Weekly exercise does not improve fatigue levels in Parkinson's disease

The Feasibility and Efficacy of a Virtual Reality Tandem Cycling Program for Persons with Parkinson's Disease and Their Care Partners

INTRODUCTION

Persons with Parkinson's disease (PwPD) suffer from motor and non-motor symptoms which significantly affect their quality of life (QoL), and the QoL of their care partners (CP). Tandem cycling reduces PwPD motor symptoms; however, no studies have examined other benefits or included PwPD CP. We conducted an 8-week community virtual reality (VR) tandem cycling intervention to assess the feasibility and efficacy for PwPD and their CP (i.e., PD dyads). We hypothesized that dyadic tandem cycling would improve (1) PwPD motor and non-motor symptoms and (2) dimensions of PD dyads' QoL and physiologic health.

METHODS

Ten PD dyads were recruited to complete 8 weeks of progressive intensity, bi-weekly tandem cycling. At pre- and post-testing, PwPD were assessed using the Movement Disorder Society-Unified Parkinson's Disease Rating Scale-III (MDS-UPDRS-III), functional gait assessment (FGA), and 10-m gait speed test. PD dyads also completed emotional and cognitive status questionnaires [e.g., Geriatric Depression Scale-Short Form (GDS-SF)], and wore BodyGuard 2 heart rate (HR) monitors for 48 h to assess surrogate measures of heart rate variability. Statistical analyses were conducted using Student's t tests with significance set at p ≤ 0.05.

RESULTS

Eight PD dyads and one PwPD completed the intervention. Retention of PwPD (90%) and CP (80%) was adequate, and PD dyad adherence ranged from 91.67 to 97.91%. PwPD demonstrated significant clinical improvements in MDS-UPDRS-III scores (- 7.38, p < 0.01), FGA scores (+ 3.50, p < 0.01), and 10-m gait speed times (+ 0.27 m/s, p < 0.01), in addition to significant self-reported improvements in mobility (- 13.61, p = 0.02), fatigue (- 5.99, p = 0.02), and social participation (+ 4.69, p < 0.01). CP depressive symptoms significantly decreased (- 0.88, p = 0.02), and PD dyads shared a significant increase in root mean square of the successive differences (RMSSD; p = 0.04).

CONCLUSION

Our pilot study demonstrated feasibility and multiple areas of efficacy supporting further investigation of community VR tandem cycling as a therapeutic intervention for PD dyads.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Pharmacological and Behavioral Interventions for Fatigue in Parkinson's Disease: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

This study aims to evaluate pharmacological and behavioral interventions for the treatment of fatigue in Parkinson's disease (PD) patients.

METHODS

We systematically searched PubMed, PsycINFO, Web of Science, EMBASE, CNKI, Wan fang, and VIP up to July 31, 2022. We used Revman 5.3 software for the meta-analysis. The outcomes included Fatigue Severity Scale (FSS) and Parkinson's Fatigue Scale (PFS). The mean difference (MD) and 95% confidence intervals (CI) were collected or calculated.

RESULTS

Thirteen randomized controlled trials (RCTs) with a total of 1758 patients were included. The meta-analysis showed that current clinical treatments reduced FSS (MD: -1.60, 95% CI: -3.14 to -0.05) and PFS (MD: -0.61, 95% CI: -1.17 to -0.05) in patients with PD. Subgroup meta-analysis showed that: (1) neither pharmacological interventions nor behavioral interventions reduced FSS in PD patients; (2) dopaminergic drugs dose-dependently significantly reduced the PFS in patients with PD; (3) behavioral interventions have an almost significant effect (MD: -6.69, 95% CI: -13.71 to 0.33, P = 0.06, I2 = 74%) on alleviating PFS in PD patients; (4) vestibular rehabilitation training significantly reduced the PFS in patients with PD.

CONCLUSIONS

Current clinical treatments alleviate fatigue in PD patients. Dopaminergic drugs may act a stronger effect than amphetamines. Behavioral interventions, especially vestibular rehabilitation training, may be a promising way for the treatment of fatigue in patients with PD though further evidence is still needed.

Effectiveness of physical activity interventions on reducing perceived fatigue among adults with chronic conditions: a systematic review and meta-analysis of randomised controlled trials

Fatigue is barrier of physical activity participation in adults with chronic conditions. However, physical activity alleviates fatigue symptoms. This systematic review and meta-analysis aimed to (1) synthesise evidence from randomised controlled trials (RCTs) exploring the effects of physical activity interventions on fatigue reduction and (2) evaluate their effectiveness. Medline/CINAHL/EMBASE/Web of Science and Scopus were searched up to June 24th, 2023. Two reviewers independently conducted study screening and selection (RCTs), extracted data and assessed risk of bias (RoB2). Outcome was the standardised mean difference (SMD) with 95% confidence intervals in fatigue between experimental and control groups. 38 articles met the inclusion criteria. Overall, physical activity interventions moderately reduced fatigue (SMD = 0.54, p < 0.0001). Interventions lasting 2-6 weeks demonstrated a larger effect on fatigue reduction (SMD = 0.86, p < 0.00001). Interventions with 18-24 sessions showed a large effect on fatigue reduction (SMD = 0.97, p < 0.00001). Aerobic cycling and combination training interventions had a large to moderate effect (SMD = 0.66, p = 0.0005; SMD = 0.60, p = 0.0010, respectively). No long-term effects were found during follow-up. Physical activity interventions moderately reduced fatigue among adults with chronic conditions. Duration, total sessions, and mode of physical activity were identified as key factors in intervention effectiveness. Further research is needed to explore the impact of physical activity interventions on fatigue.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Physical Exercise as a Potential Treatment for Fatigue in Parkinson's Disease? A Systematic Review and Meta-Analysis of Pharmacological and Non-Pharmacological Interventions

BACKGROUND

Fatigue is one of the most common and debilitating non-motor symptoms among patients with Parkinson's disease (PD) and significantly impacts quality of life. Therefore, effective treatment options are needed.

