Physiotherapy in Parkinson's Disease: A Meta-Analysis of Present Treatment Modalities

Wuzi Yanzong Pill Plays A Neuroprotective Role in Parkinson's Disease Mice via Regulating Unfolded Protein Response Mediated by Endoplasmic Reticulum Stress

OBJECTIVE

To investigate the protective effects and its possible mechanism of Wuzi Yanzong Pill (WYP) on Parkinson's disease (PD) model mice.

METHODS

Thirty-six C57BL/6 male mice were randomly assigned to 3 groups including normal, PD, and PD+WYP groups, 12 mice in each group. One week of intraperitoneal injection of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) was used to establish the classical PD model in mice. Meanwhile, mice in the PD+WYP group were administrated with 16 g/kg WYP, twice daily by gavage. After 14 days of administration, gait test, open field test and pole test were measured to evaluate the movement function. Tyrosine hydroxylase (TH) neurons in substantia nigra of midbrain and binding immunoglobulin heavy chain protein (GRP78) in striatum and cortex were observed by immunohistochemistry. The levels of TH, GRP78, p-PERK, p-eIF2α, ATF4, p-IRE1α, XBP1, ATF6, CHOP, ASK1, p-JNK, Caspase-12, -9 and -3 in brain were detected by Western blot.

RESULTS

Compared with the PD group, WYP treatment ameliorated gait balance ability in PD mice (P<0.05). Similarly, WYP increased the total distance and average speed (P<0.05 or P<0.01), reduced rest time and pole time (P<0.05). Moreover, WYP significantly increased TH positive cells (P<0.01). Immunofluorescence showed WYP attenuated the levels of GRP78 in striatum and cortex. Meanwhile, WYP treatment significantly decreased the protein expressions of GRP78, p-PERK, p-eIF2α, ATF4, p-IRE1 α, XBP1, CHOP, Caspase-12 and Caspase-9 (P<0.05 or P<0.01).

CONCLUSIONS

WYP ameliorated motor symptoms and pathological lesion of PD mice, which may be related to the regulation of unfolded protein response-mediated signaling pathway and inhibiting the endoplasmic reticulum stress-mediated neuronal apoptosis pathway.

Worsening of Parkinson's Disease After Termination of COVID-19 Quarantine Cannot Be Reversed Despite Resumption of Physiotherapy

In a retrospective analysis, we recently reported findings on the detrimental motor effects of interrupted physiotherapy following the COVID-19 pandemic in parkinsonian patients. Using an extended follow-up period, we investigated the beneficial effect of reinstated physiotherapy on patients' disease severity and reversal of interruption-induced motor deterioration. Compared to before the COVID-19 outbreak, we observed persistence of motor disease worsening despite full resumption of state-of-the-art physical therapy suggesting that motor deterioration after discontinuation of physical therapy could not be compensated for. Therefore, and considering possible future crises, establishing means to safeguard continuation of physical therapy and to foster remote provision of care should be major goals.

Rehabilitation effects in idiopathic normal pressure hydrocephalus: a randomized controlled trial

BACKGROUND

Gait-balance disturbances are core symptoms of idiopathic normal pressure hydrocephalus (iNPH). However, the rehabilitation effects of cerebrospinal fluid (CSF) shunting along with other treatment or no further treatment (natural course [NC]) for iNPH are unknown.

OBJECTIVES

This study evaluated whether dynamic equilibrium gait training (DEGT) can improve gait-balance functions after CSF shunting of patients with iNPH compared to standard exercise (SE) and NC. Furthermore, it investigated the incidence of falls.

METHODS

A total of 70 patients with iNPH who underwent CSF shunting were randomly assigned to 6 weeks of DEGT (n = 23), 6 weeks of SE (n = 23), or NC (n = 24). Evaluation was performed at baseline (preoperatively) and at 1 week, 7 weeks (postintervention), and 6 months postoperatively (follow-up). Outcomes were measured using the functional gait assessment (FGA), 10-m walk test, timed up-and-go test, life-space assessment (LSA), and fall incidence.

RESULTS

A total of 65 participants completed the study. During the intention-to-treat analysis, the DEGT group demonstrated significant recovery of gait-balance functions according to only the FGA at postintervention and follow-up compared to the SE and NC groups; however, recovery of the SE group did not differ from that of the NC group. The DEGT group had a significantly lower fall incidence than the other groups at follow-up. Significantly better LSA results were observed for all groups at follow-up compared to baseline; however, no difference in LSA results were observed between groups.

CONCLUSIONS

DEGT in addtion to CSF shunting can facilitate the recovery of gait-balance function and reduce the fall incidence of iNPH patients.

Effects and parameters of community-based exercise on motor symptoms in Parkinson's disease: a meta-analysis

BACKGROUND

Community-based exercise is a continuation and complement to inpatient rehabilitation for Parkinson's disease and does not require a professional physical therapist or equipment. The effects, parameters, and forms of each exercise are diverse, and the effect is affected by many factors. A meta-analysis was conducted to determine the effect and the best parameters for improving motor symptoms and to explore the possible factors affecting the effect of community-based exercise.  METHODS: We conducted a comprehensive search of six databases: PEDro, PubMed/Medline, CENTRAL, Scopus, Embase, and WOS. Studies that compared community-based exercise with usual care were included. The intervention mainly included dance, Chinese martial arts, Nordic walking, and home-based exercise. The primary outcome measure was the Unified Parkinson's Disease Rating Scale part III (UPDRS-III) score. The mean difference (95% CI) was used to calculate the treatment outcomes of continuous outcome variables, and the I² statistic was used to estimate the heterogeneity of the statistical analysis. We conducted subgroup analysis and meta-regression analysis to determine the optimal parameters and the most important influencing factors of the exercise effect.  RESULTS: Twenty-two studies that enrolled a total of 809 subjects were included in the analysis. Exercise had a positive effect on the UPDRS-III (MD = -5.83; 95% CI, -8.29 to -3.37), Timed Up and Go test (MD = -2.22; 95% CI -3.02 to -1.42), UPDRS ((MD = -7.80; 95% CI -10.98 to -6.42), 6-Minute Walk Test (MD = 68.81; 95% CI, 32.14 to 105.48), and Berg Balance Scale (MD = 4.52; 95% CI, 2.72 to 5.78) scores. However, the heterogeneity of each included study was obvious. Weekly frequency, age, and duration of treatment were all factors that potentially influenced the effect.

CONCLUSIONS

This meta-analysis suggests that community-based exercise may benefit motor function in patients with PD. The most commonly used modalities of exercise were tango and tai chi, and the most common prescription was 60 min twice a week. Future studies should consider the influence of age, duration of treatment, and weekly frequency on the effect of exercise.

PROSPERO TRIAL REGISTRATION NUMBER

CRD42022327162.

An Online Dual-Task Cognitive and Motor Exercise Program for Individuals With Parkinson Disease (PD3 Move Program): Acceptability Study

BACKGROUND

Dual-task training is an emerging field used for people with Parkinson disease (PD) to improve their physical and cognitive well-being, but the patients' acceptability, safety, and adherence to such training in online settings are unknown.

OBJECTIVE

This study aims to evaluate the acceptability of a dual-task cognitive and motor online training program for people with PD as a group online community program.

METHODS

People with PD were invited to participate in an online program (PD3 Move) consisting of physical and vocal exercises in response to different cognitive challenges displayed as dynamic backgrounds on Zoom. The program ran twice per week for 16 weeks. Patient acceptability was assessed at 4 months by monitoring attendance rates and feedback from an exit questionnaire emailed to all participants assessing satisfaction, perceived benefit, safety, and willingness to continue and recommend to others.

RESULTS

The online program was delivered to 15 participants (n=9, 60%, females) with a diagnosis of PD, a mean age of 69.4 (SD 9.3) years, and Hoehn and Yahr (H&Y) stages I-IV. The attendance rate was high, with participants coming to more than 13 (81%) of the sessions. Participants were very satisfied (n=8, 53%) or satisfied (n=7, 47%) with the program. Participants reported that what they most liked were the new cognitive physical challenges. The 3 main facilitators to participating were perceiving the benefits, instructor's flexibility and engagement, and the social interaction moments with others. The 3 main difficulties were dealing with motor fluctuations (n=3, 20%), difficulties in using technology (n=2, 13%), and difficulty hearing instructions due to hearing loss (n=2, 13%). Patients had favorable perceived benefits of the program, with 14 (93%) considering it very useful for the current management of health and 1 (7%) moderately useful. No adverse events were reported, and all participants said that they were willing to continue the program and recommend it to others.

CONCLUSIONS

Our findings suggest that the online cognitive and motor program was well received, safe, and perceived to be of benefit to this group of medically stable people with PD in H&Y stages I-IV. Access to specialized care and enhancement of long-term adherence to regular exercise can be achieved with online community group programs.

