Neurorehabilitation for Parkinson's disease: Future perspectives for behavioural adaptation

Exploring cognitive reserve's influence: unveiling the dynamics of digital telerehabilitation in Parkinson's Disease Resilience

Telerehabilitation is emerging as a promising digital method for delivering rehabilitation to Parkinson's Disease (PD) patients, especially in the early stages to promote brain resilience. This study explores how cognitive reserve (CR), the brain's ability to withstand aging and disease, impacts the effectiveness of telerehabilitation. It specifically examines the influence of lifelong cognitive activities on the relationship between neural reserve and improved functional abilities following rehabilitation. In the study, 42 PD patients underwent a 4-month neuromotor telerehabilitation program. CR proxies were assessed using the Cognitive Reserve Index questionnaire (CRIq), brain changes via 3T-MRI, and functional response through changes in the 6-Minute Walk Distance (6MWD). Participants were divided into responders (n = 23) and non-responders (n = 19) based on their 6MWD improvement. A multiple regression model was run to test significant predictors of 6MWD after treatment in each group. The results revealed a significant correlation between 6MWD and CRIq scores, but only among responders. Notably, the CRIq Leisure-Time sub-index, along with baseline 6MWD, were predictors of post-treatment 6MWD. These findings highlight CR's role in enhancing the benefits of telerehabilitation on PD patients' neuromotor functions. Clinically, these results suggest that neurologists and clinicians should consider patients' lifestyles and cognitive engagement as important factors in predicting and enhancing the outcomes of telerehabilitation. The study underscores the potential of CR as both a predictor and booster of telerehabilitation's effects, advocating for a personalized approach to PD treatment that takes into account individual CR levels.

A wearable system for visual cueing gait rehabilitation in Parkinson's disease: a randomized non-inferiority trial

BACKGROUND

Gait disturbances represent one of the most disabling features of Parkinson's disease (PD).

AIM

The aim of this study was to evaluate the non-inferiority of a new wearable visual cueing system (Q-Walk) for gait rehabilitation in PD subjects, compared to traditional visual cues (stripes on the floor).

DESIGN

Open-label, monocentric, randomized controlled non-inferiority trial.

SETTING

Outpatients.

POPULATION

Patients affected by idiopathic PD without cognitive impairment, Hoehn and Yahr stage II-IV, Unified Parkinson's Disease Rating Scale motor section III ≥2, stable drug usage since at least 3 weeks.

METHODS

At the enrollment (T0), all subjects underwent a clinical/functional evaluation and the instrumental gait and postural analysis; then they were randomly assigned to the Study Group (SG) or Control Group (CG). Rehabilitation program consisted in 10 consecutive individual sessions (5 sessions/week for 2 consecutive weeks). Each session included 60 minutes of conventional physiotherapy plus 30 minutes of gait training by Q-Walk (SG) or by traditional visual cues (CG). Follow-up visits were scheduled at the end of the treatment (T1) and after 3 months (T2).

RESULTS

Fifty-two subjects were enrolled in the study, 26 in each group. The within-groups analysis showed a significant improvement in clinical scales and instrumental data at T1 and at T2, compared to baseline, in both groups. According to the between-group analysis, Q-Walk cueing system was not-inferior to the traditional cues for gait rehabilitation. The satisfaction questionnaire revealed that most subjects described the Q-Walk cueing system as simple, motivating and easily usable, possibly suitable for home use.

CONCLUSIONS

Data showed that motor rehabilitation of PD subjects performed by means of the new wearable Q-Walk cueing system was feasible and as effective as traditional cues in improving gait parameters and balance.

CLINICAL REHABILITATION IMPACT

Wearable devices can act as an additional rehabilitation strategy for long-term and continuous care, allowing patients to train intensively and extensively in household settings, favoring a tailor-made and personalized approach as well as remote monitoring.

Evidence for the Efficacy of Commercially Available Wearable Biofeedback Gait Devices: Consumer-Centered Review

BACKGROUND

The number of wearable technological devices or sensors that are commercially available for gait training is increasing. These devices can fill a gap by extending therapy outside the clinical setting. This was shown to be important during the COVID-19 pandemic when people could not access one-on-one treatment. These devices vary widely in terms of mechanisms of therapeutic effect, as well as targeted gait parameters, availability, and strength of the evidence supporting the claims.

OBJECTIVE

This study aimed to create an inventory of devices targeting improvement in gait pattern and walking behavior and identify the strength of the evidence underlying the claims of effectiveness for devices that are commercially available to the public.

METHODS

As there is no systematic or reproducible way to identify gait training technologies available to the public, we used a pragmatic, iterative approach using both the gray and published literature. Four approaches were used: simple words, including some suggested by laypersons; devices endorsed by condition-specific organizations or charities; impairment-specific search terms; and systematic reviews. A findable list of technological devices targeting walking was extracted separately by 3 authors. For each device identified, the evidence for efficacy was extracted from material displayed on the websites, and full-text articles were obtained from the scientific databases PubMed, Ovid MEDLINE, Scopus, or Google Scholar. Additional information on the target population, mechanism of feedback, evidence for efficacy or effectiveness, and commercial availability was obtained from the published material or websites. A level of evidence was assigned to each study involving the device using the Oxford Centre for Evidence-Based Medicine classification. We also proposed reporting guidelines for the clinical appraisal of devices targeting movement and mobility.

RESULTS

The search strategy for this consumer-centered review yielded 17 biofeedback devices that claim to target gait quality improvement through various sensory feedback mechanisms. Of these 17 devices, 11 (65%) are commercially available, and 6 (35%) are at various stages of research and development. Of the 11 commercially available devices, 4 (36%) had findable evidence for efficacy potential supporting the claims. Most of these devices were targeted to people living with Parkinson disease. The reporting of key information about the devices was inconsistent; in addition, there was no summary of research findings in layperson's language.

CONCLUSIONS

The amount of information that is currently available to the general public to help them make an informed choice is insufficient, and, at times, the information presented is misleading. The evidence supporting the effectiveness does not cover all aspects of technology uptake. Commercially available technologies help to provide continuity of therapy outside the clinical setting, but there is a need to demonstrate effectiveness to support claims made by the technologies.

Multidisciplinary Intensive Rehabilitation Program for People with Parkinson's Disease: Gaps between the Clinic and Real-World Mobility

Intensive rehabilitation programs improve motor and non-motor symptoms in people with Parkinson's disease (PD), however, it is not known whether transfer to daily-living walking occurs. The effects of multidisciplinary-intensive-outpatient rehabilitation (MIOR) on gait and balance in the clinic and on everyday walking were examined. Forty-six (46) people with PD were evaluated before and after the intensive program. A 3D accelerometer placed on the lower back measured daily-living walking during the week before and after the intervention. Participants were also stratified into "responders" and "non-responders" based on daily-living-step-counts. After the intervention, gait and balance significantly improved, e.g., MiniBest scores (p < 0.001), dual-task gait speed increased (p = 0.016) and 6-minute walk distance increased (p < 0.001). Many improvements persisted after 3 months. In contrast, daily-living number of steps and gait quality features did not change in response to the intervention (p > 0.1). Only among the "responders", a significant increase in daily-living number of steps was found (p < 0.001). These findings demonstrate that in people with PD improvements in the clinic do not necessarily carry over to daily-living walking. In a select group of people with PD, it is possible to ameliorate daily-living walking quality, potentially also reducing fall risk. Nevertheless, we speculate that self-management in people with PD is relatively poor; therefore, to maintain health and everyday walking abilities, actions such as long-term engaging in physical activity and preserving mobility may be needed.

