Movement Disorders in People With Parkinson Disease: A Model for Physical Therapy

Effectiveness of physiotherapy rehabilitation approaches for Parkinson's disease: A Durrës case study

BACKGROUND AND PURPOSE

The article's significance lies in the substantial rise in the risk of developing Parkinson's disease (PD), necessitating the exploration of various approaches to rehabilitation and medical treatment. The purpose of the article is to detect the direct effect of physiotherapy for patients with PD and to identify how it helps in slowing down cardio-pulmonary failure, improving the posture, balance, bradykinesia and tremor.

METHODS

The research utilised clinical data from 407 PD patients aged 30-100 years at the Central Polyclinic of Durrës, spanning 2011-2022, and included a systematic literature review and statistical analysis comparing physiotherapy outcomes with European Union standards.

RESULTS

The research demonstrates the efficiency of physiotherapy in the short and long term in the treatment of PD for patients and medical personnel. All information can be used to increase the functional abilities of patients and minimise complications after physiotherapy and to estimate the effectiveness of different exercises in delaying PD. Older adults, particularly those aged 71-80, are most affected by PD, with males more likely to be diagnosed. Physiotherapy rehabilitation improves motor symptoms, posture, and balance in 30-80-year-olds, but its effectiveness declines with age. Advanced rehabilitation methods in Italy lead to better outcomes, suggesting the potential for improvement in Durres disease.

CONCLUSIONS

The study emphasises the need for improved rehabilitation strategies for older patients by recommending tailored programs, advanced methods, standardisation, training, and long-term monitoring. Further research should concentrate on the long-term sustainability of physiotherapy benefits, the development of targeted interventions for older patients, and the integration of innovative therapeutic approaches.

Biomechanical Gait Analysis Using a Smartphone-Based Motion Capture System (OpenCap) in Patients with Neurological Disorders

This study evaluates the utility of OpenCap (v0.3), a smartphone-based motion capture system, for performing gait analysis in patients with neurological disorders. We compared kinematic and kinetic gait parameters between 10 healthy controls and 10 patients with neurological conditions, including stroke, Parkinson's disease, and cerebral palsy. OpenCap captured 3D movement dynamics using two smartphones, with data processed through musculoskeletal modeling. The key findings indicate that the patient group exhibited significantly slower gait speeds (0.67 m/s vs. 1.10 m/s, p = 0.002), shorter stride lengths (0.81 m vs. 1.29 m, p = 0.001), and greater step length asymmetry (107.43% vs. 91.23%, p = 0.023) compared to the controls. Joint kinematic analysis revealed increased variability in pelvic tilt, hip flexion, knee extension, and ankle dorsiflexion throughout the gait cycle in patients, indicating impaired motor control and compensatory strategies. These results indicate that OpenCap can effectively identify significant gait differences, which may serve as valuable biomarkers for neurological disorders, thereby enhancing its utility in clinical settings where traditional motion capture systems are impractical. OpenCap has the potential to improve access to biomechanical assessments, thereby enabling better monitoring of gait abnormalities and informing therapeutic interventions for individuals with neurological disorders.

Assessing impaired bed mobility in patients with Parkinson's disease: a scoping review

BACKGROUND

Although most patients with Parkinson's disease (PD) experience difficulties in bed mobility, evidence on the suitability of the methods for assessing impaired bed mobility in PD are lacking.

OBJECTIVES

To identify objective methods for assessing impaired bed mobility in PD and to discuss their clinimetric properties and feasibility for use in clinical practice.

DATA SOURCES

PubMed, Web of Science, and Cochrane Library were searched between 1995 and 2022.

SELECTION CRITERIA

Studies were included if they described an objective assessment method for assessing impaired bed mobility in PD.

DATA EXTRACTION AND DATA SYNTHESIS

Characteristics of the identified measurement methods such as clinimetric properties and feasibility were extracted by two authors. The methodological quality of studies was evaluated using the Appraisal of studies tool.

RESULTS

Twenty-three studies were included and categorised into three assessment methods: sensor-based assessments (48%), rating scales (39%), and timed-tests (13%). The risk of bias was low for all but one study, which was medium.

LIMITATIONS

Despite applying wide selection criteria, a relatively small number of studies were identified in our results.

CONCLUSION

Rating scales may be the most preferred for assessing impaired bed mobility in PD in clinical practice, until clinimetric validity are adequately demonstrated in the other assessment methods. CONTRIBUTION OF PAPER.

Analyzing Wav2Vec 1.0 Embeddings for Cross-Database Parkinson's Disease Detection and Speech Features Extraction

Advancements in deep learning speech representations have facilitated the effective use of extensive unlabeled speech datasets for Parkinson's disease (PD) modeling with minimal annotated data. This study employs the non-fine-tuned wav2vec 1.0 architecture to develop machine learning models for PD speech diagnosis tasks, such as cross-database classification and regression to predict demographic and articulation characteristics. The primary aim is to analyze overlapping components within the embeddings on both classification and regression tasks, investigating whether latent speech representations in PD are shared across models, particularly for related tasks. Firstly, evaluation using three multi-language PD datasets showed that wav2vec accurately detected PD based on speech, outperforming feature extraction using mel-frequency cepstral coefficients in the proposed cross-database classification scenarios. In cross-database scenarios using Italian and English-read texts, wav2vec demonstrated performance comparable to intra-dataset evaluations. We also compared our cross-database findings against those of other related studies. Secondly, wav2vec proved effective in regression, modeling various quantitative speech characteristics related to articulation and aging. Ultimately, subsequent analysis of important features examined the presence of significant overlaps between classification and regression models. The feature importance experiments discovered shared features across trained models, with increased sharing for related tasks, further suggesting that wav2vec contributes to improved generalizability. The study proposes wav2vec embeddings as a next promising step toward a speech-based universal model to assist in the evaluation of PD.