Cognitive parameters can predict change of walking performance in advanced Parkinson's disease - Chances and limits of early rehabilitation

Introduction

Links between cognition and walking performance in patients with Parkinson's disease (PD), which both decline with disease progression, are well known. There is lack of knowledge regarding the predictive value of cognition for changes in walking performance after individualized therapy. The aim of this study is to identify relevant predictive cognitive and affective parameters, measurable in daily clinical routines, for change in quantitative walking performance after early geriatric rehabilitation.

Methods

Forty-seven acutely hospitalized patients with advanced PD were assessed at baseline (T1) and at the end (T2) of a 2-week early rehabilitative geriatric complex treatment (ERGCT). Global cognitive performance (Montreal Cognitive Assessment, MoCA), EF and divided attention (Trail Making Test B minus A, delta TMT), depressive symptoms, and fear of falling were assessed at T1. Change in walking performance was determined by the difference in quantitative walking parameters extracted from a sensor-based movement analysis over 20 m straight walking in single (ST, fast and normal pace) and dual task (DT, with secondary cognitive, respectively, motor task) conditions between T1 and T2. Bayesian regression (using Bayes Factor BF₁₀) and multiple linear regression models were used to determine the association of non-motor characteristics for change in walking performance.

Results

Under ST, there was moderate evidence (BF₁₀ = 7.8, respectively, BF₁₀ = 4.4) that lower performance in the ∆TMT at baseline is associated with lower reduction of step time asymmetry after treatment (R ² _adj = 0.26, p ≤ 0.008, respectively, R ² _adj = 0.18, p ≤ 0.009). Under DT walking-cognitive, there was strong evidence (BF₁₀ = 29.9, respectively, BF₁₀ = 27.9) that lower performance in the ∆TMT is associated with more reduced stride time and double limb support (R ² _adj = 0.62, p ≤ 0.002, respectively, R ² _adj = 0.51, p ≤ 0.009). There was moderate evidence (BF₁₀ = 5.1) that a higher MoCA total score was associated with increased gait speed after treatment (R ² _adj = 0.30, p ≤ 0.02).

Discussion

Our results indicate that the effect of ERGT on change in walking performance is limited for patients with deficits in EF and divided attention. However, these patients also seem to walk more cautiously after treatment in walking situations with additional cognitive demand. Therefore, future development of individualized treatment algorithms is required, which address individual needs of these vulnerable patients.

Clinical Trial Highlights - Aerobic Exercise for Parkinson's Disease

Converging lines of evidence suggest that aerobic exercise impacts Parkinson's disease (PD) motor symptoms and might slow it's progression. We provide an overview of the ongoing randomized clinical trials (RCTs) on aerobic exercise in PD. We found six RCTs with sample sizes between 28 and 370 and a follow-up between 8 weeks and 18 months. PD motor symptoms is mostly used as primary outcome while various secondary outcomes are reported. We need more trials that use both clinical endpoints and markers of neuroplasticity, and provide insight into the optimal exercise mode, duration and intensity.

Daily-Living Freezing of Gait as Quantified Using Wearables in People With Parkinson Disease: Comparison With Self-Report and Provocation Tests

OBJECTIVE

Freezing of gait (FOG) is an episodic, debilitating phenomenon that is common among people with Parkinson disease. Multiple approaches have been used to quantify FOG, but the relationships among them have not been well studied. In this cross-sectional study, we evaluated the associations among FOG measured during unsupervised daily-living monitoring, structured in-home FOG-provoking tests, and self-report.

METHODS

Twenty-eight people with Parkinson disease and FOG were assessed using self-report questionnaires, percentage of time spent frozen (%TF) during supervised FOG-provoking tasks in the home while off and on dopaminergic medication, and %TF evaluated using wearable sensors during 1 week of unsupervised daily-living monitoring. Correlations between those 3 assessment approaches were analyzed to quantify associations. Further, based on the %TF difference between in-home off-medication testing and in-home on-medication testing, the participants were divided into those responding to Parkinson disease medication (responders) and those not responding to Parkinson disease medication (nonresponders) in order to evaluate the differences in the other FOG measures.

RESULTS

The %TF during unsupervised daily living was mild to moderately correlated with the %TF during a subset of the tasks of the in-home off-medication testing but not the on-medication testing or self-report. Responders and nonresponders differed in the %TF during the personal "hot spot" task of the provoking protocol while off medication (but not while on medication) but not in the total scores of the self-report questionnaires or the measures of FOG evaluated during unsupervised daily living.

CONCLUSION

The %TF during daily living was moderately related to FOG during certain in-home FOG-provoking tests in the off-medication state. However, this measure of FOG was not associated with self-report or FOG provoked in the on-medication state. These findings suggest that to fully capture FOG severity, it is best to assess FOG using a combination of all 3 approaches.

IMPACT

These findings suggest that several complementary approaches are needed to provide a complete assessment of FOG severity.

Effectiveness of home-based rehabilitation using active video games on quality of life, cognitive and motor functions in people with Parkinson's disease: a systematic review

PURPOSE

We summarized the effectiveness of home-based active video game interventions on physical and cognitive functions, as well as quality of life in adults with Parkinson's disease. We also assessed the feasibility, safety, adherence, and retention of benefits of these interventions.

METHOD

We searched studies in eight databases from 1st March to 30th November 2020. Two authors independently performed the selection, data extraction and risk of bias evaluation (PROSPERO ID: CRD42020178138).

RESULTS

Nine studies were included in this systematic review (412 participants). All in all, home-based active video games were found effective in improving gait and balance functions in people with Parkinson's disease, equivalent to usual care and conventional therapy. No conclusion can be drawn on cognition and quality of life. Home-based active video games seemed feasible, safe, and were enjoyed by people with Parkinson's disease. The optimal dose, the need for supervision and the retention of benefits of these interventions are still to be determined. These results should be interpreted carefully, considering the limited number of included studies and their small sample sizes, the widespread heterogeneity of included studies and their medium average methodological quality.

CONCLUSION

Future research should focus on the effects of home-based active video games on impairments specific to Parkinson's disease, such as falls, freezing of gait and attention, as well as the dose, need for supervision and retention of the benefits of these interventions.IMPLICATIONS FOR REHABILITATIONHome-based active video games are effective in improving motor functions in people with PD.No conclusion can be drawn regarding cognition in people with PD.No conclusion can be drawn regarding quality of life in people with PD.Home-based active video games seem feasible and safe, and are enjoyed by people with PD.The dose, need for control and retention of the benefits still need to be determined.

Parkinson's disease multimodal complex treatment improves gait performance: an exploratory wearable digital device-supported study

BACKGROUND

Wearable device-based parameters (DBP) objectively describe gait and balance impairment in Parkinson's disease (PD). We sought to investigate correlations between DBP of gait and balance and clinical scores, their respective changes throughout the inpatient multidisciplinary Parkinson's Disease Multimodal Complex Treatment (PD-MCT), and correlations between their changes.

METHODS

This exploratory observational study assessed 10 DBP and clinical scores at the start (T1) and end (T2) of a two-week PD-MCT of 25 PD in patients (mean age: 66.9 years, median HY stage: 2.5). Subjects performed four straight walking tasks under single- and dual-task conditions, and four balance tasks.

RESULTS

At T1, reduced gait velocity and larger sway area correlated with motor severity. Shorter strides during motor-motor dual-tasking correlated with motor complications. From T1 to T2, gait velocity improved, especially under dual-task conditions, stride length increased for motor-motor dual-tasking, and clinical scores measuring motor severity, balance, dexterity, executive functions, and motor complications changed favorably. Other gait parameters did not change significantly. Changes in motor complications, motor severity, and fear of falling correlated with changes in stride length, sway area, and measures of gait stability, respectively.

CONCLUSION

DBP of gait and balance reflect clinical scores, e.g., those of motor severity. PD-MCT significantly improves gait velocity and stride length and favorably affects additional DBP. Motor complications and fear of falling are factors that may influence the response to PD-MCT. A DBP-based assessment on admission to PD inpatient treatment could allow for more individualized therapy that can improve outcomes.

TRIAL REGISTRATION NUMBER AND DATE

DRKS00020948 number, 30-Mar-2020, retrospectively registered.

Efficacy and evaluation of therapeutic exercises on adults with Parkinson's disease: a systematic review and network meta-analysis

Background

Exercises are an effective treatment in Parkinson’s disease (PD), but there is still controversy over which types should be used. We aimed to compare and rank the types of exercise that improve PD symptoms by quantifying information from randomised controlled trials.

