Four-week trunk-specific exercise program decreases forward trunk flexion in Parkinson's disease: A single-blinded, randomized controlled trial

Current interventional model for movement in Parkinson's disease: network meta-analysis based on the improvement of motor ability

Aim

To identify optimally therapeutic exercise interventions for improving motor ability among patients with Parkinson's disease (PD), we conducted a network meta-analysis (NMA) of randomized controlled trials comparing different exercise regimens.

Methods

Relevant RCTs were retrieved by searching PubMed, Embase, Cochrane, Web of Science, CINAHL, CBM, China National Knowledge Infrastructure (CNKI), Wan fang, VIP, and other databases from inception to July 9, 2023 is available in English as the primary language. Exercise outcomes as measured by Movement Disorder Society- Unified Parkinson's Disease Rating Scale Part III (MDS-UPDRS-III) score change were evaluated and ranked using STATA software version 18.0. All included studies were assessed for methodological quality using the Cochrane Risk of Bias tool.

Results

The final NMA included 71 studies involving 3,732 participants, 87 intervention experiments, and 27distinct interventions. Although most exercise interventions showed some efficacy (reducing MDS-UPDRS-III score), cumulative ranking probability surface (SUCRA) values indicated that the best exercise interventions for motor function improvement were archery (95.6%), riding a bicycle (80.9%), and binary rhythm dance (80.8%).

Conclusion

An exercise intervention comprising archery, cycling, and(or) binary rhythm dance may yield superior improvements in motor function among patients with Parkinson's disease.

Research Progress of Camptocormia in Parkinson Disease

Camptocormia, also known as bent spine syndrome, primarily affects individuals with Parkinson disease (PD). This review provides an overview of camptocormia in PD, covering its definition, epidemiology, causes, diagnosis, and treatment. In the epidemiology section, we delve into its prevalence, gender disparities, and ongoing genetic research. Regarding diagnosis and assessment, we discuss evolving diagnostic criteria and measurement techniques, as well as new diagnostic tools. For management and treatment, a wide array of options is available, from conservative methods such as physical therapy and botulinum toxin injections to surgical interventions such as spinal orthopedic surgery and deep brain stimulation. We stress the significance of personalized care and multidisciplinary collaboration. This comprehensive review aims to provide clinicians, researchers, and healthcare professionals with a comprehensive understanding of camptocormia in PD, highlighting its clinical features, diagnostic strategies, management approaches, and future perspectives.

Sensory training combined with motor training improves trunk proprioception in stroke patients: a single-blinded randomized controlled trial

OBJECTIVES

Inadequate trunk function is the underlying cause of many problems such as impaired balance and mobility. Although there have been trunk-based physiotherapy approaches in recent years, almost all of these approaches focus on motor problems. This study aims to investigate the effects of sensory training combined with trunk-centered Bobath exercises on trunk control and proprioception, balance, gait, and the activity of daily living (ADL).

MATERIALS AND METHODS

This study is a randomized controlled trial included with twenty-seven stroke patients. Participants were separated into two groups, Group 1; 'sensory training combined with trunk-centered Bobath exercises' and Group 2; 'trunk-centered Bobath exercises'. Trunk-centered Bobath exercises were used for motor training. Sensory training included transcutaneous electric nerve stimulation and a set of exercises that provide tactile and proprioceptive stimulation. Trunk Impairment Scale, Trunk Reposition Error, Berg Balance Scale, 2-minute walk test, and Barthel Index were used to assess trunk control, trunk proprioception, balance, gait, and ADL respectively.

RESULTS

Intra-group analysis results showed that trunk control, trunk proprioception, balance, gait, and ADL improved in both groups after treatment (p < 0.05). The changes in the Trunk Reposition Error values of the participants in Group 1 before and after treatment was found to be significantly higher than Group 2 (p < 0.05).

CONCLUSIONS

The findings indicated that the application of trunk-centered motor training is effective in improving trunk proprioception and trunk control, balance, gait, and ADL in stroke patients. Also, sensory training combined with trunk-centered motor training was found more effective in improving trunk proprioception than solely motor training.

Botulinum Toxin for Axial Postural Abnormalities in Parkinson's Disease: A Systematic Review

Axial postural abnormalities (APAs), characterized by their frequency, disabling nature, and resistance to pharmacological treatments, significantly impact Parkinson's disease and atypical Parkinsonism patients. Despite advancements in diagnosing, assessing, and understanding their pathophysiology, managing these complications remains a significant challenge. Often underestimated by healthcare professionals, these disturbances can exacerbate disability. This systematic review assesses botulinum toxin treatments' effectiveness, alone and with rehabilitation, in addressing APAs in Parkinson's disease, utilizing MEDLINE (PubMed), Web of Science, and SCOPUS databases for source material. Of the 1087 records retrieved, 16 met the selection criteria. Most research has focused on botulinum toxin (BoNT) as the primary treatment for camptocormia and Pisa syndrome, utilizing mostly observational methods. Despite dose and injection site variations, a common strategy was using electromyography-guided injections, occasionally enhanced with ultrasound. Patients with Pisa syndrome notably saw consistent improvements in APAs and pain. However, studies on the combined effects of botulinum toxin and rehabilitation are limited, and antecollis is significantly under-researched. These findings recommend precise BoNT injections into hyperactive muscles in well-selected patients by skilled clinicians, avoiding compensatory muscles, and underscore the necessity of early rehabilitation. Rehabilitation is crucial in a multidisciplinary approach to managing APAs, highlighting the importance of a multidisciplinary team of experts.