OBJECTIVE

To provide an update on randomized controlled trials (RCTs) including pharmacological and non-pharmacological (but non-surgical) treatments that examine the effects of fatigue on PD patients.

METHODS

We searched the MEDLINE, EMBASE, PsycINFO, CENTRAL, and CINAHL databases for (cross-over) RCTs on pharmacological and non-pharmacological interventions for treating fatigue in PD patients until May 2021. Meta-analyses for random-effects models were calculated when two or more studies on the same treatment option were available using standardized mean differences (SMDs) with 95% confidence intervals (CIs).

RESULTS

Fourteen pharmacological and 16 non-pharmacological intervention RCTs were identified. For pharmacological approaches, a meta-analysis could only be performed for modafinil compared to placebo (n = 2) revealing a non-significant effect on fatigue (SMD = - 0.21, 95% CI - 0.74-0.31, p = 0.43). Regarding non-pharmacological approaches, physical exercise (n = 8) following different training approaches versus passive or placebo control groups showed a small significant effect (SMD = - 0.37, 95% CI - 0.69- - 0.05, p = 0.02) which could not be demonstrated for acupuncture vs. sham-acupuncture (SMD = 0.16, 95% CI - 0.19-0.50, p = 0.37).

CONCLUSION

Physical exercise may be a promising strategy to treat fatigue in PD patients. Further research is required to examine the efficacy of this treatment strategy and further interventions. Future studies should differentiate treatment effects on physical and mental fatigue as the different underlying mechanisms of these symptoms may lead to different treatment responses. More effort is required to develop, evaluate, and implement holistic fatigue management strategies for PD patients.

Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association

A clinical practice guideline on Parkinson disease was developed by an American Physical Therapy Association volunteer guideline development group that consisted of physical therapists and a neurologist. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for management of Parkinson disease. The Spanish version of this clinical practice guideline is available as a supplement (Suppl. Appendix 1).

Happiness: A Novel Outcome in Parkinson Studies?

In this viewpoint, we draw attention to using happiness in clinical studies as an interesting outcome that is highly relevant to patients with Parkinson’s disease. Quality of life (QoL) is thus far commonly used as main outcome in clinical trials. Happiness is a part of QoL, but also represents a construct on its own. While QoL mainly consists of quality perceptions of different extrinsic aspects of life, such as the environment or performance, happiness entails the intrinsic quality of the subjective enjoyment of life. Around 70% of people rate happiness as the most important thing in life. Happiness can be a difficult construct to measure, but we argue that self-compassion and well-being could serve as reliable indicators for happiness. We expect that happiness as outcome could probe the true value of an intervention for a patient, well beyond what is captured by more traditional outcomes such as motor scores or the general concept of QoL, which better reflect external factors. Because of the apparent importance of happiness to many people, we recommend that this concept is used more widely as outcome measure in future clinical trials.

Non-pharmacological therapies for pain management in Parkinson's disease: A systematic review

Among the various non-motor symptoms of Parkinson's disease (PD), pain is often cited as the most common and debilitating feature. Currently, the literature contains gaps in knowledge with respect to the various forms of treatment available, particularly non-pharmacological therapies. Thus, the purpose of this systematic review is to provide an examination of the literature on non-pharmacological therapies for pain in PD. We compared the findings of research articles indexed within various literature databases related to non-pharmacological treatments of pain in PD patients. Our review identified five major non-pharmacological methods of pain therapy in PD: acupuncture, hydrotherapy, massage therapy, neuromodulation, and exercise. Treatments such as exercise therapy found a reduction in pain perception due to various factors, including the analgesic effects of neurotransmitter release during exercise and increased activity leading to a decrease in musculoskeletal rigidity and stiffness. By the same token, hydrotherapy has been shown to reduce pain perception within PD patients, with authors often citing a combined treatment of exercise and hydrotherapy as an effective treatment for pain management. Multiple methods of neurostimulation were also observed, including deep brain stimulation and spinal cord stimulation. Deep brain stimulation showed efficacy in alleviating certain pain types (dystonic and central), while not others (musculoskeletal). Hence, patients may consider deep brain stimulation as an additive procedure for their current treatment protocol. On the other hand, spinal cord stimulation showed significant improvement in reducing VAS scores for pain. Finally, although the literature on massage therapy and acupuncture effectiveness on pain management is limited, both have demonstrated a reduction in pain perception, with common reasons such as tactile stimulation and release of anti-nociceptive molecules in the body. Although literature pertaining to non-pharmacological treatments of pain in PD is sparse, there is copious support for these treatments as beneficial to pain management. Further exploration in the form of clinical trials is warranted to assess the efficacy of such therapies.

What Fatigue Means to Persons Living with Parkinson's Disease? A Qualitative Study

BACKGROUND

Fatigue is one of the most prevalent non-motor symptoms of Parkinson's disease (PD). Research is hampered by imprecise terminology and the lack of case definition criteria.

OBJECTIVES

To elicit the experiences of persons living with PD-related fatigue and provide ecological validation for case definition criteria.

METHODS

Qualitative interviews were conducted with 22 individuals and 4 focus groups, and analyzed using an inductive qualitative method.

RESULTS

Six core themes emerged: (i) difficulty initiating and completing important tasks; (ii) desire for others to understand their fatigue experience; (iii) heterogeneity of experiences and descriptions of fatigue; (iv) complex relationships with other non-motor symptoms; (v) variable self-management strategies; and (vi) general alignment with proposed case definition criteria.

CONCLUSIONS

PD-related fatigue impacts function, is subjectively distinguishable from other non-motor symptoms, has heterogeneous descriptions, and may be mitigated by various self-management strategies. Proposed case definition criteria appear ecologically valid and warrant further optimization and testing.