Methods

We performed a systematic review and network meta-analysis and searched PubMed, MEDLINE, Embase, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and China National Knowledge Infrastructure (CNKI) from their inception date to June 30, 2022. We included randomized controlled trials of 24 types of exercise for the interventional treatment of adults (≥ 50 years old) with PD. Effect size measures were standardized mean differences (SMDs) with 95% credible intervals (CrIs). The confidence of evidence was examined using Confidence in Network Meta-Analysis (CINeMA).

Results

We identified 10 474 citations and included 250 studies involving 13 011 participants. Results of NMA showed that power training (PT) had the best benefits for motor symptoms compared with the control group (CON), with SMDs (95% CrI) (-1.46, [-2.18 to -0.74]). Body weight support treadmill training (BWS_TT) showed the best improvement in balance (1.55, [0.72 to 2.37]), gait velocity (1.15 [0.57 to 1.31]) and walking distance (1.96, [1.18 to 2.73]), and robotic assisted gait training (RA_GT) had the most benefits for freezing of gait (-1.09, [-1.80 to -0.38]). For non-motor symptoms, Dance showed the best benefits for depression (-1.71, [-2.79 to -0.73]). Only Yoga significantly reduced anxiety symptom compared with CON (-0.53, [0.96 to -0.11]). Only resistance training (RT) significantly enhanced sleep quality and cognition (-1.42, [-2.60 to -0.23]; 0.51, [0.09 to 0.94]). For muscle strength, PT showed the best advance (1.04, [0.64 to 1.44]). For concern of falling, five types of exercise were more effective than CON.

Conclusions

There is low quality evidence that PT, Yoga, BWS_TT, Dance, and RT are the most effective treatments, pending outcome of interest, for adults with PD.

Trial registration

PROSPERO (CRD42021220052).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03510-9.

Resistance Training Combined with Balance or Gait Training for Patients with Parkinson's Disease: A Randomized Controlled Pilot Study

Background

Gait and balance disorders in patients with idiopathic Parkinson's disease (PD) lead to major mobility limitations. To counteract this, physical therapy such as gait, balance, or resistance training is applied. Integrative training methods, which combine these elements, could be particularly effective.

Objective

The objective of this study is to evaluate and compare the effects of two integrative interventions on gait and balance of patients with PD.

Methods

Twenty-six patients with PD received either resistance training in combination with gait training (gait resistance training, GRT) or resistance training in combination with balance training (stability resistance training, SRT) for six weeks. Gait and balance outcome parameters were assessed before, immediately after, and six weeks after the interventions. The primary outcome parameters were the functional reach test to evaluate balance and stride length to evaluate gait. Secondary outcomes included further gait analysis parameters, knee extension strength, the timed up and go test, and the six-minute walk test.

Results

The functional reach test results were significantly better after the intervention in both groups. Stride length increased significantly only in the GRT group. Several further gait parameters and the six-minute walk test improved in the GRT group, and the increase in gait speed was significantly higher than in the SRT group. The SRT group performed better after the intervention regarding the timed up and go test and knee extension strength, the latter being significantly more improved than in the SRT group. At six-week follow-up, the improvement in functional reach was maintained in the SRT group.

Conclusions

Integrative therapies, combining gait or balance training with resistance training, have specific positive effects in PD rehabilitation. More pronounced effects on gait parameters are achieved by GRT, while SRT has more impact on balance. Thus, the combination of both training methods might be particularly efficient in improving the mobility of PD patients.

Comparison of the Effects of an Exergame-Based Program with Conventional Physiotherapy Protocol Based on Core Areas of the European Guideline on Postural Control, Functional Mobility, and Quality of Life in Patients with Parkinson's Disease: Randomized Clinical Trial

Introduction: Impairment of postural control and functional mobility are debilitating symptoms of Parkinson's disease (PD). In addition to limiting performance in activities of daily living, it is associated with a higher prevalence of falls in this population. Particularly, dysfunction in postural control does not respond to dopaminergic replacement therapy, but physiotherapy can improve this outcome in patients with PD. Objective: The aim of this study was to analyze the effects of training based on Kinect Adventures games compared with a conventional physiotherapy protocol based on the core areas of the European physiotherapy guideline in patients with PD on postural control, functional mobility, self-perception of confidence in the balance, quality of life (QoL), lower limb muscle strength, transfer skill and motor function, as well as to observe adherence and safety interventions. Methods: Thirty-eight patients diagnosed with idiopathic PD were randomized into two groups, and performed 14 training sessions, twice a week for 60 minutes. The primary outcome assessed postural control using the Mini-Balance Evaluation Systems Test (Mini-BESTest). The following were evaluated as secondary outcomes: limit of stability; balance functional reserve and center of pressure area by computerized posturography; functional mobility by the Timed Up and Go test; self-confidence in balance through the Activities-specific Balance Confidence scale; QoL through the Parkinson's Disease Questionnaire; lower limb muscle strength by the Five Times Sit-To-Stand test; and motor function by the Unified Parkinson's Disease Rating Scale. Results: Patients completed training sessions with high rates of safety and adherence. After training, there was a significant improvement in postural control, motor function, and QoL. Conclusion: Both interventions proved to be safe, applicable, and effective to improve postural control, QoL, and motor function in patients with PD. However, there was no difference between the effects of Kinect Adventures games and conventional physiotherapeutic protocol in patients with PD. Brazilian Registry of Clinical Trials (RBR-27kqv5).

Effect of Long-term Exercise Therapy on Motor Symptoms in Parkinson Disease Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVES

The aims of the study were to assess the effectiveness of long-term exercise therapy (≥12 wks) for patients with Parkinson disease and to derive specific suggestions on how the motor symptom improvements can be optimized by exercise type and exercise dose.

DESIGN

The PubMed, Web of Science, Cochrane Central Register, Embase, Scopus, and CNKI databases were searched up to January 2021 for randomized controlled trials focusing on the effects of long-term exercise for Parkinson disease. Two researchers independently evaluated the quality of papers using the PEDro scale. Twenty-six studies with a total of 1243 participants were included.

RESULTS

Tai Chi, resistance training, and dance provide significant improvements in physical function and functional mobility. Furthermore, Tai Chi and dance result in balance benefits. However, walking capacity outcomes did not improve after Tai Chi and resistance training but did improve after dance. With an increase in the intervention duration or length of each session, the effect sizes of exercise on these outcomes increased; higher benefits of exercise on these outcomes were observed at a frequency of 2 times/wk.

CONCLUSIONS

Long-term exercise therapy is an effective treatment for improving motor symptoms, with dance being an ideal exercise choice.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Recognize that long-term exercise slows clinical progression of motor symptoms in patients with Parkinson disease; (2) Acquire knowledge regarding the effectiveness of long-term exercise therapy on motor symptoms in Parkinson disease; and (3) Incorporate specific suggestions on dose-response relationships of different exercise therapy on motor symptoms in Parkinson disease.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Effect of therapeutic exercise on the balance of patients with progressive supranuclear palsy: A pilot study

Background

Progressive supranuclear palsy (PSP) is a parkinsonian-like progressive neurodegenerative syndrome. Key clinical features include ocular motor dysfunction, postural instability, and cognitive dysfunction. Maintaining and improving balance function and gait function are very important for patients with PSP with severe postural dysfunction and repeated falls. In addition, patients with PSP have a poor response to pharmacological treatment; hence, rehabilitation is a key approach in dealing with this syndrome. However, no conclusion on the beneficial effects of rehabilitation for patients with PSP have been established in the literature.

Objectives

The effectiveness of multiple therapeutic exercise program with probable or possible PSP according to the Movement Disorder Society criteria for the clinical diagnosis of PSP was validated.

Methods

Participants underwent multiple therapeutic exercise program customized for each participant, including resistance training, balance training, and walking exercises that were performed for 60–80 minutes a day, 5 days a week for 4 weeks. The outcomes measured were as follows: pull test, Berg Balance Scale (BBS), timed up and go test (TUG), and gait speed test.

Results

A total of 117 patients with PSP were enrolled and the analysis was performed on 20 patients with probable PSP. Four-week rehabilitation significantly improved pull test (p = 0.034) and BBS scores (p = 0.001). There were no significant differences both TUG (p = 0.502) and gait speed (p = 0.813).

Conclusion

The multiple therapeutic exercise program had beneficial effects on balance performance in patients with PSP in 4 weeks and could be an essential element in their rehabilitation. Although this pilot study was conducted without a control group, it provided valuable information for future prospective randomized controlled trials.

Which type of mind-body exercise is most effective in improving functional performance and quality of life in patients with Parkinson's disease? A systematic review with network meta-analysis

BACKGROUND

Several studies have investigated the effect of mind-body exercise (MBE) on functional performance and health-related quality of life (HRQoL) in Parkinson's disease (PD), but it is still very difficult for clinicians to make informed decision on the best mind-body exercise for PD.