Premotor, nonmotor and motor symptoms of Parkinson's Disease: A new clinical state of the art

Parkinson's Disease (PD) is a neurodegenerative disorder that affects dopaminergic neurons in the mesencephalic substantia nigra, causing a progressive clinical course characterized by pre-motor, non-motor and motor symptoms, which negatively impact the quality of life of patients and cause high health care costs. Therefore, the present study aims to discuss the clinical manifestations of PD and to make a correlation with the gut-brain (GB) axis, approaching epidemiology and therapeutic perspectives, to better understand its clinical progression and identify symptoms early. A literature review was performed regarding the association between clinical progression, the gut-brain axis, epidemiology, and therapeutic perspectives, in addition to detailing pre-motor, non-motor symptoms (neuropsychiatric, cognitive, autonomic, sleep disorders, sensory abnormalities) and cardinal motor symptoms. Therefore, this article addresses a topic of extreme relevance, since the previously mentioned clinical manifestations (pre-motor and non-motor) can often act as prodromal markers for the early diagnosis of PD and may precede it by up to 20 years.

Both Motor and Non-Motor Fluctuations Matter in the Clinical Management of Patients with Parkinson's Disease: An Exploratory Study

Non-motor symptoms (NMS) characterize the Parkinson's disease (PD) clinical picture, and as well as motor fluctuations, PD patients can also experience NMS fluctuations (NMF). The aim of this observational study was to investigate the presence of NMS and NMF in patients with PD using the recently validated Non-Motor Fluctuation Assessment questionnaire (NoMoFa) and to evaluate their associations with disease characteristics and motor impairment. Patients with PD were consecutively recruited, and NMS, NMF, motor impairment, motor fluctuations, levodopa-equivalent daily dose, and motor performance were evaluated. One-third of the 25 patients included in the study (10 females, 15 males, mean age: 69.9 ± 10.3) showed NMF, and patients with NMF presented a higher number of NMS (p < 0.01). Static NMS and NoMoFa total score were positively associated with motor performance assessed with the Global Mobility Task (p < 0.01 and p < 0.001), and the latter was also correlated with motor impairment (p < 0.05) but not with motor fluctuations. Overall, this study shows evidence that NMF are frequently reported by mild-to-moderate PD patients and associated with an increased number of NMS. The relationship between NoMoFa total score and motor functioning highlights the importance of understanding the clinical role of NMS and NMF in the management of PD patients.

Can we really 'read' art to see the changing brain? A review and empirical assessment of clinical case reports and published artworks for systematic evidence of quality and style changes linked to damage or neurodegenerative disease

The past three decades have seen multiple reports of people with neurodegenerative disorders, or other forms of changes in their brains, who also show putative changes in how they approach and produce visual art. Authors argue that these cases may provide a unique body of evidence, so-called 'artistic signatures' of neurodegenerative diseases, that might be used to understand disorders, provide diagnoses, be employed in treatment, create patterns of testable hypotheses for causative study, and also provide unique insight into the neurobiological linkages between the mind, brain, body, and the human penchant for art-making itself. However-before we can begin to meaningfully build from such emerging findings, much less formulate applications-not only is such evidence currently quite disparate and in need of systematic review, almost all case reports and artwork ratings are entirely subjective, based on authors' personal observations or a sparse collection of methods that may not best fit underlying research aims. This leads to the very real question of whether we might actually find patterns of systematic change if fit to a rigorous review-Can we really 'read' art to illuminate possible changes in the brain? How might we best approach this topic in future neuroscientific, clinical, and art-related research? This paper presents a review of this field and answer to these questions. We consider the current case reports for seven main disorders-Alzheimer's and Parkinson's disease, frontotemporal and Lewy body dementia, corticobasal degeneration, aphasia, as well as stroke-consolidating arguments for factors and changes related to art-making and critiquing past methods. Taking the published artworks from these papers, we then conduct our own assessment, employing computerized and human-rater-based approaches, which we argue represent best practice to identify stylistic or creativity/quality changes. We suggest, indeed, some evidence for systematic patterns in art-making for specific disorders and also find that case authors showed rather high agreement with our own assessments. More important, through opening this topic and past evidence to a systematic review, we hope to open a discussion and provide a theoretical and empirical foundation for future application and research on the intersection of art-making and the neurotypical, the changed, and the artistic brain.

Enriched Rehabilitation Improves Gait Disorder and Cognitive Function in Parkinson's Disease: A Randomized Clinical Trial

Background: Studies on non-pharmacological strategies for improving gait performance and cognition in Parkinson's disease (PD) are of great significance. We aimed to investigate the effect of and mechanism underlying enriched rehabilitation as a potentially effective strategy for improving gait performance and cognition in early-stage PD. Methods: Forty participants with early-stage PD were randomly assigned to receive 12 weeks (2 h/day, 6 days/week) of enriched rehabilitation (ER; n = 20; mean age, 66.14 ± 4.15 years; 45% men) or conventional rehabilitation (CR; n = 20; mean age 65.32 ± 4.23 years; 50% men). In addition, 20 age-matched healthy volunteers were enrolled as a control (HC) group. We assessed the general motor function using the Unified PD Rating Scale-Part III (UPDRS-III) and gait performance during single-task (ST) and dual-task (DT) conditions pre- and post-intervention. Cognitive function assessments included the Montreal Cognitive Assessment (MoCA), the Symbol Digit Modalities Test (SDMT), and the Trail Making Test (TMT), which were conducted pre- and post-intervention. We also investigated alteration in positive resting-state functional connectivity (RSFC) of the left dorsolateral prefrontal cortex (DLPFC) in participants with PD, mediated by ER, using functional magnetic resonance imaging (fMRI). Results: Compared with the HC group, PD participants in both ER and CR groups performed consistently poorer on cognitive and motor assessments. Significant improvements were observed in general motor function as assessed by the UPDRS-III in both ER and CR groups post-intervention. However, only the ER group showed improvements in gait parameters under ST and DT conditions post-intervention. Moreover, ER had a significant effect on cognition, which was reflected in increased MoCA, SDMT, and TMT scores post-intervention. MoCA, SDMT, and TMT scores were significantly different between ER and CR groups post-intervention. The RSFC analysis showed strengthened positive functional connectivity between the left DLPFC and other brain areas including the left insula and left inferior frontal gyrus (LIFG) post-ER. Conclusion: Our findings indicated that ER could serve as a potentially effective therapy for early-stage PD for improving gait performance and cognitive function. The underlying mechanism based on fMRI involved strengthened RSFC between the left DLPFC and other brain areas (e.g., the left insula and LIFG).