A Single Session of Whole-Body Electromyostimulation Increases Muscle Strength, Endurance and proNGF in Early Parkinson Patients

Parkinson's disease (PD) patients lead a sedentary lifestyle, being unable or unwilling to exercise conventionally, due to physical and mental limitations. The aim of this study was to assess the acute effects of a single session of whole-body electromyostimulation (WB-EMS) on the physical performances and serum levels of the neurotrophic factors in PD patients. Ten subjects (aged 72.60 ± 6.82) underwent 20 min of physical activity with superimposed WB-EMS and, after four weeks, the same protocol with no WB-EMS. WB-EMS was conducted with intermittent stimulation, with 4 s WB-EMS/4 s rest, at 85 Hz, 350 μs. A physical fitness assessment and blood samples collection, to evaluate neurotrophic factors' levels (BDNF, FGF21, proNGF, mNGF), were collected before and after the intervention. The RM-ANOVA showed significant improvements in sit-to-stand (p < 0.01), arm curl (p < 0.01), handgrip (p < 0.01) and soda pop test (p < 0.01) after the WB-EMS intervention. Higher proNFG serum levels were observed in the WB-EMS condition compared to the no WB-EMS after 60 min post-intervention (p = 0.0163). The effect of WB-EMS confirmed the electrostimulation ability to modulate the proNGF quantity. The positive impact of the WB-EMS protocol on physical functioning, and eye-hand coordination, makes this intervention a promising strategy to improve motor and non-motor symptoms in PD patients.

Fatigue in hypokinetic, hyperkinetic, and functional movement disorders

The emerging science of fatigue has soundly endorsed the need for its unified definition, shared terminology and increased recognition in neurological illnesses. Nevertheless, the real impact of fatigue remains under-recognized. Fatigue describes a sense of tiredness, lack of energy or need for increased effort often perceived as overwhelming, pervasive, and disabling. It is a common feature of chronic medical conditions and neurological diseases, including Parkinson's disease (PD) and other hypokinetic, hyperkinetic, and functional movement disorders (FMD). While there is solid evidence for the burden of fatigue in PD, knowledge of fatigue in other movement disorders (MDS) is still limited. Lack of consensus definition, rigorous measures and the high prevalence of potential confounders such as apathy, depression and sleepiness are the main obstacles in studying fatigue in MDS. This review of the prevalence, impact, and clinical correlates of fatigue in common MDS summarizes current hypotheses for the pathophysiological mechanisms underlying fatigue and gives a brief overview of treatment options. Fatigue is a prevalent, disabling, primary non-motor symptom (NMS) in MDS, including atypical and secondary parkinsonisms, dystonia, essential tremor (ET) and a hallmark feature of FMD. We report the hypothesis that fatigue is a perceptual disorder of the sensorimotor system. Given the relevance of this burdensome symptom, fatigue deserves greater clinical and research attention to better understand its manifestation and pathophysiology and to improve diagnosis and treatment.

Triggers and alleviating factors for fatigue in Parkinson's disease

BACKGROUND

Fatigue is common in Parkinson's Disease, but few effective treatments are available for it. Exploring triggers and alleviating factors, including effects of exercise, could inform development of management strategies for Parkinson's Disease fatigue.

OBJECTIVES

To examine triggers and alleviating factors for fatigue reported by individuals with Parkinson's Disease, including perceived effect of exercise.

METHODS

A sample of individuals with self-reported Parkinson's Disease participating in the study Fox Insight were administered an online survey. The survey included the Parkinson's Fatigue Scale, the Physical Activity Scale for the Elderly, and multiple-choice questions about triggers and alleviating factors for fatigue.

RESULTS

Among the sample of 1,029 individuals with Parkinson's disease, mean (standard deviation (SD)) age was 67.4 (9.3) years, 44.0% were female. Parkinson's Fatigue Scale score ranged from 16-80, mean (SD) 48.8 (16.2). Poor sleep (62.1%) and physical exertion (45.1%) were frequently reported triggers for fatigue. Coping strategies including sitting quietly (58.1%), laying down with or without napping, and exercise (20%). Physical Activity Scale for the Elderly scores were higher in those who reported that exercise alleviated their fatigue (49.7%) compared to those who reported it worsened their fatigue (18.9%) (mean (SD) score 158.5 (88.8) vs 119.8 (66.6) respectively; p<0.001).

CONCLUSIONS

Several behavioral and environmental triggers and alleviating strategies for fatigue are reported by individuals with Parkinson's disease. Many feel that exercise alleviates fatigue, though the relationship between exercise and fatigue in Parkinson's Disease appears complex. This exploratory study may inform future development of treatments or coping strategies for Parkinson's disease fatigue.

Effect of Exercise on Quality of Life in Parkinson's Disease: A Systematic Review and Meta-Analysis

Background

Exercise has an integral impact on the physical and mental wellbeing of patients with Parkinson's disease (PD), yet no comprehensive and quantitative analysis has been conducted on the effect of exercise on quality of life (QoL) in these patients. This study aimed to evaluate the effect of exercise on overall QoL and different domains of QoL in people with PD, as well as investigating the influence of factors such as the exercise type and intervention period.

Methods

Databases, such as PubMed, Embase, and Cochrane Central Register of Controlled Trials, were searched since inception to August 14, 2018 to identify randomized controlled trials that compare the effect of exercise versus no intervention on QoL in PD patients. Following the subgroup analysis, heterogeneity was further explored. The quality of eligible studies was assessed according to PRISMA guidelines.

Results

20 studies were included with 1,143 participants in total. A meta-analysis showed a significant improvement in QoL after exercise intervention in PD patients (SMD = −0.24, 95% CI = −0.36 to −0.12, P < 0.001). A subgroup analysis of exercise types revealed significant QoL improvement with aerobic exercise, martial arts, and dance, but not anaerobic exercise and combined exercise. Interventions lasting 12 weeks or longer improved QoL significantly.

