The ParkinsonNet trial: design and baseline characteristics

Effects of dual-task interference on dexterity performance in people with mild to moderately severe Parkinson's disease: An observational analysis

BACKGROUND

Debilitating problems with hand function experienced by people with Parkinson's disease (PD) can worsen during multitasking.

PURPOSE

To investigate the effects of dual-task interference on a pegboard task in people with mild to moderately severe PD.

STUDY DESIGN

Descriptive analysis.

METHODS

A secondary analysis of baseline data from the ParkinsonNet physiotherapy study conducted in 2006 in the Netherlands. The 9-hole peg test was performed with the more affected hand under single- and dual-task conditions. In dual-task trials, a cognitive task was added. The patient specific index-Parkinson's disease identified two functional priority groups-those reporting arm and hand problems as a priority for allied health management ("upper extremity priority") and those prioritizing other issues ("other priority"). We investigated differences in single- and dual-task performance at different levels of disease severity (Hoehn and Yahr stage) and for the two priority groups, and calculated the dual-task effect.

RESULTS

Participants were 566 people with PD (Hoehn and Yahr stages I-IV). Dual-task interference occurred at each disease stage. Significant interactions existed between the task condition and disease severity (F (3, 559) = 4.28, p = 0.005) and task condition and priority group (F (1, 561) = 4.44, p = 0.036). Dual-task interference was greater in participants with more advanced disease or those prioritizing upper extremity problems.

CONCLUSION

We described the effects of dual-task interference on more affected hand performance of a standardized dexterity test in a broad sample of people with PD. Dual-task interference may impact the daily lives of people with PD, especially those with more severe disease or who report arm and hand problems. It is important for clinicians to consider dual-task interference during upper extremity assessment and treatment.

Specialized Versus Generic Allied Health Therapy and the Risk of Parkinson's Disease Complications

BACKGROUND

Specialized versus generic physiotherapy (PT) reduces Parkinson's disease (PD)-related complications. It is unclear (1) whether other specialized allied heath disciplines, including occupational therapy (OT) and speech and language therapy (S&LT), also reduce complications; (2) whether there is a synergistic effect among multiple specialized disciplines; and (3) whether each allied health discipline prevents specific complications.

OBJECTIVES

To longitudinally assessed whether the level of expertise (specialized vs. generic training) of PT, OT, and S&LT was associated with the incidence rate of PD-related complications.

METHODS

We used claims data of all insured persons with PD in the Netherlands between January 1, 2010, and December 31, 2018. ParkinsonNet-trained therapists were classified as specialized, and other therapists as generic. We used mixed-effects Poisson regression models to estimate rate ratios adjusting for sociodemographic and clinical characteristics.

RESULTS

The population of 51,464 persons with PD (mean age, 72.4 years; standard deviation 9.8) sustained 10,525 PD-related complications during follow-up (median 3.3 years). Specialized PT was associated with fewer complications (incidence rate ratio [IRR] of specialized versus generic = 0.79; 95% confidence interval, [0.74-0.83]; P < 0.0001), as was specialized OT (IRR = 0.88 [0.77-0.99]; P = 0.03). We found a trend of an association between specialized S&LT and a lower rate of PD-related complications (IRR = 0.88 [0.74-1.04]; P = 0.18). The inverse association of specialized OT persisted in the stratum, which also received specialized PT (IRR = 0.62 [0.42-0.90]; P = 0.001). The strongest inverse association of PT was seen with orthopedic injuries (IRR = 0.78 [0.73-0.82]; P < 0.0001) and of S&LT with pneumonia (IRR = 0.70 [0.53-0.93]; P = 0.03).

CONCLUSIONS

These findings support a wider introduction of specialized allied health therapy expertise in PD care and conceivably for other medical conditions. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Interventions for preventing falls in Parkinson's disease

BACKGROUND

Most people with Parkinson's disease (PD) experience at least one fall during the course of their disease. Several interventions designed to reduce falls have been studied. An up-to-date synthesis of evidence for interventions to reduce falls in people with PD will assist with informed decisions regarding fall-prevention interventions for people with PD.

