and professionals' experiences with a group-based rehabilitation program for Huntington's disease: a qualitative study

BACKGROUND

Research suggests that rehabilitation is beneficial for persons with Huntington's disease (HD), but there is limited knowledge about participants' experiences with residential rehabilitation programs. We therefore did a study to explore patients', family caregivers', and health professionals' experiences with a group-based, residential rehabilitation program for individuals with early to mid-stage HD, focusing on three research questions: How did participants experience the structure and content of the program? What outcomes did patients experience? What challenges and success factors did health professionals report?

METHODS

Qualitative, explorative study, collecting data through in-depth interviews with nine family caregivers and 11 patients with early- and mid-stage HD, and focus group interviews with 15 health professionals. Data were analysed using systematic text condensation.

RESULTS

Some participants reported difficulties with defining individual rehabilitation goals, but written individualised plans and schedules were appreciated by all participants. Participants highlighted being member of an "HD-group" as a valuable experience, though tensions and conflicts could occur in groups. Participants typically reported improved gait and balance, increased self-confidence, and social benefits as outcomes. The intensive schedule was acceptable for most participants, but adjustments had been made to allow participants more time to eat, shower and dress between sessions. Success factors reported by health professionals were assigning every patient with a contact person, using clinical tests results to motivate patients, and supervising health professionals in patients' local municipalities.

CONCLUSIONS

Group-based residental rehabilitation was feasible for individuals with early- and mid-stage HD, and participants emphasised mental and social outcomes in addition to physical outcomes. The needs of persons with HD should be considerd when designing programs, to secure structure, continuity in personnel, and sufficient time between sessions.

Effects of a One Year Intensive Multidisciplinary Rehabilitation Program for Patients with Huntington's Disease: a Prospective Intervention Study

OBJECTIVE

To assess the effects of an intensive, multidisciplinary rehabilitation program for patients with early to mid-stage Huntington's disease.

DESIGN

A prospective intervention study.

SETTING

Two Norwegian inpatient rehabilitation centers.

SUBJECTS

37 patients, with early- to midstage Huntington's disease Interventions: A one year rehabilitation program, consisting of three admissions of three weeks each, and a five-day evaluation stay approximately 3 months after the last rehabilitation admission. Focus was on physical exercise, social activities, and group/teaching sessions. There was also emphasis to implement of coordinated health care and social services for the patients.

MAIN OUTCOME MEASURES

standard measures for motor function, including gait and balance, cognitive function, including MMSE and UHDRS cognitive assessment, anxiety and depression, activities of daily living (ADL), health related quality of life and Body Mass Index (BMI).

RESULTS

Significant improvements were observed in gait function, balance, in physical quality of life, anxiety and depression, as well as in BMI. ADL-function remained stable with no significant decline. Only one cognitive measure (SDMT) showed significant decline, while no decline was observed for the remaining cognitive measures.

CONCLUSION

A multidisciplinary intensive rehabilitation program in patients with early and mid stage HD is associated with improved balance, gait function, physical quality of life and with reduced depressive and anxiety symptoms. Longer follow-up is needed to assess if these positive effects are sustained. There should be emphasis to establishment of long term and coordinated health care services for the HD patient.

Barriers to exercise in people with Parkinson disease

BACKGROUND

Exercise is known to reduce disability and improve quality of life in people with Parkinson disease (PD). Although barriers to exercise have been studied in older adults, barriers in people with chronic progressive neurological diseases, such as PD, are not well defined.

OBJECTIVE

The purpose of this study was to identify perceived barriers to exercise in people with PD.

DESIGN

The study had a cross-sectional design.

METHODS

People who had PD, dwelled in the community, and were at stage 2.4 on the Hoehn and Yahr scale participated in this cross-sectional study (N=260; mean age=67.7 years). Participants were divided into an exercise group (n=164) and a nonexercise group (n=96). Participants self-administered the barriers subscale of the Physical Fitness and Exercise Activity Levels of Older Adults Scale, endorsing or denying specific barriers to exercise participation. Multivariate logistic regression analysis was used to examine the contribution of each barrier to exercise behavior, and odds ratios were reported.