Influence of Verbal Instruction on Gait Training in Parkinson Disease: A Randomized Controlled Trial

OBJECTIVE

Verbal instruction is one of the most commonly used methods that therapists use to correct walking pattern for people with Parkinson disease. This study aimed to compare the long-term training effects of two different verbal instructions that either asked the participants to "take big steps" or "strike the ground with the heel" on walking ability in individuals with Parkinson disease.

DESIGN

Forty-five participants with Parkinson disease were randomized into the big-step or heel strike group. The participants underwent 12 sessions of treadmill and overground gait training. Throughout the interventions, the big-step group received an instruction to "take big steps," while the heel strike group received an instruction to "strike the ground with your heel." The primary outcome was gait performance, including velocity, stride length, cadence, and heel strike angle. The participants were assessed before, immediately after, and 1 mo after training.

RESULTS

Both groups showed significant improvements in gait performance after training. The heel strike group showed continuous improvements in velocity and stride length during the follow-up period; however, the big-step group showed slightly decreased performance.

CONCLUSIONS

A verbal instruction emphasizing heel strike can facilitate long-term retention of walking performance in people with Parkinson disease.

Too little or too much nocturnal movements in Parkinson's disease: A practical guide to managing the unseen

Nocturnal and sleep-related motor disorders in people with Parkinson's disease (PD) have a wide spectrum of manifestations and present a complex clinical picture. Problems can arise due to impaired movement ability (hypokinesias), e.g. nocturnal hypokinesia or early-morning akinesia, or to excessive movement (hyperkinesias), e.g. end-of-the-day dyskinesia, parasomnias, periodic limb movement during sleep and restless legs syndrome. These disorders can have a significant negative impact on the sleep, daytime functional ability, and overall quality of life of individuals with PD and their carers. The debilitating motor issues are often accompanied by a combination of non-motor symptoms, including pain and cramping, which add to the overall burden. Importantly, nocturnal motor disorders encompass a broader timeline than just the period of sleep, often starting in the evening, as well as occurring throughout the night and on awakening, and are not just limited to problems of insomnia or sleep fragmentation. Diagnosis can be challenging as, in many cases, the 'gold standard' assessment method is video polysomnography, which may not be available in all settings. Various validated questionnaires are available to support evaluation, and alternative approaches, using wearable sensors and digital technology, are now being developed to facilitate early diagnosis and monitoring. This review sets out the parameters of what can be considered normal nocturnal movement and describes the clinical manifestations, usual clinical or objective assessment methods, and evidence for optimal management strategies for the common nocturnal motor disorders that neurologists will encounter in people with PD in their clinical practice.

Effectiveness and Safety of Meridian Activation Remedy System for Alleviating Motor Symptoms in Parkinson's Disease: an Observational Study

Background

Parkinson's disease (PD) lacks disease-modifying drugs or sustainable interventions, creating an unmet treatment need. Investigating complementary and alternative medicines aims to improve PD patients' quality of life by alleviating symptoms and delaying the course of the disease.

Objectives

In this single-center, prospective, observational, single-arm study, we aimed to assess the effectiveness and safety of acupuncture combined with exercise therapy and the Meridian Activation Remedy System (MARS).

Methods

From March to October 2021, 13 PD patients with Hoehn and Yahr stages 1 to 3 were recruited. For 8 weeks, MARS intervention was carried out twice a week. T-statistics were used to evaluate functional near-infrared spectroscopy (fNIRS) and GAITRite outcomes. All of the remaining outcome variables were evaluated using the Wilcoxon signed-rank test.

Results

The MARS intervention significantly reduced PD patients' Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDSUPDRS) Part III score (from 20.0 ± 11.8 to 8.8 ± 5.5, p = 0.003), 10-meter walk test speed (from 9.5 ± 1.8 to 8.7 ± 1.3 seconds, p = 0.040), and timed up and go time (from 9.8 ± 1.8 to 8.9 ± 1.4 seconds, p = 0.040). Moreover, the MDS-UPDRS Part II, fNIRS hemodynamics, 360-degree turn test, fall efficacy scale, and Parkinson's Disease Questionnaire 39 scores improved but not significantly. All participants completed the 8-week intervention without any adverse reactions.

Conclusion

An 8-week MARS intervention improved motor symptoms in PD patients. In particular, improvements in UPDRS Part III scores exhibited large clinically important differences. The findings are encouraging, and a randomized controlled trial will be conducted to determine the efficacy and cost-effectiveness of MARS intervention.

The effects of dance interventions on physical function and quality of life among middle-aged and older adults: A systematic review

BACKGROUND

Fundamental physical functions such as postural control and balance are vital in preserving everyday life, affecting an individual's quality of life. Dance is a physical activity that offers health advantages across various life stages. Nevertheless, the effects of dance interventions on physical function, postural control, and quality of life among older adults have remained underexplored. The review aimed to examine the strength of evidence for dance interventions on physical function and quality of life among middle-aged and older adults.

METHODS

A systematic review was conducted across four databases (PubMed, Cochrane Library, Web of Science, and Medline), focusing on studies involving more than four weeks of dance interventions. MeSH terms [dance or dance intervention or dance rehabilitation or dance movement] and [motor function or functional capacity or postural control or functional mobility or mobility or postural balance or balance or flexibility or gait] and [well-being or quality of life or life satisfaction] were utilized in the search. This review was registered in the PROSPERO database (CRD42023422857). Included studies were assessed using the Cochrane Risk of Bias.