Treatment of axial postural abnormalities in parkinsonism disorders: A systematic review of pharmacological, rehabilitative and surgical interventions

Axial postural abnormalities (PA) are frequent, highly disabling, and drug-refractory motor complications affecting patients with Parkinson's disease (PD) or atypical parkinsonism. Over the past few years, advances have been reached across diagnosis, assessment, and pathophysiological mechanisms of PA. Nonetheless, their management remains a challenge, and these disturbances are generally overlooked by healthcare professionals, potentially resulting in their worsening and impact on patients' disabilities. From shared consensus-based assessment and diagnostic criteria, PA calls for interdisciplinary management based on the complexity and multifactorial pathogenesis. In this context, we conducted a systematic literature review to analyze the available pharmacological and non-pharmacological treatment options for PA in PD according to the new expert-based classification of axial PA in Parkinsonism. Different multidisciplinary approaches, including dopaminergic therapy adjustment, physiotherapy, botulinum toxin injection, and deep brain stimulation, can improve PA depending on its type and severity. An early, interdisciplinary approach is recommended in PD patients to manage PA.

Dynamic evaluation of spine kinematics in individuals with Parkinson's disease and freezing of gait

BACKGROUND

Freezing of gait (FoG) is an episodic failure of gait exposing people with Parkinson's disease (PD) to a high risk of falling. Despite growing evidence of the interconnection between impaired trunk control and FoG, a detailed description of spinal kinematics during walking is still lacking in this population.

RESEARCH QUESTION

Do spinal alterations impact gait performance in individuals with PD and FoG?

METHODS

We analyzed kinematic data of 47 PD participants suffering (PD-FOG, N = 24) or not suffering from FoG (PD-NFOG, N = 23) and 15 healthy controls (HCO) during quiet standing and unperturbed walking. We estimated the main spinal variables (i.e., spinal length, lordosis and kyphosis angles, trunk inclination), the pelvis angles, and the shoulder-pelvis angles during gait and standing. We studied differences across conditions and groups and the relationships between postural and gait parameters using linear regression methods.

RESULTS

During standing and walking, both PD groups showed increased trunk inclination and decreased lordosis angle with respect to HCO, as well as a decreased range in variation of kyphosis angle, pelvic obliquity, and shoulder-pelvis angles. Only PD-FOG participants showed reduced range of lordosis angle and spinal length compared to HCO. PD-FOG individuals were also not able to straighten their spine during walking compared to standing. Stride length and velocity were decreased in both patient groups compared to HCO, while swing duration was reduced only in the PD-FOG group. In individuals with FoG, trunk inclination and lordosis angle showed moderate but significant positive correlations with all gait alterations.

SIGNIFICANCE

Spine alterations impacted gait performance in individuals with PD suffering from FoG. Excessive trunk inclination and poor mastering of the lordosis spinal region may create an unfavourable postural precondition for forward walking. Physical therapy should target combined spinal and stepping alterations in these individuals.

Wearable devices for gait and posture monitoring via telemedicine in people with movement disorders and multiple sclerosis: a systematic review

INTRODUCTION

Wearable devices and telemedicine are increasingly used to track health-related parameters across patient populations. Since gait and postural control deficits contribute to mobility deficits in persons with movement disorders and multiple sclerosis, we thought it interesting to evaluate devices in telemedicine for gait and posture monitoring in such patients.

METHODS

For this systematic review, we searched the electronic databases MEDLINE (PubMed), SCOPUS, Cochrane Library, and SPORTDiscus. Of the 452 records retrieved, 12 met the inclusion/exclusion criteria. Data about (1) study characteristics and clinical aspects, (2) technical, and (3) telemonitoring and teleconsulting were retrieved, The studies were quality assessed.

RESULTS

All studies involved patients with Parkinson's disease; most used triaxial accelerometers for general assessment (n = 4), assessment of motor fluctuation (n = 3), falls (n = 2), and turning (n = 3). Sensor placement and count varied widely across studies. Nine used lab-validated algorithms for data analysis. Only one discussed synchronous patient feedback and asynchronous teleconsultation.

CONCLUSIONS

Wearable devices enable real-world patient monitoring and suggest biomarkers for symptoms and behaviors related to underlying gait disorders. thus enriching clinical assessment and personalized treatment plans. As digital healthcare evolves, further research is needed to enhance device accuracy, assess user acceptability, and integrate these tools into telemedicine infrastructure.

PROSPERO REGISTRATION

CRD42022355460.

Pain and the Non-Pharmacological Management of Pain in People with Parkinson's Disease

Pain is a distressing and universal experience, yet everyone's pain experience is influenced by a complex array of biological, psychological, and social factors. For people with Parkinson's disease (PwP), these biopsychosocial factors include neurodegeneration and the psychological and social factors that accompany living with a chronic, neurodegenerative condition in addition to the factors experienced by those in the general population (e.g., living with co-morbidities such as osteoarthritis). The way these factors influence each individual is likely to determine which pain management strategies are optimal for them. This review first describes pain and the biopsychosocial model of pain. It explores how pain is classified in Parkinson's disease (PD) and describes the three main types of pain: nociceptive, neuropathic, and nociplastic pain. This background provides context for a discussion of non-pharmacological pain management strategies that may aid in the management of pain in PwP; exercise, psychological strategies, acupuncture and massage. While there is little PD-specific research to inform the non-pharmacological management of pain, findings from current PD research are combined with that from chronic pain research to present recommendations for clinical practice. Recommendations include assessment that incorporates potential biopsychosocial contributors to pain that will then guide a holistic, multi-modal approach to management. As exercise provides overall benefits for PwP, those with chronic pain should be carefully monitored with exercise prescribed and adjusted accordingly. Research is needed to develop and evaluate multi-modal approaches to pain management that are delivered in a biopsychosocial framework.

