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Espay AJ, Stocchi F, Pahwa R, Albanese A, Ellenbogen A, Ferreira JJ, Giladi N, Gurevich T, Hassin-Baer S, Hernandez-Vara J, Isaacson SH, Kieburtz K, LeWitt PA, Lopez-Manzanares L, Olanow CW, Poewe W, Sarva H, Yardeni T, Adar L, Salin L, Lopes N, Sasson N, Case R, Rascol O. Safety and efficacy of continuous subcutaneous levodopa-carbidopa infusion (ND0612) for Parkinson's disease with motor fluctuations (BouNDless): a phase 3, randomised, double-blind, double-dummy, multicentre trial. Lancet Neurol 2024; 23:465-476. [PMID: 38499015 DOI: 10.1016/s1474-4422(24)00052-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/18/2024] [Accepted: 01/30/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Conventional oral levodopa therapy for the treatment of Parkinson's disease can be associated with variations in plasma concentrations. Levodopa infusion strategies might provide more consistent drug delivery and fewer motor fluctuations. We aimed to assess the safety and efficacy of a continuous 24 h/day subcutaneous infusion of ND0612 (a levodopa-carbidopa solution) compared with oral immediate-release levodopa-carbidopa for the treatment of motor fluctuations in people with Parkinson's disease. METHODS We conducted a phase 3, randomised, double-blind, double-dummy, active-controlled, multicentre trial at 117 academic and community neurology sites in 16 countries, including in Europe, Israel, and the USA. Eligible participants were men and women aged 30 years or older with a diagnosis of Parkinson's disease (Hoehn and Yahr stage ≤3 in the on state) who experienced at least 2·5 h/day of off time. Participants underwent an open-label run-in phase (<12 weeks), during which time optimal regimens were established for both oral immediate-release levodopa-carbidopa and for 24 h/day subcutaneous ND0612 infusion (levodopa-carbidopa 60·0/7·5 mg/mL), with supplemental oral levodopa-carbidopa if needed. Participants were then randomly assigned (1:1) to 12 weeks of double-blind treatment with their optimised regimen of either subcutaneous ND0612 or oral levodopa-carbidopa, with matching oral or subcutaneous placebo given as required to maintain blinding. Randomisation was done via an interactive web response system, stratified by region, using a permuted block schedule. Participants, study partners, treating investigators, study site personnel, and the sponsor were masked to treatment group allocation. The primary efficacy endpoint was the change from baseline (ie, time of randomisation, when all patients were receiving an optimised open-label ND0612 regimen) to end of the double-blind phase in total daily on time without troublesome dyskinesia, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, NCT04006210, and is complete. FINDINGS Between Sept 30, 2019, and April 8, 2022, 381 participants were enrolled, of whom 259 (68%) were randomly assigned, 128 (49%) to subcutaneous ND0612 and 131 (51%) to oral levodopa-carbidopa. 243 (94%) participants completed the study. Treatment with subcutaneous ND0612 provided an additional 1·72 h (95% CI 1·08 to 2·36) of on time without troublesome dyskinesia compared with oral levodopa-carbidopa (change from baseline of -0·48 h [-0·94 to -0·02] with subcutaneous ND0612 vs -2·20 h [-2·65 to -1·74] with oral levodopa-carbidopa; p<0·0001). Significant treatment differences favouring subcutaneous ND0612 were also found in the first four of nine prespecified hierarchical outcomes of daily off time (-1·40 h [95% CI -1·99 to -0·80]), Movement Disorders Society-Unified Parkinson's Disease Rating Scale part II scores (-3·05 [-4·28 to -1·81]), Patients Global Impression of Change (odds ratio [OR] 5·31 [2·67 to 10·58]), and Clinical Global Impression of Improvement (OR 7·23 [3·57 to 14·64]). Hierarchical testing ended after the fourth secondary endpoint. Adverse events were reported by 287 (89%) of 322 participants during open-label ND0612 optimisation, and by 103 (80%) of 128 in the ND0612 group and 97 (74%) of 131 in the oral levodopa-carbidopa group during the double-blind phase. The most common adverse events were infusion-site reactions (266 [83%] participants during open-label ND0612, and 73 [57%] in the ND0612 group vs 56 [43%] in the oral levodopa-carbidopa group during the double-blind phase), most of which were mild. Serious adverse events in four participants in the ND0612 group were related to study treatment (infusion-site cellulitis [n=2], infusion-site abscess and infusion-site ulcer [n=1]; and paraesthesia and peripheral sensorimotor neuropathy [n=1]). One participant in the ND0612 group died during the double-blind phase, but the death was not related to study treatment (fall leading to traumatic brain injury). INTERPRETATION Results of this phase 3 study showed that subcutaneous ND0612 used in combination with oral immediate-release levodopa-carbidopa increased on time without troublesome dyskinesia and reduced off time, with a favourable benefit-risk profile. ND0612 might offer a safe and efficacious subcutaneous levodopa infusion approach to managing motor fluctuations in people with Parkinson's disease. The ongoing open-label extension phase will provide further information on the long-term efficacy and safety of treatment. FUNDING NeuroDerm.