OBJECTIVES

To assess the effects of interventions designed to reduce falls in people with PD.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, four other databases and two trials registers were searched on 16 July 2020, together with reference checking, citation searching and contact with study authors to identify additional studies. We also conducted a top-up search on 13 October 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of interventions that aimed to reduce falls in people with PD and reported the effect on falls. We excluded interventions that aimed to reduce falls due to syncope.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane Review procedures. Primary outcomes were rate of falls and number of people who fell at least once. Secondary outcomes were the number of people sustaining one or more fall-related fractures, quality of life, adverse events and economic outcomes. The certainty of the evidence was assessed using GRADE.

MAIN RESULTS

This review includes 32 studies with 3370 participants randomised. We included 25 studies of exercise interventions (2700 participants), three studies of medication interventions (242 participants), one study of fall-prevention education (53 participants) and three studies of exercise plus education (375 participants). Overall, participants in the exercise trials and the exercise plus education trials had mild to moderate PD, while participants in the medication trials included those with more advanced disease. All studies had a high or unclear risk of bias in one or more items. Illustrative risks demonstrating the absolute impact of each intervention are presented in the summary of findings tables. Twelve studies compared exercise (all types) with a control intervention (an intervention not thought to reduce falls, such as usual care or sham exercise) in people with mild to moderate PD. Exercise probably reduces the rate of falls by 26% (rate ratio (RaR) 0.74, 95% confidence interval (CI) 0.63 to 0.87; 1456 participants, 12 studies; moderate-certainty evidence). Exercise probably slightly reduces the number of people experiencing one or more falls by 10% (risk ratio (RR) 0.90, 95% CI 0.80 to 1.00; 932 participants, 9 studies; moderate-certainty evidence).  We are uncertain whether exercise makes little or no difference to the number of people experiencing one or more fall-related fractures (RR 0.57, 95% CI 0.28 to 1.17; 989 participants, 5 studies; very low-certainty evidence). Exercise may slightly improve health-related quality of life immediately following the intervention (standardised mean difference (SMD) -0.17, 95% CI -0.36 to 0.01; 951 participants, 5 studies; low-certainty evidence). We are uncertain whether exercise has an effect on adverse events or whether exercise is a cost-effective intervention for fall prevention. Three studies trialled a cholinesterase inhibitor (rivastigmine or donepezil). Cholinesterase inhibitors may reduce the rate of falls by 50% (RaR 0.50, 95% CI 0.44 to 0.58; 229 participants, 3 studies; low-certainty evidence). However, we are uncertain if this medication makes little or no difference to the number of people experiencing one or more falls (RR 1.01, 95% CI 0.90 to 1.14230 participants, 3 studies) and to health-related quality of life (EQ5D Thermometer mean difference (MD) 3.00, 95% CI -3.06 to 9.06; very low-certainty evidence). Cholinesterase inhibitors may increase the rate of non fall-related adverse events by 60% (RaR 1.60, 95% CI 1.28 to 2.01; 175 participants, 2 studies; low-certainty evidence). Most adverse events were mild and transient in nature.  No data was available regarding the cost-effectiveness of medication for fall prevention. We are uncertain of the effect of education compared to a control intervention on the number of people who fell at least once (RR 10.89, 95% CI 1.26 to 94.03; 53 participants, 1 study; very low-certainty evidence), and no data were available for the other outcomes of interest for this comparisonWe are also uncertain (very low-certainty evidence) whether exercise combined with education makes little or no difference to the number of falls (RaR 0.46, 95% CI 0.12 to 1.85; 320 participants, 2 studies), the number of people sustaining fall-related fractures (RR 1.45, 95% CI 0.40 to 5.32,320 participants, 2 studies), or health-related quality of life (PDQ39 MD 0.05, 95% CI -3.12 to 3.23, 305 participants, 2 studies). Exercise plus education may make little or no difference to the number of people experiencing one or more falls (RR 0.89, 95% CI 0.75 to 1.07; 352 participants, 3 studies; low-certainty evidence). We are uncertain whether exercise combined with education has an effect on adverse events or is a cost-effective intervention for fall prevention.  AUTHORS' CONCLUSIONS: Exercise interventions probably reduce the rate of falls, and probably slightly reduce the number of people falling in people with mild to moderate PD.  Cholinesterase inhibitors may reduce the rate of falls, but we are uncertain if they have an effect on the number of people falling. The decision to use these medications needs to be balanced against the risk of non fall-related adverse events, though these adverse events were predominantly mild or transient in nature. Further research in the form of large, high-quality RCTs are required to determine the relative impact of different types of exercise and different levels of supervision on falls, and how this could be influenced by disease severity. Further work is also needed to increase the certainty of the effects of medication and further explore falls prevention education interventions both delivered alone and in combination with exercise.