RESULTS

The search revealed 885 studies, and 16 met the inclusion criteria. The effects of various dance genres on physical functions and quality of life were compared. Most studies showed that dance intervention improved physical function, balance, postural control and quality of life. Dance intervention showed a high level of adherence compared to physiotherapy, self-care, conventional therapy, and aerobic and resistance exercise.

CONCLUSION

In terms of improving physical function and quality of life, structured dance is a safe and relatively effective alternative to exercise. Note the effect of movement selection and intensity in the dance interventions. Dance with music may increase participants' interest, encouraging more physical activity among middle-aged and older adults.

Nanoplastics exacerbate Parkinson's disease symptoms in C. elegans and human cells

The increasing prevalence of nanoplastics in our environment due to the widespread use of plastics poses potential health risks that are not yet fully understood. This study examines the physiological and neurotoxic effects of these minuscule nanoplastic particles on the nematode Caenorhabditis elegans as well as on human cells. Here, we find that 25 nm polystyrene nanoplastic particles can inhibit animal growth and movement at very low concentrations, with varying effects on their surface groups. Furthermore, these nanoplastic particles not only accumulate in the digestive tract but also penetrate further into extraintestinal tissues. Such nanoplastics significantly compromise the integrity of the intestinal barrier, leading to "leaky gut" conditions and cause mitochondrial fragmentation in muscles, which possibly explains the observed movement impairments. A striking discovery was that these nanoplastics exacerbate symptoms similar to those of Parkinson's disease (PD), including dopaminergic neuronal degeneration, locomotor dysfunction, and accumulation of α-Synuclein aggregates. Importantly, our study demonstrates that the detrimental effects of nanoplastics on the aggregation of α-Synuclein extend to both C. elegans and human cell models of PD. In conclusion, our research highlights the potential health hazards linked to the physicochemical properties of nanoplastics, underlining the urgency of understanding their interactions with biological systems. ENVIRONMENTAL IMPLICATION: The escalating prevalence of nanoplastics in the environment due to widespread plastic usage raises potential health risks. Studies conducted on C. elegans indicate that even low concentrations of 25 nm polystyrene nanoplastics can impair growth and movement. These particles accumulate in the digestive system, compromising the intestinal barrier, causing "leaky gut", as well as inducing Parkinson's-like symptoms. Importantly, in both C. elegans and human cell models of Parkinson's disease, such nanoplastics penetrate tissues or cells and increase α-Synuclein aggregates. This underscores the urgent need to understand the interactions of nanoplastics with biological systems and highlights potential environmental and health consequences.

Effects of Functional Electrical Stimulation Cycling Combined With Arm Cranking Exercise on Cardiorespiratory Fitness in People With Central Nervous System Disorders: A Systematic Review and Meta-analysis

OBJECTIVE

To examine the evidence regarding the potential of hybrid functional electrical stimulation (FES) cycling for improving cardiorespiratory fitness for people with a mobility disability related to a central nervous system (CNS) disorder.

DATA SOURCES

Nine electronic databases: MEDLINE, EMBASE, Web of Science, CINAHL, PsycInfo, SPORTDiscus, Pedro, Cochrane, and Scopus, were searched from inception until October 2022.

STUDY SELECTION

Search terms included multiple sclerosis, spinal cord injury (SCI), stroke, Parkinson's disease, cerebral palsy, synonyms of FES cycling, arm crank ergometry (ACE) or hybrid exercise, and V̇o2. All experimental studies, including randomized controlled trials that included an outcome measure related to peak or sub-maximal V̇o2 were eligible.

DATA EXTRACTION

From a total of 280 articles, 13 were studies included. The Downs and Black Checklist was used to assess study quality. Random effects (Hedges' g) meta-analyses were undertaken to determine whether there were differences in V̇o2peak during acute bouts of hybrid FES cycling vs other modes of exercise and changes resulting from longitudinal training.

DATA SYNTHESIS

During acute bouts of exercise, hybrid FES cycling was moderately more effective than ACE (effect size [ES] of 0.59 (95% CI 0.15-1.02, P=.008) in increasing V̇o2peak from rest. There was a large effect on the increase of V̇o2peak from rest for hybrid FES cycling compared with FES cycling (ES of 2.36 [95% CI 0.83-3.40, P=.003]). Longitudinal training with hybrid FES cycling showed a significant improvement in V̇o2peak from pre to post intervention with a large, pooled ES of 0.83 (95% CI 0.24-1.41, P=.006).

CONCLUSIONS

Hybrid FES cycling produced higher V̇o2peak compared with ACE or FES cycling during acute bouts of exercise. Hybrid FES cycling can improve cardiorespiratory fitness in people with SCI. Additionally, there is emerging evidence that hybrid FES cycling might increase aerobic fitness in people with mobility disability related to CNS disorders.

Nordic walking training in persons with Parkinson's disease: Individualized prescription-A case series

INTRODUCTION

Physical therapy interventions for patients with Parkinson's disease prioritize task-specific exercise to address gait and motor dysfunction. Nordic walking (NW) is a moderate intensity exercise promoting walking speed and rhythm. This case series describes the application of customized NW training in individuals with varied severity of Parkinson's gait dysfunction and the outcomes specific to gait, motor and non-motor symptoms; and NW engagement and retention in the follow-up phase.