Conclusions

Exercise interventions, especially aerobic exercise, dance, and Tai Chi, significantly improve QoL in PD patients. At least 12 weeks of exercise is needed to bring about significant benefits.

Fitness coordinators' and fitness instructors' perspectives on implementing a task-oriented community exercise program within a healthcare-recreation partnership for people with balance and mobility limitations: a qualitative study

Background: Healthcare organizations are partnering with recreation organizations to support the delivery of community-based exercise programs for people with balance and mobility limitations. The value and impact of support strategies provided by healthcare organizations, however, have not been examined.Objective: Study objectives were to explore fitness coordinators' and fitness instructors' experiences with implementing a task-oriented community-based exercise program for people with balance and mobility limitations within the context of a healthcare-recreation partnership.Methods: A qualitative descriptive study was conducted. Fitness coordinators and instructors involved with delivering a licensed, group, task-oriented community-based exercise program for people with balance and mobility limitations supported by a healthcare-recreation partnership were interviewed by telephone. Interviews were audio-recorded and transcribed verbatim. A thematic analysis was performed.Results: Eight fitness coordinators and 8 fitness instructors from 14 recreation centres were interviewed. Findings showed that healthcare-recreation partnerships help to optimize exercise program quality and safety through multiple strategies. Fitness coordinators and instructors still face challenges with program implementation at start-up and over time. Recommendations to address these challenges included increased training content related to adjusting exercises to accommodate participant abilities, 1-2 visits from a healthcare professional each program after initial program implementation, suggestions to increase exercise variety, and ongoing education.Conclusions: Findings clarify the role of healthcare organizations, ongoing challenges, and directions for improvement in this program delivery model.Implications for rehabilitationCommunity recreation centres can provide task-oriented exercise programs to help people with balance and mobility limitations safely engage in regular exerciseHealthcare organizations should provide specific supports to help increase the safety and quality of task-oriented exercise programs in recreation centresSupports include providing clear exercise guidelines, and a healthcare professional who trains fitness instructors, visits the program, answers questions between visits, promotes collaboration and information exchange between recreation centres, and provides ongoing education.

Update on treatments for nonmotor symptoms of Parkinson's disease-an evidence-based medicine review

OBJECTIVE

To update evidence-based medicine recommendations for treating nonmotor symptoms in Parkinson's disease (PD).

BACKGROUND

The International Parkinson and Movement Disorder Society Evidence-Based Medicine Committee's recommendations for treatments of PD were first published in 2002, updated in 2011, and now updated again through December 31, 2016.

METHODS

Level I studies testing pharmacological, surgical, or nonpharmacological interventions for the treatment of nonmotor symptoms in PD were reviewed. Criteria for inclusion and quality scoring were as previously reported. The disorders covered were a range of neuropsychiatric symptoms, autonomic dysfunction, disorders of sleep and wakefulness, pain, fatigue, impaired olfaction, and ophthalmologic dysfunction. Clinical efficacy, implications for clinical practice, and safety conclusions are reported.

RESULTS

A total of 37 new studies qualified for review. There were no randomized controlled trials that met inclusion criteria for the treatment of anxiety disorders, rapid eye movement sleep behavior disorder, excessive sweating, impaired olfaction, or ophthalmologic dysfunction. We identified clinically useful or possibly useful interventions for the treatment of depression, apathy, impulse control and related disorders, dementia, psychosis, insomnia, daytime sleepiness, drooling, orthostatic hypotension, gastrointestinal dysfunction, urinary dysfunction, erectile dysfunction, fatigue, and pain. There were no clinically useful interventions identified to treat non-dementia-level cognitive impairment.

CONCLUSIONS

The evidence base for treating a range of nonmotor symptoms in PD has grown substantially in recent years. However, treatment options overall remain limited given the high prevalence and adverse impact of these disorders, so the development and testing of new treatments for nonmotor symptoms in PD remains a top priority. © 2019 International Parkinson and Movement Disorder Society.

Effects of a Group Protocol on Physical Activity and Associated Changes in Mood and Health Locus of Control in Adults with Parkinson Disease and Reduced Mobility

BACKGROUND

Parkinson disease (PD) is a degenerative nervous disorder that affects motor functioning. Although physical activity is beneficial, it often is reduced, and psychosocial issues persist such as low mood and perceptions of loss of control over health.

OBJECTIVE

To determine the extent to which a community-based physical activity/self-regulatory skills intervention affects overall physical activity and changes in psychosocial factors in adults with PD and in adults with reduced mobility without PD.

METHODS

Existing participants (N = 45, mean age = 71 years) of community-based PD group movement classes, who also participated in an individualized 6-session protocol for exercise support that emphasized self-regulation through barriers, completed validated self-report surveys. Participants' mean length of movement class participation was 11.8 months at the time of survey administration.

RESULTS

Mixed-model repeated-measures analysis of variance indicated significant improvements in physical activity, self-regulation, exercise self-efficacy, negative mood, and task social cohesion but not internal health locus of control. Improvement in social cohesion was significantly greater in the PD group (n = 27) than in the non-PD (n = 18) group. Changes in exercise self-efficacy mediated a significant relationship between changes in self-regulation and physical activity. Changes in social cohesion mediated a significant relationship between changes in physical activity and mood. Changes in mood and social cohesion had a reciprocal, mutually reinforcing relationship. For the PD group, length of program involvement predicted vigor change (r = 0.52, p = 0.006).

CONCLUSION

The intervention demonstrated positive effects on physical activity and psychosocial factors in adults with PD and with reduced mobility. Effects on social cohesion were important. Such programming should be considered as an adjunct to traditional medical treatment.