Pedrosa D, Antonini A, Côté D, Fabbri M, Ferreira JJ, Růžička E, Grimes D, Mestre TA. Moving towards Integrated and Personalized Care in Parkinson's Disease: A Framework Proposal for Training Parkinson Nurses

Delivering healthcare to people living with Parkinson's disease (PD) may be challenging in face of differentiated care needs during a PD journey and a growing complexity. In this regard, integrative care models may foster flexible solutions on patients' care needs whereas Parkinson Nurses (PN) may be pivotal facilitators. However, at present hardly any training opportunities tailored to the care priorities of PD-patients are to be found for nurses. Following a conceptual approach, this article aims at setting a framework for training PN by reviewing existing literature on care priorities for PD. As a result, six prerequisites were formulated concerning a framework for training PN. The proposed training framework consist of three modules covering topics of PD: (i) comprehensive care, (ii) self-management support and (iii) health coaching. A fourth module on telemedicine may be added if applicable. The framework streamlines important theoretical concepts of professional PD management and may enable the development of novel, personalized care approaches.

Employment Resources for People with Parkinson's Disease: A Resource Review and Needs Assessment

Purpose People with Parkinson's disease (PwP) exit the workforce on average 5 years earlier than people without Parkinson's due to motor, cognitive, communicative, and affective symptoms. Decreased employment results in significant individual and societal costs. The objectives of this study were to identify strengths and weaknesses of employment resources and assess the needs of consumer and clinical stakeholders to improve job retention. Methods The study used a qualitative content analysis and Quasi Needs Assessment Framework. Sixteen PwP and 10 clinician stakeholders participated in two rounds of stakeholder discussion panels. Main outcomes included (1) the resources identified through the online content search and themes derived from those resources, and (2) the information gained from discussion panels and themes derived from their conversations. Results Literature review and online searches yielded 59 resources (30 consumer-focused documents, 17 peer-reviewed articles, and 12 documents supplied by key informants who are experts in Parkinson's disease and/or employment). Themes frequently found in the consumer-focused content but not the peer-reviewed literature included diagnosis disclosure decision-making, the benefits of retiring compared to working, and workplace accommodations. Stakeholders identified three key needs with regard to employment-related support for PwP: (1) knowledge about employment support options; (2) a clinician to start the discussion about employment challenges; and (3) an individualized and flexible approach to employment-related interventions. Conclusions Many people with Parkinson's experience unmet employment-related resource and process needs. An individually-tailored interdisciplinary intervention care path could facilitate decisions regarding disclosure and accommodations.

From trials to clinical practice: Temporal trends in the coverage of specialized allied health services for Parkinson's disease

BACKGROUND AND PURPOSE

To determine how the coverage of specialized allied health services for patients with Parkinson's disease (PD) has developed in the Netherlands since the publication of trials that demonstrated cost-effectiveness.

METHODS

We used healthcare expenditure-based data on all insured individuals in the Netherlands to determine the annual proportion of patients with PD who received either specialized or generic allied health services (physiotherapy, occupational therapy, speech-language therapy) in 2 calendar years separated by a 5-year interval (2012 and 2017). Specialized allied health services were delivered through the ParkinsonNet approach, which encompassed professional training and concentration of care among specifically trained professionals.