Protocol for the DeFOG trial: A randomized controlled trial on the effects of smartphone-based, on-demand cueing for freezing of gait in Parkinson's disease

Background

Freezing of gait (FOG) is a highly incapacitating symptom that affects many people with Parkinson's disease (PD). Cueing triggered upon real-time FOG detection (on-demand cueing) shows promise for FOG treatment. Yet, the feasibility of implementation and efficacy in daily life is still unknown. Therefore, this study aims to investigate the effectiveness of DeFOG: a smartphone and sensor-based on-demand cueing solution for FOG.

Methods

Sixty-two PD patients with FOG will be recruited for this single-blind, multi-center, randomized controlled phase II trial. Patients will be randomized into either the intervention group or the active control group. For four weeks, both groups will receive feedback about their physical activity using the wearable DeFOG system in daily life. In addition, the intervention group will also receive on-demand auditory cueing and instructions. Before and after the intervention, home-based assessments will be performed to evaluate the primary outcome, i.e., “percentage time frozen” during a FOG-provoking protocol. Secondary outcomes include the training effects on physical activity monitored over 7 days and the user-friendliness of the technology.

Discussion

The DeFOG trial will investigate the effectiveness of personalized on-demand cueing in a controlled design, delivered for 4 weeks in the patient's home environment. We anticipate that DeFOG will reduce FOG to a greater degree than in the control group and we will explore the impact of the intervention on physical activity levels. We expect to gain in-depth insight into whether and how patients control FOG using cueing methods in their daily lives.

Trial registration

Clinicaltrials.gov NCT03978507.

Functional and Cognitive Improvement After an Intensive Inpatient Multidisciplinary Rehabilitation Program in Mild to Severe Parkinson's Disease: A Retrospective and Observational Study

Parkinson's disease (PD) is a neurodegenerative disorder characterized by motor (resting tremor, rigidity, bradykinesia, postural instability, and gait disturbances) and nonmotor symptoms (cognitive, neuropsychiatric, and autonomic problems). In recent years, several studies demonstrated that neurorehabilitation therapy is an effective treatment in addition to pharmacological personalized interventions in persons with PD (PwPD). The main aim of this study was to explore the short-term changes in functional, cognitive, and geriatric domains after a multidimensional rehabilitation program in PwPD (as primary condition) in mild-moderate (M-Ms) to severe (Ss) stages. Our second aim was to compare the effects of multidimensional rehabilitation in M-Ms versus Ss of PD. Twenty-four PwPD in M-Ms to Ss [age (mean ± SD) = 76.25 ± 9.42 years; male/female = 10/14; Hoehn and Yahr (median; IQR) = 4.00; 1.75] were included in a retrospective, observational study. Motor, cognitive, functional, and neuropsychiatric aspects were collected in admission (T0) and in discharge (T1). PwPD were involved in a person-tailored (to individual's needs), inpatient, intensive (5-7 days per week), multidisciplinary (combining cognitive, physical, occupational, and speech therapies), comprehensive, and rehabilitative program. According to Movement Disorders Society Unified Parkinson's Disease Rating Scale III cutoff, PwPD were classified in M-Ms or Ss (M-Ms ≤59; Ss >59); 87.50% of our sample reported significant reduction of functional disability at Barthel Index (p < 0.001). A significant improvement in Token test (p = 0.021), semantic fluency (p = 0.036), Rey's Figure-Copy (p < 0.001), and Raven's Colored Progressive Matrices (p = 0.004) was observed. The pain intensity perception (p < 0.001) and the risk of developing pressure ulcers (p < 0.001) as assessed, respectively, by the Numeric Rating Scale and by the Norton Scale were improved. With regard to the second aim, in M-Ms group, we found a positive correlation between the number of neuromotor sessions and the change in functional disability and language comprehension; in the Ss group, on the other hand, despite a higher number of hospitalization days, the total number of completed sessions was positively associated with the change in visuoconstructional abilities. Our findings suggest that an intensive, inpatient, and multidisciplinary rehabilitation program may improve functional abilities, some strategic cognitive functions, and geriatric aspects in PwPD with mild-moderate motor impairment.

The Role of Mental Imagery in Parkinson's Disease Rehabilitation

Parkinson’s disease (PD) is a disabling neurodegenerative disease whose manifestations span motor, sensorimotor, and sensory domains. While current therapies for PD include pharmacological, invasive, and physical interventions, there is a constant need for developing additional approaches for optimizing rehabilitation gains. Mental imagery is an emerging field in neurorehabilitation and has the potential to serve as an adjunct therapy to enhance patient function. Yet, the literature on this topic is sparse. The current paper reviews the motor, sensorimotor, and sensory domains impacted by PD using gait, balance, and pain as examples, respectively. Then, mental imagery and its potential for PD motor and non-motor rehabilitation is discussed, with an emphasis on its suitability for addressing gait, balance, and pain deficits in people with PD. Lastly, future research directions are suggested.

Assistive HCI-Serious Games Co-design Insights: The Case Study of i-PROGNOSIS Personalized Game Suite for Parkinson's Disease

Human-Computer Interaction (HCI) and games set a new domain in understanding people's motivations in gaming, behavioral implications of game play, game adaptation to player preferences and needs for increased engaging experiences in the context of HCI serious games (HCI-SGs). When the latter relate with people's health status, they can become a part of their daily life as assistive health status monitoring/enhancement systems. Co-designing HCI-SGs can be seen as a combination of art and science that involves a meticulous collaborative process. The design elements in assistive HCI-SGs for Parkinson's Disease (PD) patients, in particular, are explored in the present work. Within this context, the Game-Based Learning (GBL) design framework is adopted here and its main game-design parameters are explored for the Exergames, Dietarygames, Emotional games, Handwriting games, and Voice games design, drawn from the PD-related i-PROGNOSIS Personalized Game Suite (PGS) (www.i-prognosis.eu) holistic approach. Two main data sources were involved in the study. In particular, the first one includes qualitative data from semi-structured interviews, involving 10 PD patients and four clinicians in the co-creation process of the game design, whereas the second one relates with data from an online questionnaire addressed by 104 participants spanning the whole related spectrum, i.e., PD patients, physicians, software/game developers. Linear regression analysis was employed to identify an adapted GBL framework with the most significant game-design parameters, which efficiently predict the transferability of the PGS beneficial effect to real-life, addressing functional PD symptoms. The findings of this work can assist HCI-SG designers for designing PD-related HCI-SGs, as the most significant game-design factors were identified, in terms of adding value to the role of HCI-SGs in increasing PD patients' quality of life, optimizing the interaction with personalized HCI-SGs and, hence, fostering a collaborative human-computer symbiosis.

Novel Human-Centered Robotics: Towards an Automated Process for Neurorehabilitation

The global requirement of patient rehabilitation has surged with time due to the growing number of accidents, injuries, age-related issues, and other aspects. Parallelly, the cost of treatment and patient care also increased in a manifold. Moreover, constant monitoring and support for the patients having physical disabilities have become an ongoing challenge to the medical system. Robotics-based neurorehabilitation has reduced the human error while assisting such patients, precisely interpreting the signals, and communicating to the patient. Gradual precise application and improvement of the technology with time yielded a novel direction for patient care and support. The interdisciplinary contribution of many advanced technical branches allowed us to develop robotics-based assistance with high precision for the upper limb and the lower limb impairments. The present review summarizes the generation and background of robotic implementation for patient support, progress, present status, and future requirements.

