Controlled pilot study of the effects of neuromuscular therapy in patients with Parkinson's disease

Efficacy of non-pharmacological interventions for depression in individuals with Parkinson's disease: A systematic review and network meta-analysis

BACKGROUND

Depression in Parkinson's disease (PD) is a major health concern worldwide. Recently, an increasing number of non-pharmacological interventions have been used in PD to alleviate depressive symptoms. However, it is uncertain which intervention is the best, and related evidence is limited. This network meta-analysis was performed to compare and rank non-pharmacological interventions for PD and analyze their effects on depression to provide evidence for clinicians to choose appropriate non-pharmacological management options.

METHODS

The PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, China National Knowledge Infrastructure (CNKI), and Wanfang databases were searched from inception to April 7, 2022. Two authors screened all studies, extracted the data, and evaluated the methodological quality. STATA software version 16.0 was used to conduct the network meta-analysis.

RESULTS

Our network meta-analysis included 62 studies involving 3,050 participants and 35 non-pharmacological interventions. Although most non-pharmacological interventions showed non-significant effects, the surface under the cumulative ranking curve (SUCRA) values indicated that the best non-pharmacological intervention for depression was dance (82.3%), followed by LSVT-BIG therapy (77.4%), and CBT (73.6%).

CONCLUSION

Dance can be considered as an effective therapy for improving depression in patients with PD. In the future, more strictly designed trials are needed to verify the conclusions of this network meta-analysis.

Parkinsonics: A Randomized, Blinded, Cross-Over Trial of Group Singing for Motor and Nonmotor Symptoms in Idiopathic Parkinson Disease

Introduction

Parkinson's disease (PD) frequently causes communication difficulties due to various voice impairments and there are few treatment options for vocal/communication complaints. We assessed the effects of weekly group singing on PD patients' objective vocal and motoric function, cognition, mood, self-efficacy, and quality of life.

Methods

Thirty-two participants were randomly assigned to either a singing group or a facilitated discussion group weekly over 12 weeks. After 12 weeks, participants crossed over for an additional 12 weeks. Evaluations were performed at baseline and every six weeks for 30 weeks. Objective voice measures included volume/loudness (decibels), held vowel duration, jitter, shimmer, and harmonic-to-noise ratio. Additional outcome measures included patient-centered quality of life, voice-related quality of life, MDS-UPDRS, Montreal Cognitive Assessment, and questionnaires assessing depression, self-efficacy, and overall well-being.

Results

Twenty-six participants (16 M/10F; Hoehn & Yahr stage 2.3 (range 2–3); and age 68.6 (55–89)) completed the study. Across participants in both groups (intention-to-treat analyses), there was significant improvement from baseline in average loudness on the Cookie Theft picture description at 24 weeks (end of interventions), corresponding with improved minimal reading volumes at 24 weeks and 30 weeks (end of study). Similarly, there were improvements in minimal loudness on Rainbow passage reading at 24 and 30 weeks. There were improvements observed in the Emotional Well-Being (mean delta −12.7 points, p = 0.037) and Body Discomfort (mean delta −18.6 points, p = 0.001) domains of the PDQ-39 from baseline to week 24 in the overall cohort and greater improvement in the Communication domain for Group S than Group D after 12 weeks of singing (delta −12.9 points, p = 0.016). Baseline differences between the participant groups (age, gender, Hoehn & Yahr stage, and several voice loudness measures) and observed improvements during the weekly discussion group period limited our ability to attribute all of the above results specifically to singing (per-protocol analyses). No significant changes in other assessed outcome measures were found.

Conclusions

Weekly group singing may improve some aspects of conversational voice volume and quality of life in PD. Some improvements were sustained at least six weeks after interventions ended. Further investigations of the mechanism of benefit and randomized controlled studies (without crossover) to assess the longitudinal effects of singing in PD are necessary.