PURPOSE

We analyzed the relative efficacy of MBE (yoga, Tai-Chi, Pilates, Qigong, and dance) in improving functional performance and HRQoL in patients with PD.

METHODS

A systematic review of randomized controlled trials (RCTs) was performed using network meta-analysis (NMA), searching the following databases: Cochrane, Web of Science, and PubMed using specific keywords until December 28, 2021, assessing the effects of MBE on functional performance and HRQoL in patients with PD.

RESULTS

This review included 60 RCTs with 2037 participants. A ranking of MBE for modifying various aspects of functional performance and HRQoL was achieved. Pairwise NMA showed Pilates to be the most effective in improving functional mobility (MD: - 3.81; 95% CI (- 1.55, - 6.07) and balance performance (SMD: 2.83; 95% CI (1.87, 3.78). Yoga (MD: - 5.95; 95% CI (- 8.73, - 3.16) and dance (MD: - 5.87; 95% CI (- 8.73, - 3.01) to be the most effective in improving motor function, whereas Qigong (MD: 0.32; 95% CI (0.00, 0.64) was most effective in improving gait speed. Considering HRQoL, dance was found to be the most effective (SMD: - 0.36; 95% CI (- 0.70, -0.01).

CONCLUSION

MBE should be considered an effective strategy for improving functional performance and HRQoL in patients with PD. The most effective MBE intervention varied with the functional performance domain. Dance was an effective exercise for improving HRQoL among people with PD.

PROSPERO REGISTRATION ID

CRD42022301030.

Treadmill training and physiotherapy similarly improve dual task gait performance: a randomized-controlled trial in Parkinson's disease

Motor-cognitive dual tasks are used to investigate the interplay between gait and cognition. Dual task walking in patients with Parkinson's disease (PD) results in decreased gait speed and more importantly in an increased fall risk. There is evidence that physical training may improve gait during dual task challenge. Physiotherapy and treadmill walking are known to improve single task gait. The aim of this study was to investigate the impact of individualized physiotherapy or treadmill training on gait during dual task performance. 105 PD patients were randomly assigned to an intervention group (physiotherapy or treadmill). Both groups received 10 individual interventional sessions of 25 min each and additional group therapy sessions for 14 days. Primary outcome measure was the dual task gait speed. Secondary outcomes were additional gait parameters during dual task walking, UPDRS-III, BBS and walking capacity. All gait parameters were recorded using sensor-based gait analysis. Gait speed improved significantly by 4.2% (treadmill) and 8.3% (physiotherapy). Almost all secondary gait parameters, UPDRS-III, BBS, and walking capacity improved significantly and similarly in both groups. However, interaction effects were not observed. Both interventions significantly improved gait in patients with mild to moderate PD. However, treadmill walking did not show significant benefits compared to individualized physiotherapy. Our data suggest that both interventions improve dual task walking and therefore support safe and independent walking. This result may lead to more tailored therapeutic preferences.

Lifestyle Interventions for the Prevention of Parkinson Disease: A Recipe for Action

The prevalence of Parkinson disease (PD) is growing fast, amplifying the quest for disease-modifying therapies in early disease phases where pathology is still limited. Lifestyle interventions offer a promising avenue for preventing progression from prodromal to manifest PD. We illustrate this primarily for 1 specific lifestyle intervention, namely aerobic exercise because the case for the other main lifestyle factor (dietary interventions) to modify the course of prodromal PD is currently less persuasive. Various observations have hinted at the disease-modifying potential of exercise. First, studies in rodents with experimental parkinsonism showed that exercise elicits adaptive neuroplasticity in basal ganglia circuitries. Second, exercise is associated with a reduced risk of developing PD, suggesting a disease-modifying potential. Third, 2 large trials in persons with manifest PD indicate that exercise can help to stabilize motor parkinsonism, although this could also reflect a symptomatic effect. In addition, exercise seems to be a feasible intervention, given its minimal risk of side effects. Theoretical risks include an increase in fall incidents and cardiovascular complications, but these concerns seem to be acceptably low. Innovative approaches using gamification elements indicate that adequate long-term compliance with regular exercise programs can be achieved, although more work remains necessary to demonstrate enduring adherence for multiple years. Advances in digital technology can be used to deliver the exercise intervention in the participant's own living environment and also to measure the outcomes remotely, which will help to further boost long-term compliance. When delivering exercise to prodromal participants, outcome measures should focus not just on phenoconversion to manifest PD (which may well take many years to occur) but also on measurable intermediate outcomes, such as physical fitness or prodromal nonmotor symptoms. Taken together, there seems to be sufficient evidence to advocate the first judicious attempt of investigating exercise as a disease-modifying treatment in prodromal PD.

Walking function determinants in parkinson patients undergoing rehabilitation

BACKGROUND: To date little is known about factors affecting walking rehabilitation in Parkinson’s disease (PD) patients. OBJECTIVE: This prospective observational cohort study evaluated the walking distance covered in 6 minutes (6 MWD) before and after conventional rehabilitation and verified which among PD motor disorders was the most important determinant of walking distance in PD patients undergoing rehabilitation. METHODS: Data were collected from 55 PD patients, performing a conventional outpatient motor rehabilitation program. The 6MWD at the end of rehabilitation and gain in 6MWD were the outcome measures. The Unified Parkinson’s Disease Rating Scale, Hoehn and Yahr scale, Nine Hole Peg Test, Grip and Pinch test, ROM wrist motility, and Berg Balance Scale (BBS) were used to assess PD patients at admission and were considered as dependent variables. Backward multiple regression analyses identified the determinants of 6MWD outcomes. RESULTS: The 6MWD was 246.58±115 meters at admission and 286.90±116 at the end of rehabilitation. At end of rehabilitation, the 6MWD was 42.32±47 meters greater than admission (p <  0.001), corresponding to an increase of +17.16% . At the end of rehabilitation, the 6MWD was significantly longer in PD patients with stages 1–3 of the Hoehn and Yahr scale. Berg Balance Scale (β= 0.47, p <  0.001) and right Grip and Pinch at admission (β= 0.36, p = 0.001) were the only determinants of final 6MWD. The R2 value of the model was 0.47 (R2 adjusted 0.45). No variable was a determinant of gain in 6MWD. CONCLUSIONS: The study indicates that balance and generalized muscle strength are important determinants of walking rehabilitation in PD patients, in whom it is essential to maintain high levels of balance and muscle strength for a time as long as possible. These findings suggest planning more intensive rehabilitation treatments in PD patients with low levels of balance and muscle strength.

Physical Therapy for at Least 6 Months Improves Motor Symptoms in Parkinson’s Patients: A Meta-Analysis

Objective

Long-term physical therapy helps to improve the motor symptoms of patients with Parkinson's disease, but the effectiveness is not clear. The purpose of this study was to evaluate the effect of long-term physical therapy on improving motor symptoms or daily activities in Parkinson's patients with drug use or discontinuation, as well as its impact on drug treatment dose. A subgroup analysis was conducted on different treatment methods to determine the most effective treatment method.

Methods

The researchers independently searched databases, including PubMed, Medline, Embase, Ovid, Cochrane Library, and ISI Web of science. The search deadline was June 2022. A randomized controlled trial was conducted on Parkinson's disease patients with HY stages 1-3 who received continuous physical therapy for 6 months or more. Systematic evaluation and meta-analysis were carried out by using common clinical evaluation indicators, namely, MDS-UPDRS exercise score, daily activity (ADL) score, or LED dose. The quality of the literature was assessed using the modified Jadad scale of Cochrane's bias risk tool.

Results

A total of 523 Parkinson's disease patients with HY stages of 1-3 were included in the study. The results showed that long-term physical therapy could improve patients' motor symptoms with combined antiparkinsonian drugs (Z = 2.61 and P = 0.009) and had a significant positive effect on the motor symptoms of patients with discontinued antiparkinsonian drugs (Z = 2.73 and P = 0.006). Meanwhile, it could reduce the LED dose of patients with Parkinson's disease. The difference was statistically significant (Z = 2.58 and P = 0.010).

Conclusion

The results of this study indicated that physical therapy for at least 6 months or longer for patients with mild to moderate Parkinson's HY could effectively improve the motor symptoms of Parkinson's patients, whether or not combined with antiparkinson drugs. Meanwhile, long-term physical therapy reduced the LED dose of patients treated with drugs compared with patients in the control group who received short-term physical therapy, other types of intervention group, or no treatment.

Community Exercise: A New Tool for Personalized Parkinson’s Care or Just an Addition to Formal Care?

Physiotherapy and exercise are associated with motor and non-motor benefits in Parkinson’s disease (PD). Community exercise programs may increase ongoing exercise participation and help people with Parkinson’s disease actively participate in their health management. But there is still limited knowledge about these programs regarding their benefits, safety, implications over the long-term, and effective implementation. These questions could hold relevant clinical implications. In this perspective article, we identify the current challenges and reflect upon potential solutions to help community exercise to be implemented as an additional anchor to personalize management models for Parkinson’s disease.