Climb up! Head up! Climbing improves posture in Parkinson's disease. A secondary analysis from a randomized controlled trial

OBJECTIVE

To investigate the effect of sport climbing on a biomechanical marker of axial posture in patients with Parkinson's disease, as well as its association with age, body mass index and health-related quality-of-life outcome measures.

DESIGN

Pre-planned secondary analysis of our randomized controlled, semi-blind trial (unblinded patients, blinded assessors) comparing sport climbing to unsupervised exercise.

SETTING

Single-centre study conducted at the Department of Neurology of the Medical University of Vienna, Austria.

PARTICIPANTS

Forty-eight Parkinson's disease patients (aged 64 ± 8 years, Hoehn & Yahr stage 2-3) were included.

INTERVENTION

Sport climbers (n = 24) followed a 12-week, 90 min/week supervised top-rope sport climbing course in an indoor climbing gym. The unsupervised training group (n = 24) independently followed the 'European Physiotherapy Guidelines for Parkinson's Disease' and World Health Organization recommendations for an active lifestyle for 12 weeks.

MAIN MEASURES

Posture was assessed with the horizontal distance of the seventh cervical vertebra to the wall at baseline and after the intervention.

RESULTS

Participating in the sport climbing group significantly predicted the biomechanical marker of axial posture (P = 0.044). The improvement in the biomechanical marker did not affect the quality of life, depression, fatigue, physical activity or fear of falling. Participants in the sport climbing group showed a significantly decreased horizontal distance of the seventh cervical vertebra to the wall after the intervention (-1.7 cm (95%CI [-2.6, -0.8]). In the unsupervised training group, no difference was found (-0.5 cm; 95%CI -1.3, 0.2]).

CONCLUSIONS

We conclude that sport climbing improves a biomechanical marker of axial posture in Parkinson's disease.

Updates in Parkinson's Disease Integrative Therapies: an Evidence-Based Review

PURPOSE OF REVIEW

This review summarizes recent evidence-based integrative therapies for Parkinson's disease (PD) that may improve motor and non-motor symptoms, enhance quality of life, and alter disease progression.

RECENT FINDINGS

Imaging studies have demonstrated that aerobic exercise changes brain structure and function, while strength training improves posture and balance. Loneliness is associated with worsening PD severity, but social prescribing and cognitive behavioral therapy may effectively foster connections. Ayurvedic and traditional Chinese medicine practices including yoga, meditation, tai chi, and acupuncture may help improve mobility, mood, sleep, and quality of life. Art therapy enhances visuospatial skills, whereas music and dance therapy can alleviate freezing of gait. Several studies demonstrate successful use of these integrative strategies virtually, thereby improving patient accessibility and participation. PD management has broadened to include integrative approaches combining conventional and complementary therapies. Potential benefits of movement, nutrition, sleep, socialization, and mind-body practices have been confirmed with several recent randomized controlled trials.

Predictors and Pathophysiology of Axial Postural Abnormalities in Parkinsonism: A Scoping Review

Background

Postural abnormalities involving the trunk are referred to as axial postural abnormalities and can be observed in over 20% of patients with Parkinson's disease (PD) and in atypical parkinsonism. These symptoms are highly disabling and frequently associated with back pain and a worse quality of life in PD. Despite their frequency, little is known about the pathophysiology of these symptoms and scant data are reported about their clinical predictors, making it difficult to prompt prevention strategies.

Objectives

We conducted a scoping literature review of clinical predictors and pathophysiology of axial postural abnormalities in patients with parkinsonism to identify key concepts, theories and evidence on this topic.

Methods

We applied a systematic approach to identify studies, appraise quality of evidence, summarize main findings, and highlight knowledge gaps.

Results

Ninety-two articles were reviewed: 25% reported on clinical predictors and 75% on pathophysiology. Most studies identified advanced disease stage and greater motor symptoms severity as independent clinical predictors in both PD and multiple system atrophy. Discrepant pathophysiology data suggested different potential central and peripheral pathogenic mechanisms.

Conclusions

The recognition of clinical predictors and pathophysiology of axial postural abnormalities in parkinsonism is far from being elucidated due to literature bias, encompassing different inclusion criteria and measurement tools and heterogeneity of patient samples. Most studies identified advanced disease stage and higher burden of motor symptoms as possible clinical predictors. Pathophysiology data point toward many different (possibly non-mutually exclusive) mechanisms, including dystonia, rigidity, proprioceptive and vestibular impairment, and higher cognitive deficits.

Telerehabilitation-based trunk exercise training for motor symptoms of individuals with Parkinson's disease: A randomized controlled clinical trial

BACKGROUND

Poor gait and static balance performance may be associated with trunk muscles in individuals with Parkinson's disease.

AIM

The study aims at evaluating the effects of a home-based trunk exercise program on gait and balance performance in Parkinson's disease.

METHODS

A randomized controlled trial was conducted with 28 individuals with Parkinson's disease with Hoehn & Yahr stage II-IV. The control group (n = 14) performed upper and lower limb exercises, while the experimental group (n = 14) engaged in a trunk exercise program. Both groups performed home-based exercises three times daily for 3 weeks. At the end of interventions (post-training) and 4 weeks after post-training (follow-up), static balance (force plate) and gait (motion capture system) were evaluated. Mixed analysis of variance compared time × group interaction (α = 5%).