Music as Add-On Therapy in the Rehabilitation Program of Parkinson's Disease Patients-A Romanian Pilot Study

Music has been proven to have therapeutic potential in neurological disorders, especially Parkinson’s disease (PD), since rhythmic auditory cueing can partially replace the progressive loss of rhythmicity and automaticity. Several reports have highlighted improvements in motor outcomes in PD patients undergoing music therapy, but only a few studies have evaluated non-motor outcomes, such as quality of life (QoL), which deteriorates with disease progression. The current pilot study aims to examine the effects of a multimodal rehabilitation program centered on physical therapy combined with listening to music on self-reported QoL in people with PD, compared to the same rehabilitation program alone. The study was conducted on patients with idiopathic PD who attended a specific rehabilitation program with a duration of 2.5 h daily for 14 days. The patients were divided into the study group (16 patients), who listened to background music during the rehabilitation program sessions, and the control group who did not listen to music during sessions. The patients were assessed using the self-report Parkinson’s Disease Questionnaire (PDQ-39) at the beginning of the program and 1 month after its initiation. The patients in the study group registered greater improvements in five of the eight areas of life assessed by PDQ-39 compared to the control group. In conclusion, listening to music combined with a multimodal rehabilitation program centered on physical therapy may be beneficial for the patients’ quality of life.

Possible modulation of the amplitude and frequency of resting parkinsonian tremor by touching the trapezius muscle

The pathophysiological mechanism of resting tremor in Parkinson's disease remains obscure. Spinal/peripheral mechanisms may modulate oscillatory activity from central origin, thereby changing amplitude and frequency of tremor in Parkinson's disease.

Massage therapy as a complementary treatment for Parkinson's disease: A Systematic Literature Review

OBJECTIVE

There is no definite cure for Parkinson's disease (PD); therefore, the goals for symptomatic treatment are to improve quality of life and manage the motor and non-motor symptoms of the disease. Although massage is the one of the commonest used forms of complementary and alternative medicine (CAM), there is no systematically-oriented review focusing specifically on the efficacy of the different massage techniques on PD.Aim of this review was to evaluate the quality of evidence referring to massage therapy for PD.

DESIGN

A systematic search was conductedin the MEDLINE database to identify the efficacy of massage on PD between 01/01/1970 and 06/12/2019.

RESULTS

A total of 12 studies were analyzed in this systematic review. Massage therapy seems to induce relaxation in most cases, which is accompanied by biological measures involving urine stress hormones. Quality of life has been shown to be improved upon various therapeutic massage styles, involving classical whole-body therapeutic massage and reflexology. Non-motor symptoms, such as sleep disturbances, pain, fatigue, anxiety and depressive symptoms have been demonstrated to be improved upon different massage techniques, including classical deep therapeutic massage, Traditional Japanese (Anma) massage, Thai massage, neuromuscular therapy and Yin Tui Na massage. Regarding motor symptoms, classical therapeutic massage, Traditional Japanese (Anma) massage, Thai massage, and neuromuscular therapy seemed to improve motor symptoms, whereas Yin Tui Na technique combined with acupuncture was associated with worse motor scores.

CONCLUSIONS

Despite the methodological concerns regarding the existing evidence, there is a wide range of safe massage techniques with beneficial effects on both motor and non-motor symptoms of PD. Longitudinal studies are needed to justify the introduction of massage therapy into clinical practice.

How to evaluate effects of occupational therapy - lessons learned from an exploratory randomized controlled trial

BACKGROUND

Although occupational therapy (OT) is frequently prescribed in clinical practice, there is still insufficient evidence regarding its efficacy to improve Parkinson's Disease (PD)-related activity limitations.

OBJECTIVES

To evaluate the efficacy of OT and the validity of different outcome-parameters to reflect efficacy, including gold-standard clinical rating scales and quantitative motor assessments.

METHODS

40 patients were included in an exploratory, randomized-controlled, single-blinded trial, receiving either (I) ten weeks of OT, with a main focus on motor aspects of activity limitations and a ten-week follow-up assessment or (II) no intervention. Inclusion criteria were diagnosis of PD and Hoehn & Yahr stage 2-3. Patients with major depression, other neurological or orthopedic diseases or OT beforehand were excluded from the study. To monitor treatment effects the MDS-UPDRS part II and III were used for patient- and clinician-based assessment. Objective Pegboard as well as Q-Motor "tremormotography" and "digitomotography" were applied.

RESULTS

The interventional group reported a subjective amelioration of activity limitations, with a significant improvement of MDS-UPDRS part II at the end of the study (p = 0.030). However, clinician's rating and quantitative motor assessment failed to detect a significant improvement of motor impairment and fine motor control.