Parkinson's disease: Diagnosis and appreciation of comorbidities

Parkinson's disease (PD) is a complex neuropsychiatric disorder that manifests with a variety of motor and nonmotor symptoms. Its incidence increases with age. It is important for clinicians to be able to distinguish symptoms of aging and other comorbidities from those of PD. The diagnosis of PD has traditionally been rendered using strict criteria that mainly rely on the cardinal motor symptoms of rest tremor, rigidity, and bradykinesia. However, newer diagnostic criteria proposed by the Movement Disorders Society for diagnosis of PD collectively reflect a greater appreciation for the nonmotor symptoms. The treatment of PD remains symptomatic and the most noticeable improvements have been documented in the motor symptoms. Levodopa remains the gold standard for therapy, however there are now many other potential medical and surgical treatment strategies. Nonmotor symptoms have been shown to affect quality of life more than the motor symptoms. There is ongoing research into symptomatic and disease modifying treatments. Given the multisystem involvement in PD, an interdisciplinary patient-centered approach is recommended by most experts. This chapter addresses first the diagnostic approach and the many geriatric considerations. This is followed by a review of the nonmotor symptoms. Finally, a summary of current treatment strategies in PD is presented along with potential treatment complications.

Understanding physical activity in Veterans with Parkinson disease: A mixed-methods approach

INTRODUCTION

Physical activity is critical in Parkinson disease (PD) management, but barriers and motivators of activity in Veterans with PD may be unique. We examined activity habits, including barriers and motivators, in this population.

METHODS

Participants completed the Physical Activity Scale in the Elderly (PASE). Compliance with American Heart Association (AHA) recommendations was assessed. Veterans also completed the Exercise Perceptions Questionnaire (EPQ), assessing knowledge, barriers, and motivators of activity. Free-text barriers/motivators were analyzed by the overlapping clusters method.

RESULTS

Seventy-five Veterans were recruited; mean age (standard deviation [SD]) was 70.5 (8.2) years and mean disease duration (SD) was 5.4 (5.2) years. Raw median PASE was 120.4 (interquartile range [IQR] 68.8-165.7); age-adjusted median PASE was 135.3. Only 9 Veterans (14.3%) were AHA-compliant. There were trends toward negative association between PASE and UPDRS-3 (r = -0.24, p = 0.06) and between PASE and PDQ-8 (r = -0.23, p = 0.08). Sixty-three subjects (84%) completed the EPQ; 27 (42.9%) preferred scheduled exercise, and only 33 (53.2%) reported that they preferred to exercise with others. Common themes of 46 free-text responses included desire to improve PD symptoms (n = 15, 32.6%) and social engagement (n = 12, 26.1%).

CONCLUSIONS

Self-reported activity in Veterans with PD is low, with less than 15% of subjects meeting recommended activity targets. Qualitative analysis of barriers and motivators revealed that although many Veterans enjoy the social aspects of group exercise, they may not feel comfortable in general exercise classes aimed at younger participants without chronic illnesses. These data will be useful in designing Veteran- and/or PD-specific interventions to increase activity levels.

Fatigue in Parkinson's disease: A systematic review and meta-analysis

We conducted a systematic review and meta-analysis aimed at establishing robust prevalence estimates and identifying clinical correlates of fatigue in PD. From 2,459 titles and abstracts, we selected 44 relevant studies (n = 7427 patients). Overall, the meta-analysis showed a prevalence of fatigue of 50% in PD. This prevalence estimate, however, was significantly moderated by study heterogeneity in measurement scales and cut-off thresholds. In contrast, demographic features, disease severity, cognitive impairment, and depression did not moderate prevalence estimates. Moreover, fatigue prevalence did not differ between de novo and treated PD patients. Compared to nonfatigued patients, fatigued patients had sligthly higher age (1.44 years), disease duration (0.93 years), l-dopa equivalent daily dose (50.89 units), UPDRS-III (4.99 points), and H & Y (0.33 points), as well as risk of comorbid depression (risk ratio = 1.89) and had a little lower MMSE score (-0.66 points). Fatigue was moderately associated with apathy (Hedges' g = 0.55), anxiety (Hedges' g = 0.67), daytime somnolence (Hedges' g = 0.43), sleep disturbances (Hedges' g = 0.66), and poorer quality of life (Hedges' g = 1.23). Our analyses suggest that fatigue is a frequent, independent nonmotor symptom in PD appearing early and persisting throughout the disease course, and that establishing uniform diagnostic criteria for PD-related fatigue is critical. In addition, several nonmotor symptoms appear to be associated with fatigue and negatively impact quality of life. Pharmacological and nonpharmacological interventions targeting fatigue and associated symptoms may improve quality of life in patients with PD. © 2018 International Parkinson and Movement Disorder Society.

Considerations for expanding community exercise programs incorporating a healthcare-recreation partnership for people with balance and mobility limitations: a mixed methods evaluation

OBJECTIVE

To increase access to safe and appropriate exercise for people with balance and mobility limitations, community organizations have partnered with healthcare providers to deliver an evidence-based, task-oriented group exercise program in community centers in Canada. We aimed to understand challenges and solutions to implementing this program model to inform plans for expansion.

RESULTS

At a 1-day meeting, 53 stakeholders (healthcare/recreation personnel, program participants/caregivers, researchers) identified challenges to program implementation that were captured by seven themes: Resources to deliver the exercise class (e.g., difficulty finding instructors with the skills to work with people with mobility limitations); Program marketing (e.g., to foster healthcare referrals); Transportation (e.g., particularly from rural areas); Program access (e.g., program full); Maintaining program integrity; Sustaining partnerships (i.e., with healthcare partners); and Funding (e.g., to deliver program or register). Stakeholders prioritized solutions to form an action plan. A survey of individuals supervising 28 programs revealed that people with stroke, acquired brain injury, multiple sclerosis, and Parkinson's disease register at 95-100% of centers. The most prevalent issues with program fidelity across centers were not requiring a minimum level of walking ability (32%), class sizes exceeding 12 (21%), and instructor-to-participant ratios exceeding 1:4 (19%). Findings provide considerations for program expansion.