RESULTS

No time × group interaction was observed in the center of pressure displacement, center of pressure mean velocity, and anteroposterior and mediolateral center of pressure range during bipedal support with eyes opened and closed; and gait speed, hip, knee, and ankle range of motion during gait analysis. No intragroup differences were found.

CONCLUSION

Trunk strengthening exercises did not improve gait and balance compared with upper and lower limb exercises. The non-adherence rate (33%) to the remote intervention may have also hindered our results.

Predictors of balance in individuals with Parkinson's disease: A cross-sectional study

INTRODUCTION

Some previous studies investigated predictors of balance in individuals with Parkinson's Disease (PD). However, outcomes commonly evaluated in the rehabilitation of individuals with PD that could predict balance deficits have not yet been investigated.

OBJECTIVE

To determine whether the variables muscle strength, physical activity and depression are predictors of balance in individuals with PD.

MATERIAL AND METHODS

This is a cross-sectional study in which the investigated variables included: trunk and knee extensors' muscle strength (modified sphygmomanometer test - MST), physical activity level (Adjusted Human Activity Profile score) and depression (Patient Health Questionnaire-9 - PHQ-9). The outcome variable was balance, as assessed by the Mini-BESTest. Multiple regression analysis was used to determine which predictor variables explain the outcome variable.

RESULTS

A total of 50 individuals with PD, mean age 67 ± 8.8 years, 68% male, 40% HY 2.5 were included. The mean value of the dominant limb extensor muscle strength was 139 ± 45 mmHg, and the mean trunk extensor muscle strength value was 81.9 ± 19 mmHg. More than half of the sample (52%, n = 26) was classified as moderately active. Most of the sample (78%) had mild depression. The average Mini-BESTest score was 21 ± 5.4. The physical activity level explained 29% of the balance variance. When depression was included in the model, the explained variance increased to 35%. The other independent variables were not included in the model.

CONCLUSION

The findings of the present study showed that the physical activity level and depression were able to explain 35% of the balance variation.

Multiscale Entropy Algorithms to Analyze Complexity and Variability of Trunk Accelerations Time Series in Subjects with Parkinson's Disease

The aim of this study was to assess the ability of multiscale sample entropy (MSE), refined composite multiscale entropy (RCMSE), and complexity index (CI) to characterize gait complexity through trunk acceleration patterns in subjects with Parkinson's disease (swPD) and healthy subjects, regardless of age or gait speed. The trunk acceleration patterns of 51 swPD and 50 healthy subjects (HS) were acquired using a lumbar-mounted magneto-inertial measurement unit during their walking. MSE, RCMSE, and CI were calculated on 2000 data points, using scale factors (τ) 1-6. Differences between swPD and HS were calculated at each τ, and the area under the receiver operating characteristics, optimal cutoff points, post-test probabilities, and diagnostic odds ratios were calculated. MSE, RCMSE, and CIs showed to differentiate swPD from HS. MSE in the anteroposterior direction at τ4 and τ5, and MSE in the ML direction at τ4 showed to characterize the gait disorders of swPD with the best trade-off between positive and negative posttest probabilities and correlated with the motor disability, pelvic kinematics, and stance phase. Using a time series of 2000 data points, a scale factor of 4 or 5 in the MSE procedure can yield the best trade-off in terms of post-test probabilities when compared to other scale factors for detecting gait variability and complexity in swPD.

Camera- and Viewpoint-Agnostic Evaluation of Axial Postural Abnormalities in People with Parkinson's Disease through Augmented Human Pose Estimation

Axial postural abnormalities (aPA) are common features of Parkinson's disease (PD) and manifest in over 20% of patients during the course of the disease. aPA form a spectrum of functional trunk misalignment, ranging from a typical Parkinsonian stooped posture to progressively greater degrees of spine deviation. Current research has not yet led to a sufficient understanding of pathophysiology and management of aPA in PD, partially due to lack of agreement on validated, user-friendly, automatic tools for measuring and analysing the differences in the degree of aPA, according to patients' therapeutic conditions and tasks. In this context, human pose estimation (HPE) software based on deep learning could be a valid support as it automatically extrapolates spatial coordinates of the human skeleton keypoints from images or videos. Nevertheless, standard HPE platforms have two limitations that prevent their adoption in such a clinical practice. First, standard HPE keypoints are inconsistent with the keypoints needed to assess aPA (degrees and fulcrum). Second, aPA assessment either requires advanced RGB-D sensors or, when based on the processing of RGB images, they are most likely sensitive to the adopted camera and to the scene (e.g., sensor-subject distance, lighting, background-subject clothing contrast). This article presents a software that augments the human skeleton extrapolated by state-of-the-art HPE software from RGB pictures with exact bone points for posture evaluation through computer vision post-processing primitives. This article shows the software robustness and accuracy on the processing of 76 RGB images with different resolutions and sensor-subject distances from 55 PD patients with different degrees of anterior and lateral trunk flexion.

Rehabilitation Interventions for Improving Balance in Parkinson's Disease: A Narrative Review

INTRODUCTION

Postural instability is one of the latest clinical manifestations of Parkinson disease. Because of the limited therapeutic effect of pharmacological therapies, a favorable consideration has now become toward rehabilitation interventions. Thus, this study aimed to synthesize literature evidence to summarize the effects of rehabilitation interventions for improving balance in Parkinson disease.