CONCLUSIONS

This study goes in line with previous trials, showing an individual improvement of activity limitations from the patients' point of view. The discrepancy between self-perception, focusing on activity limitation, and clinician-based rating, focusing on motor impairment, challenges the current gold standard assessments as valid outcome parameters for occupational therapy trials aiming for an individualized improvement of disease burden.

Volitional Suppression of Parkinsonian Resting Tremor

BACKGROUND

We have observed in the clinic that a number of patients with Parkinson's disease (PD) can suppress their tremor at will for brief periods, by conscious mental processes. To our knowledge, the ability to consciously diminish one's resting tremor has not yet been reported nor assessed quantitatively.

OBJECTIVE

To provide the first detailed systematic investigation of the phenomenon of voluntary tremor suppression in PD.

METHODS

We examined changes in tremor characteristics during voluntary tremor suppression in 37 PD patients (on medication) presenting with rest tremor in their upper limb. We measured tremor oscillations with a triaxis accelerometer on the index finger of the most-affected hand (n = 27). With surface electromyography (EMG), we measured changes in neuromuscular activity of the forearm flexor digitorum superficialis and extensor digitorum muscles (n = 15). Participants completed four 1-minute trials, consisting of alternating consecutive 30-second periods of resting tremor and 30-second periods of attempted tremor suppression.

RESULTS

Bayesian multilevel modeling revealed that attempted voluntary tremor suppression did indeed reduce tremor amplitude (peak power) of the acceleration signal and increased tremor frequency of the acceleration and EMG signals. Relative EMG power in the 3- to 8-Hz tremor band was also smaller. Tremor suppression was not by enhanced voluntary contraction of the relevant muscle pairs.

CONCLUSIONS

We present novel empirical evidence that PD resting tremor can be suppressed by an act of will, as evidenced by significant modulation of key neurophysiological tremor characteristics. These data highlight that it is possible to exert significant conscious control over parkinsonian resting tremor.

Nonpharmacologic Interventions for the Self-Management of Anxiety in Parkinson's Disease: A Comprehensive Review

Anxiety in Parkinson's disease (aPD) is underdiagnosed, undertreated, and understudied. As many as 50% of persons diagnosed with Parkinson's disease (PD) are reported to suffer from anxiety. Current treatment is largely pharmacologic, which can result in a myriad of undesirable and unsafe side effects. The aim of this paper is to examine intervention studies of self-managed nonpharmacological strategies for the treatment of anxiety. A comprehensive review was conducted on experimental or quasi-experimental trials that included self-management approaches for the nonpharmacologic treatment of anxiety as a primary or secondary aim or outcome measure. Thirteen studies were identified from four databases. Study quality demonstrated variability in design and delivery of self-managed interventions; sample sizes were small; anxiety was most commonly a secondary aim; and the use of anxiety measures varied widely. Statistical significance was evident in slightly more than 50% of the anxiety intervention studies. A common element in the interventions in all studies was the focused use of breath. Further research is needed to determine the feasibility of using focused breathing, alone, as an intervention for the self-management of anxiety in Parkinson's disease.

Massage, reflexology and other manual methods for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour, and this may contribute towards the popularity of complementary methods of pain management. This review examined the evidence currently available on manual methods, including massage and reflexology, for pain management in labour. This review is an update of the review first published in 2012.

OBJECTIVES

To assess the effect, safety and acceptability of massage, reflexology and other manual methods to manage pain in labour.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (30 June 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 6), MEDLINE (1966 to 30 June 2017, CINAHL (1980 to 30 June 2017), the Australian New Zealand Clinical Trials Registry (4 August 2017), Chinese Clinical Trial Registry (4 August 2017), ClinicalTrials.gov, (4 August 2017), the National Center for Complementary and Integrative Health (4 August 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (4 August 2017) and reference lists of retrieved trials.