RESULTS

Three barriers were retained in the multivariate regression model. The nonexercise group had significantly greater odds of endorsing low outcome expectation (ie, the participants did not expect to derive benefit from exercise) (odds ratio [OR]=3.93, 95% confidence interval [CI]=2.08-7.42), lack of time (OR=3.36, 95% CI=1.55-7.29), and fear of falling (OR=2.35, 95% CI=1.17-4.71) than the exercise group.

LIMITATIONS

The cross-sectional nature of this study limited the ability to make causal inferences.

CONCLUSIONS

Low outcome expectation from exercise, lack of time to exercise, and fear of falling appear to be important perceived barriers to engaging in exercise in people who have PD, are ambulatory, and dwell in the community. These may be important issues for physical therapists to target in people who have PD and do not exercise regularly. The efficacy of intervention strategies to facilitate exercise adherence in people with PD requires further investigation.

Community-based exercise and wellness program for people diagnosed with Parkinson disease: experiences from a 10-month trial

OBJECTIVE

This study considered whether a therapy community could create an infrastructure for developing and maintaining a service delivery model grounded in a clinic-based physiotherapy model. A longitudinal clinical study was conducted to assess the abilities of participants with Parkinson disease in a 10-month community exercise program.

METHODS

Fifteen individuals averaging stage 3 on the Hoehn and Yahr scale, 6 years since Parkinson disease diagnosis, and 72 years old, participated.

RESULTS

Graphical analysis of ambulation endurance demonstrated the strongest improvement over time (11%). Walking speeds, balance, and mobility showed a maintenance effect over the 10 months. The total unified Parkinson disease rating scale, activities of daily living subscale, and motor subscale remained statistically unchanged in the study. Scores on the unified Parkinson disease rating scale mentation, behavior, and mood subscale improved by 38%. None of the scores met or exceeded the minimal detectable change, MDC95 but two scores demonstrated more than 10% change.

CONCLUSION

This clinical study implemented previous short-term research findings into an ongoing community wellness program for individuals with Parkinson disease. No community-based studies have demonstrated an ability to maintain a group for an extended time frame. Group exercise including forward and backward treadmill training, designed and monitored by a physical therapist, may improve or maintain functional outcomes.

Repair of the CNS using endogenous and transplanted neural stem cells

Restoration of the damaged central nervous system is a vast challenge. However, there is a great need for research into this topic, due to the prevalence of central nervous system disorders and the devastating impact they have on people's lives. A number of strategies are being examined to achieve this goal, including cell replacement therapy, enhancement of endogenous plasticity and the recruitment of endogenous neurogenesis. The current chapter reviews this topic within the context of Parkinson's disease, Huntington's disease and stroke. For each disease exogenous cell therapies are discussed including primary (foetal) cell transplants, neural stem cells, induced pluripotent stem cells and marrow stromal cells. This chapter highlights the different mechanistic approaches of cell replacement therapy versus cells that deliver neurotropic factors, or enhance the endogenous production of these factors. Evidence of exogenously transplanted cells functionally integrating into the host brain, replacing cells, and having a behavioural benefit are discussed, along with the ability of some cell sources to stimulate endogenous neuroprotective and restorative events. Alongside exogenous cell therapy, the role of endogenous neurogenesis in each of the three diseases is outlined and methods to enhance this phenomenon are discussed.

Androgen function in the pathophysiology and treatment of male Huntington's disease patients

Low concentrations of circulating testosterone have been associated with dementia manifesting with advancing age and in neurodegenerative conditions. Huntington's disease (HD) is a dominantly inherited neurodegenerative disease with an invariably fatal outcome. Severe motor symptoms, psychosis and dementia are symptomatic hallmarks of the progression of HD that result from the dysfunction and death of neocortical and basal ganglia neurones. Treatments are directed toward manifest symptoms, although they are largely ineffectual in slowing or preventing disease progression. Emerging data have identified hypothamic pathologies in HD that result in endocrine disturbances. Clinically defined primary or secondary hypogonadism elicit low circulating testosterone concentrations and have been linked to the development of Alzheimer's disease in men. Examining similar neuroendocrine dysfunction in HD including the nature of manifest hypogonadism in male patients could allow an elucidation of the complex pathophysiology of HD and provide an impetus for hitherto untested testosterone replacement therapy.