MATERIALS AND METHODS

We conducted a narrative review of randomized-controlled clinical trials comparing the effects of interventions, control interventions, and no interventions on balance-related outcomes. A comprehensive search using the MEDLINE database was conducted from January 2000 to September 2021. This review included the following causes of balance-related impairments: inability to control body weight in the base of support, impaired attention and focus on balance, postural deformities, proprioceptive deficiency, sensory-motor integration, and coordination disorders, including visual and auditory-motor coordination.

RESULTS

Twenty randomized-controlled clinical trials were included in the review. Various balance-related outcomes were included. The included studies focused on the effectiveness of different rehabilitation interventions, including physical therapy, virtual reality and telerehabilitation, treadmill training, hydrotherapy, action observation training, balance and cues training interventions, and cognitive rehabilitation.

CONCLUSIONS

The results suggest that most of the included rehabilitation interventions have promising therapeutic effects in improving balance in Parkinson disease.

Efficacy of Specific Trunk Exercises in the Balance Dysfunction of Patients with Parkinson's Disease: A Systematic Review and Meta-Analysis

Parkinson's disease (PD) is a neurodegenerative pathology classified as a movement disorder. Physical exercise within a physiotherapy program is an important element to improve postural stability, balance and mobility in order to reduce falls in people with PD. The aim of this work was to determine the efficacy of specific balance and trunk mobility exercises, as well as their benefits for and effects on patients with idiopathic PD. A systematic review and meta-analysis was conducted according to PRISMA standards. The search was performed in five databases: Cochrane Library, SciELO, PEDro, Scopus and PubMed, in February 2022 with the following descriptors: Parkinson's disease, trunk, exercise, therapy and physical therapy. The inclusion criteria were randomized controlled trials (RCTs) over the last ten years. A meta-analysis on static and dynamic balance was conducted with the software Review Manager. Nine articles met the objectives and inclusion criteria, with a total of 240 participants. The trials had moderate methodological quality according to the PEDro scale. The studies included differed with regard to intervention protocol and outcome measures. Finally, eight studies were included in a quantitative analysis in which it was shown that trunk-specific exercises interventions did not significantly improve static balance (SMD = -0.10, 95% CI = -0.29, 0.08; p = 0.28) or dynamic balance (SMD = 0.64 95% CI = -0.24, 1.52; p = 0.15). However, significant differences were found in static balance measured subjectively using the Berg Balance Scale (SMD = -0.52, 95% CI = -1.01, -0.02; p = 0.04). Although some differences were not significant, the studies included in this systematic review consider that specific trunk exercises or balance training combined with muscle strengthening in patients with idiopathic PD should be a complement to pharmacological treatment for improving balance dysfunction and postural instability, preventing falls and promoting wellness.

Association of sagittal spinal alignment in the standing position with the masses and amounts of intramuscular non-contractile tissue of the trunk and lower extremity muscles in patients with Parkinson's disease

BACKGROUND

We examined the association of sagittal spinal alignment in the standing position with the masses and amounts of intramuscular non-contractile tissue of multiple trunk and lower extremity muscles, such as the hip joint muscles, measured using an ultrasound imaging device in patients with Parkinson's disease (PD).

METHODS

The participants were 10 patients with PD. Sagittal spinal alignment (thoracic kyphosis, lumbar lordosis, and sacral anterior inclination angles) in the standing position was measured using a Spinal Mouse. Muscle thicknesses and echo intensities of the trunk and lower extremity muscles, including the hip joint muscles, were also measured in the prone or supine position using an ultrasound imaging device.

FINDINGS

Partial correlation analysis with body height and weight as control variables showed that a low lumbar lordosis angle in the standing position was significantly associated with low thicknesses of the trunk extensor muscles (lumbar erector spinae and multifidus). Partial correlation analysis also revealed that a high sacral anterior inclination angle in the standing position was significantly associated with low lumbar multifidus muscle thickness. However, the thicknesses and echo intensities of the trunk flexor and hip joint muscles were not significantly related to thoracic kyphosis, lumbar lordosis, or sacral anterior inclination angles.

INTERPRETATION

The results of this study suggested the association between a low lumbar lordosis angle in the standing position and low lumbar erector spinae and multifidus muscle thicknesses and between a high sacral anterior inclination angle in the standing position and low lumbar multifidus muscle thickness in patients with PD.

A noninvasive method to quantify the impairment of spinal motion ability in Parkinson's disease

PURPOSE

There is a high demand on spinal surgery in patients with Parkinson's disease (PD) but the results are sobering. Although detailed clinical and radiological diagnostics were carried out with great effort and expense, the biodynamic properties of the spine of PD patients have never been considered. We propose a noninvasive method to quantify the impairment of motion abilities in patients with PD.

METHODS

We present an analytical cross-sectional study of 21 patients with severe PD. All patients underwent a biodynamic assessment during a standardized movement-choreography. Thus, individual spinal motion profiles of each patient were objectively assessed and compared with a large comparative cohort of individuals without PD. Moreover, clinical scores to quantify motor function and lumbar back pain were collected and X-ray scans of the spine in standing position were taken and analysed.

RESULTS

Biodynamic measurement showed that 36.9% of the assessed motions of all PD patients were severely impaired. Men were generally more functionally impaired than women, in 52% of all motion parameters. The neurological and radiological diagnostics recorded pathological values, of which UPDRS-III ON correlated with findings of the biodynamics assessment (R = 0.52, p = 0.02).

CONCLUSIONS

The decision to operate on a PD patient's spine is far-reaching and requires careful consideration. Neurological and radiological scores did not correlate with the biodynamics of the spine. The resulting motion profile could be used as individual predictive factor to estimate whether patients are eligible for spinal surgery or alternative therapies.