SELECTION CRITERIA

We included randomised controlled trials comparing manual methods with standard care, other non-pharmacological forms of pain management in labour, no treatment or placebo. We searched for trials of the following modalities: massage, warm packs, thermal manual methods, reflexology, chiropractic, osteopathy, musculo-skeletal manipulation, deep tissue massage, neuro-muscular therapy, shiatsu, tuina, trigger point therapy, myotherapy and zero balancing. We excluded trials for pain management relating to hypnosis, aromatherapy, acupuncture and acupressure; these are included in other Cochrane reviews.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality, extracted data and checked data for accuracy. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included a total of 14 trials; 10 of these (1055 women) contributed data to meta-analysis. Four trials, involving 274 women, met our inclusion criteria but did not contribute data to the review. Over half the trials had a low risk of bias for random sequence generation and attrition bias. The majority of trials had a high risk of performance bias and detection bias, and an unclear risk of reporting bias. We found no trials examining the effectiveness of reflexology.MassageWe found low-quality evidence that massage provided a greater reduction in pain intensity (measured using self-reported pain scales) than usual care during the first stage of labour (standardised mean difference (SMD) -0.81, 95% confidence interval (CI) -1.06 to -0.56, six trials, 362 women). Two trials reported on pain intensity during the second and third stages of labour, and there was evidence of a reduction in pain scores in favour of massage (SMD -0.98, 95% CI -2.23 to 0.26, 124 women; and SMD -1.03, 95% CI -2.17 to 0.11, 122 women). There was very low-quality evidence showing no clear benefit of massage over usual care for the length of labour (in minutes) (mean difference (MD) 20.64, 95% CI -58.24 to 99.52, six trials, 514 women), and pharmacological pain relief (average risk ratio (RR) 0.81, 95% CI 0.37 to 1.74, four trials, 105 women). There was very low-quality evidence showing no clear benefit of massage for assisted vaginal birth (average RR 0.71, 95% CI 0.44 to 1.13, four trials, 368 women) and caesarean section (RR 0.75, 95% CI 0.51 to 1.09, six trials, 514 women). One trial reported less anxiety during the first stage of labour for women receiving massage (MD -16.27, 95% CI -27.03 to -5.51, 60 women). One trial found an increased sense of control from massage (MD 14.05, 95% CI 3.77 to 24.33, 124 women, low-quality evidence). Two trials examining satisfaction with the childbirth experience reported data on different scales; both found more satisfaction with massage, although the evidence was low quality in one study and very low in the other.Warm packsWe found very low-quality evidence for reduced pain (Visual Analogue Scale/VAS) in the first stage of labour (SMD -0.59, 95% CI -1.18 to -0.00, three trials, 191 women), and the second stage of labour (SMD -1.49, 95% CI -2.85 to -0.13, two trials, 128 women). Very low-quality evidence showed reduced length of labour (minutes) in the warm-pack group (MD -66.15, 95% CI -91.83 to -40.47; two trials; 128 women).Thermal manual methodsOne trial evaluated thermal manual methods versus usual care and found very low-quality evidence of reduced pain intensity during the first phase of labour for women receiving thermal methods (MD -1.44, 95% CI -2.24 to -0.65, one trial, 96 women). There was a reduction in the length of labour (minutes) (MD -78.24, 95% CI -118.75 to -37.73, one trial, 96 women, very low-quality evidence). There was no clear difference for assisted vaginal birth (very low-quality evidence). Results were similar for cold packs versus usual care, and intermittent hot and cold packs versus usual care, for pain intensity, length of labour and assisted vaginal birth.Music One trial that compared manual methods with music found very low-quality evidence of reduced pain intensity during labour in the massage group (RR 0.40, 95% CI 0.18 to 0.89, 101 women). There was no evidence of benefit for reduced use of pharmacological pain relief (RR 0.41, 95% CI 0.16 to 1.08, very low-quality evidence).Of the seven outcomes we assessed using GRADE, only pain intensity was reported in all comparisons. Satisfaction with the childbirth experience, sense of control, and caesarean section were rarely reported in any of the comparisons.

AUTHORS' CONCLUSIONS

Massage, warm pack and thermal manual methods may have a role in reducing pain, reducing length of labour and improving women's sense of control and emotional experience of labour, although the quality of evidence varies from low to very low and few trials reported on the key GRADE outcomes. Few trials reported on safety as an outcome. There is a need for further research to address these outcomes and to examine the effectiveness and efficacy of these manual methods for pain management.