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Affiliation(s)
- Alberto J Espay
- James J and Joan A Gardner Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, OH, USA.
| | - Fabrizio Stocchi
- Department of Neurology, University San Raffaele Roma and Institute for Research and Medical Care IRCCS San Raffaele, Rome, Italy
| | - Rajesh Pahwa
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Alberto Albanese
- Department of Neurology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Aaron Ellenbogen
- Michigan Institute for Neurological Disorders, Farmington Hills, MI, USA
| | - Joaquim J Ferreira
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal; Campus Neurológico Sénior, Torres Vedras, Portugal
| | - Nir Giladi
- Brain Institute, Tel Aviv Medical Center, Faculty of Medicine, Sagol School of Neurosciences, Tel Aviv University, Tel Aviv, Israel
| | - Tanya Gurevich
- Movement Disorders Unit, Neurological Institute, Tel Aviv Medical Center, Faculty of Medicine, Sagol School of Neurosciences, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Hassin-Baer
- Movement Disorders Institute, Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jorge Hernandez-Vara
- Neurology Department and Neurodegenerative Disorders Research Group, Vall D'Hebron Hospital, Barcelona, Spain; Hospital Universitari Vall D'Hebron, Barcelona, Spain
| | - Stuart H Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, Boca Raton, FL, USA
| | | | - Peter A LeWitt
- Department of Neurology, Wayne State University School of Medicine, Detroit, MI, USA; Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | | | - C Warren Olanow
- Clintrex Research Corp, Sarasota, FL, USA; Department of Neurology, Mount Sinai School of Medicine, New York, NY, USA
| | - Werner Poewe
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | | | | | | | | | | | | | | | - Olivier Rascol
- University of Toulouse 3, University Hospital of Toulouse, INSERM, Clinical Investigation Center CIC1436, Department of Neurosciences and Department of Clinical Pharmacology, Toulouse, France; NS-Park/FCRIN Network, Toulouse, France.
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Schröter N, Sajonz BEA, Jost WH, Rijntjes M, Coenen VA, Groppa S. Advanced therapies in Parkinson's disease: an individualized approach to their indication. J Neural Transm (Vienna) 2024:10.1007/s00702-024-02773-3. [PMID: 38613674 DOI: 10.1007/s00702-024-02773-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 03/25/2024] [Indexed: 04/15/2024]
Abstract
Device aided therapies (DAT) comprising the intrajejunal administration of levodopa/carbidopa intestinal gel (LCIG) and levodopa/carbidopa/entacapone intestinal gel (LECIG), the continuous subcutaneous application of foslevodopa/foscarbidopa or apomorphine infusion (CSAI) and deep brain stimulation (DBS) are used to treat Parkinson's disease with insufficient symptom alleviation under intensified pharmacotherapy. These DAT significantly differ in their efficacy profiles, indication, invasiveness, contraindications, and potential side effects. Usually, the evaluation of all these procedures is conducted simultaneously at the same point in time. However, as disease progression and symptom burden is extremely heterogeneous, clinical experience shows that patients reach the individual milestones for a certain therapy at different points in their disease course. Therefore, advocating for an individualized therapy evaluation for each DAT, requiring an ongoing evaluation. This necessitates that, during each consultation, the current symptomatology should be analyzed, and the potential suitability for a DAT be assessed. This work represents a critical interdisciplinary appraisal of these therapies in terms of their individual profiles and compares these DAT regarding contraindications, periprocedural considerations as well as their efficacy regarding motor- and non-motor deficits, supporting a personalized approach.
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Affiliation(s)
- Nils Schröter
- Department of Neurology and Clinical Neuroscience, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Bastian E A Sajonz
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Michel Rijntjes
- Department of Neurology and Clinical Neuroscience, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center of Deep Brain Stimulation, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sergiu Groppa
- Section of Movement Disorders and Neurostimulation, Department of Neurology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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Smilowska K, Pietrzykowski T, Chaudhuri KR, Bloem BR, van Wamelen DJ. Accessibility of Device-Aided Therapies for Persons With Parkinson's Disease in Poland. J Mov Disord 2024; 17:208-212. [PMID: 37980901 PMCID: PMC11082617 DOI: 10.14802/jmd.23172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/13/2023] [Accepted: 11/17/2023] [Indexed: 11/21/2023] Open
Abstract
OBJECTIVE Access to care for people with Parkinson's disease (PD), particularly to device-aided therapies (DAT), is not equally distributed. The objective was to analyze accessibility to DAT (deep brain stimulation, intraduodenal levodopa pump therapy, and apomorphine pump therapy) in Poland. METHODS We analyzed the distribution of DAT use in Poland by determining the number of persons with PD receiving one of the three DATs during 2015-2021. RESULTS In 2021, the number of persons receiving DAT in Poland was 0.56% of the total PD population, increasing from 0.21% in 2015. Overall, deep brain stimulation was the preferred DAT in Poland, but strong regional differences in the use of the other DATs were observed. Accessibility to DAT was negatively associated with average annual income (p < 0.001). CONCLUSION Access to DAT for persons with PD in Poland is still limited, and strong regional differences in accessibility were observed, although its general increase over the last decade is encouraging.