Development of physiotherapy guidance and treatment-based classifications for people with Huntington’s disease

SUMMARY Background: Physiotherapy may provide a means of delaying onset or progression of Huntington’s disease (HD), resulting in improved daily functioning and quality of life. Physiotherapy is being more frequently recommended for people with HD, but there have been no specific guidelines published for implementation of a structured physiotherapy program. The Physiotherapy Working Group (PWG) of the European Huntington’s Disease Network (EHDN) set out to develop a comprehensive Guidance Document for physiotherapists to provide best practice guidelines. Methods: A review of the literature was conducted using a systematic approach. There was insufficient literature in support of physiotherapy interventions and approaches to be able to conduct a complete evidenced-based review, therefore, physiotherapy expert subgroups were formed to incorporate consensus as to best practice. A draft document was distributed to the entire membership of the working group, to outside physiotherapists and other healthcare professionals within EHDN to elicit feedback and comments. Results: A Guidance Document covering eight specific areas pertaining to physiotherapy management of HD was developed. In order to facilitate the document’s practical usability among clinicians, a treatment-based classification system is proposed to categorize patients based on presenting signs and symptoms, and provide a foundation for development of a more standardized intervention approach. Discussion: The Physiotherapy Guidance for HD is a comprehensive, consensus- and evidence-based document that can be used by physiotherapists to implement a plan of care that is currently consistent with best practice for individuals at all stages of HD. As evidence becomes available, future systematic reviews will be required in order to inform further development. The use of treatment-based classifications, which aim to better categorize common signs and symptoms and link them to appropriate intervention plans, may be useful in relatively rare diseases, such as HD, to aid clinical reasoning and promote effective outcome evaluation.

Adherence to use of a home-based exercise DVD in people with Huntington disease: participants' perspectives

BACKGROUND

Individualized exercise instruction on a regular basis may be desirable for people with Huntington disease (HD). Sustained interventions, however, may not be the most feasible for lifelong disease management. It is critical, therefore, for physical therapists to find ways to facilitate engagement in independent exercise programs. The capabilities of DVD technology can make the DVD a useful format to facilitate engagement for people with HD who have motivational and cognitive problems.

OBJECTIVE

The purpose of this study was to explore how people with HD used a home-based exercise DVD and how it was perceived by the participants and their caregivers.

DESIGN

An exploratory, mixed-method design was used in this study.

METHODS

Fifteen participants with HD were provided with an exercise DVD, developed by the authors, to support their engagement in a home-based exercise program. Exercise diaries were used to record adherence rates. Semistructured interviews were conducted to explore what factors affected the usability of the DVD. Conversations were audio recorded and fully transcribed. Content analysis approach was used to analyze the interviews.

RESULTS

Most of the participants (11/15, 73.3%) adhered well to the use of the DVD. Participants felt that the exercises were suitable. Commitment of the caregiver as a key to the success of the program was the main theme that emerged from the data. Participants identified barriers and facilitators that affected adherence to using the exercise DVD and described management strategies that helped promote adherence to the exercise program.

CONCLUSIONS

The DVD was perceived to be suitable and supportive. The DVD could be appropriate for use in supporting people with HD to engage in exercise at home, either outside of therapy sessions or upon completion of a therapy program.

Role of experience, training, and plasticity in the functional efficacy of striatal transplants

Cell-based treatments of neurodegenerative diseases have been tested clinically with partial success. In the context of Huntington's disease (HD), experimental studies show that the grafted embryonic striatal cells survive, integrate within the host brain, and reverse some functional deficits. Importantly, once transplanted, the grafted striatal neurons retain a significant level of cellular, morphological, and functional plasticity which allows the experimental modification of their character through the manipulation of environmental cues or learning protocols. Using embryonic striatal grafts in the rodent model of HD as the principal example, this chapter summarizes seminal experiments that demonstrate that environmental factors, training, and activity can tap into mechanisms that influence the development of the grafted cells and can change the profile of graft-mediated behavioral recovery. Although currently there is limited understanding of the biological rationale behind the recovery, we put forward experimental data indicating that striatal grafts can express experience-dependent physiological plasticity at the synaptic as well as at the systemic functional level.