Can therapeutic Thai massage improve upper limb muscle strength in Parkinson's disease? An objective randomized-controlled trial

Muscle weakness is a frequent complaint amongst Parkinson's disease (PD) patients. However, evidence-based therapeutic options for this symptom are limited. We objectively measure the efficacy of therapeutic Thai massage (TTM) on upper limb muscle strength, using an isokinetic dynamometer. A total of 60 PD patients with muscle weakness that is not related to their ‘off’ periods or other neurological causes were equally randomized to TTM intervention (n = 30), consisting of six TTM sessions over a 3-week period, or standard medical care (no intervention, n = 30). Primary outcomes included peak extension and flexion torques. Scale-based outcomes, including Unified Parkinson's Disease Rating Scale (UPDRS) and visual analogue scale for pain (VAS) were also performed. From baseline to end of treatment, patients in the intervention group showed significant improvement on primary objective outcomes, including peak flexion torque (F = 30.613, p < .001) and peak extension torque (F = 35.569, p < .001) and time to maximal flexion speed (F = 14.216, p = .001). Scale-based assessments mirrored improvements in the objective outcomes with a significant improvement from baseline to end of treatment of the UPDRS-bradykinesia of a more affected upper limb (F = 9.239, p = .005), and VAS (F = 69.864, p < .001) following the TTM intervention, compared to the control group. No patients reported adverse events in association with TTM. Our findings provide objective evidence that TTM used in combination with standard medical therapies is effective in improving upper limb muscle strength in patients with PD. Further studies are needed to determine the efficacy of TTM on other motor and non-motor symptoms in PD.

Effects of Non-Pharmacological Treatments on Quality of Life in Parkinson's Disease: A Review

Parkinson's disease is a neurodegenerative chronic condition with a declining trajectory and lack of a cure, making quality of life an important aspect of care. The purpose of this literature review was to analyze the state-of-the-science on the effects of non-pharmacological treatments on quality of life in person's with Parkinson's disease. Literature search was conducted using keywords in electronic databases up to September 1, 2016 and cross-searching the references of identified articles. Of the 259 articles generated, 26 met the eligibility criteria and were included in this review. The majority of studies (77%) were Level I evidence and 23% Level II evidence. The levels of study quality were: strong (50%), moderate (15%), and weak (35%). The interventions varied across studies with 15 studies evaluating a similar intervention. About 58% of the studies showed that the interventions improved quality of life. In conclusion, a variety of non-pharmacological interventions have been increasingly studied for their effects on quality of life in Parkinson's disease, showing initial promising results. However, most interventions were only examined by a limited number of studies and the minimal and optimal intervention doses needed for improving quality of life are yet unknown.

Use of Complementary Health Approaches in Individuals With Parkinson's Disease

Parkinson's disease (PD) is neurodegenerative and requires ongoing therapy. The purpose of the current study was two-fold: to (a) describe the prevalence, types, and associated factors of complementary health approaches (CHA) used in individuals with PD; and (b) explore reasons for CHA use. A self-administered, cross-sectional survey was used. The response rate was 61.9% (N = 135), and 74.1% of participants used CHA for either PD or general health. The most widely used CHA included exercise, yoga, massage, vitamins, coenzyme Q10, and coconut oil. Higher levels of education and treatment by a movement disorder specialist were significantly related to CHA use. Nurses and other health care professionals may have a role in providing safe care for individuals with PD. Further studies on effectiveness and safety of commonly used CHA are warranted. [Journal of Gerontological Nursing, 43(2), 46-54.].

Massage Therapy Treatment and Outcomes for a Patient with Parkinson's Disease: a Case Report

Introduction

Parkinson’s disease (PD) is a complex neurological disorder. The disease is progressive and, in time, results in severe disability. Many patients turn to massage in an attempt to alleviate symptoms of pain and rigidity, though the effects of massage with respect to PD are not well studied. This case adds one more instance in which massage therapy has provided temporary respite from resting tremor, one unrelenting symptom of PD.

Objective

To determine if massage therapy can produce favorable outcomes with respect to the severity of rigidity and tremor in a patient with PD.

Case Presentation

A 63-year-old female patient with idiopathic, long-standing, Hoehn-Yahr Stage 4 PD was treated with massage therapy five times over the course of six weeks. A SPES/SCOPA Motor Impairments rating scale was used to measure rigidity and tremor pre- and post-treatment, to gauge treatment effectiveness. The massage treatments consisted of deep longitudinal stroking, muscle squeezing techniques, passive range of motion movements, and general relaxation techniques to encourage a soothing environment while promoting a decrease in muscular tone and hyperactivity. Massage therapy administration was by a student near the end of her two-year diploma.