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Affiliation(s)
- Katarzyna Smilowska
- Department of Neurology, 5th Regional Hospital, Sosnowiec, Poland
- Radboud University Medical Centre; Donders institute for Brain, Cognition and Behaviour; Department of Neurology; Centre of Expertise for Parkinson & Movement Disorders; Nijmegen, The Netherlands
| | - Tomasz Pietrzykowski
- Research Centre for Public Policy and Regulatory Governance, Faculty of Law and Administration, University of Silesia in Katowice, Katowice, Poland
| | - K. Ray Chaudhuri
- King’s College London, Institute of Psychiatry, Psychology & Neuroscience, Department of Basic and Clinical Neuroscience, London, UK
- Parkinson’s Foundation Center of Excellence, King’s College Hospital, Denmark Hill, London, UK
| | - Bastiaan R. Bloem
- Radboud University Medical Centre; Donders institute for Brain, Cognition and Behaviour; Department of Neurology; Centre of Expertise for Parkinson & Movement Disorders; Nijmegen, The Netherlands
| | - Daniel J. van Wamelen
- Radboud University Medical Centre; Donders institute for Brain, Cognition and Behaviour; Department of Neurology; Centre of Expertise for Parkinson & Movement Disorders; Nijmegen, The Netherlands
- Parkinson’s Foundation Center of Excellence, King’s College Hospital, Denmark Hill, London, UK
- King’s College London, Institute of Psychiatry, Psychology & Neuroscience, Department of Neuroimaging, London, UK
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Sasidharan A, Bagepally BS, Kumar SS. Cost Effectiveness of Deep Brain Stimulation for Parkinson's Disease: A Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:181-192. [PMID: 38015368 DOI: 10.1007/s40258-023-00848-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND OBJECTIVE Deep brain stimulation (DBS) is an established treatment for Parkinson's disease (PD) in patients with advanced motor symptoms with an inadequate response to pharmacotherapies. Despite its effectiveness, the cost effectiveness of DBS remains a subject of debate. This systematic review aims to update and synthesize evidence on the cost effectiveness of DBS for PD. METHODS To identify full economic evaluations that compared the cost effectiveness of DBS with other best medical treatments, a comprehensive search was conducted of the PubMed, Embase, Scopus, and Tufts Cost-Effective Analysis registry databases. The selected papers were systematically reviewed, and the results were summarized. For the quality appraisal, we used the modified economic evaluations bias checklist. The review protocol was a priori registered with PROSPERO, CRD42022345508. RESULTS Sixteen identified cost-utility analyses that reported 19 comparisons on the use of DBS for PD were systematically reviewed. The studies were primarily conducted in high-income countries and employed Markov models. The costs considered were direct costs: surgical expenses, calibration, pulse generator replacement, and annual drug expenses. The majority of studies used country-specific thresholds. Fourteen comparisons from 12 studies reported on the cost effectiveness of DBS compared to best medical treatments. Eleven comparisons reported DBS as cost effective based on incremental cost-utility ratio results. CONCLUSIONS The cost effectiveness of DBS for PD varies by time horizon, costs considered, threshold utilized, and stage of PD progression. Standardizing approaches and comparing DBS with other treatments are needed for future research on effective PD management.
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Affiliation(s)
- Akhil Sasidharan
- ICMR-National Institute of Epidemiology, Health Technology Assessment Resource Centre, ICMR-NIE, R-127, Tamil Nadu Housing Board, Phase I and II, Ayapakkam, Chennai, 600077, India
| | - Bhavani Shankara Bagepally
- ICMR-National Institute of Epidemiology, Health Technology Assessment Resource Centre, ICMR-NIE, R-127, Tamil Nadu Housing Board, Phase I and II, Ayapakkam, Chennai, 600077, India.
| | - S Sajith Kumar
- ICMR-National Institute of Epidemiology, Health Technology Assessment Resource Centre, ICMR-NIE, R-127, Tamil Nadu Housing Board, Phase I and II, Ayapakkam, Chennai, 600077, India
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Ueno T, Haga R, Arai A, Tomiyama M. Quality of life assessment when considering the introduction of device-assisted therapies in advanced Parkinson's disease: A retrospective observational cross-sectional study. J Neurol Sci 2024; 457:122890. [PMID: 38232467 DOI: 10.1016/j.jns.2024.122890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/05/2023] [Accepted: 01/11/2024] [Indexed: 01/19/2024]
Abstract
INTRODUCTION Device-aided therapy (DAT) is an established treatment for improving the quality of life (QOL) in individuals with advanced Parkinson's disease (APD). Criteria for starting DAT, including motor and non-motor symptoms, have been proposed. However, it remains unclear whether QOL differences among patients with APD influence DAT introduction. Therefore, we aimed to investigate QOL differences between patients with and without DAT introduction. METHODS This retrospective observational cross-sectional study included 245 patients with PD who were followed up between January 1, 2020, and June 30, 2022. We defined cases that underwent DAT introduction after evaluation as "planned-DAT" and those that did not as "not-planned-DAT." We performed between-group comparisons of the PD questionnaire-39 (PDQ-39) summary index (SI) in patients with APD who met the 5-2-1 criteria (≥5 times the oral levodopa dose/day, ≥2 h of "off" symptoms/day, and ≥ 1 h of troublesome dyskinesia/day). RESULTS Seventy-nine patients met the inclusion criteria for APD (median age: 68 [61.0-73.0] years; 62.8% [N = 52] women). The PDQ-39 SI scores were higher in the planned-DAT group (N = 12) than in the not-planned-DAT group (N = 67) (29.2 [22.1-33.6] vs. 19.0 [10.3-49.6] points, P < 0.05). After propensity-score matching according to age and sex, the PDQ-39 SI scores remained higher in the planned-DAT (N = 9) than in the not-planned-DAT group (N = 18) (40.0 [25.4-60.0] vs. 18.5 [7.9-46.8] points, P < 0.05). CONCLUSIONS Our results suggest that QOL assessment using PDQ-39 can be used to identify patients eligible for DAT.