Exercise and motor training in people with Parkinson's disease: a systematic review of participant characteristics, intervention delivery, retention rates, adherence, and adverse events in clinical trials

There is research evidence that exercise and motor training are beneficial for people with Parkinson's disease (PD), and clinicians seek to implement optimal programs. This paper summarizes important factors about the nature and reporting of randomized controlled trials of exercise and/or motor training for people with PD which are likely to influence the translation of research into clinical practice. Searches identified 53 relevant trials with 90 interventions conducted for an average duration of 8.3 (SD 4.2) weeks. Most interventions were fully supervised (74%) and conducted at a facility (79%). Retention rates were high with 69% of interventions retaining ≥85% of their participants; however adherence was infrequently reported, and 72% of trials did not report adverse events. Overall, the labor-intensive nature of most interventions tested in these trials and the sparse reporting of adherence and adverse events are likely to pose difficulties for therapists attempting to balance benefits and costs when selecting protocols that translate to sustainable clinical practice for people with PD.

Attitudes toward exercise following participation in an exercise intervention study

BACKGROUND AND PURPOSE

Exercise intervention studies for people with Parkinson disease (PD) have been shown to result in improvement in a variety of outcome measures. However, after the supervised exercise period, these measures tend to return toward baseline values. This regression may reflect the progressive nature of PD but may also reflect a decline in activity levels. The purpose of this qualitative study was to learn more about the motivations and barriers to continued exercise among persons with PD following a 16-month exercise intervention study.

METHODS

Eighteen individuals with PD (12 men and 6 women) and their spouses participated in structured interviews concerning reasons for entering the exercise study, experiences during the study, activity levels after the study, and strategies to encourage ongoing activity. Of those with PD, 15 had completed the exercise study and 3 had dropped out before completion.

RESULTS

Among the 18 individuals who participated in the interviews, motivations for exercising included: hope that exercise would slow the disease or prevent a decline in function (7 individuals [39%]), feeling better with exercise (3 individuals [17%]), belief that exercise is beneficial (3 individuals [17%]), and encouragement from family members (3 individuals [17%]). After the study, all graduates and 2 of the 3 dropouts maintained some physical activity. For 14 (79%) respondents, intensity and/or frequency was reduced from maximal activity levels achieved during the intervention. To encourage ongoing activity, participants wanted evidence supporting the benefits of exercise (5 participants [28%]), greater availability of programs (4 participants [22%]), and guidance from medical providers toward exercise studies (3 participants [17%]).

DISCUSSION AND CONCLUSIONS

This study provides insights into the motivations and barriers for continued exercise after an exercise study. The issues identified provide information that may assist practitioners as they design exercise programs for individuals with PD. It may be of value to explore these issues in future experimental studies.

Exercise is not beneficial and may accelerate symptom onset in a mouse model of Huntington's disease

Exercise benefits both general health and brain function in rodents and humans. However, it is less clear whether physical activity prevents or ameliorates neurodegenerative diseases. The aim of the present study was to determine whether voluntary wheel running can delay the onset or reduce the severity of Huntington’s disease (HD) in a mouse model. To investigate whether running may delay HD symptoms lifespan, disease onset, locomotor activity, glucose levels, weight, striatal volume, inclusions, cognition and hippocampal neurogenesis were studied in male N171-82Q transgenic HD mice. Running started in pre-symptomatic (44±1 days old) male HD mice, did not improve function and appeared to accelerate disease onset. In particular, HD runners had an earlier onset of disease symptoms (shaking, hunched back and poor grooming), reduced striatal volume and impaired motor behavior, including a shorter latency to fall from the rotarod compared to sedentary controls. Furthermore, weight loss, reduced lifespan, hyperglycemia, Morris water maze learning deficits, diminished hippocampal neurogenesis, deficits in immature neuronal morphology, intranuclear inclusions and decreased dentate gyrus volume were refractory to physical activity. Taken together our research indicates that exercise is not beneficial, and may be detrimental to a vulnerable nervous system.