Managing freezing of gait in Parkinson's disease: a systematic review and network meta-analysis

BACKGROUND

Freezing of gait (FOG) is one of the most disabling gait disorders affecting 80% of patients with Parkinson's disease (PD). Clinical guidelines recommend a behavioral approach for gait rehabilitation, but there is a wide diversity of behavioral modalities.

OBJECTIVE

The objective of this network meta-analysis was to compare the effectiveness of different behavioral interventions for FOG management in PD patients.

METHODS

Six databases were searched for randomized controlled trials of behavioral interventions for FOG management among PD patients from 1990 to December 2021. Bayesian network meta-analysis was used to combine both direct and indirect trial evidence on treatment effectiveness, while the surface under the cumulative ranking (SUCRA) score was used to estimate the ranked probability of intervention effectiveness.

RESULTS

Forty-six studies were included in the qualitative synthesis. Among, 36 studies (1454 patients) of 72 interventions or control conditions (12 classes) were included in the network meta-analysis, with a mean intervention period of 10.3 weeks. After adjusting for the moderating effect of baseline FOG severity, obstacle training [SMD -2.1; 95% credible interval (Crl): -3.3, -0.86], gait training with treadmill (SMD -1.2; 95% Crl: -2.0, -0.34), action observation training (SMD -1.0; 95% Crl: -1.9, -0.14), conventional physiotherapy (SMD -0.70; 95% Crl: -1.3, -0.12) and general exercise (SMD -0.64; 95% Crl: -1.2, -0.11) demonstrated significant improvement on immediate FOG severity compared to usual care. The SUCRA rankings suggest that obstacle training, gait training on treadmill and general exercises are most likely to reduce FOG severity.

CONCLUSION

Obstacle training, gait training on treadmill, general exercises, action observation training and conventional physiotherapy demonstrated immediate real-life benefits on FOG symptoms among patients with mild-moderate PD. With the promising findings, the sustained effects of high complexity motor training combined with attentional/cognitive strategy should be further explored. Future trials with rigorous research designs using both subjective and objective outcome measures, long-term follow-up and cost-effective analysis are warranted to establish effective behavioral strategies for FOG management.

Evaluation of an individualized, tablet-based physiotherapy training programme for patients with Parkinson's disease: the ParkProTrain study, a quasi-randomised controlled trial

BACKGROUND

Regular physical activity is of great relevance in Parkinson's disease (PD). It is part of the inpatient multimodal Parkinson's complex treatment (MKP) in Germany. However, there is often a lack of human resources in outpatient settings to continue an interprofessional approach. A large proportion of PD patients live a predominantly sedentary lifestyle and do not get enough exercise.

METHODS

The intervention group (IG) used a tablet-based physiotherapy training programme at home for a period of nine months. We conducted a quasi-randomised longitudinal study with three measurement times (at the beginning (t0) and end of MKP (t1) and at 9 months after MKP (t2)). The primary outcome measured was PD-specific quality of life using the PDQ-8. The secondary outcome focused on participation restrictions, falling anxiety, sleep disorder, anxiety and depression as well as comorbidity, pain, performance capability and physical activity.

RESULTS

For n = 93 IG and n = 137 control group (CG) patients, evaluable cases were available for all measurement times. Both groups achieved significant improvements in all parameters at the end of MKP. These parameters deteriorated again at nine months after MKP for most parameters and were even below the baseline levels. However, this deterioration was less pronounced in the IG than in the CG. For general health and social participation, a significant slightly positive effect was observed in the IG nine months after MKP when compared with the baseline level. Paying attention to physical activity slightly increased in the IG for the catamnesis survey compared to baseline. Nearly all IG patients were satisfied with the intervention, especially with the consultations with the physiotherapist.

CONCLUSIONS

Although the expected extent of effects could not be determined for the IG, stabilisation effects could be demonstrated. These stabilisation effects shown for the IG might be attributed to the intervention. The effects might have been greater without the COVID-19 pandemic.

TRIAL REGISTRATION

German Register of Clinical Trials, drks.de. Identifier: DRKS00014952. Registered 20/06/2018. Date and version identifier 25/04/2019; version 1.

Parkinson's disease and intensive exercise therapy - An updated systematic review and meta-analysis

In 2015, Uhrbrand et al. published the first review on Parkinson´s disease (PD) and exercise entirely based on randomized controlled trials (RCT) applying strict exercise definitions. The present review aimed to update the PD literature by assessing the effects of different intensive exercise modalities: resistance training (RT), endurance training (ET), and other intensive exercise modalities (OITM). An updated systematic literature search identified 33 new RCTs. Qualitative and quantitative analyses were performed. A total of 18 RT, 14 ET, and 1 OITM studies were identified (adding to the 8 RT, 6 ET, and 4 OITM studies identified by Uhrbrand et al. in 2015). RT, ET, and OITM were feasible, safe, and did not worsen PD symptoms. Furthermore, RT, ET, and OITM may positively affect functional outcomes (e.g., balance) and depressive symptoms in PD but inconsistencies across these findings warrant cautious conclusions. Meta-analyses showed that RT had a positive impact on muscle strength (standardized mean difference (SMD) = 0.83 [95% CI;0.54, 1.12]), functional capacity (Timed Up and Go Test (TUG): SMD = -0.62 [-1.01, -0.24]), and quality of life (SMD = -0.41 [-0.72, -0.09]), while ET had a positive impact on cardiorespiratory fitness (SMD = 0.27 [0.07, 0.47]) and functional capacity (TUG: SMD = -0.21 [-0.46, 0.04], 6-Min Walk Test: SMD = 0.89 [0.17, 1.62]), and a potentially positive impact on "on-medication" UPDRS-III (SMD = -0.15 [-0.38, 0.09]) and "off-medication" UPDRS-III (SMD = -0.19 [-0.41, 0.04]). In conclusion, RT, ET, and OITM all represent safe, feasible, and beneficial adjunct rehabilitation strategies in PD, with particularly RT and ET showing solid effects.

How I treat Parkinson's disease

BACKGROUND

Parkinson's disease (PD) is a complex neurodegenerative condition. Treatment strategies through all stages of disease progression could affect quality of life and influence the development of future complications, making it crucial for the clinician to be on top of the literature.

OBJECTIVE

This paper reviews the current treatment of PD, from early to advanced stages.

METHODS

A literature review was conducted focusing on the treatment of PD, in the different stages of progression.

RESULTS

Every individual with a new diagnosis of PD should be encouraged to start exercising regularly. In the early stage, treatment should focus on using the lowest dose of levodopa or combination therapy that provides maximum functional capacity, and does not increase the risk of complications, such as peak dose dyskinesias and impulse control disorders. At the moderate and advanced stages, motor fluctuations and complications of treatment dominate the picture, making quality of life one important issue. Rehabilitation programs can improve motor symptoms and should be offered to all patients at any stage of disease progression.

CONCLUSION

Many factors need to be considered when deciding on the best treatment strategy for PD, such as disease progression, presence of risk factors for motor and behavioral complications, potential side effects from dopaminergic therapy and phenotypical variabilities. Treatment should focus on functional capacity and quality of life throughout the whole disease course.

The Category of Conventional Physiotherapy: The Case of Parkinson’s Disease Guidelines

This opinion paper reviews the use of the category of “conventional physiotherapy” (CPT) in Parkinson’s disease (PD)-relevant reviews and meta-analyses and points out serious inconsistencies within and among them. These are first discussed in general, leading to the conclusion that, in most cases, the category of CPT encompasses a range of incompatible interventions. This undermines previous conclusions about their superiority or inferiority relative to various other treatment modalities. Next, the update to the European Physiotherapy Guidelines is discussed in detail, since it treats CPT as a global and time-independent category per se, ascribing effects in various domains to it. This introduces several important biases into the findings presented in this publication. These are subsequently discussed, and it is concluded that the categorisation of various physiotherapy techniques under the umbrella term of CPT is empty, or even dangerous, and should be abandoned. Other categories are suggested as a replacement, including “Other Physiotherapy Techniques” and “Multimodal Training”.

Associations between resting-state functional connectivity changes and prolonged benefits of writing training in Parkinson's disease

BACKGROUND

Our earlier work showed that automaticity and retention of writing skills improved with intensive writing training in Parkinson's disease (PD). However, whether this training changed the resting-state networks in the brain and how these changes underlie retention of motor learning is currently unknown.

OBJECTIVE

To examine changes in resting-state functional connectivity (rs-FC) and their relation to behavioral changes immediately after writing training and at 6 week follow-up.