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Affiliation(s)
- Tatsuya Ueno
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan.
| | - Rie Haga
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Akira Arai
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Masahiko Tomiyama
- Department of Neurology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Bywall KS, Drevin J, Groothuis-Oudshoorn C, Veldwijk J, Nyholm D, Widner H, van Vliet T, Jiltsova E, Hansson M, Johansson JV. Patients accept therapy using embryonic stem cells for Parkinson's disease: a discrete choice experiment. BMC Med Ethics 2023; 24:83. [PMID: 37828462 PMCID: PMC10571417 DOI: 10.1186/s12910-023-00966-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/03/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND New disease-modifying ways to treat Parkinson's disease (PD) may soon become a reality with intracerebral transplantation of cell products produced from human embryonic stem cells (hESCs). The aim of this study was to assess what factors influence preferences of patients with PD regarding stem-cell based therapies to treat PD in the future. METHODS Patients with PD were invited to complete a web-based discrete choice experiment to assess the importance of the following attributes: (i) type of treatment, (ii) aim of treatment, (iii) available knowledge of the different types of treatments, (iv) effect on symptoms, and (v) risk for severe side effects. Latent class conditional logistic regression models were used to determine preference estimates and heterogeneity in respondents' preferences. RESULTS A substantial difference in respondents' preferences was observed in three latent preference patterns (classes). "Effect on symptoms" was the most important attribute in class 1, closely followed by "type of treatment," with medications as preferred to other treatment alternatives. Effect on symptoms was also the most important attribute in class 2, with treatment with hESCs preferred over other treatment alternatives. Likewise for class 3, that mainly focused on "type of treatment" in the decision-making. Respondents' class membership was influenced by their experience in treatment, side effects, and advanced treatment therapy as well as religious beliefs. CONCLUSIONS Most of the respondents would accept a treatment with products emanating from hESCs, regardless of views on the moral status of embryos. Preferences of patients with PD may provide guidance in clinical decision-making regarding treatments deriving from stem cells.
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Affiliation(s)
- Karin Schölin Bywall
- School of Health, Care and Social Welfare, Division of Health and Welfare Technology, Mälardalen University, Västerås, Sweden.
- Centre for Research Ethics and Bioethics, Uppsala University, Box 564, Uppsala, SE-751 22, Sweden.
| | - Jennifer Drevin
- Centre for Research Ethics and Bioethics, Uppsala University, Box 564, Uppsala, SE-751 22, Sweden
| | - Catharina Groothuis-Oudshoorn
- Health Technology and Services Research (HTSR), Faculty of Behavioural Management and Social Sciences, University of Twente, Enschede, The Netherlands
| | - Jorien Veldwijk
- Centre for Research Ethics and Bioethics, Uppsala University, Box 564, Uppsala, SE-751 22, Sweden
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus Choice Modelling Centre, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Dag Nyholm
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, Uppsala, SE-751 85, Sweden
| | - Hakan Widner
- Department of Neurology, Skåne University Hospital, Lund, SE-221 85, Sweden
| | - Trinette van Vliet
- Department of Neurology, Skåne University Hospital, Lund, SE-221 85, Sweden
| | - Elena Jiltsova
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, Uppsala, SE-751 85, Sweden
| | - Mats Hansson
- Centre for Research Ethics and Bioethics, Uppsala University, Box 564, Uppsala, SE-751 22, Sweden
| | - Jennifer Viberg Johansson
- Centre for Research Ethics and Bioethics, Uppsala University, Box 564, Uppsala, SE-751 22, Sweden
- The Institute for Future Studies, Holländargatan 13, 111 36, Stockholm, Sweden
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Chhetri JK, Mei S, Wang C, Chan P. New horizons in Parkinson's disease in older populations. Age Ageing 2023; 52:afad186. [PMID: 37847793 DOI: 10.1093/ageing/afad186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 07/07/2023] [Indexed: 10/19/2023] Open
Abstract
Parkinson's disease (PD) is the second most common neurodegenerative disorder after Alzheimer's disease. Ageing is considered to be the greatest risk factor for PD, with a complex interplay between genetics and the environment. With population ageing, the prevalence of PD is expected to escalate worldwide; thus, it is of utmost importance to reduce the burden of PD. To date, there are no therapies to cure the disease, and current treatment strategies focus on the management of symptoms. Older adults often have multiple chronic diseases and geriatric syndromes, which further complicates the management of PD. Healthcare systems and care models necessary to address the broad needs of older PD patients are largely unavailable. In this New Horizon article, we discuss various aspects of PD from an ageing perspective, including disease management. We highlight recent advancements in PD therapies and discuss new care models with the potential to improve patient's quality of life.