CASE DESCRIPTION

Three individuals with idiopathic PD (two males and one female; ages 59-69; Hoehn & Yahr stages II-III) participated. Supervised NW training phase included 15 one-hour sessions over 6-weeks, individually progressed for each participant. During the 3-month follow-up phase independent NW exercise was prescribed 3 times a week. Primary outcome measures examined gait function and impairment-based measures assessed Parkinson's motor and nonmotor symptoms.

OUTCOMES

Participants improved in: 10-Meter walk-fast speed (0.13, 0.18, 0.15 m/s; respectively); 6-Minute Walk distance (137.5, 56.4, 129.4 m, respectively); Unified Parkinson's Disease Rating Scale-Motor Score (-6, -7, -14, respectively); and all Timed-Up-Go subtests. Participant 2 had 44.4% decline in freezing episodes and reduced fall rate. Participants' gains were retained at the 3-month follow-up.

DISCUSSION

This case series suggests that NW has therapeutic benefits for three individuals with varied Parkinson's gait dysfunction. Independent NW exercise was sustained post-training and motor and gait function gains were retained.

The effects of augmented and virtual reality gait training on balance and gait in patients with Parkinson's disease

OBJECTIVE

Augmented reality (AR) and virtual reality (VR) facilitate motor learning by enabling the practice of task-specific activities in a rich environment. Therefore, AR and VR gait training may improve balance and gait in Parkinson's Disease (PD).

METHODS

Thirty patients with PD were randomly divided into study (n = 15) and control (n = 15) groups. The study group was given AR and VR gait training combined with conventional training. The control group was given conventional training only. The training was applied to both groups 3 days a week for 6 weeks. Motor symptoms with the Unified Parkinson Disease Rating Scale-Motor Examination (UPDRS-III), balance with posturography and Berg Balance Scale (BBS), perceived balance confidence with Activity-Specific Balance Confidence Scale (ABC), gait with spatio-temporal gait analysis, and functional mobility with Timed Up and Go Test (TUG) were assessed.

RESULTS

At the end of the study; UPDRS-III, posturography measurements, BBS, ABC, spatio-temporal gait parameters, and TUG improved in the study group (p < 0.05), while BBS, ABC, and only spatial gait parameters (except for step width) improved in the control group (p < 0.05). There was no change in posturography measurement, temporal gait parameters, and TUG in control group (p > 0.05). When the developed parameters in both groups were compared, the amount of improvement in BBS and ABC was found similar (p > 0.05), while the improvement in the other parameters was found higher in the study group (p < 0.05).

CONCLUSION

It was concluded that AR and VR gait training provides the opportunity to practice walking with different tasks in increasingly difficult environments, thus improving balance and walking by facilitating motor learning.

A computational musculoskeletal arm model for assessing muscle dysfunction in chronic obstructive pulmonary disease

Computational models have been used extensively to assess diseases and disabilities effects on musculoskeletal system dysfunction. In the current study, we developed a two degree-of-freedom subject-specific second-order task-specific arm model for characterizing upper-extremity function (UEF) to assess muscle dysfunction due to chronic obstructive pulmonary disease (COPD). Older adults (65 years or older) with and without COPD and healthy young control participants (18 to 30 years) were recruited. First, we evaluated the musculoskeletal arm model using electromyography (EMG) data. Second, we compared the computational musculoskeletal arm model parameters along with EMG-based time lag and kinematics parameters (such as elbow angular velocity) between participants. The developed model showed strong cross-correlation with EMG data for biceps (0.905, 0.915) and moderate cross-correlation for triceps (0.717, 0.672) within both fast and normal pace tasks among older adults with COPD. We also showed that parameters obtained from the musculoskeletal model were significantly different between COPD and healthy participants. On average, higher effect sizes were achieved for parameters obtained from the musculoskeletal model, especially for co-contraction measures (effect size = 1.650 ± 0.606, p < 0.001), which was the only parameter that showed significant differences between all pairwise comparisons across the three groups. These findings suggest that studying the muscle performance and co-contraction, may provide better information regarding neuromuscular deficiencies compared to kinematics data. The presented model has potential for assessing functional capacity and studying longitudinal outcomes in COPD.

Intermittent theta-burst stimulation combined with physical therapy as an optimal rehabilitation in Parkinson's disease: study protocol for a randomised, double-blind, controlled trial

BACKGROUND

First-line rehabilitative strategies to improve motor deficits are based on functional training (physical or occupational therapy), which has been demonstrated to facilitate neural reorganisation. Accumulating evidence suggests that non-invasive brain stimulation techniques, such as repetitive TMS (rTMS), may enhance neuroplasticity, thereby facilitating neural reorganisation and recovery from Parkinson's disease. Evidence also shows that intermittent theta-burst stimulation (iTBS) can improve motor function and quality of life in patients by promoting the excitability and neural remodelling of cerebral cortex. We aimed to combine iTBS stimulation with physiotherapy to improve the rehabilitation effect compared to physiotherapy alone in patients with Parkinson's disease.

METHODS

This randomised, double-blind clinical trial will enrol 50 Parkinson's disease patients aged 45-70 years with Hoehn and Yahr scale scores of 1-3. Patients are randomly assigned to either the iTBS + physiotherapy or sham-iTBS + physiotherapy group. The trial consists of a 2-week double-blind treatment period and a 24-week follow-up period. iTBS and sham-iTBS will be administered twice daily for 10 days based on physiotherapy. The primary outcome will be the third part of Movement Disorders-Unified Parkinson's Disease Rating Scale (MDS-UPDRS III) from the baseline to the first 2 days following completion hospitalised intervention. The secondary outcome will be 39-item Parkinson's Disease Questionnaire (PDQ-39) at 4 weeks, 12 weeks and 24 weeks after intervention. Tertiary outcomes are clinical evaluations and mechanism study outcomes such as NMSS, 6MWD, 10MT, TUG, BBS, MRI, and EEG, the length of time between the drug needs to be adjusted when symptoms fluctuate.