Interventions for preventing falls in Parkinson's disease

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

Task-related trunk training on balance, trunk control, pulmonary function and quality of life in patients with Parkinson's disease. A randomised controlled trial

Background/Aims

Stooped posture and ‘en-bloc’ movement of the trunk in people with Parkinson's disease are related to balance issues, pulmonary dysfunction and difficulty in daily tasks. The primary objective of this study was to examine the effects of task-related trunk training on balance in people with Parkinson's disease. The secondary objective was to observe whether trunk control, thoracic rotation range, pulmonary function and quality of life would change for patients with Parkinson's disease after trunk training.

Methods

A total of 32 individuals participated in this randomised controlled trial. They had a mean age of 70.8 years, with a modified Hoehn and Yahr Scale grade of 1.5–3, could take more than six steps in the 360° turn test, were scored as grade I or II on the retropulsion test and had an absence of severe cognitive deficits. Task-related trunk training emphasised the thoracic spine's extension and rotation in prone position on elbows, hands and knees and in kneeling, sitting and standing positions. Standard physiotherapy included breathing exercises, stretching of shoulder and neck muscles, balance and walking training. Both groups practised for 1 hour a day, 3 days a week over 6 weeks. The primary outcome measure was the Mini-Balance Evaluation Systems Test. The secondary outcome measures were the Trunk Control Test, thoracic rotation range of movement, Pulmonary Function Test and Parkinson's Disease Questionnaire-39.

Results

Repeated measure analysis of variance revealed significant group by time interaction for the Mini-Balance Evaluation Systems Test and thoracic rotation range (P<0.05), but not for the pulmonary function test and quality of life measures.

Conclusions

Task-related trunk training appears to be more beneficial in the balance capacity of individuals with Parkinson's disease than standard physiotherapy, but does not have any significant effects for pulmonary function and health-related quality of life.

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

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

Transcutaneous vagus nerve stimulation (tVNS) as a potential therapeutic application for neurodegenerative disorders - A focus on dysautonomia in Parkinson's disease

The understandings of pathogenic processes in major neurodegenerative diseases has significantly advanced in recent years, with evidence showing pathological spread of intraneuronal proteinaceous inclusions as a fundamental factor. In Parkinson's disease (PD), the culprit protein has been identified as α-synuclein as the main component for mediating progressive neurodegeneration. With severe pathology evident in the autonomic nervous system prior to clinical manifestations of PD, pathogenic spread can occur from the peripheral nervous system through key nuclei, such as the anterior olfactory nucleus and dorsal motor nucleus of the glossopharyngeal and vagal nerves, gradually reaching the brainstem, midbrain and cerebral cortex. With this understanding and the proposed involvement of the vagus nerve in disease progression in PD, notably occurring prior to characterized clinical motor features, it raises intriguing questions as to whether vagal nerve pathology can be accurately detected, and importantly used as a reliable marker for determining early neurodegeneration. Along with this is the potential use of vagus nerve neuromodulation for treatment of early disease symptoms like dysautonomia, for modulating sympatho-vagal imbalances and easing severe comorbidities of the disease. In this article, we take a closer look at the pathogenic transmission processes in neurodegenerative disorders that impact the vagus nerve, and how vagus nerve neuromodulation can be potentially applied as a therapeutic approach for major neurodegenerative disorders.

Designing a screening battery for exercisers with Parkinson's disease

PURPOSE

Develop a screening battery for persons with Parkinson's Disease (PD) that is easily administered in a short amount of time by community exercise professionals and measures changes in function.

METHODS

An integrated, stakeholder-engaged, mixed methods approach included interviews and meetings with community exercise professionals on the development of a screening battery. Persons with PD (n = 57, age = 72.1 ± 8.1 years) who were already enrolled in fitness classes or individualized training at three locations participated in the screening battery twice over 8-16 weeks and provided feedback. Trends from interviews and meeting notes were identified using summative content analysis. Quantitative changes in performance were compared with paired t-tests. Cohen's d effect sizes were calculated for all significant differences.

RESULTS

Current barriers for functional screenings included time and space. Using this feedback, we developed a screening battery that took under 20 min, required little equipment, had been previously validated, could be performed in individual and group settings, and provided objective feedback that was motivating for persons with PD to continue exercising. Persons with PD demonstrated improved functional performance on sit-to-stand (d = -0.71), two-minute walk test (d = -3.83), and arm curls (d = -0.78).

CONCLUSION

Test results can be a motivator for persons with PD and lead to increased exercise adherence. Easily administered tests can show improvements in this population. Community exercise professionals are able to safely screen persons with PD to detect functional deficits and assist with programming.Implications for RehabilitationRegular exercise can slow declines in physical function and quality of life in people with Parkinson's disease.Use of physical assessments in community exercise programs can improve motivation to exercise for this population.Physical assessments such as sit-to-stand and arm curls can be used to demonstrate improvements in people with Parkinson's disease.

A Three-Arm Parallel-Group Exploratory Trial documents balance improvement without much evidence of white matter integrity changes in people with multiple sclerosis following two months ambulatory neuroproprioceptive "facilitation and inhibition" physical therapy

BACKGROUND

Changes of white matter integrity in people with multiple sclerosis (MS) were documented following mainly motor/skill acquisitions physical therapy, while following neuroproprioceptive "facilitation, inhibition" (neurofacilitation) only by two pilot studies. Neurofacilitation has potential to induce white matter changes due to possibility to interfere with the neuronal tactility threshold, but stronger evidence is missing.

AIM

This study investigates whether neurofacilitation (three physical therapy types) induce white matter changes and if they relate to clinical improvement.