Interventions Involving Biofeedback to Improve Swallowing in People With Parkinson Disease and Dysphagia: A Systematic Review

OBJECTIVES

To examine the effectiveness of biofeedback used in the treatment of adults with Parkinson disease (PD) and dysphagia, define the factors associated with biofeedback treatment outcomes, and inform a theory to guide the implementation of biofeedback in future dysphagia interventions.

DATA SOURCES

A systematic review using a narrative synthesis approach of all published and unpublished studies were sought with no date or language restrictions. Ten electronic databases (EMBASE, PubMed, CINAHL, Web of Science, Scopus, Science Direct, AMED, The Cochrane Database of Systematic Reviews, ProQuest Dissertations and Theses A & I, Google Scholar) were searched from inception to April 2019. This search was updated in January 2020. The methodological quality of included studies was assessed using Downs and Black checklist.

STUDY SELECTION

Four studies were included. The methodological quality of the included studies was low with a high risk of bias. Data were analyzed narratively and descriptively. Despite the heterogeneity of the included studies, the findings suggest that interventions incorporating visual biofeedback may have positive effects on swallowing-related quality of life.

CONCLUSIONS

Based on these preliminary findings, we provide directions for further research and clinical interventions that incorporate an augmentative biofeedback component of swallowing interventions in people with PD. Future studies should be rigorously designed and set appropriate biofeedback treatment in terms of types, schedules, and timing.

A physical therapy decision-making tool for stratifying persons with Parkinson's disease into community exercise classes

Aim: Physical therapy and exercise are considered essential components in the management of Parkinson's disease (PD). Using our retrospective data and years of experience in assigning persons with PD to multilevel group classes we propose a two-part physical therapy decision-making tool consisting of participant and exercise program considerations. Methods: Retrospective medical record review and therapist consensus identified evaluation considerations determined to aide clinical decision making. The ability of these variables (i.e., demographics, clinical characteristics, clinical measures cut-offs) to predict the class assignment decision of PD-specialized physical therapists was evaluated using discriminant function analysis. Results: Therapist-assigned groups differed significantly on all clinical measures (p < 0.001) which provided the categorical data required for discriminant analysis. Using all variables, the discriminant function analysis predicted class assignment of the therapists with 79% agreement. Conclusion: This proposed tool provides a framework that may guide the process for increasing access to multilevel group classes.

Investigation on human rights ethics in artificial intelligence researches with library literature analysis method

Purpose

The purpose of this paper was to identify whether artificial intelligence (AI) products can possess human rights, how to define their rights and obligations and what ethical standards they should follow. In this study, the human rights ethical dilemma encountered in the application and development of AI technology has been focused on and analyzed in detail in the light of the existing research status of AI ethics.

Design/methodology/approach

In this study, first of all, the development and application of AI technology, as well as the concept and characteristics of human rights ethics, are introduced. Second, the human rights ethics of AI technology are introduced in detail, including the human rights endowment of AI machines, the fault liability of AI machines and the moral orientation of AI machines. Finally, the approaches to human rights ethics are proposed to ensure that AI technology serves human beings. Every link of its research, production and application should be strictly managed and supervised.

Findings

The results show that the research in this study can provide help for the related problems encountered in AI practice. Intelligent library integrates human rights protection organically so that readers or users can experience more intimate service in this system. It is a kind of library operation mode with more efficient and convenient characteristics, which is based on digital, networked and intelligent information science. It aims at using the greenest way and digital means to realize the reading and research of human rights protection literature in the literature analysis method.

Originality/value

Intelligent library is the future development mode of new libraries, which can realize broad interconnection and sharing. It is people-oriented and can make intelligent management and service and establish the importance of the principle of human rights protection and the specific idea of the principle. The development of science and technology brings not only convenience to people's social life but also questions to be thought. People should reduce its potential harm, so as to make AI technology continue to benefit humankind.

Validation of the Auditory Stroop Task to increase cognitive load in walking tasks in healthy elderly and persons with Parkinson's disease

Background

The development of treatments for freezing of gait (FOG) in Parkinson’s disease (PD) requires experimental study set-ups in which FOG is likely to occur, and is amenable to therapeutic interventions. We explore whether the ‘Auditory Stroop Task’ (AST) can be used to increase cognitive load (and thereby elicit FOG), simultaneously with visual cues (as a therapeutic intervention for FOG). We additionally examined how these two contrasting effects might interact in affecting gait and FOG parameters.

Objectives

We investigated whether: (1) the ‘Auditory Stroop Task’ (AST) influences gait in healthy elderly and persons with PD who experience FOG, and increases the frequency of FOG events among PD patients; (2) the AST and visual cues interact; and (3) different versions of the AST exert different cognitive loads.

Methods

In ‘Experiment 1’, 19 healthy elderly subjects performed a walking task while performing a high and low load version of the AST. Walking with a random numbers task, and walking without cognitive load served as control conditions. In ‘Experiment 2’, 20 PD patients with FOG and 18 healthy controls performed a walking task with the AST, and no additional cognitive load as control condition. Both experiments were performed with and without visual cues. Velocity, cadence, stride length, and stride time were measured in all subjects. FOG severity was measured in patients.

Results

Compared to the control conditions, the AST negatively affected all gait parameters in both patients and controls. The AST did not increase the occurrence of FOG in patients. Visual cues reduced the decline in stride length induced by cognitive load in both groups. Both versions of the AST exerted similar effects on gait parameters in controls.

Conclusions

The AST is well-suited to simulate the effects of cognitive load on gait parameters, but not FOG severity, in gait experiments in persons with PD and FOG.

Exercise for Parkinson's disease

Parkinson's disease is the second most common neurodegenerative disease with a prevalence rate of 1-2 per 1000 of the population worldwide. Pharmacological management is the mainstay of treatment. Despite optimal medication, motor impairment particularly balance and gait impairment persist leading to various degree of disability and reduced quality-of-life. The present review describes motor impairment including postural impairment, gait dysfunction, reduced muscle strength and aerobic capacity and falls. Physical therapy and complementary exercises have been proven to improve motor performance and functional mobility. Evidence on the efficacy of physical therapy and complementary exercises is presented in this review. These exercises include gait training with cues, gait training with treadmill, Nordic walking, brisk walking, balance training, virtual reality interventions, Tai Chi and dance. All these treatment interventions produce short-term beneficial effects and some interventions demonstrate long-term benefit. Gait training with treadmill enhance walking performance and the effects sustain for 3-6 months. Balance training improves balance, function and reduces fall rate, and these effects carry over to at least 12 months after training ended. Sustained Tai Chi for 6 months, dance therapy for 12 months, progressive resistive training for 24 months alleviates the PD motor symptoms, suggesting that they could slow down PD progression. Based on this evidence, individuals with PD are encouraged to sustain their training in order to improve/maintain their physical ability and to combat the progression of PD.

