Effectiveness of exergaming-based interventions for mobility and balance performance in older adults with Parkinson's disease: systematic review and meta-analysis of randomised controlled trials

Self-Management Systems for Patients and Clinicians in Parkinson Care: Protocol for an Integrated Scoping Review, Product Search, and Evaluation

BACKGROUND

Parkinson disease (PD) poses emotional and financial challenges to patients, families, caregivers, and health care systems. Self-management systems show promise in empowering people with PD and enabling more control over their treatment. The collaborative nature of PD care requires communication between patients and health care professionals. While past reviews explored self-management systems in PD diagnosis and symptom management with a focus on patient portals, there is limited research addressing the interconnectivity of systems catering to the needs of both patients and clinicians. A system's acceptability and usability for clinicians are pivotal for enabling comprehensive data collection and supporting clinical decision-making, which can enhance patient care and treatment outcomes.

OBJECTIVE

This review study aims to assess PD self-management systems that include a clinician portal and to determine which features enhance acceptability and usability for clinicians. The primary aim is to assess evidence of clinicians' acceptability and usability of self-management systems with a focus on the integration of systems into clinical workflows, data collection points, monitoring, clinical decision-making support, and extended education and training.

METHODS

The review will entail 3 separate stages: a literature review following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines, a product search, and an evaluation of the level of evidence for the identified products. For the first stage, 5 databases will be searched: PubMed, CINAHL, Scopus, ACM digital library, and IEEE Xplore. Studies eligible for inclusion will be qualitative, quantitative, and mixed methods studies examining patients' and clinician's perceptions of the acceptability and usability of digital health interventions, synthesized by a narrative qualitative analysis. A web search in the iOS Apple App Store and Android Google Play Store will identify currently available tools; the level of evidence for these will then be assessed using the Oxford Centre for Evidence-Based Medicine guidelines.

RESULTS

Literature search and screening began soon after submission of the protocol, and the review is expected to be completed by end of September 2024.

CONCLUSIONS

This review will examine currently available self-management systems in PD care, focusing on their acceptability and usability. This is significant because there is limited research addressing the integration of clinicians into these systems. The findings from this study may provide critical knowledge and insight to help inform future research and will contribute to the design of self-management systems that promote collaborative efforts in PD care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/58845.

A gamified virtual environment intervention for gait rehabilitation in Parkinson's Disease: co-creation and feasibility study

BACKGROUND

Treadmill gait training has been shown to improve gait performance in People with Parkinson's Disease (PwPD), and in combination with Virtual Reality, it can be an effective tool for gait rehabilitation. The addition of gamification elements can create a more stimulating and adherent intervention. However, implementation of new technologies in healthcare can be challenging. This study aimed to develop and evaluate the feasibility of a treadmill rehabilitation program in a Gamified Virtual Reality Environment (GVRE) for PwPD.

METHODS

The GVRE was developed following a user-centered design approach, involving both PwPD and physiotherapists in the development and evaluation of the intervention. The intervention consisted of a walking simulation in three different environments (countryside, city, and park), which had a progressive increase in difficulty. To test its feasibility, three sessions were carried out with four PwPD and four physiotherapists. To assess the usability, the System Usability Scale (SUS), Assistive Technology Usability Questionnaire for people with Neurological diseases (NATU Quest) and Simulator Sickness Questionnaire (SSQ) were used. To assess the intervention's acceptability, feedback and in-game performance was collected from participants.

RESULTS

Results showed the feasibility of the intervention, with a SUS score of 74.82 ± 12.62, and a NATU Quest score of 4.49 ± 0.62, and positive acceptability feedback. Participants showed clear preferences for naturalistic environments, and gamification elements were seen as positive. Difficulty settings worked as intended, but lowered enjoyment of the experience in some cases.

CONCLUSIONS

This intervention was successfully shown as a feasible option for the training of gait under Dual Task conditions for PwPD. It offers a safe and replicable environment in which complex situations can be trained. However, further iterations of the intervention need to be improved in order to guarantee accurate tracking and a more realistic training progression.

TRIAL REGISTRATION NUMBER

NCT05243394-01/20/2022.

PEMOCS: theory derivation of a concept for PErsonalized MOtor-Cognitive exergame training in chronic Stroke-a methodological paper with an application example

Background

Coping with residual cognitive and gait impairments is a prominent unmet need in community-dwelling chronic stroke survivors. Motor-cognitive exergames may be promising to address this unmet need. However, many studies have so far implemented motor-cognitive exergame interventions in an unstructured manner and suitable application protocols remain yet unclear. We, therefore, aimed to summarize existing literature on this topic, and developed a training concept for motor-cognitive exergame interventions in chronic stroke.