Complementary and Alternative Medicine and Exercise in Nonmotor Symptoms of Parkinson's Disease

The use of complementary and alternative medicine (CAM) therapy in nonmotor symptoms (NMS) for Parkinson disease (PD) is growing worldwide. Well-performed, systematic evidence-based research is largely lacking in this area and many studies include various forms of CAM with small patient numbers and a lack of standardization of the approaches studied. Taichi, Qigong, dance, yoga, mindfulness, acupuncture, and other CAM therapies are reviewed and there is some evidence for the following: Taichi in sleep and PDQ39; dance in cognition, apathy, and a mild trend to improved fatigue; yoga in PDQ39; and acupuncture in depression, PDQ39, and sleep. Exercise including occupational therapy (OT) and physical therapy (PT) has been studied in motor symptoms of PD and balance but only with small studies with a mounting evidence base for use of exercise in NMS of PD including PDQ39, sleep, fatigue, depression, and some subsets of cognition. Studies of OT and PT largely show some benefit to depression, apathy, and anxiety. Sustainability of an improvement has not been shown given short duration of follow up. Finding optimal control groups and blind for these interventions is also an issue. This is a very important area of study since patients want to be self-empowered and they want guidance on which form of exercise is the best. Additionally, evidence for PT and OT in NMS would give added weight to get these interventions covered through medical insurance.

Fatigue in Parkinson's disease

Fatigue is one of the most common nonmotor symptoms in Parkinson's disease and may affect a wide range of everyday activities, cause disability and reduce quality of life. It occurs at every stage of PD, and once present will often persist and may worsen over time. Lack of a consensus of definition and classification, and a range of different self-reporting scales has so far made the study of fatigue challenging. We review a unifying taxonomy for defining fatigue in clinical and research contexts as well as case definition criteria for PD-related fatigue. The potential causes of fatigue in PD are discussed as are recommendations for treatment.

Characterising community exercise programmes delivered by fitness instructors for people with neurological conditions: a scoping review

A scoping review was conducted to characterise evaluations of community-based exercise programmes (CBEPs) delivered by fitness instructors to people with neurological conditions. Literature published from 1946 to April 2014 in MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews and the grey literature were searched. Search terms included community, programme, exercise, adult, brain disease and spinal cord disease. Two reviewers independently screened titles and abstracts for inclusion. One author reviewed full-text articles to evaluate eligibility. Studies were included if the study objective was to evaluate an exercise programme, the programme was community-based and delivered by fitness instructors, exercise participants were ≥18 years of age and had a neurological condition, and a full-text article was available and written in English. After reviewing 1785 titles and abstracts, 18 (1.01%) articles describing 15 studies were included in the review. One author completed data abstraction from the included studies. A second reviewer independently verified the extracted data for accuracy. Exercise programmes most commonly included people with stroke (47%) and Parkinson's disease (40%), incorporated a stand-alone (80%), multi-component (20%), group (67%), individual (20%) and combined format (13%), strength training (40%) and functional/task-oriented training (40%), reported a minimum walking requirement (67%), and involved a healthcare professional (HCP) with various roles (53%), including training (27%), advising and supporting (33%). The most commonly examined participant outcomes were health-related quality of life (60%) and functional balance (47%). More research is needed to develop CBEPs targeting individuals with low ambulatory function and multiple neurological conditions, to develop recommendations for the involvement of HCPs in CBEPs and document their involvement, and to evaluate system-level outcomes such as cost, healthcare utilisation and impact on caregivers. The findings support a number of considerations to guide future research into CBEPs delivered by fitness instructors for individuals with neurological conditions.

Auditing the Physical Activity and Parkinson Disease Literature Using the Behavioral Epidemiologic Framework

Motor and nonmotor symptoms associated with Parkinson disease place individuals at greater risk of sedentary behaviors and comorbidities. Physical activity is one modifiable means of improving health and reducing the risk of morbidity. We applied a behavioral framework to classify existing research on physical activity and Parkinson disease to describe the current evolution and inform knowledge gaps in this area. Research placed in phase 1 establishes links between physical activity and health-related outcomes; phase 2 develops approaches to quantify physical activity behavior; phase 3 identifies factors associated with implementation of physical activity behaviors; phase 4 assesses the effectiveness of interventions to promote activity; and phase 5 disseminates evidence-based recommendations. Peer-reviewed literature was identified by searching PubMed, Google Scholar, and EBSCO-host. We initially identified 287 potential articles. After further review, we excluded 109 articles, leaving 178 included articles. Of these, 75.84% were categorized into phase 1 (n = 135), 10.11% in phase 2 (n = 18), 9.55% into phase 3 (n = 17), 3.37% into phase 4 (n = 6), and 1.12% into phase 5 (n = 2). By applying the behavioral framework to the physical activity literature for people with Parkinson disease, we suggest this area of research is nascent with more than 75% of the literature in phase 1.

LEVEL OF EVIDENCE

III.

The Effects of Physical Activity in Parkinson's Disease: A Review

BACKGROUND

Physical activity (PA) is increasingly advocated as an adjunct intervention for individuals with Parkinson's disease (PD). However, the specific benefits of PA on the wide variety of impairments observed in patients with PD has yet to be clearly identified.

OBJECTIVE

Highlight health parameters that are most likely to improve as a result of PA interventions in patients with PD.

METHODS

We compiled results obtained from studies examining a PA intervention in patients with PD and who provided statistical analyses of their results. 868 outcome measures were extracted from 106 papers published from 1981 to 2015. The results were classified as having a statistically significant positive effect or no effect. Then, outcome measures were grouped into four main categories and further divided into sub-categories.

RESULTS

Our review shows that PA seems most effective in improving Physical capacities and Physical and cognitive functional capacities. On the other hand, PA seems less efficient at improving Clinical symptoms of PD and Psychosocial aspects of life, with only 50% or less of results reporting positive effects. The impact of PA on Cognitive functions and Depression also appears weaker, but few studies have examined these outcomes.