Recent advances in rehabilitation for Parkinson's Disease with Exergames: A Systematic Review

OBJECTIVE

The goal of this contribution is to gather and to critically analyze recent evidence regarding the potential of exergaming for Parkinson's disease (PD) rehabilitation and to provide an up-to-date analysis of the current state of studies on exergame-based therapy in PD patients.

METHODS

We performed our search based on the conclusions of a previous systematic review published in 2014. Inclusion criteria were articles published in the indexed databases Pubmed, Scopus, Sciencedirect, IEEE and Cochrane published since January 1, 2014. Exclusion criteria were papers with a target group other than PD patients exclusively, or contributions not based on exergames. Sixty-four publications out of 525 matches were selected.

RESULTS

The analysis of the 64 selected publications confirmed the putative improvement in motor skills suggested by the results of the previous review. The reliability and safety of both Microsoft Kinect and Wii Balance Board in the proposed scenarios was further confirmed by several recent studies. Clinical trials present better (n = 5) or similar (n = 3) results than control groups (traditional rehabilitation or regular exercise) in motor (TUG, BBS) and cognitive (attention, alertness, working memory, executive function), thus emphasizing the potential of exergames in PD. Pilot studies (n = 11) stated the safety and feasibility of both Microsoft Kinect and Wii Balance Board, potentially in home scenarios as well. Technical papers (n = 30) stated the reliability of balance and gait data captured by both devices. Related meta-analyses and systematic reviews (n = 15) further support these statements, generally citing the need for adaptation to patient's skills and new input devices and sensors as identified gaps.

CONCLUSION

Recent evidence indicates exergame-based therapy has been widely proven to be feasible, safe, and at least as effective as traditional PD rehabilitation. Further insight into new sensors, best practices and different cognitive stadiums of PD (such as PD with Mild Cognitive Impairment), as well as task specificity, are required. Also, studies linking game parameters and results with traditional assessment methods, such as UPDRS scores, are required. Outcomes for randomized controlled trials (RCTs) should be standardized, and follow-up studies are required, particularly for motor outcomes.

Efficacy of intensive multidisciplinary rehabilitation in Parkinson's disease: a randomised controlled study

OBJECTIVE

To evaluate whether a 4-week multidisciplinary, aerobic, motor-cognitive and intensive rehabilitation treatment (MIRT) improves the quality of life (QoL) of patients with Parkinson's disease (PD), in the short-term and long-term period.

METHODS

This is a prospective, parallel-group, single-centre, single-blind, randomised clinical trial (ClinicalTrials.gov NCT02756676). 186 patients with PD, assigned to experimental group, underwent MIRT; conversely, 48 patients, assigned to control group, did not receive rehabilitation. Parkinson's Disease Questionnaire-39 was assessed 2 (T0), 10 (T1) and 18 (T2, only experimental group) weeks after the enrolment. We compared T1 versus T0 scores within subjects and delta scores (T1-T0) between subjects. To investigate the long-term effects, we compared T2 and T0 scores in the experimental group.

RESULTS

At T0, no between-group differences in the Global Index Score (GBI) were observed (experimental group: 43.6±21.4, controls: 41.6±22.9, P=0.50). At T1, we did not find significant changes in controls (delta score: 1.2±9.9, P=0.23), and we found an improvement in GBI in the experimental group (delta score: -8.3±18.0, P<0.0001), significant also between subjects (P<0.0001). Comparing T2 versus T0 in the experimental group, the GBI maintained a significant improvement (delta score: -4.8±17.5, P<0.0001).

CONCLUSIONS

A rehabilitation treatment such as MIRT could improve QoL in patients with PD in the short-term and long-term period. Even though the single-blind design and the possible role of the placebo effect on the conclusive results must be considered as limitations of this study, the improvement in outcome measure, also maintained after a 3-month follow-up period, suggests the effectiveness of MIRT on the QoL.

CLINICAL TRIAL REGISTRATION

NCT02756676: Pre-results.

Basal ganglia and beyond: The interplay between motor and cognitive aspects in Parkinson's disease rehabilitation

Parkinson's disease (PD) is characterized by motor and cognitive dysfunctions, affecting the motor behaviour. We summarize evidence that the interplay between motor and cognitive approaches is crucial in PD rehabilitation. Rehabilitation is complementary to pharmacological therapy and effective in reducing the PD disturbances, probably acting by inducing neuroplastic effects. The motor behaviour results from a complex integration between cortical and subcortical areas, underlying the motor, cognitive and motivational aspects of movement. The close interplay amongst these areas makes possible to learn, control and express habitual-automatic actions, which are dysfunctional in PD. The physiopathology of PD could be considered the base for the development of effective rehabilitation treatments. As the volitional action control is spared in early-medium stages of disease, rehabilitative approaches engaging cognition permit to achieve motor benefits and appear to be the most effective for PD. We will point out data supporting the relevance of targeting both motor and cognitive aspects in PD rehabilitation. Finally, we will discuss the role of cognitive engagement in motor rehabilitation for PD.

The feasibility and positive effects of a customised videogame rehabilitation programme for freezing of gait and falls in Parkinson's disease patients: a pilot study

BACKGROUND

Freezing of gait and falls represent a major burden in patients with advanced forms of Parkinson's disease (PD). These axial motor signs are not fully alleviated by drug treatment or deep-brain stimulation. Recently, virtual reality has emerged as a rehabilitation option for these patients. In this pilot study, we aim to determine the feasibility and acceptability of rehabilitation with a customised videogame to treat gait and balance disorders in PD patients, and assess its effects on these disabling motor signs.

METHODS

We developed a customised videogame displayed on a screen using the Kinect system. To play, the patient had to perform large amplitude and fast movements of all four limbs, pelvis and trunk, in response to visual and auditory cueing, to displace an avatar to collect coins and avoid obstacles to gain points. We tested ten patients with advanced forms of PD (median disease duration = 16.5 years) suffering from freezing of gait and/or falls (Hoehn&Yahr score ≥ 3) resistant to antiparkinsonian treatment and deep brain stimulation. Patients performed 18 training sessions during a 6-9 week period. We measured the feasibility and acceptability of our rehabilitation programme and its effects on parkinsonian disability, gait and balance disorders (with clinical scales and kinematics recordings), positive and negative affects, and quality of life, after the 9th and 18th training sessions and 3 months later.

RESULTS

All patients completed the 18 training sessions with high feasibility, acceptability and satisfaction scores. After training, the freezing-of-gait questionnaire, gait-and-balance scale and axial score significantly decreased by 39, 38 and 41%, respectively, and the activity-balance confidence scale increased by 35%. Kinematic gait parameters also significantly improved with increased step length and gait velocity and decreased double-stance time. Three months after the final session, no significant change persisted except decreased axial score and increased step length and velocity.

CONCLUSIONS

This study suggests that rehabilitation with a customised videogame to treat gait and balance disorders is feasible, well accepted, and effective in parkinsonian patients. These data serve as preliminary evidence for further larger and controlled studies to propose this customised videogame rehabilitation programme at home.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02469350 .

