Patients’ and caregivers’ perspectives: assessing an intensive rehabilitation programme and outcomes in Huntington’s disease

Approach to Posture and Gait in Huntington's Disease

Disturbances of gait occur in all stages of Huntington’s disease (HD) including the premanifest and prodromal stages. Individuals with HD demonstrate the slower speed of gait, shorter stride length, and increased variability of gait parameters as compared to controls; cognitive disturbances in HD often compound these differences. Abnormalities of gait and recurrent falls lead to decreased quality of life for individuals with HD throughout the disease. This scoping review aims to outline the cross-disciplinary approach to gait evaluation in HD and will highlight the utility of objective measures in defining gait abnormalities in this patient population.

A Systematic Review of Rehabilitation for Corticobulbar Symptoms in Adults with Huntington's Disease

Background:

Corticobulbar symptoms have been reported in all stages of Huntington’s disease (HD); aspiration pneumonia associated with swallowing impairment has been identified as the most common cause of death. Whilst recent research has described positive effects of corticobulbar rehabilitation in other neurodegenerative conditions, it is unclear if this is similarly effective in HD. Preliminary evidence in corticospinal rehabilitation has revealed physical therapy and exercise could be beneficial for individuals with HD.

Objective:

This systematic review will explore the literature relative to rehabilitation of corticobulbar symptoms in adults with HD.

Methods:

Two investigators independently searched relevant electronic databases for literature related to corticobulbar rehabilitation in HD, published in English until October 2019. Included studies were critically appraised using the Oxford Centre for Evidence-based Medicine Levels of Evidence, Cochrane Risk of Bias Tool and Scottish Intercollegiate Guidelines Network checklists. Study outcomes included measurements of function, quality of life or neuromuscular physiology.

Results:

Seventy-seven publications were screened with eight studies meeting the inclusion criteria – two randomised control trials and six intervention studies. Validated and objective outcome measures of corticobulbar symptoms were infrequently used. There was a high risk of bias identified in 7/8 studies. The data suggested positive clinical outcomes, no adverse effects and no deterioration observed across longitudinal studies.

Conclusions:

This systematic review documented a lack of high-quality evidence to support the use of rehabilitation to treat corticobulbar symptoms in HD. However, the suggestion of potential positive effects based on available, albeit limited, studies provides justification for further research in this area.

An exploration of physical activity experiences throughout the Huntington's disease journey: supporting development of theoretically underpinned complex interventions

PURPOSE

Huntington's disease is an autosomal dominant neurodegenerative disease. Progressive physical, behavioural and cognitive impairments cause loss of independent function. Physical activity interventions are important components of comprehensive intervention strategies and may help alter the functional decline trajectory. Qualitative research has an important role to play in developing theoretically sound, well-defined physical activity interventions in Huntington's disease.

MATERIALS AND METHODS

Eight focus groups were conducted with people with prodromal to late stage Huntington's disease, caregivers (family members/formal), and healthcare professionals. An analytical coding framework was developed from the data and Levanthal's self-regulation model to assist analysis.

RESULTS AND CONCLUSIONS

Key themes were identified: evolving representations of Huntington's disease and physical activity; varying social environment of the person with Huntington's disease and the impact on physical activity; achieving physical activity participation while coping with the nuances of Huntington's disease. Levanthal's model facilitated understanding of physical activity experiences, however with progression, self-regulation of activities needs to become more collaborative with caregivers. A modified self-regulation model specific to physical activity in Huntington's disease is presented. Using a novel approach to generate new understanding of physical activity across the Huntington's disease lifespan facilitated development of an original and significant theoretical foundation to underpin development of a range of much needed physical activity and exercise interventions in Huntington's disease.Implications for rehabilitationSocial and familial context of individuals with HD is a key consideration for health care professionals supporting physical activity participation.Strategies such as using physical activity as a way of achieving control and adjusting expectations can help people with HD to continue to be active.People with HD adapt physical activity from high level to more functional activities with symptom progression.

Physical Therapy and Exercise Interventions in Huntington's Disease: A Mixed Methods Systematic Review

Background:

A number of studies evaluating physical therapy and exercise interventions in Huntington’s disease have been conducted over the past 15 years. However, an assessment of the quality and strength of the evidence in support of these interventions is lacking.