RESULTS

Between 2012 and 2017, there was an increase in the number of patients with any physiotherapy (from 17,843 [62% of all patients with PD that year] to 22,282 [68%]), speech-language therapy (from 2171 [8%] to 3378 [10%]), and occupational therapy (from 2813 [10%] to 5939 [18%]). Among therapy-requiring patients, the percentage who were treated by a specialized therapist rose substantially for physiotherapy (from 36% in 2012 to 62% in 2017; χ²  = 2460.2; p < 0.001), speech-language therapy (from 59% to 85%; χ²  = 445.4; p < 0.001), and occupational therapy (from 61% to 77%; χ²  = 231.6; p < 0.001). By contrast, the number of patients with generic therapists did not change meaningfully. By 2017, specialized care delivery had extended to regions that had been poorly covered in 2012, essentially achieving nationwide coverage.

CONCLUSIONS

Following the publication of positive trials, specialized allied healthcare delivery was successfully scaled for patients with PD in the Netherlands, potentially serving as a template for other healthcare innovations for patients with PD elsewhere.

Hand dexterity assessment in Parkinson's disease: construct validity of the 9-Hole peg test for the more affected hand

Purpose: There is limited understanding of the characteristics and evaluation of more affected hand dexterity loss in Parkinson's disease. We described 9-Hole Peg Test performance for the more affected hand and examined the construct validity of these pegboard scores in mild to severe Parkinson's disease. Methods: This observational study analysed baseline data from a cluster-randomised controlled trial.Participants (n = 582) completed the pegboard with their more affected hand, the Patient-Specific Index-Parkinson's Disease and Self-assessment Parkinson's Disease Disability Scale. Mean pegboard performance was summarised at each disease stage. To investigate known groups validity, we explored differences in pegboard scores between participants identifying upper limb problems in their 'top three' functional limitations, and those prioritising other limitations. Convergent validity investigated correlations between pegboard performance and self-reported hand function.Results: Pegboard performance was reduced compared with normative values, and problems with hand activities were reported at each disease stage. Significant differences in pegboard performance between the two functional limitation priority groups (p < 0.05), and moderate correlations between pegboard dexterity and hand function (Self-assessment Parkinson's Disease Disability Scale) provided evidence for construct validity.Conclusions: People with mild to severely disabling Parkinson's disease have reduced dexterity and problems with hand function. Evidence supported the construct validity of 9-Hole Peg Test more affected hand performance.IMPLICATIONS FOR REHABILITATIONPeople with mild to severely disabling PD experience dexterity loss and problems with hand function.It is important for clinicians to assess dexterity and hand function in people with this movement disorder.Evidence supports the construct validity of 9-Hole Peg Test for measuring more affected hand performance in Parkinson's disease.

Treatment options for postural instability and gait difficulties in Parkinson's disease

Introduction: Gait and balance disorders in Parkinson's disease (PD) represent a major therapeutic challenge as frequent falls and freezing of gait impair quality of life and predict mortality. Limited dopaminergic therapy responses implicate non-dopaminergic mechanisms calling for alternative therapies.Areas covered: The authors provide a review that encompasses pathophysiological changes involved in axial motor impairments in PD, pharmacological approaches, exercise, and physical therapy, improving physical activity levels, invasive and non-invasive neurostimulation, cueing interventions and wearable technology, and cognitive interventions.Expert opinion: There are many promising therapies available that, to a variable degree, affect gait and balance disorders in PD. However, not one therapy is the 'silver bullet' that provides full relief and ultimately meaningfully improves the patient's quality of life. Sedentariness, apathy, and emergence of frailty in advancing PD, especially in the setting of medical comorbidities, are perhaps the biggest threats to experience sustained benefits with any of the available therapeutic options and therefore need to be aggressively treated as early as possible. Multimodal or combination therapies may provide complementary benefits to manage axial motor features in PD, but selection of treatment modalities should be tailored to the individual patient's needs.