Methods

The development of the training concept for personalized motor-cognitive exergame training for stroke (PEMOCS) followed Theory Derivation procedures. This comprised (1.1) a thorough (narrative) literature search on long-term stroke rehabilitation; (1.2) a wider literature search beyond the topic of interest to identify analogies, and to induce creativity; (2) the identification of parent theories; (3) the adoption of suitable content or structure of the main parent theory; and (4) the induction of modifications to adapt it to the new field of interest. We also considered several aspects of the "Framework for Developing and Evaluating Complex Interventions" by the Medical Research Council. Specifically, a feasibility study was conducted, and refining actions based on the findings were performed.

Results

A training concept for improving cognitive functions and gait in community-dwelling chronic stroke survivors should consider the principles for neuroplasticity, (motor) skill learning, and training. We suggest using a step-based exergame training for at least 12 weeks, 2-3 times a week for approximately 45 min. Gentile's Taxonomy for Motor Learning was identified as suitable fundament for the personalized progression and variability rules, and extended by a third cognitive dimension. Concepts and models from related fields inspired further additions and modifications to the concept.

Conclusion

We propose the PEMOCS concept for improving cognitive functioning and gait in community-dwelling chronic stroke survivors, which serves as a guide for structuring and implementing motor-cognitive exergame interventions. Future research should focus on developing objective performance parameters that enable personalized progression independent of the chosen exergame type.

Effectiveness of sensor-based interventions in improving gait and balance performance in older adults: systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Sensor-based interventions (SI) have been suggested as an alternative rehabilitation treatment to improve older adults' functional performance. However, the effectiveness of different sensor technologies in improving gait and balance remains unclear and requires further investigation.

METHODS

Ten databases (Academic Search Premier; Cumulative Index to Nursing and Allied Health Literature, Complete; Cochrane Central Register of Controlled Trials; MEDLINE; PubMed; Web of Science; OpenDissertations; Open grey; ProQuest; and Grey literature report) were searched for relevant articles published up to December 20, 2022. Conventional functional assessments, including the Timed Up and Go (TUG) test, normal gait speed, Berg Balance Scale (BBS), 6-Minute Walk Test (6MWT), and Falling Efficacy Scale-International (FES-I), were used as the evaluation outcomes reflecting gait and balance performance. We first meta-analyzed the effectiveness of SI, which included optical sensors (OPTS), perception sensors (PCPS), and wearable sensors (WS), compared with control groups, which included non-treatment intervention (NTI) and traditional physical exercise intervention (TPEI). We further conducted sub-group analysis to compare the effectiveness of SI (OPTS, PCPS, and WS) with TPEI groups and compared each SI subtype with control (NTI and TPEI) and TPEI groups.

RESULTS

We scanned 6255 articles and performed meta-analyses of 58 selected trials (sample size = 2713). The results showed that SI groups were significantly more effective than control or TPEI groups (p < 0.000) in improving gait and balance performance. The subgroup meta-analyses between OPTS groups and TPEI groups revealed clear statistically significant differences in effectiveness for TUG test (mean difference (MD) = - 0.681 s; p < 0.000), normal gait speed (MD = 4.244 cm/s; p < 0.000), BBS (MD = 2.325; p = 0.001), 6MWT (MD = 25.166 m; p < 0.000), and FES-I scores (MD = - 2.036; p = 0.036). PCPS groups also presented statistically significant differences with TPEI groups in gait and balance assessments for normal gait speed (MD = 4.382 cm/s; p = 0.034), BBS (MD = 1.874; p < 0.000), 6MWT (MD = 21.904 m; p < 0.000), and FES-I scores (MD = - 1.161; p < 0.000), except for the TUG test (MD = - 0.226 s; p = 0.106). There were no statistically significant differences in TUG test (MD = - 1.255 s; p = 0.101) or normal gait speed (MD = 6.682 cm/s; p = 0.109) between WS groups and control groups.

CONCLUSIONS

SI with biofeedback has a positive effect on gait and balance improvement among a mixed population of older adults. Specifically, OPTS and PCPS groups were statistically better than TPEI groups at improving gait and balance performance, whereas only the group comparison in BBS and 6MWT can reach the minimal clinically important difference. Moreover, WS groups showed no statistically or clinically significant positive effect on gait and balance improvement compared with control groups. More studies are recommended to verify the effectiveness of specific SI. Research registration PROSPERO platform: CRD42022362817. Registered on 7/10/2022.