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Affiliation(s)
- Jagadish K Chhetri
- National Clinical Research Center for Geriatric Diseases, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Shanshan Mei
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Chaodong Wang
- National Clinical Research Center for Geriatric Diseases, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Piu Chan
- National Clinical Research Center for Geriatric Diseases, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
- Key Laboratory for Neurodegenerative Disease of the Ministry of Education, Beijing Key Laboratory for Parkinson's Disease, Parkinson Disease Center of Beijing Institute for Brain Disorders, Beijing, China
- Clinical Center for Parkinson's Disease, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
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Kukkle PL, Garg D, Merello M. Continuous Subcutaneous Infusion Delivery of Apomorphine in Parkinson's Disease: A Systematic Review. Mov Disord Clin Pract 2023; 10:1253-1267. [PMID: 37772305 PMCID: PMC10525070 DOI: 10.1002/mdc3.13810] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 05/18/2023] [Accepted: 05/28/2023] [Indexed: 09/30/2023] Open
Abstract
Background Continuous subcutaneous apomorphine infusion (CSAI) is one of the advanced therapies for Parkinson's disease (PD). Methods A systematic review of all published articles in English on CSAI for PD till January 30, 2022 was conducted. Results A total of 82 articles met the search criteria. Publications included retrospective or prospective open-label observational studies, with a limited number of randomized control trials (RCT). Publications were highly heterogeneous and focused on different aspects of CSAI and included clinical audits, effects on cognition/behavior, axial symptoms, nocturnal issues, adverse events/reasons for discontinuation and comparison with other continuous dopaminergic therapies. CSAI was used in patients who presented severe motor fluctuations not resolved by oral therapy, poor candidates for deep brain stimulation (DBS) due to cognitive/behavioral issues or in those with DBS weaning effect. Recent studies have also shown that CSAI was useful for nocturnal usage in advanced PD, in addition to daytime utilization. Adverse effects were common and include skin lesions, sedation and nausea. Pump management difficulties and patient decisions were common reasons for therapy dropout, predominantly during the initial stages of the CSAI. Conclusion There is consistent agreement on the benefits of CSAI in reducing OFF periods and improving ON periods without troublesome dyskinesia and specific motor and non-motor symptoms. Although there is a paucity of RCTs, current data from almost 30 years of use suggests CSAI to be beneficial in advanced cases of PD.
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Affiliation(s)
- Prashanth Lingappa Kukkle
- Center for Parkinson's Disease and Movement DisordersManipal HospitalBangaloreIndia
- Parkinson's Disease and Movement Disorders ClinicBangaloreIndia
| | - Divyani Garg
- Department of NeurologyAll India Institute of Medical SciencesNew DelhiIndia
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Current Treatments and New, Tentative Therapies for Parkinson’s Disease. Pharmaceutics 2023; 15:pharmaceutics15030770. [PMID: 36986631 PMCID: PMC10051786 DOI: 10.3390/pharmaceutics15030770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/02/2023] Open
Abstract
Parkinson’s disease (PD) is a neurodegenerative pathology, the origin of which is associated with the death of neuronal cells involved in the production of dopamine. The prevalence of PD has increased exponentially. The aim of this review was to describe the novel treatments for PD that are currently under investigation and study and the possible therapeutic targets. The pathophysiology of this disease is based on the formation of alpha-synuclein folds that generate Lewy bodies, which are cytotoxic and reduce dopamine levels. Most pharmacological treatments for PD target alpha-synuclein to reduce the symptoms. These include treatments aimed at reducing the accumulation of alpha-synuclein (epigallocatechin), reducing its clearance via immunotherapy, inhibiting LRRK2, and upregulating cerebrosidase (ambroxol). Parkinson’s disease continues to be a pathology of unknown origin that generates a significant social cost for the patients who suffer from it. Although there is still no definitive cure for this disease at present, there are numerous treatments available aimed at reducing the symptomatology of PD in addition to other therapeutic alternatives that are still under investigation. However, the therapeutic approach to this pathology should include a combination of pharmacological and non-pharmacological strategies to maximise outcomes and improve symptomatological control in these patients. It is therefore necessary to delve deeper into the pathophysiology of the disease in order to improve these treatments and therefore the quality of life of the patients.
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Levodopa-carbidopa intestinal gel in advanced Parkinson's disease: long-term results from COSMOS. J Neurol 2023; 270:2765-2775. [PMID: 36802031 PMCID: PMC10130122 DOI: 10.1007/s00415-023-11615-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/17/2023] [Accepted: 02/07/2023] [Indexed: 02/21/2023]
Abstract
BACKGROUND While immediate benefits of levodopa-carbidopa intestinal gel (LCIG) are evident in patients with Parkinson's disease (PD), long-term LCIG effects require further study. OBJECTIVES We explored long-term LCIG on motor symptoms, nonmotor symptoms (NMS), and LCIG treatment settings in patients with advanced PD (APD). METHODS Data were obtained (medical records and patient visit) from COSMOS, a multinational, retrospective, cross-sectional post-marketing observational study in patients with APD. Patients were stratified into 5 groups based on LCIG treatment duration at the patient visit, from 1-2 to > 5 years LCIG. Between-group differences were assessed for changes from baseline in LCIG settings, motor symptoms, NMS, add-on medications, and safety. RESULTS Out of 387 patients, the number of patients per LCIG group was: > 1- ≤ 2 years LCIG (n = 156); > 2- ≤ 3 years LCIG (n = 80); > 3- ≤ 4 years LCIG (n = 61); > 4- ≤ 5 years LCIG (n = 30); > 5 years LCIG (n = 60). Baseline values were similar; data reported are changes from the baseline. There were reductions in "off" time, dyskinesia duration, and severity across LCIG groups. Prevalence, severity, and frequency of many individual motor symptoms and some NMS were reduced amongst all LCIG groups, with few differences between groups. Doses for LCIG, LEDD and LEDD for add-on medications were similar across groups both at LCIG initiation and patient visit. Adverse events were similar across all LCIG groups and consistent with the established safety profile of LCIG. CONCLUSIONS LCIG may provide sustained, long-term symptom control, while potentially avoiding increases in add-on medication dosages. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03362879. Number and date: P16-831, November 30, 2017.