DISCUSSION

The aim of this study is to demonstrate that iTBS can promote overall function and quality of life in Parkinson's disease patients using physiotherapy and that this efficacy may be associated with altered neuroplasticity in exercise-related brain regions. The iTBS combined with physiotherapy training model will be evaluated during a 6-month follow-up period. With significant improvement in quality of life and motor function, iTBS combined with physiotherapy can be considered as a first-line rehabilitation option for Parkinson's disease. The potential of iTBS to enhance neuroplasticity in the brain should have a more positive impact in increasing the generality and efficiency of physiotherapy, improving the quality of life and overall functional status of patients with Parkinson's disease.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200056581. Registered on 8 February 2022.

Rate control deficits during pinch grip and ankle dorsiflexion in early-stage Parkinson's disease

BACKGROUND

Much of our understanding of the deficits in force control in Parkinson's disease (PD) relies on findings in the upper extremity. Currently, there is a paucity of data pertaining to the effect of PD on lower limb force control.

OBJECTIVE

The purpose of this study was to concurrently evaluate upper- and lower-limb force control in early-stage PD and a group of age- and gender-matched healthy controls.

METHODS

Twenty individuals with PD and twenty-one healthy older adults participated in this study. Participants performed two visually guided, submaximal (15% of maximum voluntary contractions) isometric force tasks: a pinch grip task and an ankle dorsiflexion task. PD were tested on their more affected side and after overnight withdrawal from antiparkinsonian medication. The tested side in controls was randomized. Differences in force control capacity were assessed by manipulating speed-based and variability-based task parameters.

RESULTS

Compared with controls, PD demonstrated slower rates of force development and force relaxation during the foot task, and a slower rate of relaxation during the hand task. Force variability was similar across groups but greater in the foot than in the hand in both PD and controls. Lower limb rate control deficits were greater in PD with more severe symptoms based on the Hoehn and Yahr stage.

CONCLUSIONS

Together, these results provide quantitative evidence of an impaired capacity in PD to produce submaximal and rapid force across multiple effectors. Moreover, results suggest that force control deficits in the lower limb may become more severe with disease progression.

Dancing for Parkinson's Disease Online: Clinical Trial Process Evaluation

Background: Dancing is an engaging physical activity for people living with Parkinson's disease (PD). We conducted a process evaluation for a PD trial on online dancing. Methods: "ParkinDANCE Online" was co-produced by people with PD, healthcare professionals, dance instructors, and a PD organisation. The evaluation mapped the following inputs: (i) stakeholder steering group to oversee program design, processes, and outcomes; (ii) co-design of online classes, based on a research evidence synthesis, expert advice, and stakeholder recommendations; (iii) trial fidelity. The key activities were (i) the co-design of classes and instruction manuals, (ii) the education of dance teachers, (iii) fidelity checking, (iv) online surveys, (v) and post-trial focus groups and interviews with participants. The outputs pertained to: (i) recruitment, (ii) retention, (iii) adverse events, (iv) fidelity, (v) protocol variations, and (vi) participant feedback. Results: Twelve people with PD, four dance instructors and two physiotherapists, participated in a 6-week online dance program. There was no attrition, nor were there any adverse events. Program fidelity was strong with few protocol variations. Classes were delivered as planned, with 100% attendance. Dancers valued skills mastery. Dance teachers found digital delivery to be engaging and practical. The safety of online testing was facilitated by careful screening and a home safety checklist. Conclusions: It is feasible to deliver online dancing to people with early PD.

Effects of an incentive spirometer versus a threshold inspiratory muscle trainer on lung functions in Parkinson's disease patients: a randomized trial

Upper airway obstruction, reduced maximal expiratory and inspiratory flows, reduced lung volumes, abnormal ventilatory control, and diaphragmatic dyskinesias are reported in patients with Parkinson's disease (PD). Inspiratory muscle training (IMT) has been reported to be effective in improving respiratory functions; however, no studies have compared the effects of the incentive spirometer (IS) with the threshold inspiratory muscle trainer (TIMT) in patients with PD. The study aimed to compare the effects of IS and TIMT on maximum inspiratory pressure (MIP), 6-min walk distance (6-MWD), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and peak expiratory flow rate (PEFR) in patients with stage 1-3 according to the Hoehn and Yahr scale. 18 patients were randomly assigned to two groups, i.e., incentive spirometer (IS) and threshold inspiratory muscle trainer (TIMT) group. The IS group received IMT with volume-based IS, and the TIMT group received IMT with TIMT. MIP, 6-MWD, FVC, FEV1, and PEFR were measured before and after six weeks of training. In IS group: A significant increase (p < 0.05) was observed in MIP and 6-MWD by 18.13 and 5%, respectively. In the TIMT group: A significant increase (p < 0.05) was observed in MIP and 6-MWD by 30.15 and 8.94%, respectively. Both groups observed no significant difference (p > 0.05) in FVC, FEV1, and PEFR. When the two groups were compared, a greater increase (p < 0.05) was observed in the MIP and 6-MWD in the TIMT group compared to IS group. IMT with IS or TIMT for six weeks effectively increased MIP and 6-MWD in patients with stage 1-3 (Hoehn and Yahr scale) of PD. No improvement was observed in FVC, FEV1, or PEFR with any of the techniques. TIMT is more effective than IS in improving MIP and 6-MWD.