Effects of physical exercise programs on cognitive function in Parkinson's disease patients: A systematic review of randomized controlled trials of the last 10 years

Background

Given the relative importance of cognitive impairment, there was considerable interest in identifying the cognitive profile of PD patients, in order to ensure specific and appropriate therapeutic interventions.

Purpose

To determine the effects of physical exercise programs on cognitive function in PD patients, compared with the control group.

Data sources

Medline, Cochrane, Scopus, PEDro and Web of Science (last searched in September 2016).

Study selection

Randomized clinical trials examining the effects of physical exercise programs and cognitive function in PD patients. Nine studies fulfilled the selection criteria and were included in this review.

Data extraction

Characteristics of the publication, characteristics of the participants, test used for cognitive screening, cognitive domain assessed, tools used to assess cognitive function, characteristics of the experimental intervention, characteristics of the control group, mean results and standard deviation of function cognitive. The PEDro score was used to evaluate methodological quality.

Data synthesis

Most eligible studies showed good methodological quality based on the PEDro scale. Studies have shown that adapted tango for PD patients, cognitive training combined with motor training, and treadmill training promote the preservation or improvement of cognitive function in PD patients.

Limitations

The diversity of cognitive tests used to assess cognitive function and the high heterogeneity identified between the physical exercise programs.

Conclusions

Physical exercise programs promote positive and significant effects on global cognitive function, processing speed, sustained attention and mental flexibility in PD patients, at a mild to moderate stage for patients with a 6-year clinical diagnosis of PD. However, treadmill training performed 3 times a week for about 60 minutes and for a period of 24 weeks produced larger improvements in cognition.

Effectiveness of Rotigotine plus intensive and goal-based rehabilitation versus Rotigotine alone in "de-novo" Parkinsonian subjects: a randomized controlled trial with 18-month follow-up

Background

Dopamine Replacement Therapy (DRT) represents the most effective treatment for Parkinson’s disease (PD). Nevertheless, several symptoms are unresponsive to treatment and its long-term use leads to serious side effects. To optimize the pharmacological management of PD, dopamine-agonists are often prescribed to “de-novo” patients. Moreover, several studies have shown the effectiveness and the synergic effect of rehabilitation in treating PD.

Objective

To evaluate the synergism between DRT and rehabilitation in treating PD, by investigating the short and the long-term effectiveness of a multidisciplinary, intensive and goal-based rehabilitation treatment (MIRT) in a group of patients treated with Rotigotine.

Materials and methods

In this multicenter, single blinded, parallel-group, 1:1 allocation ratio, randomized, non-inferiority trial, 36 “de-novo” PD patients were evaluated along 18 months: 17 were treated with Rotigotine plus MIRT; 19 were treated with Rotigotine alone (R). The primary outcome measure was the total score of Unified Parkinson’s Disease Rating Scale (UPDRS). The secondary outcomes included the UPDRS sub-sections II and III (UPDRS II-III), the 6-Minute Walk Test (6MWT), the Timed Up and Go Test (TUG) and the amount of Rotigotine. Patients were evaluated at baseline (T0), 6 months (T1), 1 year (T2), and at 18 months (T3).

Results

No differences in UPDRS scores in the two groups (total score, III part and II part, p = 0.48, p = 0.90 and p = 0.40, respectively) were found in the time course. Conversely, a greater improvement in Rotigotine + MIRT group was observed for 6MWT (p < 0.0001) and TUG (p = 0.03). Along time, the dosage of Rotigotine was higher in patients who did not undergo MIRT, at all observation times following T0.

Conclusions

Over the course of 18 months, the effectiveness of the combined treatment (Rotigotine + MIRT) on the patients’ global clinical status, evaluated with total UPDRS, was not inferior to that of the pharmacological treatment with Rotigotine alone. Importantly, rehabilitation allowed patients to gain better motor performances with lower DRT dosage.

Effects of Exercise on Non-motor Symptoms in Parkinson's Disease

Patients with Parkinson's disease experience disabling non-motor symptoms, including autonomic dysfunction, cognitive decline, and sleep disorders. Pharmacologic treatments for these symptoms are often ineffective or have intolerable side effects. Therefore, non-pharmacologic interventions are an attractive alternative. Exercise in particular has the potential to alleviate the progressive impairment related to these non-motor symptoms. In this commentary, we explore available research that addresses the impact of exercise and physical activity on autonomic dysfunction, cognitive impairment, and sleep disorders in Parkinson's disease and suggest areas in need of further study. Many gaps remain in our understanding of the most effective exercise intervention for these symptoms, the mechanisms underlying exercise-induced changes, and the best way to monitor response to therapy. However, available research suggests that exercise is a promising approach to improve non-motor symptoms in patients with Parkinson's disease.

Being on Target: Visual Information during Writing Affects Effective Connectivity in Parkinson's Disease

A common motor symptom of Parkinson's disease (PD) is micrographia, characterized by a decrease in writing amplitude. Despite the relevance of this impairment for activities of daily living, the underlying neural network abnormalities and the impact of cueing strategies on brain connectivity are unknown. Therefore, we investigated the effects of visual cues on visuomotor network interactions during handwriting in PD and healthy controls (HCs). Twenty-eight patients with early disease, ON dopaminergic medication, and 14 age-matched controls performed a pre-writing task with and without visual cues in the scanner. Patients displayed weaker right visuo-parietal coupling than controls, suggesting impaired visuomotor integration during writing. Surprisingly, cueing did not have the expected positive effects on writing performance. Patients and controls, however, did activate similar networks during cued and uncued writing. During cued writing, the stronger influence of both visual and motor areas on the left superior parietal lobe suggested that visual cueing induced greater visual steering. In the absence of cues, there was enhanced coupling between parietal and supplementary motor areas (SMA) in line with previous findings in HCs during uncued motor tasks. In conclusion, the present study showed that patients with PD, despite their compromised brain function, were able to shift neural networks similar to controls. However, it seemed that visual cues provided a greater accuracy constraint on handwriting rather than offering unequivocal beneficial effects. Altogether, the results suggest that the effectiveness of using compensatory neural networks through applying external stimuli is task dependent and may compromise motor control during writing.

The laser shoes: A new ambulatory device to alleviate freezing of gait in Parkinson disease

OBJECTIVE

To assess, in a cross-sectional study, the feasibility and immediate efficacy of laser shoes, a new ambulatory visual cueing device with practical applicability for use in daily life, on freezing of gait (FOG) and gait measures in Parkinson disease (PD).

METHODS

We tested 21 patients with PD and FOG, both "off" and "on" medication. In a controlled gait laboratory, we measured the number of FOG episodes and the percent time frozen occurring during a standardized walking protocol that included FOG provoking circumstances. Participants performed 10 trials with and 10 trials without cueing. FOG was assessed using offline video analysis by an independent rater. Gait measures were recorded in between FOG episodes with the use of accelerometry.