Results

The results obtained indicated that massage therapy treatment had a positive effect on reducing resting and postural tremor in a patient with long-standing PD. The treatment was also effective in temporarily reducing rigidity during treatment, but did not produce a lasting effect.

Conclusion

Further study is required; however, the results of this case were consistent with the limited research available on the subject of massage therapy and Parkinson’s disease, in that positive change with respect to tremor—and to a lesser degree, rigidity—were achieved with focused, intentional treatment.

Mechanisms for alternative treatments in Parkinson's disease: acupuncture, tai chi, and other treatments

At least 40% of patients with Parkinson's disease (PD) use one or more forms of alternative therapy (AT) to complement standard treatments. This article reviews the commonest forms of AT for PD, including acupuncture, tai chi, yoga, mindfulness, massage, herbal medicine, and cannabis. We discuss the current evidence for the clinical efficacy of each AT and discuss potential mechanisms, including those suggested by animal and human studies. With a few notable exceptions, none of the treatments examined were investigated rigorously enough to draw definitive conclusions about efficacy or mechanism. Tai chi, acupuncture, Mucuna pruriens, cannabinoids, and music therapy have all been proposed to work through specific mechanisms, although current evidence is insufficient to support or refute these claims, with the possible exception of Mucuna pruriens (which contains levodopa). It is likely that most ATs predominantly treat PD patients through general mechanisms, including placebo effects, stress reduction, and improved mood and sleep, and AT may provide patients with a greater locus of control regarding their illness.

Complementary & alternative management of Parkinson's disease: an evidence-based review of eastern influenced practices

The prevalence of Parkinson’s disease (PD) appears to be lower in Asia compared to the Western world. It is unclear if this is related to the ubiquitous use of traditional medicine in Eastern healthcare, but the use of complementary and alternative medicine (CAM) modalities in countries like Korea may be as high as 76%. Among patients with PD, herbal medicines, health supplement foods, and acupuncture are interventions which are increasingly used throughout the world. Countries like Korea, China, India, and Japan have long embraced and incorporated traditional medicine into modern management of conditions such as PD, but research into various CAM modalities remains in its infancy limiting evidence-based recommendations for many treatments. We reviewed the literature on CAM treatments for PD, focusing on mind-body interventions and natural products. Based on evidence limited to randomized-controlled trials we found that mind-body interventions are generally effective forms of physical activity that are likely to foster good adherence and may reduce disability associated with PD. Based on the current data, modalities like Tai Chi and dance are safe and beneficial in PD, but better studies are needed to assess the effects of other frequently used modalities such as yoga and acupuncture. Furthermore, despite centuries of experience using medicinal herbs and plants in Eastern countries, and despite substantial preclinical data on the beneficial effects of nutritional antioxidants as neuroprotective agents in PD, there is insufficient clinical evidence that any vitamin, food additive, or supplement, can improve motor function or delay disease progression in PD.

A review of the clinical evidence for complementary and alternative therapies in Parkinson's disease

OPINION STATEMENT

No conventional treatment has been convincingly demonstrated to slow or stop the progression of Parkinson's disease (PD). Dopaminergic therapy is the gold standard for managing the motor disability associated with PD, but it falls short of managing all of the aspects of the disease that contribute to quality of life. Perhaps for this reason, an increasing number of patients are searching for a more holistic approach to healthcare. This is not to say that they are abandoning the standard and effective symptomatic therapies for PD, but rather are complementing them with healthy living, mind-body practices, and natural products that empower patients to be active participants in their healthcare and widen the net under which disease modification might one day be achieved. Despite high rates of utilization of complementary and alternative medicine (CAM) practices, data on efficacy is generally limited, restricting physicians in providing guidance to interested patients. Exercise is now well-established as integral in the management of PD, but mind-body interventions such as Tai Chi that incorporate relaxation and mindfulness with physical activity should be routinely encouraged as well. While no comment can be made about neuroplastic or disease-modifying effects of mind-body interventions, patients should be encouraged to be as active as possible and engage with others in enjoyable and challenging activities such as dance, music therapy, and yoga. Many PD patients also choose to try herbs, vitamins, and neutraceuticals as part of a healthy lifestyle, with the added expectation that these products may lower free radical damage and protect them against further cell death. Evidence for neuroprotection is limited, but patients can be encouraged to maintain a healthy diet rich in "high-power," low-inflammatory foods, while at the same time receiving education that many promising natural products have produced disappointing results in clinical trials. It is vital that the science of holistic medicine reaches a point where all neutraceuticals are investigated with the same rigor as conventional drugs. A number of agents discussed here that have a proposed role in the treatment of neurodegenerative diseases (and PD in particular), including cannabis, mucuna pruriens, and Chinese herbals, deserve more attention from basic science researchers and clinical investigators before they can be either safely utilized or dismissed.