Objective:

The purpose of this systematic review was to investigate the effectiveness of physical therapy and exercise interventions in people with Huntington’s disease, and to examine the perceptions of patients, families and caregivers of these interventions.

Methods:

This mixed-methods systematic review utilized the Joanna Briggs Institute (JBI) approach and extraction tools to evaluate the literature from January 2003 until May 2016. The review considered interventions that included exercise and physical therapy interventions, and included both quantitative and qualitative outcome measures.

Results:

Twenty (20) studies met the inclusion criteria, including eighteen (18) that had quantitative outcome measures and two (2) that utilized qualitative methods. JBI Levels of evidence for the 18 quantitative studies were as follows: Eight studies were at evidence Level 1, seven were at Level 2, two were at Level 3, and one was at Level 4.

Conclusions:

Our review suggests that there is preliminary support for the benefits of exercise and physical activity in Huntington’s disease in terms of motor function, gait speed, and balance, as well as a range of physical and social benefits identified through patient-reported outcomes. Variability in mode of intervention as well as outcome measures limits the interpretability of these studies, and high-quality studies that incorporate adaptive trial designs for this rare disease are needed.

The role of rehabilitation therapy in Huntington disease

The role of rehabilitation interventions is increasingly considered a key component to effective management of people with Huntington disease (HD). Lifestyle factors, such as activity level and exercise, as well as specific motor training may be helpful in managing the functional sequelae of HD and possibly slowing disease progression. In this chapter, we focus on the role of rehabilitation therapy in secondary and tertiary prevention of the potentially devastating consequences of HD. We provide a brief overview of the range of motor and cognitive impairments in HD and their effect on functional abilities. We further discuss emerging evidence in terms of the role of exercise, physical activity, and physical therapies in helping to minimize functional loss and maximize quality of life throughout the disease process. Future directions with respect to intensive and goal-directed exercise, including aerobic and strengthening programs, are also discussed. This is an area of particular importance alongside exploring the potential that motor-training paradigms have in mediating the effects of disease-modifying drugs, cell replacement therapy, or genetic manipulations, when available.

Development of a community-based exercise program for people diagnosed and at-risk for Huntington's disease: A clinical report

BACKGROUND

Given the neurodegenerative nature of Huntington's disease (HD), community-based exercise programs that meet the ongoing needs of those living with HD are needed. The genetic nature of HD warrants the inclusion of those at-risk for HD. The purpose of this clinical report is to describe an evidence-based approach to the design of a community-based exercise program to improve gait, balance, and fatigue for individuals diagnosed with and at-risk for HD.

PROGRAM DESIGN

Based on the literature, clinical expertise and patient values, the program was designed to include four key features: (1) community-based group format for individuals with HD, caregivers, and those at-risk for HD; (2) individualized prescription within the group; (3) circuit training; and (4) use of outcome measures. PROGRAM IMPLEMENTATION AND OUTCOMES: The group met once weekly for 8 weeks for balance, strength, and cardiovascular fitness exercises. Three individuals participated, two diagnosed with HD and 1 considered "at-risk" for HD. Pre- and post- outcome measures included the 10 meter walk test, Berg Balance Scale, Fatigue Impact Scale, and the Timed Up and Go. Participants demonstrated improvement or maintenance of abilities in all measures with no adverse events.

DISCUSSION

This clinical report describes the integration of the evidence, clinical expertise, and patient values to develop and implement individualized, community-based exercise groups, aimed to improve balance, gait speed, and fatigue measures for persons with HD and those at-risk. Post-program reflections and recommendations for those who are interested in developing similar programs in other communities are described.

Participants', caregivers', and professionals' experiences with a group-based rehabilitation program for Huntington's disease: a qualitative study

BACKGROUND

Research suggests that rehabilitation is beneficial for persons with Huntington's disease (HD), but there is limited knowledge about participants' experiences with residential rehabilitation programs. We therefore did a study to explore patients', family caregivers', and health professionals' experiences with a group-based, residential rehabilitation program for individuals with early to mid-stage HD, focusing on three research questions: How did participants experience the structure and content of the program? What outcomes did patients experience? What challenges and success factors did health professionals report?

METHODS

Qualitative, explorative study, collecting data through in-depth interviews with nine family caregivers and 11 patients with early- and mid-stage HD, and focus group interviews with 15 health professionals. Data were analysed using systematic text condensation.