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Thaler A, Alcalay RN. Diagnosis and Medical Management of Parkinson Disease. Continuum (Minneap Minn) 2022; 28:1281-1300. [DOI: 10.1212/con.0000000000001152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Rajan R, Garg K, Srivastava AK, Singh M. Device-Assisted and Neuromodulatory Therapies for Parkinson's Disease: A Network Meta-Analysis. Mov Disord 2022; 37:1785-1797. [PMID: 35866929 DOI: 10.1002/mds.29160] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/28/2022] [Accepted: 06/28/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Device-assisted and neuromodulatory therapies are the standard of care for Parkinson's disease (PD) with disabling motor complications. We aimed to compare and rank the currently available advanced therapies for PD on patient relevant outcomes. METHODS We searched various databases for randomized controlled trials that studied subthalamic nucleus deep brain stimulation (STN-DBS), globus pallidus interna (GPi) DBS, pallidotomy, subthalamotomy, continuous subcutaneous apomorphine infusion (CSAI), or intrajejunal levodopa infusion (IJLI), in patients with PD and motor complications. Primary outcome was the quality of life (QOL) at 6 months. Secondary outcomes included Unified Parkinson's Disease Rating Scale III and II, ON time, OFF time, levodopa equivalent daily doses, and adverse events (AE). Data were pooled using a Bayesian network meta-analysis, summarized as mean difference (MD) with 95% credibility intervals (CrI) and visualized in forest plots/league tables. Surface under the cumulative ranking curve plots determined the ranking probability. RESULTS We identified 6745 citations and included 26 trials. STN-DBS (MD, -8.0; 95% CrI, -11, -5.8), GPi-DBS (MD, -7.1; 95% CrI, -11, -2.9), and IJLI (MD, -7.0; 95% CrI, -12, -1.8) led to better QOL than medical therapy alone, without significant differences among them. STN-DBS had the highest probability of being ranked the best treatment for QOL (79.6%), followed by IJLI (63.5%) and GPi-DBS (62.8%). CONCLUSIONS In advanced PD, STN-DBS alleviates more patient and clinician relevant outcomes, followed by GPi-DBS and IJLI. In resource limited settings, unilateral pallidotomy may improve motor symptoms and activities of daily living, although overall QOL may not be improved. © 2022 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Roopa Rajan
- Departments of Neurology, CN Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, CN Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Achal K Srivastava
- Departments of Neurology, CN Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery, CN Centre, All India Institute of Medical Sciences, New Delhi, India
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Hu Y, Gu S, Yuan X, Li H, Yuan C, Ye Q. Traditional Chinese medicine syndrome differentiation and treatment by stages of Parkinson's disease: study protocol for a multicentre, randomized, double-blind, placebo-controlled clinical trial. Chin Med 2022; 17:68. [PMID: 35698234 PMCID: PMC9190110 DOI: 10.1186/s13020-022-00625-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/28/2022] [Indexed: 11/18/2022] Open
Abstract
Background Parkinson’s disease (PD) is a progressive neurodegenerative disease common in aged populations. Classified by Hoehn & Yahr stages, patients are often divided into mild/early stage, moderate/middle stage, and advanced/late stage. With disease progression, PD shows high heterogeneity in each stage. Based on traditional Chinese medicine (TCM) syndrome differentiation theory and our previous works, we found that during the early stage, the main syndrome is Yin deficiency of the liver and kidney; during the moderate stage, the main syndromes are phlegm heat and wind stirring and blood stasis and wind stirring; and during the late stage, the dominant syndromes are deficiency of Yin and Yang and deficiency of Qi and blood. Hence, we proposed a new model of TCM treatment by the stage of PD. Based on Shudi Pingchan formula, an experimental formula of our team, we developed Ziyin Pingchan formula, Jiedu Pingchan formula, and Fuzheng Pingchan formula to treat each stage. This study is designed to evaluate the therapeutic effect of treating Parkinson’s disease by stages using traditional Chinese medicine and to provide an evidence base for forming a standardized scheme of diagnosis and treatment. Methods This study is designed as a multicentre, randomized, double-blind, placebo-controlled clinical trial. Patients will be stratified into 3 subgroups according to Hoehn & Yahr stage; 172, 168, and 72 participants will be required to be in the mild PD, moderate PD, and advanced PD subgroups, respectively, and will be randomized into the treatment or control group at a 1:1 ratio. The mild PD subgroup will receive a 48-week intervention, and the other 2 groups will receive a 24-week intervention. All groups will have a follow-up visit 12 weeks after starting the intervention. The intervention group will receive the Ziyin Pingchan formula, Jiedu Pingchan formula, or Fuzheng Pingchan formula, and the control group will receive the corresponding placebo. The primary outcomes will be the first addition of levodopa for the mild PD subgroup, the duration of the “OFF” period for the moderate PD subgroup, and the Parkinson's Disease Questionnaire (PDQ-39) for the advanced PD subgroup. The secondary outcomes will also be verified by subgroups, including the Unified Parkinson’s Disease Rating Scale (UPDRS), Parkinson’s Disease Sleep Scale-2 (PDSS-2), scales for Outcomes in Parkinson’s Disease—Autonomic (SCOPA-AUT), and the nonmotor symptom scale (NMSS). Expected outcomes To our knowledge, this is the first trial to combine TCM syndrome differentiation with PD clinical stages and put it into clinical practice. The results of this trial will provide clinical evidence for the therapeutic effect of TCM formulas on PD patients of all stages and help build a new TCM treatment by stage model of PD. Trial registration: This trial is registered at the Chinese Clinical Trial Registry (http://www.chictr.org.cn/). Registration number: ChiCTR2200056373, Date: 2022–02-04, version 1.