Virtual Reality for Motor and Cognitive Rehabilitation

Virtual Reality (VR) affords clinicians the ability to deliver safe, controlled, task-specific customised interventions that are enjoyable, motivating and engaging. Elements of training in VR comply with principles of learning implicated in new skill acquisition and re-learning skills post-neurological disorders. However, heterogeneity in the description of VR systems and the description and control of 'active' ingredients of interventions (like dosage, type of feedback, task specificity, etc.) have led to inconsistency in the synthesis and interpretation of evidence related to the effectiveness of VR-based interventions, particularly in post-stroke and Parkinson's Disease (PD) rehabilitation. This chapter attempts to describe VR interventions with respect to their compliance with principles of neurorehabilitation, with the goal of optimising interventions for effective training and facilitation of maximum functional recovery. This chapter also advocates using a uniform framework to describe VR systems to promote homogeneity in literature in order to help in the synthesis of evidence. An overview of the evidence revealed that VR systems are effective in mediating deficits in upper extremity, posture and gait function seen in people post-stroke and PD. Generally, interventions were more effective when they were delivered as an adjunct to conventional therapy and were customised for rehabilitation purposes, in addition to complying with principles of learning and neurorehabilitation. Although recent studies imply that their VR intervention is compliant with principles of learning, only a few explicitly describe how these principles are incorporated as 'active ingredients' of the intervention. Finally, VR interventions targeting community ambulation and cognitive rehabilitation are yet limited and therefore warrant attention.

People with mild Parkinson's disease have impaired force production in upper limb muscles: A cross-sectional study

BACKGROUND

There has been little examination of force production of the upper limb in people with Parkinson's disease (PD), despite its impact on activities of daily living and clear evidence that force production is significantly reduced in lower limb muscle groups. The aim of this study was to determine the force production of the major muscle groups of the upper limb in people with PD during the "on" phase after medication, compared with aged-matched neurologically-normal controls.

METHOD

A cross-sectional study was carried out.

PARTICIPANTS

Thirty people with mild PD (Hoehn Yahr mean 1.1) and 24 age-matched neurologically-normal controls.

OUTCOME MEASURES

Maximum isometric force production of the shoulder flexors, extensors, abductors, adductors, internal rotators and external rotators, elbow flexors and extensors, wrist flexors and extensors and hand grip using dynamometry.

RESULTS

There was a significant impairment in force production in all upper limb muscle groups, compared with control participants, except in the wrist flexors. On average the deficit in force production was 22%, despite people with PD having mild disease, being physically active and being measured during the "on" phase of medication. The most severely affected muscle groups were the upper limb extensors.

CONCLUSION

People with PD have a significant deficit in force production of the upper limb muscle groups compared with age-matched neurologically normal controls.

CLINICAL IMPLICATIONS

Regular assessment of strength of the upper limb should be considered by clinicians and strengthening interventions could be implemented if a deficit is identified.

An investigation of the contribution of different turn speeds during standing turns in individuals with and without Parkinson's disease

Issues around turning can impair daily tasks and trigger episodes of freezing of gait in individuals with Parkinson's disease (PD). Slow speeds associated with aging produce a more en-bloc movement strategy which have been linked with falls while turning. However, the influence of speed of turning on the complex whole-body coordination considering eye movements, turning kinematics, and stepping characteristics during turning has not been examined. The aim of this study was to investigate if individuals with PD have a different response to changes in turning speed compared to healthy older adults during 180° standing turns. 20 individuals with PD and 20 healthy age matched adults participated in this study. Data were collected during clockwise and counter-clockwise turns at three self-selected speeds in a randomised order: (a) normal; (b) faster than normal; and (c) slower than normal. Eye movement and turning kinematics were investigated using electrooculography and Inertial Measurement Units. Mixed Model Analysis of Variance (MM ANOVA) tests with post hoc pairwise comparisons were performed to assess the differences between groups and turning speed. In addition, further post hoc Repeated Measures ANOVA (RM ANOVA) tests were performed if any significant interactions were seen between groups and turning speed. Significant interaction effects were found in eye movement and turning kinematics, and the RM ANOVA showed significant main effects for turning speeds within the PD and the control groups. Turning slowly resulted in similar alterations in eye movement, turning kinematics and stepping characteristics in the PD group and the healthy controls. However, individuals with PD showed a different response to the healthy controls, with a greater delay in eye movement and onset latency of segments in turning kinematics and step variables between the different speeds. These findings help our understanding regarding the turning strategies in individuals with PD. The incorporation of guidance with regard to faster turning speeds may be useful in the management of individuals with PD. Clinical training using different turn directions and speeds may improve coordination, increase confidence and reduce the risk of falling.

Scoring the Sit-to-Stand Performance of Parkinson's Patients with a Single Wearable Sensor

Monitoring disease progression in Parkinson's disease is challenging. Postural transfers by sit-to-stand motions are adapted to trace the motor performance of subjects. Wearable sensors such as inertial measurement units allow for monitoring motion performance. We propose quantifying the sit-to-stand performance based on two scores compiling kinematics, dynamics, and energy-related variables. Three groups participated in this research: asymptomatic young participants (n = 33), senior asymptomatic participants (n = 17), and Parkinson's patients (n = 20). An unsupervised classification was performed of the two scores to differentiate the three populations. We found a sensitivity of 0.4 and a specificity of 0.96 to distinguish Parkinson's patients from asymptomatic subjects. In addition, seven Parkinson's patients performed the sit-to-stand task "ON" and "OFF" medication, and we noted the scores improved with the patients' medication states (MDS-UPDRS III scores). Our investigation revealed that Parkinson's patients demonstrate a wide spectrum of mobility variations, and while one inertial measurement unit can quantify the sit-to-stand performance, differentiating between PD patients and healthy adults and distinguishing between "ON" and "OFF" periods in PD patients is still challenging.