DISCUSSION

Our results indicate that PA interventions have a positive impact on physical capacities and functional capacities. However, the effect of PA on symptoms of the disease and psychosocial aspects of life are moderate and show more variability. This review also highlights the need for more research on the effects of PA on cognitive functions, depression as well as specific symptoms of PD.

Rasagiline for the symptomatic treatment of fatigue in Parkinson's disease

BACKGROUND

Fatigue affects 40% to 50% of all PD patients and is a leading cause of disability, with no clearly established or efficacious established treatments.

METHODS

In this double-blinded, placebo-controlled, pilot trial, we investigated whether rasagiline improved fatigue among PD patients. Subjects were randomized to 1 mg daily of rasagiline or placebo for 12 weeks. The primary endpoint was a change in the Modified Fatigue Impact Scale from baseline to week 12.

RESULTS

Thirty PD subjects (16 men), with Modified Fatigue Impact Scale baseline score of 67 ± 15, were randomized (16 to rasagiline vs. 14 to placebo). Significant improvement was noted in the mean Modified Fatigue Impact Scale score of the rasagiline group (12 points) as compared to placebo (8.5 points) from baseline to week 12 (P = 0.003).

CONCLUSION

In this pilot study, rasagiline at a dose of 1 mg per day improved fatigue. Larger randomized studies are needed to confirm this finding.

The Impact of Physical Activity on Non-Motor Symptoms in Parkinson's Disease: A Systematic Review

Parkinson's disease (PD) is a neurological disorder that is associated with both motor and non-motor symptoms (NMS). The management of PD is primarily via pharmaceutical treatment; however, non-pharmaceutical interventions have become increasingly recognized in the management of motor and NMS. In this review, the efficacy of physical activity, including physiotherapy and occupational therapy, as an intervention in NMS will be assessed. The papers were extracted between the 20th and 22nd of June 2016 from PubMed, Web of Science, Medline, Ovid, SportsDiscuss, and Scopus using the MeSH search terms "Parkinson's," "Parkinson," and "Parkinsonism" in conjunction with "exercise," "physical activity," "physiotherapy," "occupational therapy," "physical therapy," "rehabilitation," "dance," and "martial arts." Twenty studies matched inclusion criteria of having 10 or more participants with diagnosed idiopathic PD participating in the intervention as well as having to evaluate the effects of physical activity on NMS in PD as controlled, randomized intervention studies. The outcomes of interest were NMS, including depression, cognition, fatigue, apathy, anxiety, and sleep. Risk of bias in the studies was evaluated using the Cochrane Collaboration's tool for assessing risk of bias. Comparability of the various intervention methods, however, was challenging due to demographic variability and methodological differences. Nevertheless, physical activity can positively impact the global NMS burden including depression, apathy, fatigue, day time sleepiness, sleep, and cognition, thus supporting its therapeutic potential in neurodegenerative conditions such as PD. It is recommended that further adequately powered studies are conducted to assess the therapeutic role of physical activity on both motor and non-motor aspects of PD. These studies should be optimally designed to assess non-motor elements of disease using instruments validated in PD.

The Pathophysiology of Fatigue in Parkinson's Disease and its Pragmatic Management

BACKGROUND

Fatigue is 1 of the most common and most disabling symptoms among patients with Parkinson's disease (PD) and has a significant impact on their quality of life. Yet the pathophysiology of fatigue is poorly understood, while its treatment is "limited to an empirical approach based on plausible hypotheses."

METHODS

PubMed was searched for articles with the key words "Parkinson's disease" or "parkinsonism" and "fatigue" that were published by or before August 2015. The analysis of articles, which were selected on subjective grounds, was used to review the current knowledge of pathophysiology and treatment outcomes in studies focused on fatigue in PD.

CONCLUSIONS

Clinical and experimental findings support the view that fatigue is a primary manifestation of PD. The main hypothesized pathophysiological mechanisms include abnormal basal ganglia (BG)-cortical mechanisms, particularly frontal loops, and an imbalance between neurotransmitters (e.g., dopamine [DA] and serotonin), along with an altered hypothalamus-pituitary-adrenal axis, neuroinflammation, cardiac sympathetic denervation, etc. Pragmatic treatment of fatigue in patients with PD includes various pharmacological (dopaminergic and psychostimulant drugs, antidepressants) and nonpharmacological strategies, although current knowledge suffers from insufficient evidence to support the use of any drug or nondrug therapy.

Effects of a Nordic Walking program on motor and non-motor symptoms, functional performance and body composition in patients with Parkinson's disease

BACKGROUND

Several studies have clearly shown that physical exercise can reduce the progression of motor symptoms in Parkinson's Disease (PD). However, little is known about the effects of a Nordic Walking (NW) program in PD patients.

OBJECTIVE

To determine the effects of a NW program on motor and non-motor symptoms, functional performances and body composition in PD patients.

METHODS

Twenty PD patients (16M, 4F, 67.3±7.8 years) were enrolled and randomly assigned to NW group (NWg, n = 10) and Control group (Cg, n = 10). The training consisted in 2 sessions per week for 12 weeks. Training effects were assessed by functional and instrumental tests and motor and non-motor symptoms were assessed by UPDRS-III, Hoehn and Yahr scale, PD Fatigue Scale, Beck Depression Inventory-II, Starkstein Apathy Scale, and Non-Motor Symptoms Scale.

RESULTS

Significant changes in resting HR, in walked distance (p <  0.05), and in lower limbs muscles strength (p <  0.005) were observed in NWg. Both balance abilities and safety with mobility were increased (p <  0.005). Significant variations in some circumferences and body composition were registered. Finally, a significant improvement in motor and non-motor symptoms was detected: UPDRS-III, HY scale, PFS-16, BDI-II, SAS, NMSS.

CONCLUSIONS

A tailored exercise program including NW proved to be an effective way to improve daily activities and both motor and non-motor symptoms in PD patients.