Effectiveness of Anma massage therapy in alleviating physical symptoms in outpatients with Parkinson's disease: a before-after study

We aimed to confirm the physical effects of a single Anma massage session and continuous Anma massage therapy for outpatients with Parkinson's disease (PD). Twenty-one PD outpatients (mean age, 64.43 ± 8.39 [SD] years; Hoehn and Yahr stage I-IV) received a single 40-min Anma massage session involving upper and lower limb exercises and some subsequently received seven weekly Anma massage sessions. After a single session, visual analogue scale scores were significantly lower for muscle stiffness, movement difficulties, pain, and fatigue; gait speed and pegboard test time were significantly shortened; stride length was significantly lengthened; and shoulder flexion and abduction were significantly improved. No significant changes occurred in controls. After continuous sessions, we found general improvements in the same outcomes. In conclusion, Anma massage might effectively alleviate various physical PD symptoms; furthermore, because it is given through clothing, Anma massage is accessible for PD patients with movement difficulties.

The factor structure of the SF-36 in adults with progressive neuromuscular disorders

OBJECTIVE

Quality of life (QoL) is an important consideration in the care of patients with chronic neuromuscular disorder (NMD). The current study sought to determine the factor structure of the Medical Outcomes Study Short-Form 36 (SF-36) version 2 in patients with NMD to determine the appropriateness of using this instrument to assess QoL in this clinical population.

METHODS

Confirmatory factor analyses were conducted on self-report SF-36 data from 245 individuals diagnosed with NMD. Six structural models of the SF-36 were evaluated against the participants' data.

RESULTS

The underlying factor structure of the SF-36 in NMD was observed to be consistent with contemporary theoretical models of the instrument. However, the traditional measurement model of SF-36 performed comparatively poorly.

CONCLUSION

The use of the SF-36 in individuals with NMD can be recommended when eight sub-scales are used and reported. However, the suggestion that the SF-36 can be usefully used as a two-sub-scale measure of physical health and mental health components in this clinical group was not supported because of model fit limitations.

Psychosis, apathy, depression and anxiety in Parkinson's disease

Psychiatric symptoms are important non-motor features in PD, which occur at high frequency and have significant impact on health related quality of life. This review concentrates on the prevalence, pathophysiology, diagnosis and treatment of depression, anxiety, apathy and psychosis. The pathophysiology of these disorders is complex, reflecting the widespread brainstem and cortical pathology in PD, with involvement of several neurotransmitters, including dopaminergic, serotonergic, noradrenergic and cholinergic systems. The diagnosis of psychiatric conditions, in particular affective disorders, is challenging because of the overlap of somatic features of psychiatric disorders and underlying movement disorder. The pathogenesis is likely to differ considerably from non-PD patients, and treatments used in general psychiatry services may not be as effective in PD and will require clearer clarification in well-designed clinical studies. Management strategies include adjustment of dopaminergic medication, use of psychotropic treatments and behavioural and psychological approaches. However, the future challenge will be to develop treatments developed specifically for the pathogenesis of these disorders in PD.

Rehabilitation interventions in Parkinson disease

OBJECTIVE

This self-directed learning module provides an evidence-based update of exercise-based rehabilitation interventions to treat Parkinson disease (PD). It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This focused review emphasizes treatment of locomotion deficits, upper limb motor control deficits, and hypokinetic dysarthria. New dopaminergic agents and deep brain stimulation are facilitating longer periods of functional stability for patients with PD. Adjunctive exercise-based treatments can therefore be applied over longer periods of time to optimize function before inevitable decline from this neurodegenerative disease. As function deteriorates in patients with PD, the role of caregivers becomes more critical, thus training caregivers is of paramount importance to help maintain a safe environment and limit caregiver anxiety and depression. The overall goal of this article is to enhance the learner's existing practice techniques used to treat PD through exercise-based intervention methods.