Exploration of sensory-motor tradeoff behavior in Parkinson's disease

While slowness of movement is an obligatory characteristic of Parkinson's disease (PD), there are conditions in which patients move uncharacteristically fast, attributed to deficient motor inhibition. Here we investigate deficient inhibition in an optimal sensory-motor integration framework, using a game in which subjects used a paddle to catch a virtual ball. Display of the ball was extinguished as soon as the catching movement started, segregating the task into a sensing and acting phase. We analyzed the behavior of 9 PD patients (ON medication) and 10 age-matched controls (HC). The switching times (between sensing and acting phase) were compared to the predicted optimal switching time, based on the individual estimates of sensory and motor uncertainties. The comparison showed that deviation from predicted optimal switching times were similar between groups. However, PD patients showed a weaker correlation between variability in switching time and sensory-motor uncertainty, indicating a reduced propensity to generate exploratory behavior for optimizing goal-directed movements. Analysis of the movement kinematics revealed that PD patients, compared to controls, used a lower peak velocity of the paddle and intercepted the ball with greater velocity. Adjusting the trial duration to the time for the paddle to stop moving, we found that PD patients spent a smaller proportion of the trial duration for observing the ball. Altogether, the results do not show the premature movement initiation and truncated sensory processing that we predicted to ensue from deficient inhibition in PD.

Effects of nordic walking exercise on gait, motor/non-motor symptoms, and serum brain-derived neurotrophic factor in individuals with Parkinson's disease

Objective

The primary purpose of this study was to investigate the immediate and long-term effects of Nordic Walking (NW) exercise on walking function, motor/non-motor Parkinson's Disease (PD) symptoms, and serum brain-derived neurotrophic factor (BDNF) in persons with idiopathic PD.

Methods

Twelve community-dwelling participants with mild to moderate idiopathic PD and varied degrees of gait dysfunction were recruited for this prospective, repeated measures design that examined clinical measures and BDNF levels at baseline (T0), post-intervention (T1) and 3-month follow-up (T2). Participants engaged in 6 weeks of supervised NW exercise training with individualized instruction, followed by 14 weeks of independent NW exercise with remote coaching. Outcome measurements included daily step counts, 6-Minute Walk Test (6-MinWT), 10-Meter Walk Test (10MWT), spatiotemporalparameters, Timed Up and Go Test (TUG), dual-task TUG, Revised-Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS), Revised-Freezing of Gait Questionnaire, MDS-Nonmotor Symptom scale (NMS), Parkinson's Fatigue Scale, and serum BDNF levels. The Friedman test with post hoc Wilcoxon sign-ranked pairwise comparisons were used to compare baseline to T1, baseline to T2, and T1 to T2 timepoints with a Benjamini-Hockberg correction applied.

Results

Statistically significant improvements found post-training and retained at 3-month follow-up included 6-MinWT, daily step count, 10mWT, MDS-UPDRS, and TUG with effect sizes of 0.57 to 1.03. Serum BDNF at T2 was significantly greater than T0 and T1. Although no statistically significant improvements were observed in the MDS-NMS, 9 of 12 participants had improved non-motor symptoms. There was good adherence, sustained independent exercise engagement, and no adverse events over the 5-month study duration.

Conclusions

This study demonstrated that NW exercise was a safe, feasible, and sustainable mode of aerobic exercise for this sample of participants with varied Parkinson's disease duration and severity. Following an individualized and progressive NW training intervention, significant improvements in walking function, daily activity level, and motor function were observed. Following the supervised NW training phase, independent three-month engagement in NW exercise was sustained with long-term retention of these clinical improvements and an increase in serum BDNF levels over this five-month NW exercise trial.

Impact

Nordic walking exercise may be a safe, feasible and sustainable mode of independent exercise for improving daily ambulatory activity, gait and motor function, and serum BDNF in individuals with mild to moderate PD with varied gait abilities.

Clinical Trials Registry ID

20-101-H.

Assessing the Effect of 12 Weeks of Pilates and Aquatic Exercise on Muscle Strength and Range of Motion in Patients with Mild to Moderate Parkinson’s Disease

Background: Parkinson's disease is a chronic, progressive and degenerative disorder of the central nervous system with four main symptoms of bradykinesia, tremor, muscular rigidity, and postural instability. Objectives: The effect of 12 weeks of Pilates and aquatic exercise on muscle strength and range of motion (ROM) in male patients with Parkinson's disease was assessed in this article. Methods: In this quasi-experimental study, 25 male patients reporting to Al-Zahra Hospital, Isfahan, were selected randomly and grouped in Pilates (n = 7), Aquatic exercise (n = 10), and Control (n = 8). The experimental groups received 1-hour sessions of training three times a week for 12 weeks. Muscle strength and ROM of each patient was measured through the Biodex Isokinetic System 3 before entering the study and after the final assigned session. Results: Pilates and Aquatic exercise groups had a significant improvement in ROM, while no significant difference was observed in the control group. Muscle strength and ROM increased significantly in the experimental groups compared to the control group (P < 0.05). The effect of Pilates on muscle strength was not significant (P < 0.05). Conclusions: Non-pharmacological modalities could be contributive in the patients with Parkinson's disease recovery and lead to significant improvements in their physiological parameters of muscle strength and ROM. Next to the pharmacological treatments, patients could benefit from inexpensive and readily available options like Pilates and aquatic exercises to alleviate the disease symptoms. Further studies should be run to reveal the aforementioned and plausible benefits of these complementary activities.