Interventions for fatigue in Parkinson's disease

BACKGROUND

Factors contributing to subjective fatigue in people with idiopathic Parkinson's disease (PD) are not well known. This makes it difficult to manage fatigue effectively in PD.

OBJECTIVES

To evaluate the effects of pharmacological and non-pharmacological interventions, compared to an inactive control intervention, on subjective fatigue in people with PD.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); MEDLINE (via PubMed); Ovid EMBASE; EBSCO CINAHL; Ovid PsycINFO; PEDro; and the WHO International Clinical Trials Registry Platform Search Portal up to April 2015. References of included studies and identified review articles were screened for additional studies. There were no restrictions based on language, date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that report on subjective fatigue in people with PD.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, data collection and risk of bias assessments.

MAIN RESULTS

Eleven studies were eligible for this systematic review, with a total of 1817 people. Three studies included only people who experienced clinically relevant fatigue (Fatigue Severity Scale score ≥ 4 out of 7 or Multidimensional Fatigue Inventory total score > 48 out of 100), whereas all other studies did not select participants on the basis of experienced fatigue. Nine studies investigated the effects of medication (i.e. levodopa-carbidopa, memantine, rasagiline, caffeine, methylphenidate, modafinil or doxepin) on subjective fatigue. All studies were placebo controlled. There was insufficient evidence to determine the effect of doxepin on the impact of fatigue on activities in daily life (ADL) or fatigue severity (one study, N = 12, standardised mean difference (SMD) = -1.50, 95% confidence interval (CI) -2.84 to -0.15; low quality evidence). We found high quality evidence that rasagiline reduced or slowed down the progression of physical aspects of fatigue (one study, N = 1176, SMD = -0.27, 95% CI -0.39 to -0.16, I(2) = 0%). None of the other pharmacological interventions affected subjective fatigue in PD. With regard to adverse effects, only levodopa-carbidopa showed an increase for the risk of nausea (one study, N = 361, risk ratio (RR) = 1.85, 95% CI 1.05 to 3.27; high quality evidence). Two studies investigated the effect of exercise on fatigue compared with usual care. We found low quality evidence for the effect of exercise on reducing the impact of fatigue on ADL or fatigue severity (two studies, N = 57, SMD = -0.45, 95% CI -1.21 to 0.32, I(2) = 44%).

AUTHORS' CONCLUSIONS

Based on the current evidence, no clear recommendations for the treatment of subjective fatigue in PD can be provided. Doxepin may reduce the impact of fatigue on ADL and fatigue severity; however, this finding has to be confirmed in high quality studies. Rasagiline may be effective in reducing levels of physical fatigue in PD. No evidence was found for the effectiveness of levodopa-carbidopa, memantine, caffeine, methylphenidate, modafinil or exercise. Studies are needed to investigate the effect of exercise intensity on exercise capacity and subjective fatigue. Future studies should focus on interventions that address the maladaptive behavioural or cognitive aspects of fatigue in people with PD. Characteristics, such as severity and nature of perceived fatigue and underlying mood disorders should be considered to identify responders and non-responders when studying interventions for fatigue. The development of a core-set of self-report fatigue questionnaires with established responsiveness and known minimal important difference values will facilitate the interpretation of change in fatigue scores.

Interventions for fatigue in Parkinson's disease: A systematic review and meta-analysis

The authors sought to review the efficacy of interventions for fatigue in Parkinson's disease. A search was conducted of PubMed, Cinahl, Psychinfo, EMBASE, and Web of Knowledge up to November 2013. Methodological quality was assessed using the PEDro scale. For meta-analyses, studies were weighted on variance. Effect sizes were calculated with 95% confidence interval (CI); overall effect was presented by means of a Z-score; heterogeneity was investigated using the I(2) . Fourteen articles (n = 1,890) investigating drugs and behavioral therapy were eligible. Ten studies demonstrated excellent, three good, and one fair methodological quality. Three articles (investigating amphetamines) were appropriate for meta-analysis, which was performed according to scales used: Multidimensional Fatigue Inventory: mean difference, -6.13 (95%CI: -14.63-2.37, Z = 1.41, P = 0.16; I(2) = 0); Fatigue Severity Scale: mean difference, -4.00 (95%CI: -8.72-0.72, Z = 1.66, P = 0.10; I(2) = 0). Currently insufficient evidence exists to support the treatment of fatigue in PD with any drug or nondrug treatment. Further study is required.

Physical activity and neuropsychiatric symptoms of Parkinson disease

Neuropsychiatric symptoms of Parkinson disease (PD) such as fatigue, depression, and apathy are common and detract from quality of life. There is little published on the impact of physical activity on the neuropsychiatric symptoms of PD. A convenience sample of 45 patients with PD (mean age = 66.1 years; 33% female) completed questionnaires on physical activity, neuropsychiatric symptoms, and specific exercise preferences. Covarying for age and gender, higher levels of physical activity were associated with significantly less fatigue, as well as a trend for less apathy and depression and greater positive affect. Exercise preferences included moderate intensity (73%), at home (56%), in the morning (73%), scheduled (69%), options for varied activities (73%), and preference for both structured/supervised (50%), and unsupervised/self-paced (50%) programs. Preferred activities included the use of aerobic exercise equipment, resistance training, and yoga. Developing and tailoring exercise programs that incorporate specific preferences may result in more effective interventions for patients with PD.

Assessing and managing depression and fatigue in motor neuron disease

SUMMARY This review evaluates strategies for assessing and treating depression and fatigue for patients diagnosed with motor neuron disease. A summary is given of questionnaire, interview and laboratory methods of assessment, including disease-specific techniques. The unique physical demands of the disease may preclude accurate measurement using generic questionnaire measures and disease-validated measures should be used, where available. There is an urgent need to develop psychological therapies for depression that can cater for the needs of motor neuron disease patients and their carers. Currently, no evidence-based treatment exists for fatigue and further work is warranted to systematically evaluate current evidence and develop novel treatments for this burdensome symptom.