Self-Management Systems for Patients and Clinicians in Parkinson's Disease Care: A Scoping Review

Background

Digital self-management tools including mobile apps and wearables can enhance personalized care in Parkinson's disease, and incorporating patient and clinician feedback into their evaluation can empower users and nurture patient-clinician relationships, necessitating a review to assess the state of the art and refine their use.

Objective

This review aimed to summarize the state of the art of self-management systems used in Parkinson's disease management, detailing the application of self-management techniques and the integration of clinicians. It also aimed to provide a concise synthesis on the acceptance and usability of these systems from the clinicians' standpoint, reflecting both patient engagement and clinician experience.

Methods

The review was organized following the PRISMA extension for Scoping Reviews and PICOS frameworks. Studies were retrieved from PubMed, CINAHL, Scopus, ACM Digital Library, and IEEE Xplore. Data was collected using a predefined form and then analyzed descriptively.

Results

Of the 15,231 studies retrieved, 33 were included. Five technology types were identified, with systems combining technologies being the most evaluated. Common self-management strategies included educational material and symptom journals. Only 11 studies gathered data from clinicians or reported evidence of clinician integration; out of those, six studies point out the importance of raw data availability, data visualization, and integrated data summaries.

Conclusions

While self-management systems for Parkinson's disease are well-received by patients, the studies underscore the urgency for more research into their usability for clinicians and integration into daily medical workflows to enhance overall care quality.

Efficacy of virtual reality training on motor performance, activity of daily living, and quality of life in patients with Parkinson's disease: an umbrella review comprising meta-analyses of randomized controlled trials

OBJECTIVE

There are several meta-analyses of randomized controlled trials (RCTs) demonstrating the benefits of virtual reality (VR) training as an intervention for motor performance, activity of daily living (ADL) and quality of life (QoL) outcomes in patients with Parkinson's disease (PD). However, the aggregate evidence collected to date has not been thoroughly evaluated for strength, quality, and reproducibility. An umbrella review from published meta-analyses of RCTs was conducted to evaluate the strength and quality of existing evidence regarding the efficacy of VR training in improving the motor performance, ADL and QoL outcomes of patients with PD.

METHODS

PubMed, PsychInfo, Web of Science, and Scopus were searched to identify relevant meta-analysis of RCTs examining the effects of VR training on motor performance and quality of life outcomes in PD patients. We recalculated the effect sizes (Hedges'g) for VR training using DerSimonian and Laird (DL) random effects models. We further assessed between-study heterogeneity, prediction interval (PI), publication bias, small-size studies, and whether the results of the observed positive studies were better than would be expected by chance. Based on these calculations, the quality of evidence for each outcome was assessed by using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria.

RESULTS

Four meta-analysis with eight outcomes included in the umbrella review was recalculated effect size. Pooled results found VR training can large improve the basic balance ability, moderate improve the overall balance capacity and moderate improve the stride length in PD patients. For ADL and QoL, the effect sizes were pooled that suggested VR training can moderate improve ADL and QoL for PD patients. However, no statistically clear evidence was found in walking speed, motor function and gait function during VR training. The analyzed meta-analyses showed low-to-moderate methodological quality (AMSTAR2) as well as presented evidence of moderate-to-very low quality (GRADE). Tow adverse reactions were reported in the included meta-analyses.

CONCLUSIONS

In this umbrella review, a beneficial correlation between VR and balance ability, stride length, ADL and QoL in PD patients was discovered, especially for the very positive effect of VR on balance because of two of the eight outcomes related to balance ability showed large effect size. The observations were accompanied by moderate- to very low-quality rating evidence, supporting VR training as a practical approach to rehabilitation.