METHODS

Twenty-five PD patients underwent resting-state fMRI (ON medication) before and after 6 weeks writing training. Motor learning was evaluated with a dual task paradigm pre- and post-training and at follow-up. Next, pre-post within-network changes in rs-FC were identified by an independent component analysis. Significant clusters were used as seeds in ROI-to-ROI analyses and rs-FC changes were correlated with changes in behavioral performance over time.

RESULTS

Similar to our larger cohort findings, writing accuracy in single and dual task conditions improved post-training and this was maintained at follow-up. Connectivity within the dorsal attentional network (DAN) increased pre-post training, particularly with the right superior and middle temporal gyrus (rS/MTG). This cluster also proved more strongly connected to parietal and frontal areas and to cerebellar regions. Behavioral improvements from pre- to post-training and follow-up correlated with increased rs-FC between rS/MTG and the cerebellum.

CONCLUSIONS

Training-driven improvements in dual task writing led to functional reorganization within the DAN and increased connectivity with cerebellar areas. These changes were associated with the retention of writing gains and could signify task-specific neural changes or an inability to segregate neural networks.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Neuropsychiatric Treatments for Parkinson's Disease: Nonpharmacological Approaches

Although diagnosed by characteristic motor features, Parkinson's disease and other movement disorders are frequently accompanied by a wide range of neuropsychiatric symptoms that require a multidisciplinary approach for treatment. Neuropsychiatric symptoms such as depression, anxiety and cognitive symptoms strongly influence quality of life, motor symptoms, and non-motor bodily symptoms. This review summarizes our current understanding of the neuropsychiatric symptoms in movement disorders and discusses the evidence base for treatments focusing on rehabilitation and nonpharmacological approaches. A practical approach is then proposed for patient selection for specific treatments based on disease stage. The article focuses mostly on Parkinson's disease as a prototypical movement disorder with the largest evidence base but the principles discussed herein are applicable to a range of other movement disorders.

Professionals' Self-Reported Difficulties towards Integrating Dual Task Training in Care for People with Parkinson's Disease

Background: Despite the growing use of dual task training (DTT) in clinical practice with people with Parkinson Disease (PD), there is still limited evidence on how to best implement it. Data regarding professionals’ difficulties when integrating such practices are critical as a first step to generate further guidance on how to apply it. The aim of this study was to identify the difficulties perceived by professionals to integrate dual task in their practice. Methods: A descriptive, observational and cross-sectional study was conducted using a web-based survey. Convenience sampling was used to recruit exercise and healthcare professionals working with people with PD through various social media channels. Data were collected and then analyzed thematically using the method of constant comparisons. The study report follows the consolidated criteria for reporting qualitative research (COREQ) checklist. Results: Of the 205 eligible responses, 68.8% were Physiotherapist. The majority of the participants reported having Parkinson-specific training (91.7%) and 59.0% applied DTT in individual one-on-one sessions. We identified ten categories of difficulties faced by professionals. Conclusions: Professionals struggle to integrate DTT into PD clinical care. Challenges were identified and the most significant refer to difficulties in managing the chronicity of the disease and lack of patient compliance with home exercises. Understanding current challenges towards dual task exercise will help to reflect upon strategies to be applied effectively and safe.

Behavioural and neuroplastic effects of a double-blind randomised controlled balance exercise trial in people with Parkinson's disease

Balance dysfunction is a disabling symptom in people with Parkinson's disease (PD). Evidence suggests that exercise can improve balance performance and induce neuroplastic effects. We hypothesised that a 10-week balance intervention (HiBalance) would improve balance, other motor and cognitive symptoms, and alter task-evoked brain activity in people with PD. We performed a double-blind randomised controlled trial (RCT) where 95 participants with PD were randomised to either HiBalance (n = 48) or a control group (n = 47). We found no significant group by time effect on balance performance (b = 0.4 95% CI [-1, 1.9], p = 0.57) or on our secondary outcomes, including the measures of task-evoked brain activity. The findings of this well-powered, double-blind RCT contrast previous studies of the HiBalance programme but are congruent with other double-blind RCTs of physical exercise in PD. The divergent results raise important questions on how to optimise physical exercise interventions for people with PD.Preregistration clinicaltrials.gov: NCT03213873.

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

Background and Objectives

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

Methods

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

Results

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

Discussion

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

Trial Registration Information

ClinicalTrials.gov Identifier: NCT01176565.

Classification of Evidence

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

Evidence-Based Aquatic Therapy Guidelines for Parkinson's Disease: An International Consensus Study

BACKGROUND

Aquatic therapy is one therapy option for people living with Parkinson's disease (PD). However, the optimal prescription, dosage, and delivery remain unclear.

OBJECTIVE

i) To generate consensus statements, ii) to establish evidence-based clinical practice aquatic therapy guidelines for PD.

METHODS

Seventy-three international experts were invited to participate in a 3-step modified Delphi study. Gaps in the aquatic therapy evidence, patient preferences, and stakeholder engagement were considered when developing the initial list of 43-statements identified by the research development group. Practice experts rated each statement on an 11-point Likert scale. Consensus for inclusion was set at a priori of ≥70% of respondents scoring an item ≥7. Two rounds of Delphi questionnaires were completed online, and the expert comments were analyzed using content analysis. An online consensus meeting with an expert subgroup (n = 10) then advised on the guideline's acceptability and debated items until consensus for inclusion was reached.

RESULTS

Fifty experts participated in the Delphi round one (83% response rate) and 45 in round two (90% response rate), representing 15 countries. In round one, 35 statements met the criteria for consensus. Content analysis informed the revised statements in round two, where 12 of the remaining 16 statements met consensus. The final agreed aquatic therapy guidelines include key information about dosage, content, safety, contraindications, and the optimal aquatic therapy delivery throughout the disease course.

CONCLUSION

Stakeholders, including international practice experts, informed a rigorous evidence-based approach to integrate the best available evidence, patient preferences, and practice expertise to inform these guidelines.

Boxing with and without Kicking Techniques for People with Parkinson's Disease: An Explorative Pilot Randomized Controlled Trial

BACKGROUND

People with Parkinson's disease (PD) benefit from boxing exercise. Adding kicking variations to the boxing may provide additional benefit to improve balance. However, the benefits and adherence to such trainings is unknown.

OBJECTIVE

To explore the feasibility, safety, and benefits on balance of boxing training combined with kicking techniques in comparison to boxing without kicking in PD.

METHODS

Participants were randomized to group-based boxing training with kicking techniques (BK) or to group-based boxing alone training (BO). Both groups trained for one hour, once a week, for a period of 10 weeks. Participants were assessed at baseline and ten weeks post-intervention for difference in balance, fear of falling, balance confidence, walking ability, and quality of life.

RESULTS

Twenty-nine people with PD (median age 64 years; median disease duration 5 years) participated. Both interventions were feasible and acceptable for all participants. No adverse events occurred. Most participants (BK 80%; BO 75%) were satisfied with the training. We found no significant between group difference on either the primary (Mini-BEST) or secondary outcomes. The within group comparison showed that balance improved in both groups after the intervention (BK 22.60 (2.7) to 25.33 (2.64) p = 0.02; BO 23.09 (3.44) to 25.80 (2.39); p = 0.01 on the Mini BEST test).

CONCLUSION

Both types of boxing seem to be feasible and safe. Adding kicking techniques to boxing does not improve balance significantly more than boxing alone. Incorporation of kicking may be a valuable addition to the exercise therapy repertoire.

Breathing disorders in neurodegenerative diseases

Neurodegenerative disorders are a diverse group of conditions caused by progressive degeneration of neurons resulting in cognitive, motor, sensory, and autonomic dysfunction, leading to severe disability and death. Pulmonary dysfunction is relatively common in these conditions, may be present early in the disease, and is less well recognized and treated than other symptoms. There are variable disorders of upper and lower airways, central control of ventilation, strength of respiratory muscles, and breathing during sleep which further impact daily activities and quality of life and have the potential to injure vulnerable neurons. Laryngopharyngeal dysfunction affects speech, swallowing, and clearance of secretions, increases the risk of aspiration pneumonia, and can cause stridor and sudden death. In Parkinson's disease, L-Dopa benefits some pulmonary symptoms but there are limited pharmacological treatment options for pulmonary dysfunction. Targeted treatments include strengthening of respiratory muscles, positive airway pressure in sleep and techniques to improve cough efficacy. Well-designed clinical trials are needed to evaluate the long-term benefits of these interventions. Challenges for the future include earlier identification of pulmonary dysfunction in the clinic, institution of the most effective treatments (based on clinical trials that measure long-term meaningful outcomes) and the development of neuroprotective treatment.