Non-pharmacological and non-surgical interventions for tremor: a systematic review

Tremor is a frequent disabling consequence of many neurological conditions. We performed a search of MEDLINE, CINAHL, EMBASE and the Cochrane Library to identify all primary research studies published up to November 2010 which investigated non-pharmacological and non-surgical treatments for tremor in humans. Neuromuscular physiotherapy, strength training and functional electrical stimulation show promise in their applicability and adaptability. Limb cooling may not be feasible for continuous management, but may be appropriate for specific tasks. Tremor-suppressing orthoses based on viscous materials, weighted splints and vibration therapies need further evaluation especially in the domiciliary setting and applied to improving personal activities of daily living. The evidence base for many rehabilitation interventions in tremor is poor. Future research should focus on high quality randomized controlled trials of non-pharmacological and non-surgical interventions which show promise.

High intensity eccentric resistance training decreases bradykinesia and improves Quality Of Life in persons with Parkinson's disease: a preliminary study

Persons with Parkinson disease (PD) often demonstrate bradykinesia during mobility tasks. Bradykinesia combined with other PD-related movement deficits may contribute to self-reported reductions in quality of life. At this time, no studies have examined the effects of resistance exercise as an intervention to reduce bradykinesia and improve self-reported quality of life. Therefore, we examined changes in muscle force production, clinical measures of bradykinesia, and quality of life following 12 weeks of a high intensity eccentric resistance exercise program in persons with mild to moderate PD. Twenty individuals with idiopathic PD were matched into an experimental or an active control group. All participants were tested prior to and following a 12-week intervention period. The experimental group performed high intensity quadriceps contractions on an eccentric ergometer 3 days a week for 12 weeks. The active control group participated in an evidence based exercise program of PD. The outcome variables were quadriceps muscle force, clinical bradykinesia measures (gait speed, timed up and go) and disease specific quality of life (Parkinson's disease questionnaire-39 [PDQ-39]). Data was analyzed using separate 2 (group) x 2 (time period) ANOVAs. Results demonstrated significant time by group interaction effects for gait speed, timed up and go, and the composite PDQ-39 score (p < 0.05). Muscle force, bradykinesia, and QOL were improved to a greater degree in those that performed high intensity eccentric resistance training compared to an active control group. Additional research is needed to determine if this type of training has long-term impact and if it results in an alteration of the natural history of mobility and QOL decline in persons with PD.

The effects of exercise on balance in persons with Parkinson's disease: a systematic review across the disability spectrum

BACKGROUND AND PURPOSE

Parkinson's disease is a progressive neurodegenerative disorder that affects neurophysiologic function, movement abilities, and quality of life (QOL). Research examining the effects of exercise has suggested benefits related to a variety of outcomes; however, no reviews have synthesized research findings across the spectrum of disability. This project sought to systematically review studies that examined the impact of exercise interventions on balance outcomes for people with Parkinson's disease, within the categories defined by the World Health Organization in the International Classification of Functioning, Disability, and Health (ICF) model.

METHODS

A systematic review of medical literature databases was performed using keywords Parkinson's disease and exercise. Studies were eligible if the intervention included exercise and examined variables within one of the three ICF categories. Following the ICF model, outcomes regarding Body Structure and Function, Activity, and Participation were measured, respectively, in terms of postural instability, balance task performance, and QOL and fall events.

RESULTS

Within the Body Structure and Function category, there was moderate evidence that exercise resulted in improvements in postural instability. Within the Activity category, there was moderate evidence that exercise was effective for improving balance task performance. In contrast, within the Participation category, there was limited evidence that exercise resulted in improvements in QOL measures or fall events.

DISCUSSION AND CONCLUSIONS

Regardless of the strength of the evidence, the studies reviewed all report that exercise resulted in improvements in postural stability and balance task performance. Despite these improvements, the number and quality of the studies and the outcomes used were limited. There is a need for longer term follow-up to establish trajectory of change and to determine if any gains are retained long term. The optimal delivery and content of exercise interventions (dosing, component exercises) at different stages of the disease are not clear.