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Affiliation(s)
- Yuqing Hu
- Encephalopathy Department, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 725, South Wanping Road, Shanghai, China
| | - Sichun Gu
- Encephalopathy Department, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 725, South Wanping Road, Shanghai, China
| | - Xiaolei Yuan
- Encephalopathy Department, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 725, South Wanping Road, Shanghai, China
| | - Hui Li
- Encephalopathy Department, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 725, South Wanping Road, Shanghai, China
| | - Canxing Yuan
- Encephalopathy Department, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 725, South Wanping Road, Shanghai, China
| | - Qing Ye
- Encephalopathy Department, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 725, South Wanping Road, Shanghai, China.
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Ceballos-Baumann A. [Parkinson's Disease - What is New?]. Dtsch Med Wochenschr 2022; 147:337-343. [PMID: 35291040 DOI: 10.1055/a-1646-6321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The prevalence of Parkinson's disease (PD) will double by 2030. PD is no longer regarded as a single disease entity. Monogenetic forms may appear clinically identical to sporadic PD. The corona pandemic has caused a deterioration in a great proportion of patients due to concerns of accessing medical care. During this time, teleconsultations emerged as a helpful service for many PD patients as they can reliably administer parts of the neurological examination remotely. New studies address the ongoing controversy about whether the use of levodopa should be delayed. The conclusion is that physicians should not be afraid of using levodopa to treat patients early in the course of PD. Furthermore, the role of dopamine agonists is changing. Besides their known high rates of edema, somnolence and hallucinations dopamine agonists are associated with the development of impulse control disorders in approx. half of the treated patients. During the last 10 years, only two new substances (safinamide, opicapone) have come onto the market in Germany, both with the indication as add on therapy to levodopa in patients with fluctuations. The use of deep brain stimulation and drug pumps in patients with levodopa effect fluctuations is growing, because at this point in the course of the disease, patients also accept invasive therapies that can prolong and optimize independence. Patients who need levodopa more than 5 times a day and who have severe, disturbing OFF phases (> 2 hours a day) despite optimal non-levodopa-based treatment can consider these options. PD stage and symptom-focused, guideline-based physiotherapy has a positive effect on the course of the disease, everyday performance and quality of life and reduces the risk of falling. Multidisciplinary networks are proving effective in reducing falls and hospital admissions.
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Affiliation(s)
- Andres Ceballos-Baumann
- Abt. für Neurologie und klinische Neurophysiologie mit Parkinson-Fachklinik, Schön Klinik München Schwabing
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Personalizing decision-making for persons with Parkinson's disease: where do we stand and what to improve? J Neurol 2022; 269:3569-3578. [PMID: 35084559 PMCID: PMC9217860 DOI: 10.1007/s00415-022-10969-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/05/2022]
Abstract
Background The large variety in symptoms and treatment effects across different persons with Parkinson’s disease (PD) warrants a personalized approach, ensuring that the best decision is made for each individual. We aimed to further clarify this process of personalized decision-making, from the perspective of medical professionals. Methods We audio-taped 52 consultations with PD patients and their neurologist or PD nurse-specialist, in 6 outpatient clinics. We focused coding of the transcripts on which decisions were made and on if and how decisions were personalized. We subsequently interviewed professionals to elaborate on how and why decisions were personalized, and which decisions would benefit most from a more personalized approach. Results Most decisions were related to medication, referral or lifestyle. Professionals balanced clinical factors, including individual (disease-) characteristics, and non-clinical factors, including patients’ preference, for each type of decision. These factors were often not explicitly discussed with the patient. Professionals experienced difficulties in personalizing decisions, mostly because evidence on the impact of characteristics of an individual patient on the outcome of the decision is unavailable. Categories of decisions for which professionals emphasized the importance of a more personalized perspective include choices not only for medication and advanced treatments, but also for referrals, lifestyle and diagnosis. Conclusions Clinical decision-making is a complex process, influenced by many different factors that differ for each decision and for each individual. In daily practice, it proves difficult to tailor decisions to individual (disease-) characteristics, probably because sufficient evidence on the impact of these individual characteristics on outcomes is lacking.