Detraining Slows and Maintenance Training Over 6 Years Halts Parkinsonian Symptoms-Progression

Introduction: There are scant data to demonstrate that the long-term non-pharmaceutical interventions can slow the progression of motor and non-motor symptoms and lower drug dose in Parkinson's disease (PD). Methods: After randomization, the Exercise-only (E, n = 19) group completed an initial 3-week-long, 15-session supervised, high-intensity sensorimotor agility exercise program designed to improve the postural stability. The Exercise + Maintenance (E + M, n = 22) group completed the 3-week program and continued the same program three times per week for 6 years. The no exercise and no maintenance control (C, n = 26) group continued habitual living. In each patient, 11 outcomes were measured before and after the 3-week initial exercise program and then, at 3, 6, 12, 18, 24, 36, 48, 60, and 72 months. Results: The longitudinal linear mixed effects modeling of each variable was fitted with maximum likelihood estimation and adjusted for baseline and covariates. The exercise program strongly improved the primary outcome, Motor Experiences of Daily Living, by ~7 points and all secondary outcomes [body mass index (BMI), disease and no disease-specific quality of life, depression, mobility, and standing balance]. In E group, the detraining effects lasted up to 12 months. E+M group further improved the initial exercise-induced gains up to 3 months and the gains were sustained until year 6. In C group, the symptoms worsened steadily. By year 6, levodopa (L-dopa) equivalents increased in all the groups but least in E + M group. Conclusion: A short-term, high-intensity sensorimotor agility exercise program improved the PD symptoms up to a year during detraining but the subsequent 6-year maintenance program was needed to further increase or sustain the initial improvements in the symptoms, quality of life, and drug dose.

Structured guideline-based physiotherapy reduces difficulties in activities of daily living in Parkinson's disease

BACKGROUND

In the long term, Parkinson's disease (PD) leads to the development of difficulties in daily functional tasks. There remains a paucity of evidence on the effectiveness of physiotherapy on patient-perceived difficulties regarding basic activities of daily living (ADL).

OBJECTIVES

To assess an effect of a versatile physiotherapy intervention on patient-perceived difficulties in basic ADL.

METHODS

The study sample included 24 patients (10 men and 14 women) with PD. Participants were randomly assigned into intervention (IG) and control groups (CG). Two assessments were performed with a gap of 10 weeks. Following first assessment, during an 8-week period, IG participants attended sixteen physiotherapy 60-minutes sessions in groups that were divided into five parts to address the core areas recommended by the European Physiotherapy Guideline for PD (EPGPD): gait, transfers, balance, physical capacity, and manual activities. The main assessment tool was the Modified Patients Specific Functional Scale (ModPSFS), which represents a self-assessment rating on difficulties perceived in 17 different commonly occurring activities.

RESULTS

IG members reported a significant reduction in self-perceived difficulties as assessed by ModPSFS (effect size 1.39; 95%CI 5.1, 26.6 points, p = 0.005).

CONCLUSIONS

2-months conventional physiotherapy with incorporated core areas recommended in EPGPD for PD reduced patient-perceived difficulties in basic ADL.

Virtual reality balance training to improve balance and mobility in Parkinson's disease: a systematic review and meta-analysis

BACKGROUND

In the last few years, virtual reality (VR) has been increasingly used to strengthen the effect of balance training (BT) in Parkinson's disease (PD).

OBJECTIVE

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the effects of VR-BT relative to BT alone for improving balance and mobility PD subjects with balance/mobility difficulties.

METHODS

Four electronic databases were searched: two reviewers independently selected RCTs, extracted data, and applied the Cochrane risk-of-bias tool for randomized trials (version 2) and the GRADE framework for assessing the certainty of evidence. Primary outcomes were balanced (Berg Balance Scale-BBS), mobility (Timed Up and Go-TUG) and walking speed. Secondary outcomes were falls, walking distance and stability, spatial gait parameters, balance confidence, sensory integration ability, motor signs and quality of life.

RESULTS

We included 22 studies (901 patients). Meta-analysis on fourteen trials (430 patients) showed a mean difference (MD) of 2.09 points (95% confidence interval [CI] 0.86-3.33) on BBS favoring VR-BT compared to BT (low certainty evidence). Subgroup analyses showed higher balance improvement in most affected subjects (moderate certainty evidence) and using VR rehabilitation-specific systems vs. VR non-specific systems. Eight trials (236 patients) assessing mobility showed a MD of 1.55 s (95% CI 0.04-3.06) on TUG favoring VR-BT (very low certainty evidence). No differences were observed in walking speed. Estimated effects were not maintained for any outcome at follow-up.

CONCLUSIONS

This review suggests that VR-BT is more effective than BT to improve balance in PD subjects immediately after training, particularly in individuals with higher postural instability at baseline.

Test-retest reliability of physical activity questionnaires in Parkinson's disease

BACKGROUND

People with Parkinson's disease are less physically active than controls. It is important to promote physical activity, which can be assessed using different methods. Subjective measures include physical activity questionnaires, which are easy and cheap to administer in clinical practice. Knowledge of the psychometric properties of physical activity questionnaires for people with Parkinson's disease is limited. The aim of this study was to evaluate the test-retest reliability of physical activity questionnaires in individuals with Parkinson's disease without cognitive impairment.

METHODS

Forty-nine individuals with Parkinson's disease without cognitive impairment participated in a test-retest reliability study. At two outpatient visits 8 days apart, the participants completed comprehensive questionnaires and single-item questions: International Physical Activity Questionnaire-Short Form (IPAQ-SF), Physical Activity Scale for the Elderly (PASE), Saltin-Grimby Physical Activity Level Scale (SGPALS) and Health on Equal Terms (HOET). Test-retest reliability was evaluated using the intraclass correlation coefficient (ICC), standard error of measurement (SEM), limits of agreement, weighted kappa or the Svensson method.

RESULTS

Several of the physical activity questionnaires had relatively low test-retest reliability, including the comprehensive questionnaires (IPAQ-SF and PASE). Total physical activity according to IPAQ-SF had an ICC value of 0.46 (95% confidence interval [CI], 0.21-0.66) and SEM was 2891 MET-min/week. The PASE total score had an ICC value of 0.66 (95% CI, 0.46-0.79), whereas the SEM was 30 points. The single-item scales of SGPALS-past six months (SGPALS-6 m) and HOET question 1 (HOET-q1) with longer time frames (6 or 12 months, respectively) showed better results. Weighted kappa values were 0.64 (95% CI, 0.45-0.83) for SGPALS-6 m and 0.60 (95% CI, 0.39-0.80) for HOET-q1, whereas the single-item questions with a shorter recall period had kappa values < 0.40.

CONCLUSIONS

Single-item questions with a longer time frame (6 or 12 months) for physical activity were shown to be more reliable than multi-item questionnaires such as the IPAQ-SF and PASE in individuals with Parkinson's disease without cognitive impairments. There is a need to develop a core outcome set to measure physical activity in people with Parkinson's disease, and there might be a need to develop new physical activity questionnaires.

Assessment of Risk Factors for Falls among Patients with Parkinson's Disease

Introduction

The aim of this study was to assess the risk factors for falls in patients with Parkinson's disease.

Materials and Methods

The study comprised 53 participants (52.8% women and 47.2% men). The Hoehn and Yahr 5-point disability scale was used to assess the severity of Parkinson's disease. The Tinetti Balance and Gait Scale were used to evaluate the risk of falls. The Katz scale was used to test the independence of people with PD. The Falls Efficacy Scale-International Short Form (FES-I) was implemented to assess fear of falling.

Results

The majority of participants was at a high risk of falls, being at the same level for women and men. A significant relationship was noted between the risk of falls and subjective assessment of mobility (χ² = 31.86, p < 0.001), number of falls (χ² = 37.92, p < 0.001), independence of the subjects (χ² = 19.28, p < 0.001), type of injury suffered during the fall (χ² = 36.93, p < 0.001), external factors (χ² = 33.36, p < 0.001), and the level of fear of falling (χ² = 8.88, p < 0.001). A significant relationship also occurred between the number of falls and the fear of falling (χ² = 33.49, p < 0.001) and between the number of falls and disease severity (χ² = 45.34, p < 0.001). The applied physiotherapy did not reduce the risk of falls (χ² = 3.18, p = 0.17).

Conclusions

Individuals who rated their mobility as good or excellent were at a low risk of falls. People who fell more times were at a high risk of falling. People more independent were at a low risk of falls. Previous injuries were the most associated with being at risk of falling. Uneven surfaces and obstacles on one's path are the external factors most associated with the risk of falling. People with low levels of fall anxiety were at a low risk of falls. Most people with low fall anxiety have never fallen. Additionally, the majority of patients with stage 1 of the disease have not fallen at all. The reason for the ineffectiveness of physiotherapy may be due to the exercise programs used and the lack of systematic implementation of them. PD is different for each patient; thus, it is important to select individually customized physiotherapy depending on motor and nonmotor symptoms, as well as general health of a patient.