Visual feedback and age affect upper limb reaching accuracy and kinematics in immersive virtual reality among healthy adults

This cross-sectional study aimed to evaluate the effect of visual feedback, age and movement repetition on the upper limb (UL) accuracy and kinematics during a reaching task in immersive virtual reality (VR). Fifty-one healthy participants were asked to perform 25 trials of a reaching task in immersive VR with and without visual feedback of their hand. They were instructed to place, as accurately and as fast as possible, a controller held in their non-dominant hand in the centre of a virtual red cube of 3 cm side length. For each trial, the end-point error (distance between the tip of the controller and the centre of the cube), a coefficient of linearity (CL), the movement time (MT), and the spectral arc length of the velocity signal (SPARC), which is a movement smoothness index, were calculated. Multivariate analyses of variance were conducted to assess the influence of visual feedback, age and trial repetition on the average end-point error, SPARC, CL and MT, and their time course throughout the 25 trials. Providing visual feedback of the hand reduced average end-point error ( P  < 0.001) and MT ( P  = 0.044), improved SPARC ( P  < 0.001) but did not affect CL ( P  = 0.07). Younger participants obtained a lower mean end-point error ( P  = 0.037), a higher SPARC ( P  = 0.021) and CL ( P  = 0.013). MT was not affected by age ( P  = 0.671). Trial repetition increased SPARC ( P  < 0.001) and CL ( P  < 0.001), and reduced MT ( P  = 0.001) but did not affect end-point error ( P  = 0.608). In conclusion, the results of this study demonstrated that providing visual feedback of the hand and being younger improves UL accuracy and movement smoothness in immersive VR. UL kinematics but not accuracy can be improved with more trial repetitions. These findings could guide the future development of protocols in clinical rehabilitation and research.

Effects of Motor-Cognitive Dual-Task Standing Balance Exergaming Training on Healthy Older Adults' Standing Balance and Walking Performance

Objective: This study examined the effects of motor-cognitive dual-task exergaming standing balance training on healthy older adults' static, dynamic, and walking balance. Methods: Twenty-four adults older than 70 years (control group: n = 9, males = 6, balance training group: n = 15, males = 8) completed the experiment. Dual-tasking standing balance training comprised the accurate control of a ping-pong ball on a tray held with both hands, while standing on one leg (analog training) and three modules of Wii Fit™ exergaming (digital training). The duration of balance training was ∼15 minutes per day, 2 days per week for 8 weeks, in total 16 sessions. We measured one-leg standing time, functional reach distance, walking balance evaluated by the distance walked on a narrow beam (4-cm long, 4-cm wide, and 2-cm high) with single and dual tasking, habitual and maximal walking speed, and muscle strength of the hip extensor, hip abductor, hip adductor, knee extensor, and plantarflexor muscle groups in the right leg at baseline and after 8 weeks. Results: Control group decreased, but balance training group increased one-leg standing time. Only the balance training group improved functional reach distance and hip and knee extensor strength. There was no change in walking speed and walking balance in either group. In the balance training group, changes in maximal speed correlated with changes in dual-tasking walking balance and changes in one-leg standing time correlated with changes in single-tasking walking balance. Conclusion: These results suggest that 16 sessions of motor-cognitive dual-task standing exergaming balance training substantially improved healthy older adults' static and dynamic balance and leg muscle strength but failed to improve walking speed and walking balance. Balance exercises specific to walking balance need to be included in balance training to improve walking balance.

Digital Intervention For The Management Of Alzheimer's Disease

Alzheimer's disease (AD) is a progressive, multifactorial, chronic, neurodegenerative disease with high prevalence and limited therapeutic options, making it a global health crisis. Being the most common cause of dementia, AD erodes the cognitive, functional, and social abilities of the individual and causes escalating medical and psychosocial needs. As yet, this disorder has no cure and current treatment options are palliative in nature. There is an urgent need for novel therapy to address this pressing challenge. Digital therapeutics (Dtx) is one such novel therapy that is gaining popularity globally. Dtx provides evidence based therapeutic interventions driven by internet and software, employing tools such as mobile devices, computers, videogames, apps, sensors, virtual reality aiding in the prevention, management, and treatment of ailments like neurological abnormalities and chronic diseases. Dtx acts as a supportive tool for the optimization of patient care, individualized treatment and improved health outcomes. Dtx uses visual, sound and other non-invasive approaches for instance-consistent therapy, reminiscence therapy, computerised cognitive training, semantic and phonological assistance devices, wearables and computer-assisted rehabilitation environment to find applications in Alzheimer's disease for improving memory, cognition, functional abilities and managing motor symptom. A few of the Dtx-based tools employed in AD include "Memory Matters", "AlzSense", "Alzheimer Assistant", "smart robotic dog", "Immersive virtual reality (iVR)" and the most current gamma stimulation. The purpose of this review is to summarize the current trends in digital health in AD and explore the benefits, challenges, and impediments of using Dtx as an adjunctive therapy for the management of AD.