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Antonini A, Pahwa R, Odin P, Isaacson SH, Merola A, Wang L, Kandukuri PL, Alobaidi A, Yan CH, Bao Y, Zadikoff C, Parra JC, Bergmann L, Chaudhuri KR. Comparative Effectiveness of Device-Aided Therapies on Quality of Life and Off-Time in Advanced Parkinson's Disease: A Systematic Review and Bayesian Network Meta-analysis. CNS Drugs 2022; 36:1269-1283. [PMID: 36414908 PMCID: PMC9712309 DOI: 10.1007/s40263-022-00963-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Research comparing levodopa/carbidopa intestinal gel (LCIG), deep brain stimulation (DBS), and continuous subcutaneous apomorphine infusion (CSAI) for advanced Parkinson's disease (PD) is lacking. This network meta-analysis (NMA) assessed the comparative effectiveness of LCIG, DBS, CSAI and best medical therapy (BMT) in reducing off-time and improving quality of life (QoL) in patients with advanced PD. METHODS A systematic literature review was conducted for randomized controlled trials (RCTs), observational and interventional studies from January 2003 to September 2019. Data extracted at baseline and 6 months were off-time, as reported by diary or Unified Parkinson's Disease Rating Scale Part IV item 39, and QoL, as reported by Parkinson's Disease Questionnaire (PDQ-39/PDQ-8). Bayesian NMA was performed to estimate pooled treatment effect sizes and to rank treatments in order of effectiveness. RESULTS A total of 22 studies fulfilled the inclusion criteria (n = 2063 patients): four RCTs, and 16 single-armed, one 2-armed and one 3-armed prospective studies. Baseline mean age was between 55.5-70.9 years, duration of PD was 9.1-15.3 years, off-time ranged from 5.4 to 8.7 h/day in 9 studies, and PDQ scores ranged from 28.8 to 67.0 in 19 studies. Levodopa/carbidopa intestinal gel and DBS demonstrated significantly greater improvement in off-time and QoL at 6 months compared with CSAI and BMT (p < 0.05). There was no significant difference in the effects of LCIG and DBS, but DBS was ranked first for reduction in off-time, and LCIG was ranked first for improvement in QoL. CONCLUSIONS This NMA found that LCIG and DBS were associated with superior improvement in off-time and PD-related QoL compared with CSAI and BMT at 6 months after treatment initiation. This comparative effectiveness research may assist providers, patients, and caregivers in the selection of the optimal device-aided therapy.
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Affiliation(s)
- Angelo Antonini
- Parkinson and Movement Disorders Unit, Department of Neuroscience, Study Center for Neurodegeneration (CESNE), University of Padova, 35128, Padua, Italy.
| | - Rajesh Pahwa
- Medical Center, University of Kansas, Kansas City, KS USA
| | - Per Odin
- University of Lund, Lund, Sweden
| | | | - Aristide Merola
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Lin Wang
- AbbVie Inc., North Chicago, IL USA ,Johns Hopkins School of Public Health, Baltimore, MD USA
| | | | - Ali Alobaidi
- AbbVie Inc., North Chicago, IL USA ,University of Illinois at Chicago, Chicago, IL USA
| | - Connie H. Yan
- AbbVie Inc., North Chicago, IL USA ,University of Illinois at Chicago, Chicago, IL USA
| | | | | | | | | | - K. Ray Chaudhuri
- King’s College and Parkinson Foundation Centre of Excellence, Kings College Hospital London, London, UK
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Leal-Nascimento AH, da Silva ES, Zanardi APJ, Ivaniski-Mello A, Passos-Monteiro E, Martinez FG, Rodrigo de Carvalho A, Baptista RR, Peyré-Tartaruga LA. Biomechanical responses of Nordic walking in people with Parkinson's disease. Scand J Med Sci Sports 2021; 32:290-297. [PMID: 34780079 DOI: 10.1111/sms.14095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/28/2021] [Accepted: 11/08/2021] [Indexed: 11/27/2022]
Abstract
In healthy adults, Nordic walking (NW) is known to increase the external mechanical energy fluctuations, though the external work is unaltered due to an improved pendulum-like recovery in comparison with free walking (FW). We aimed to compare mechanical, pendulum-like, and spatiotemporal parameters of gait at different speeds with and without NW poles in people with Parkinson's disease and healthy controls. The study included 11 people (aged 65.6 ± 7.0 years) with idiopathic Parkinson's disease, scoring between 1 and 1.5 on the Hoehn and Yahr scale (H&Y), and nine healthy controls (aged 70.0 ± 5.6 years). All the people were experienced Nordic walkers. Walking tests were performed at 1.8 km h-1 and 4.7 km h-1 , on eight 3D force platforms on a walkway. We found greater pendulum-like energy recovery (p < 0.05) in the Parkinson group during NW than in FW, while external mechanical work remained similar (p > 0.05). People with Parkinson's disease showed a major increase in vertical and forward energy fluctuations using poles than in healthy controls. In addition, the Parkinson group showed increased stride frequency and reduced stride length compared to controls in the NW and FW conditions. Our findings partly justify the lower walking economy in Parkinson's disease due to reduced pendulum-like mechanism at commonly used speeds. NW alters gait mechanics similarly in Parkinson group and healthy control, increasing the total mechanical work. Therefore, NW can be a compelling strategy for rehabilitation because of its potential for improving functional mobility, increasing pendulum-like mechanism in Parkinson's disease.
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Affiliation(s)
- Antonio Henrique Leal-Nascimento
- Exercise Research Laboratory, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Federal Institute of Education, Science and Technology of Pará, Abaetetuba, Brazil
| | - Edson Soares da Silva
- Exercise Research Laboratory, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - André Ivaniski-Mello
- Exercise Research Laboratory, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Elren Passos-Monteiro
- Postgraduate in Human Movement Sciences, Faculty of Physical Education, Universidade Federal do Pará, Castanhal, Brazil
| | - Flávia Gomes Martinez
- Exercise Research Laboratory, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Rafael Reimann Baptista
- Physical Activity Research Laboratory, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
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