DESIGN

The Three-Arm Parallel-Group Exploratory Trial (NCT04355663).

SETTING

Each group underwent different kind of two months ambulatory therapy (Motor Program Activating Therapy, Vojta's reflex locomotion, and Functional Electric Stimulation in Posturally Corrected Position).

POPULATION

MS people with moderate disability.

METHODS

At baseline and after the program, participants underwent magnetic resonance diffusion tensor imaging (DTI) and clinical assessment. Fractional anisotropy maps obtained from DTI were further analyzed using tract-based spatial statistic exploring the mean values in the whole statistic skeleton. Moreover, additional exploratory analysis in 48 regions of white matter was done.

RESULTS

92 people were recruited. DTI data from 61 were analysed. The neurofacilitation (irrespective type of therapy) resulted in significant improvement on the Berg Balance Scale (p=0.0089), mainly driven by the Motor Program Activating Therapy. No statistically significant change in the whole statistic skeleton was observed (only a trend for decrement of fractional anisotropy after Vojta's reflex locomotion). Additional exploratory analysis confirmed significant decrement of fractional anisotropy in the right anterior corona radiata.

CONCLUSIONS

Neurofacilitation improved balance without much evidence of white matter integrity changes in people with MS.

CLINICAL REHABILITATION IMPACT

The study results point to the importance of neuroproprioceptive "facilitation and inhibition" physical therapy in management of balance in people with multiple sclerosis and the potential to induce white matter changes due to possibility to interfere with the neuronal tactility threshold.

Cytokine-, Neurotrophin-, and Motor Rehabilitation-Induced Plasticity in Parkinson's Disease

Neuroinflammation and cytokine-dependent neurotoxicity appear to be major contributors to the neuropathology in Parkinson's disease (PD). While pharmacological advancements have been a mainstay in the treatment of PD for decades, it is becoming increasingly clear that nonpharmacological approaches including traditional and nontraditional forms of exercise and physical rehabilitation can be critical adjunctive or even primary treatment avenues. Here, we provide an overview of preclinical and clinical research detailing the biological role of proinflammatory molecules in PD and how motor rehabilitation can be used to therapeutically modulate neuroinflammation, restore neural plasticity, and improve motor function in PD.

Current Studies and Future Directions of Exercise Therapy for Muscle Atrophy Induced by Heart Failure

Muscle atrophy is a common complication of heart failure. At present, there is no specific treatment to reverse the course of muscle atrophy. Exercise training, due to the safety and easy operation, is a recommended therapy for muscle atrophy induced by heart failure. However, the patients with muscle atrophy are weak in mobility and may not be able to train for a long time. Therefore, it is necessary to explore novel targets of exercise protection for muscle atrophy, so as to improve the quality of life and survival rate of patients with muscular atrophy induced by heart failure. This article aims to review latest studies, summarize the evidence and limitations, and provide a glimpse into the future of exercise for the treatment of muscle atrophy induced by heart failure. We wish to highlight some important findings about the essential roles of exercise sensors in muscle atrophy induced by heart failure, which might be helpful for searching potential therapeutic targets for muscle wasting induced by heart failure.

From the Gut to the Brain and Back: Therapeutic Approaches for the Treatment of Network Dysfunction in Parkinson's Disease

Parkinson's disease (PD) is a complex, multisystem, progressive, degenerative disorder characterized by severe, debilitating motor dysfunction, cognitive impairments, and mood disorders. Although preclinical research has traditionally focused on the motor deficits resulting from the loss of nigrostriatal dopaminergic neurons, up to two thirds of PD patients present separate and distinct behavioral changes. Loss of basal forebrain cholinergic neurons occurs as early as the loss of dopaminergic cells and contributes to the cognitive decline in PD. In addition, attentional deficits can limit posture control and movement efficacy caused by dopaminergic cell loss. Complicating the picture further is intracellular α-synuclein accumulation beginning in the enteric nervous system and diffusing to the substantia nigra through the dorsal motor neurons of the vagus nerve. It seems that α-synuclein's role is that of mediating dopamine synthesis, storage, and release, and its function has not been completely understood. Treating a complex, multistage network disorder, such as PD, likely requires a multipronged approach. Here, we describe a few approaches that could be used alone or perhaps in combination to achieve a greater mosaic of behavioral benefit. These include (1) using encapsulated, genetically modified cells as delivery vehicles for administering neuroprotective trophic factors, such as GDNF, in a direct and sustained means to the brain; (2) immunotherapeutic interventions, such as vaccination or the use of monoclonal antibodies against aggregated, pathological α-synuclein; (3) the continuous infusion of levodopa-carbidopa through an intestinal gel pad to attenuate the loss of dopaminergic function and manage the motor and non-motor complications in PD patients; and (4) specific rehabilitation treatment programs for drug-refractory motor complications.

Impact of Trunk Resistance and Stretching Exercise on Fall-Related Factors in Patients with Parkinson's Disease: A Randomized Controlled Pilot Study

BACKGROUND

This study aimed to examine the effect of a 12-week progressive trunk resistance and stretching exercise program on fall-related factors in patients with Parkinson's disease (PD).

METHODS

A randomized study assessed a progressive trunk resistance and stretching exercise program over a 12-week period. A total of 17 patients with PD participated and wererandomly allocated into an exercise group (n = 10) or a control group (n = 7). Participants in the exercise group completed the exercise program in 60- to 90-min sessions for three days per week. Primary and secondary outcome measures included the trunk mobility scale, functional fitness test, standing balance, and sit-to-walk test.