Physiotherapy for Parkinson's disease: a comparison of techniques

BACKGROUND

Despite medical therapies and surgical interventions for Parkinson's disease (PD), patients develop progressive disability. The role of physiotherapy is to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. The overall aim is to optimise independence, safety and wellbeing, thereby enhancing quality of life. Trials have shown that physiotherapy has short-term benefits in PD. However, which physiotherapy intervention is most effective remains unclear.

OBJECTIVES

To assess the effectiveness of one physiotherapy intervention compared with a second approach in patients with PD.

SEARCH METHODS

Relevant trials were identified by electronic searches of numerous literature databases (for example MEDLINE, EMBASE) and trial registers, plus handsearching of major journals, abstract books, conference proceedings and reference lists of retrieved publications. The literature search included trials published up to the end of January 2012.

SELECTION CRITERIA

Randomised controlled trials of one physiotherapy intervention versus another physiotherapy intervention in patients with PD.

DATA COLLECTION AND ANALYSIS

Data were abstracted independently from each paper by two authors. Trials were classified into the following intervention comparisons: general physiotherapy, exercise, treadmill training, cueing, dance and martial arts.

MAIN RESULTS

A total of 43 trials were identified with 1673 participants. All trials used small patient numbers (average trial size of 39 participants); the methods of randomisation and concealment of allocation were poor or not stated in most trials. Blinded assessors were used in just over half of the trials and only 10 stated that they used intention-to-treat analysis.A wide variety of validated and customised outcome measures were used to assess the effectiveness of physiotherapy interventions. The most frequently reported physiotherapy outcomes were gait speed and timed up and go, in 19 and 15 trials respectively. Only five of the 43 trials reported data on falls (12%). The motor subscales of the Unified Parkinson's Disease Rating Scale and Parkinson's Disease Questionnaire-39 were the most commonly reported clinician-rated disability and patient-rated quality of life outcome measures, used in 22 and 13 trials respectively. The content and delivery of the physiotherapy interventions varied widely in the trials included within this review, so no quantitative meta-analysis could be performed.

AUTHORS' CONCLUSIONS

Considering the small number of participants examined, the methodological flaws in many of the studies, the possibility of publication bias, and the variety of interventions, formal comparison of the different physiotherapy techniques could not be performed. There is insufficient evidence to support or refute the effectiveness of one physiotherapy intervention over another in PD.This review shows that a wide range of physiotherapy interventions to treat PD have been tested . There is a need for more specific trials with improved treatment strategies to underpin the most appropriate choice of physiotherapy intervention and the outcomes measured.

Sleep matters in Parkinson's disease: use of a priority list to assess the presence of sleep disturbances

BACKGROUND AND PURPOSE

Despite their high prevalence and clinical impact, sleep disorders in Parkinson's disease appear to receive insufficient attention in clinical practice. We compared the importance of sleep disorders relative to other symptoms and daily issues. Furthermore, we determined whether relevance as perceived by patients correlated with the subjective presence of sleep disruption scored with a rating scale.

METHODS

We studied a cohort of 153 consecutive patients (95 men) who were referred for problems other than sleep to our referral center. Prior to their visit, patients ranked their individual top five clinical priorities (of 23 items), indicating the most problematic domains for which they requested medical attention. Additionally, nocturnal sleep quality and excessive daytime sleepiness (EDS) were assessed with validated questionnaires.

RESULTS

The top three important domains according to the patient were movement (79.9%), medication (73.2%), and physical condition (63.4%). Sleep was the sixth most frequently reported item, marked by 37.9% of the patients. Amongst the patients who scored sleep as a priority, 47 (81%) had a poor sleep quality (Pittsburgh Sleep Quality Index > 5). Although EDS was present in almost 30% of patients, a minority of them put it on their priority list.

CONCLUSION

A priority list can be used to prioritize patient-centered quality of life issues. Our results show that sleep is a clinical priority for about one-third of patients. Surprisingly, EDS was usually not prioritized by patients during the consultation, underscoring the need to use ratings scales alongside subjective priorities.