Can a targeted home-based exercise programme improve turning characteristics in individuals with Parkinson's disease?

BACKGROUND

Turns are often cited as a difficult task for individuals with Parkinson's disease and often lead to falls, however targeted exercise interventions may help to reduce this problem. This study examined the effects of a 10-week home-based exercise program focusing on turns which may be an exercise approach for improving mobility and reducing falls in individuals with Parkinson's disease.

METHODS

Turning and stepping characteristics were recorded using Inertial Measurement Units while participants performed a 180° standing turn. Eye movements were measured using a BlueGain electrooculography system. Clinical outcomes were assessed using the Movement Disorders Society-Unified Parkinson's Disease Rating Scale, Functional axial rotation-physical score and the Falls Efficacy Scale International.

FINDINGS

Twenty individuals with Parkinson's disease were matched by severity using the Modified Hoehn and Yahr scale and were randomly allocated to an exercise (n = 10) or control group (n = 10). Significant improvements were seen after 10 weeks in the exercise group only for; onset latency of body segments, step size, number of fast phase eye movements, the Movement Disorders Society-Unified Parkinson's Disease Rating Scale in motor and rigidity scores, Functional axial rotation-physical score and the Falls Efficacy Scale International.

INTERPRETATION

These results indicate that the home-based exercise programme targeting turning characteristics had positive effects on turning performance and clinical outcomes associated with falls in individuals with Parkinson's disease. These preliminary results support the notion that targeted home-based exercises may provide an effective intervention in this population.

Differences Between Exergaming Rehabilitation and Conventional Physiotherapy on Quality of Life in Parkinson's Disease: A Systematic Review and Meta-Analysis

Parkinson's disease (PD) is a neurodegenerative condition with both motor and non-motor symptoms affecting the quality of life (QoL) of older adults. Exergaming rehabilitation allows the interaction of the subject with digital games through the implementation of repetitive functional activities. Conventional physiotherapy uses patient-centered programs that include a variety of active exercises. The aim of this review was to look into the effectiveness of exergaming rehabilitation on the QoL of people with PD and compare it with conventional physiotherapy. Five electronic databases were searched for eligible studies until February 2021. For the statistical analysis, the mean, standard deviation, and 95% confidence interval were used to calculate effect sizes between groups. To determine heterogeneity, statistical index I ² was used. A total of 548 participants were included in 14 studies. Exergaming rehabilitation related with improved QoL (p = 0.687, 95% CI: -1.682 to -0.734), balance (p = 0.039, 95% CI: 0.364-13.689), (p = 0.018, 95% CI: 0.446-4.830), and gait (p = 0.005, 95% CI: 0.351-1.924). No significant difference was found between groups regarding the Unified Parkinson's Disease Rating Scale (p = 0.196, 95% CI: -5.970 to 1.225) and for the Timed Up and Go Test (p = 0.12, 95% CI: 0.446-4.830). Exergames as a rehabilitation method can be used to provide alternative interactive intervention with positive results for QoL in people with PD. Further investigation is needed to assess the effect on mental health in this population group.

Parkinson's disease

Parkinson's disease is a recognisable clinical syndrome with a range of causes and clinical presentations. Parkinson's disease represents a fast-growing neurodegenerative condition; the rising prevalence worldwide resembles the many characteristics typically observed during a pandemic, except for an infectious cause. In most populations, 3-5% of Parkinson's disease is explained by genetic causes linked to known Parkinson's disease genes, thus representing monogenic Parkinson's disease, whereas 90 genetic risk variants collectively explain 16-36% of the heritable risk of non-monogenic Parkinson's disease. Additional causal associations include having a relative with Parkinson's disease or tremor, constipation, and being a non-smoker, each at least doubling the risk of Parkinson's disease. The diagnosis is clinically based; ancillary testing is reserved for people with an atypical presentation. Current criteria define Parkinson's disease as the presence of bradykinesia combined with either rest tremor, rigidity, or both. However, the clinical presentation is multifaceted and includes many non-motor symptoms. Prognostic counselling is guided by awareness of disease subtypes. Clinically manifest Parkinson's disease is preceded by a potentially long prodromal period. Presently, establishment of prodromal symptoms has no clinical implications other than symptom suppression, although recognition of prodromal parkinsonism will probably have consequences when disease-modifying treatments become available. Treatment goals vary from person to person, emphasising the need for personalised management. There is no reason to postpone symptomatic treatment in people developing disability due to Parkinson's disease. Levodopa is the most common medication used as first-line therapy. Optimal management should start at diagnosis and requires a multidisciplinary team approach, including a growing repertoire of non-pharmacological interventions. At present, no therapy can slow down or arrest the progression of Parkinson's disease, but informed by new insights in genetic causes and mechanisms of neuronal death, several promising strategies are being tested for disease-modifying potential. With the perspective of people with Parkinson's disease as a so-called red thread throughout this Seminar, we will show how personalised management of Parkinson's disease can be optimised.

A randomised controlled trial on effectiveness and feasibility of sport climbing in Parkinson's disease

Physical activity is of prime importance in non-pharmacological Parkinson's disease (PD) treatment. The current study examines the effectiveness and feasibility of sport climbing in PD patients in a single-centre, randomised controlled, semi-blind trial. A total of 48 PD patients without experience in climbing (average age 64 ± 8 years, Hoehn & Yahr stage 2-3) were assigned either to participate in a 12-week sport climbing course (SC) or to attend an unsupervised physical training group (UT). The primary outcome was the improvement of symptoms on the Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS-III). Sport climbing was associated with a significant reduction of the MDS-UPDRS-III (-12.9 points; 95% CI -15.9 to -9.8), while no significant improvement was to be found in the UT (-3.0 points; 95% CI -6.0 to 0.1). Bradykinesia, rigidity and tremor subscales significantly improved in SC, but not in the unsupervised control group. In terms of feasibility, the study showed a 99% adherence of participants to climbing sessions and a drop-out rate of only 8%. No adverse events occurred. This trial provides class III evidence that sport climbing is highly effective and feasible in mildly to moderately affected PD patients.

The Effects of a 10-Week Home-Based Exercise Programme in Individuals with Parkinson’s Disease during the COVID-19 Pandemic: A Pilot Study

Current restrictions on clinical visits as a consequence of the COVID-19 pandemic has increased the need for home-based exercise regimes to facilitate useful, long term patterns of behaviour in individuals with Parkinson’s disease (PD). This study aimed to evaluate the effectiveness of a 10-week home-based exercise program designed to target improvements in axial rigidity and gait. The Movement Disorders Society-Unified Parkinson’s Disease Rating Scale (MDS-UPDRS), motor scale and rigidity items, Functional axial rotation–physical (FAR-p), functional reach test (FRT), and time up and go (TUG) test were recorded. In addition, the 10-metre walk test, the fall efficacy scale international (FES-I) and the global rating of change score (GROC) were also recorded. Eighteen individuals were divided randomly into two groups: a home-based exercise group (n = 10) and a traditional physiotherapy control group (n = 8). Participants in the 10-week home-based exercise group showed significant improvements (p < 0.05) in the MDS-UPDRS rigidity item, FAR-p, step length, gait velocity, FRT and FES-I when compared with the control group. This study supports the use of home-based exercises in individuals with PD. These preliminary results also support the hypothesis that targeting axial deficits may be an effective approach for improving gait and reducing falls.

How COVID-19 will boost remote exercise-based treatment in Parkinson's disease: a narrative review

The lack of physical exercise during the COVID-19 pandemic-related quarantine measures is challenging, especially for patients with Parkinson's disease (PD). Without regular exercise not only patients, but also nursing staff and physicians soon noticed a deterioration of motor and non-motor symptoms. Reduced functional mobility, increased falls, increased frailty, and decreased quality of life were identified as consequences of increased sedentary behavior. This work overviews the current literature on problems of supplying conventional physiotherapy and the potential of telerehabilitation, allied health services, and patient-initiated exercise for PD patients during the COVID-19 period. We discuss recent studies on approaches that can improve remote provision of exercise to patients, including telerehabilitation, motivational tools, apps, exergaming, and virtual reality (VR) exercise. Additionally, we provide a case report about a 69-year-old PD patient who took part in a 12-week guided climbing course for PD patients prior to the pandemic and found a solution to continue her climbing training independently with an outdoor rope ladder. This case can serve as a best practice example for non-instructed, creative, and patient-initiated exercise in the domestic environment in difficult times, as are the current. Overall, many recent studies on telemedicine, telerehabilitation, and patient-initiated exercises have been published, giving rise to optimism that facilitating remote exercise can help PD patients maintain physical mobility and emotional well-being, even in phases such as the COVID-19 pandemic. The pandemic itself may even boost the need to establish comprehensive and easy-to-do telerehabilitation programs.