RESULTS

The exercise group showed improvements in functional fitness, trunk mobility, standing balance, and dynamic stability compared with the control group (all p < 0.05). The 2.44 m timed up and go test (odds ratio (OR): 0.125) and the 2 min step test (OR: 10.584) of the functional fitness test, and the first-step length (OR: 3.558) and first-toe clearance height (OR: 4.777) of the sit-to-walk test, were different between the groups following the exercise program.

CONCLUSION

This 12-week exercise program improved fall-related factors in patients with PD and may lead to prevention of fall-related injuries.

Clinical experience of comprehensive treatment on the balance function of Parkinson's disease

To investigate the effect of multi-disciplinary teamwork on balance performance of Parkinson's disease (PD).Sixteen primary Parkinson's disease patients (8 male, 8 female) treated with bilateral subthalamic nucleus deep brain stimulation (STN-DBS) were included in the study. The median age of patients was 60.5 years; all patients were in the Hoehn&Yahr (H&Y) 3 stage; the median PD duration of the disease was 9 years. For each patient, multi-disciplinary teamwork treatment including DBS, medication, physical therapy and psychotherapy proceeded. levodopa equivalent daily dose (LEDD, mg/day), life quality (PDQ-39), Motor disability (MDS-UPDRSIII) and balance performance (MDS-UPDRS 3.12, Berg Balance Scale BBS, Limits of Stability LoS) were assessed in different time and status respectively: preoperation (Med-off, Med-on), postoperation (Stim-Off/Med-Off, Stim-On/Med-Off, Stim-On/Med-On), 6 months postoperation (Stim-On/ Med-Off, Stim-On/Med-On) and 12 months postoperation (Stim-On/Med-Off, Stim-On/Med-On).The LEDD, life quality (PDQ-39) continued to improve during the follow-up, statistical difference were found in both 6 months postoperation and 12 months postoperation compared with preoperation. The Motor disability (MDS-UPDRSIII), balance performance (MDS-UPDRS 3.12, BBS) and the LoS (target acquisition percentage, trunk swing angle standard deviation, time) showed significant improvement in Stim-On/med-Off 6 months postoperation and 12 months postoperation separately compared with Med-Off preoperation.Multi-disciplinary teamwork for PD patients with STN-DBS could improve balance performance.

Does the Degree of Trunk Bending Predict Patient Disability, Motor Impairment, Falls, and Back Pain in Parkinson's Disease?

Background: Postural abnormalities in Parkinson's disease (PD) form a spectrum of functional trunk misalignment, ranging from a "typical" parkinsonian stooped posture to progressively greater degrees of spine deviation. Objective: To analyze the association between degree of postural abnormalities and disability and to determine cut-off values of trunk bending associated with limitations in activities of daily living (ADLs), motor impairment, falls, and back pain. Methods: The study population was 283 PD patients with ≥5° of forward trunk bending (FTB), lateral trunk bending (LTB) or forward neck bending (FNB). The degrees were calculated using a wall goniometer (WG) and software-based measurements (SBM). Logistic regression models were used to identify the degree of bending associated with moderate/severe limitation in ADLs (Movement Disorders Society Unified PD Rating Scale [MDS-UPDRS] part II ≥17), moderate/severe motor impairment (MDS-UPDRS part III ≥33), history of falls (≥1), and moderate/severe back pain intensity (numeric rating scale ≥4). The optimal cut-off was identified using receiver operating characteristic (ROC) curves. Results: We found significant associations between modified Hoehn & Yahr stage, disease duration, sex, and limitation in ADLs, motor impairment, back pain intensity, and history of falls. Degree of trunk bending was associated only with motor impairment in LTB (odds ratio [OR] 1.12; 95% confidence interval [CI], 1.03-1.22). ROC curves showed that patients with LTB of 10.5° (SBM, AUC 0.626) may have moderate/severe motor impairment. Conclusions: The severity of trunk misalignment does not fully explain limitation in ADLs, motor impairment, falls, and back pain. Multiple factors possibly related to an aggressive PD phenotype may account for disability in PD patients with FTB, LTB, and FNB.

The Study of Subthalamic Deep Brain Stimulation for Parkinson Disease-Associated Camptocormia

BACKGROUND Camptocormia is an axis symptom of Parkinson disease. It remains uncertain whether treatment with medications and surgery are effective. In this study, we assessed the efficacy of subthalamic nucleus deep brain stimulation (STN DBS) in Parkinson disease-associated camptocormia and explored some of its mechanisms. MATERIAL AND METHODS Parkinson disease-associated camptocormia was diagnosed by the following procedures. All patients underwent bilateral STN DBS. The patents' camptocormia was rated by degree and MDS Unified Parkinson's Disease Rating Scale (UPDRS) item 3.13 before and after DBS surgery. Rehabilitation and psychological interventions were used after surgery, in addition to adjustments of medication and stimulus parameters. The treatment effects on camptocormia were assessed comparing medication-off (presurgery) versus stimulation-on (post-surgery). Ethical approval for this study was provided through the Center of Human Research Ethics Committee (No. 2019-35). This study trial was registered in Chinese Clinical Trial Registry (No. ChiCTR1900022655). All the participants provided written informed consent. RESULTS After DBS surgery, all of study patients' symptoms were improved, with different levels of improvement. The minimum and maximum improvement rates were 20% and 100% respectively. The score of item 3.13 of the MDS-UPDRS III and the degree of camptocormia were found to be obviously improved (P<0.05). CONCLUSIONS STN DBS can improve Parkinson disease-associated camptocormia; STN DBS assisted with rehabilitation and psychological intervention appears to be more effective.