RESULTS

Some participants reported difficulties with defining individual rehabilitation goals, but written individualised plans and schedules were appreciated by all participants. Participants highlighted being member of an "HD-group" as a valuable experience, though tensions and conflicts could occur in groups. Participants typically reported improved gait and balance, increased self-confidence, and social benefits as outcomes. The intensive schedule was acceptable for most participants, but adjustments had been made to allow participants more time to eat, shower and dress between sessions. Success factors reported by health professionals were assigning every patient with a contact person, using clinical tests results to motivate patients, and supervising health professionals in patients' local municipalities.

CONCLUSIONS

Group-based residental rehabilitation was feasible for individuals with early- and mid-stage HD, and participants emphasised mental and social outcomes in addition to physical outcomes. The needs of persons with HD should be considerd when designing programs, to secure structure, continuity in personnel, and sufficient time between sessions.

A randomized feasibility study of a 12-week community-based exercise program for people with Huntington's disease

BACKGROUND AND PURPOSE

The beneficial role of exercise as a treatment approach in Huntington's disease (HD) has support from both preclinical work and small-scale studies; however, there have been no controlled studies of gym-based exercise in people with HD. This phase 2 randomized trial (ISRCTN 59910670) assessed feasibility, safety, acceptability, and benefit of a structured exercise program.

METHODS

Thirty-one participants (16 men; mean [SD] age = 50.4 [11.4] years) were randomly allocated to intervention (n = 16) or control group (usual care; n = 15). The intervention entailed a weekly supervised gym session of stationary cycling and resistance exercises, and a twice weekly independent home-based walking program. Retention and adherence rates and adverse events were recorded. Acceptability was determined from subjective reports of tolerability and physiological measures recorded during the gym sessions. Assessment of benefit included measures of physical abilities, disease severity, and quality of life (36-Item Short Form Health Survey). Analysis of covariance was used to test outcomes of interest.

RESULTS

The retention rate was 81% (9 of the 11 individuals who started the intervention completed it) and of the 9 who completed the program, 7 attended more than 75% (9/12) of the gym sessions. There were no related adverse events and the intervention was well tolerated by most participants. The between-group effect estimate for the Mental Component Summary score of the 36-Item Short Form Health Survey (n = 9; intervention, n = 13; control) was 7 (95% CI: 0.4-13.7) Moderate effect sizes for cognitive outcomes and measures of walking were also observed.

DISCUSSION AND CONCLUSIONS

Observed effect sizes for clinical outcomes suggest the structured exercise program has benefit for persons with HD; larger scale trials are warranted.Video Abstract available (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A60) for more insights from the authors.

Development of physiotherapy guidance and treatment-based classifications for people with Huntington’s disease

SUMMARY Background: Physiotherapy may provide a means of delaying onset or progression of Huntington’s disease (HD), resulting in improved daily functioning and quality of life. Physiotherapy is being more frequently recommended for people with HD, but there have been no specific guidelines published for implementation of a structured physiotherapy program. The Physiotherapy Working Group (PWG) of the European Huntington’s Disease Network (EHDN) set out to develop a comprehensive Guidance Document for physiotherapists to provide best practice guidelines. Methods: A review of the literature was conducted using a systematic approach. There was insufficient literature in support of physiotherapy interventions and approaches to be able to conduct a complete evidenced-based review, therefore, physiotherapy expert subgroups were formed to incorporate consensus as to best practice. A draft document was distributed to the entire membership of the working group, to outside physiotherapists and other healthcare professionals within EHDN to elicit feedback and comments. Results: A Guidance Document covering eight specific areas pertaining to physiotherapy management of HD was developed. In order to facilitate the document’s practical usability among clinicians, a treatment-based classification system is proposed to categorize patients based on presenting signs and symptoms, and provide a foundation for development of a more standardized intervention approach. Discussion: The Physiotherapy Guidance for HD is a comprehensive, consensus- and evidence-based document that can be used by physiotherapists to implement a plan of care that is currently consistent with best practice for individuals at all stages of HD. As evidence becomes available, future systematic reviews will be required in order to inform further development. The use of treatment-based classifications, which aim to better categorize common signs and symptoms and link them to appropriate intervention plans, may be useful in relatively rare diseases, such as HD, to aid clinical reasoning and promote effective outcome evaluation.