RESULTS

Cueing using laser shoes was associated with a significant reduction in the number of FOG episodes, both "off" (45.9%) and "on" (37.7%) medication. Moreover, laser shoes significantly reduced the percent time frozen by 56.5% (95% confidence interval [CI] 32.5-85.8; p = 0.004) when "off" medication. The reduction while "on" medication was slightly smaller (51.4%, 95% CI -41.8 to 91.5; p = 0.075). These effects were paralleled by patients' positive subjective experience on laser shoes' efficacy. There were no clinically meaningful changes in the gait measures.

CONCLUSIONS

These findings demonstrate the immediate efficacy of laser shoes in a controlled gait laboratory, and offer a promising intervention with potential to deliver in-home cueing for patients with FOG.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for patients with PD, laser shoes significantly reduce FOG severity (both number and duration of FOG episodes).

Technology-Assisted Rehabilitation of Writing Skills in Parkinson's Disease: Visual Cueing versus Intelligent Feedback

Recent research showed that visual cueing can have both beneficial and detrimental effects on handwriting of patients with Parkinson's disease (PD) and healthy controls depending on the circumstances. Hence, using other sensory modalities to deliver cueing or feedback may be a valuable alternative. Therefore, the current study compared the effects of short-term training with either continuous visual cues or intermittent intelligent verbal feedback. Ten PD patients and nine healthy controls were randomly assigned to one of these training modes. To assess transfer of learning, writing performance was assessed in the absence of cueing and feedback on both trained and untrained writing sequences. The feedback pen and a touch-sensitive writing tablet were used for testing. Both training types resulted in improved writing amplitudes for the trained and untrained sequences. In conclusion, these results suggest that the feedback pen is a valuable tool to implement writing training in a tailor-made fashion for people with PD. Future studies should include larger sample sizes and different subgroups of PD for long-term training with the feedback pen.

Biomarkers and Stimulation Algorithms for Adaptive Brain Stimulation

The goal of this review is to describe in what ways feedback or adaptive stimulation may be delivered and adjusted based on relevant biomarkers. Specific treatment mechanisms underlying therapeutic brain stimulation remain unclear, in spite of the demonstrated efficacy in a number of nervous system diseases. Brain stimulation appears to exert widespread influence over specific neural networks that are relevant to specific disease entities. In awake patients, activation or suppression of these neural networks can be assessed by either symptom alleviation (i.e., tremor, rigidity, seizures) or physiological criteria, which may be predictive of expected symptomatic treatment. Secondary verification of network activation through specific biomarkers that are linked to symptomatic disease improvement may be useful for several reasons. For example, these biomarkers could aid optimal intraoperative localization, possibly improve efficacy or efficiency (i.e., reduced power needs), and provide long-term adaptive automatic adjustment of stimulation parameters. Possible biomarkers for use in portable or implanted devices span from ongoing physiological brain activity, evoked local field potentials (LFPs), and intermittent pathological activity, to wearable devices, biochemical, blood flow, optical, or magnetic resonance imaging (MRI) changes, temperature changes, or optogenetic signals. First, however, potential biomarkers must be correlated directly with symptom or disease treatment and network activation. Although numerous biomarkers are under consideration for a variety of stimulation indications the feasibility of these approaches has yet to be fully determined. Particularly, there are critical questions whether the use of adaptive systems can improve efficacy over continuous stimulation, facilitate adjustment of stimulation interventions and improve our understanding of the role of abnormal network function in disease mechanisms.

Italian validation of the Belastungsfragebogen Parkinson kurzversion (BELA-P-k): a disease-specific questionnaire for evaluation of the subjective perception of quality of life in parkinson's disease

BACKGROUND

Quality of life (QoL) is the sense of well-being perceived by people. The improvement of parkinsonian patient's QoL is a crucial goal for clinicians involved in rehabilitative care. In order to provide an appropriate endpoint for the assessment of the effectiveness of rehabilitation treatments on QoL of patients with Parkinson's Disease (PD), in this study we have first translated and then validated the Belastungsfragebogen Parkinson kurzversion (BELA-P-k). This tool allows evaluating separately two crucial aspects: i) the loss of personal autonomy in activities of daily life and ii) the psychological and psychosocial impact of the disease.

METHODS

The BELA-P-k was translated from Dutch into Italian. Subsequently 202 PD patients filled out the questionnaire. Patients were also evaluated by using the Parkinson Disease Questionnaire -39 (PDQ39), the Unified Parkinson's Disease Rating Scale (UPDRS), the Mini Mental State Examination (MMSE) and the Frontal Assessment Battery (FAB).

RESULTS

The internal consistency for total of two different scores Bothered by (Bb) and Need for Help (NfH) was excellent (p = 0.91) for both categories. The correlation between Bb and NfH categories was significant and strong, very-strong, ranging from 0.78 to 0.88 (all p < 0.0001). Finally, the value of Spearman r for the relationship between Bb and NfH items and PDQ 39 values were significant (p ≤ 0.003).

CONCLUSIONS

In conclusion, we validated the BELA-P-k and demonstrated that it is an appropriate and potentially useful tool for assessing QoL in the management of PD.

TRIALS REGISTRATION

This trial was retrospectively registered with ClinicalTrials.gov, NCT03073044.

Usability of Three-dimensional Augmented Visual Cues Delivered by Smart Glasses on (Freezing of) Gait in Parkinson's Disease

External cueing is a potentially effective strategy to reduce freezing of gait (FOG) in persons with Parkinson's disease (PD). Case reports suggest that three-dimensional (3D) cues might be more effective in reducing FOG than two-dimensional cues. We investigate the usability of 3D augmented reality visual cues delivered by smart glasses in comparison to conventional 3D transverse bars on the floor and auditory cueing via a metronome in reducing FOG and improving gait parameters. In laboratory experiments, 25 persons with PD and FOG performed walking tasks while wearing custom-made smart glasses under five conditions, at the end-of-dose. For two conditions, augmented visual cues (bars/staircase) were displayed via the smart glasses. The control conditions involved conventional 3D transverse bars on the floor, auditory cueing via a metronome, and no cueing. The number of FOG episodes and percentage of time spent on FOG were rated from video recordings. The stride length and its variability, cycle time and its variability, cadence, and speed were calculated from motion data collected with a motion capture suit equipped with 17 inertial measurement units. A total of 300 FOG episodes occurred in 19 out of 25 participants. There were no statistically significant differences in number of FOG episodes and percentage of time spent on FOG across the five conditions. The conventional bars increased stride length, cycle time, and stride length variability, while decreasing cadence and speed. No effects for the other conditions were found. Participants preferred the metronome most, and the augmented staircase least. They suggested to improve the comfort, esthetics, usability, field of view, and stability of the smart glasses on the head and to reduce their weight and size. In their current form, augmented visual cues delivered by smart glasses are not beneficial for persons with PD and FOG. This could be attributable to distraction, blockage of visual feedback, insufficient familiarization with the smart glasses, or display of the visual cues in the central rather than peripheral visual field. Future smart glasses are required to be more lightweight, comfortable, and user friendly to avoid distraction and blockage of sensory feedback, thus increasing usability.

Visual Dysfunction in Parkinson's Disease

This chapter describes the visual problems likely to be encountered in Parkinson's disease (PD) and whether such signs are useful in differentiating the parkinsonian syndromes. Visual dysfunction in PD may involve visual acuity, contrast sensitivity, color discrimination, pupil reactivity, saccadic and pursuit eye movements, motion perception, visual fields, and visual processing speeds. In addition, disturbance of visuospatial orientation, facial recognition problems, rapid eye movement (REM) sleep behavior disorder, and chronic visual hallucinations may be present. Problems affecting pupil reactivity, stereopsis, pursuit eye movement, and visuomotor adaptation, when accompanied by REM sleep behavior disorder, could be early features of PD. Dementia associated with PD is associated with enhanced eye movement problems, visuospatial deficits, and visual hallucinations. Visual dysfunction may be a useful diagnostic feature in differentiating PD from other parkinsonian symptoms, visual hallucinations, visuospatial dysfunction, and variation in saccadic eye movement problems being particularly useful discriminating features.

Palliative Care for Patients and Families With Parkinson's Disease

Parkinson's disease is the second most common neurodegenerative disease worldwide. There is widespread consensus that Parkinson patients, their carers, and clinicians involved in their care would benefit from a fully integrated, need-based provision of palliative care. However, the concept of palliative care in Parkinson's disease is still poorly defined and, consequently, poorly implemented into daily clinical practice. A particular challenge is the gradually progressive nature of Parkinson's disease-with insidiously increasing disability-making it challenging to clearly define the onset of palliative care needs for Parkinson patients. As people with Parkinson's disease are now living longer than in the past, future research needs to develop a more robust evidence-based approach to clarify the disease events associated with increased palliative care needs, and to examine these, prospectively, in an integrated palliative care service. The modern palliative care outlook, termed "simultaneous care,",is no longer restricted to the final stage of disease. It involves incorporating a continuity of care, effective management of the chronic-palliative interface, and a multidisciplinary network of professionals working both in the community and in specialized clinics, with active involvement of caregivers. Although promising, there is still a need to demonstrate the effectiveness of palliative care for patients with Parkinson's disease.

Curved Walking Rehabilitation with a Rotating Treadmill in Patients with Parkinson's Disease: A Proof of Concept

Training subjects to step-in-place eyes open on a rotating platform while maintaining a fixed body orientation in space [podokinetic stimulation (PKS)] produces a posteffect consisting in inadvertent turning around while stepping-in-place eyes closed [podokinetic after-rotation (PKAR)]. Since the rationale for rehabilitation of curved walking in Parkinson's disease is not fully known, we tested the hypothesis that repeated PKS favors the production of curved walking in these patients, who are uneasy with turning, even when straight walking is little affected. Fifteen patients participated in 10 training sessions distributed in 3 weeks. Both counterclockwise and clockwise PKS were randomly administered in each session. PKS velocity and duration were gradually increased over sessions. The velocity and duration of the following PKAR were assessed. All patients showed PKAR, which increased progressively in peak velocity and duration. In addition, before and at the end of the treatment, all patients walked overground along linear and circular trajectories. Post-training, the velocity of walking bouts increased, more so for the circular than the linear trajectory. Cadence was not affected. This study has shown that parkinsonian patients learn to produce turning while stepping when faced with appropriate training and that this capacity translates into improved overground curved walking.

Ocular and visual disorders in Parkinson's disease: Common but frequently overlooked

Patients with Parkinson's disease (PD) often compensate for their motor deficits by guiding their movements visually. A wide range of ocular and visual disorders threatens the patients' ability to benefit optimally from visual feedback. These disorders are common in patients with PD, yet they have received little attention in both research and clinical practice, leading to unnecessary - but possibly treatable - disability. Based on a literature search covering 50 years, we review the range of ocular and visual disorders in patients with PD, and classify these according to anatomical structures of the visual pathway. We discuss six common disorders in more detail: dry eyes; diplopia; glaucoma and glaucoma-like visual problems; impaired contrast and colour vision; visuospatial and visuoperceptual impairments; and visual hallucinations. In addition, we review the effects of PD-related pharmacological and surgical treatments on visual function, and we offer practical recommendations for clinical management. Greater awareness and early recognition of ocular and visual problems in PD might enable timely instalment of tailored treatments, leading to improved patient safety, greater independence, and better quality of life.

Pathophysiology of Motor Dysfunction in Parkinson's Disease as the Rationale for Drug Treatment and Rehabilitation

Cardinal motor features of Parkinson's disease (PD) include bradykinesia, rest tremor, and rigidity, which appear in the early stages of the disease and largely depend on dopaminergic nigrostriatal denervation. Intermediate and advanced PD stages are characterized by motor fluctuations and dyskinesia, which depend on complex mechanisms secondary to severe nigrostriatal loss and to the problems related to oral levodopa absorption, and motor and nonmotor symptoms and signs that are secondary to marked dopaminergic loss and multisystem neurodegeneration with damage to nondopaminergic pathways. Nondopaminergic dysfunction results in motor problems, including posture, balance and gait disturbances, and fatigue, and nonmotor problems, encompassing depression, apathy, cognitive impairment, sleep disturbances, pain, and autonomic dysfunction. There are a number of symptomatic drugs for PD motor signs, but the pharmacological resources for nonmotor signs and symptoms are limited, and rehabilitation may contribute to their treatment. The present review will focus on classical notions and recent insights into the neuropathology, neuropharmacology, and neurophysiology of motor dysfunction of PD. These pieces of information represent the basis for the pharmacological, neurosurgical, and rehabilitative approaches to PD.

Mild cognitive impairment in Parkinson's disease is improved by transcranial direct current stimulation combined with physical therapy

BACKGROUND

Parkinson's disease (PD) is characterized by both motor and cognitive deficits. In PD, physical exercise has been found to improve physical functioning. Recent studies demonstrated that repeated sessions of transcranial direct current stimulation led to an increased performance in cognitive and motor tasks in patients with PD.

OBJECTIVES

The present study investigated the effects of anodal transcranial direct current stimulation applied over the dorsolateral prefrontal cortex and combined with physical therapy in PD patients.

METHODS

A total of 20 patients with PD were assigned to 1 of 2 study groups: group 1, anodal transcranial direct current stimulation plus physical therapy (n = 10) or group 2, placebo transcranial direct current stimulation plus physical therapy (n = 10). The 2 weeks of treatment consisted of daily direct current stimulation application for 25 minutes during physical therapy. Long-term effects of treatment were evaluated on clinical, neuropsychological, and motor task performance at 3-month follow-up.

RESULTS

An improvement in motor abilities and a reduction of depressive symptoms were observed in both groups after the end of treatment and at 3-month follow-up. The Parkinson's Disease Cognitive Rating Scale and verbal fluency test performances increased only in the anodal direct current stimulation group with a stable effect at follow-up.

CONCLUSIONS

The application of anodal transcranial direct current stimulation may be a relevant tool to improve cognitive abilities in PD and might be a novel therapeutic strategy for PD patients with mild cognitive impairment. © 2016 International Parkinson and Movement Disorder Society.