Technological evaluation of strategies to get out of bed by people with Parkinson's disease: Insights from multisite wearable sensors

Background

Difficulty getting out of bed is a common night-time and early morning manifestation of Parkinson's disease (PD), rated by 40% of the patients as their most concerning motor symptoms. However, current assessment methods are based on clinical interviews, video analysis, and clinical scales as objective outcome measures are not yet available.

Objective

To study the technical feasibility of multisite wearable sensors in the assessment of the supine-to-stand (STS) task as a determinant of the ability to get out of bed in patients with PD and age-matched control subjects, and develop relevant objective outcome measures.

Methods

The STS task was assessed in 32 patients with PD (mean Hoehn and Yahr; HY = 2.5) in the early morning before their first dopaminergic medication, and in 14 control subjects, using multisite wearable sensors (NIGHT-Recorder®; trunk, both wrists, and both ankles) in a sleep laboratory. Objective getting out of bed parameters included duration, onset, velocity and acceleration of truncal rotation, and angle deviation (a°) from the z-axis when subjects rose from the bed at different angles from the x-axis (10°, 15°, 30°, 45°, and 60°) as measures of truncal lateral flexion. Movement patterns were identified from the first body part or parts that moved. Correlation analysis was performed between these objective outcomes and standard clinical rating scales.

Results

Compared to control subjects, the duration of STS was significantly longer in patients with PD (p = 0.012), which is associated with a significantly slower velocity of truncal rotation (p = 0.003). Moderate and significant correlations were observed between the mean STS duration and age, and the Nocturnal Hypokinesia Questionnaire. The velocity of truncal rotation negatively and significantly correlated with HY staging. Any arm and leg moved together as the first movement significantly correlated with UPDRS-Axial and item #28. Several other correlations were also observed.

Conclusion

Our study was able to demonstrate the technical feasibility of using multisite wearable sensors to quantitatively assess early objective outcome measures of the ability of patients with PD to get out of bed, which significantly correlated with axial severity scores, suggesting that axial impairment could be a contributing factor in difficulty getting out of bed. Future studies are needed to refine these outcome measures for use in therapeutic trials related to nocturia or early morning akinesia in PD.

Research Hotspots and Trends of Exercise on Parkinson's Disease: A Global Bibliometric Analysis From 2012 to 2021

Background

Parkinson's disease is a chronic neurodegenerative disease, which can be alleviated in drug treatment, but with evident side effects. At the same time, increasing evidence shows that exercise can significantly improve the symptoms of patients with Parkinson's disease, with an effect that cannot be achieved by drug treatment. The related research on exercise on Parkinson's disease increases rapidly with the passage of time. However, the research analysis on Parkinson's disease by means of bibliometrics is rare. The purpose of this study is to perform a bibliometric analysis of the research hotspots and development trends of the global movement on Parkinson's disease from 2012 to 2021.

Methods

The literature was derived from the Web of Science core collection database, and the social science citation index was set as SCI-EXPANDED. The language was set to English, and the literature category was set as article and review and published from 2012 to 2021. CiteSpace and other software were used to analyze the relationship among published documents, countries, institutions, journals, authors, references, disciplines, and keywords.

Results

A total of 2,222 articles were included in the analysis. The analysis showed that the publication volume increased with the increase in years, with a total of 76 countries and 546 academic journals published; the largest number was that of the United States. The journals are mainly concentrated in the fields of neurology, sports, and ophthalmology. Rush University and Movement Disorders journals are the main institutions and journals. The cited keywords show that trial, cognition, and interference are the research hotspots and development trends in recent years.

Conclusion

The number of published articles on Parkinson's disease by exercise has increased rapidly in the past 10 years, and the bibliometric analysis can provide useful information for future research teams and researchers.

An Activity Recognition Framework for Continuous Monitoring of Non-Steady-State Locomotion of Individuals with Parkinson’s Disease

Fundamental knowledge in activity recognition of individuals with motor disorders such as Parkinson’s disease (PD) has been primarily limited to detection of steady-state/static tasks (e.g., sitting, standing, walking). To date, identification of non-steady-state locomotion on uneven terrains (stairs, ramps) has not received much attention. Furthermore, previous research has mainly relied on data from a large number of body locations which could adversely affect user convenience and system performance. Here, individuals with mild stages of PD and healthy subjects performed non-steady-state circuit trials comprising stairs, ramp, and changes of direction. An offline analysis using a linear discriminant analysis (LDA) classifier and a Long-Short Term Memory (LSTM) neural network was performed for task recognition. The performance of accelerographic and gyroscopic information from varied lower/upper-body segments were tested across a set of user-independent and user-dependent training paradigms. Comparing the F1 score of a given signal across classifiers showed improved performance using LSTM compared to LDA. Using LSTM, even a subset of information (e.g., feet data) in subject-independent training appeared to provide F1 score > 0.8. However, employing LDA was shown to be at the expense of being limited to using a subject-dependent training and/or biomechanical data from multiple body locations. The findings could inform a number of applications in the field of healthcare monitoring and developing advanced lower-limb assistive devices by providing insights into classification schemes capable of handling non-steady-state and unstructured locomotion in individuals with mild Parkinson’s disease.

Combined effects of virtual reality techniques and motor imagery on balance, motor function and activities of daily living in patients with Parkinson's disease: a randomized controlled trial

Background

Parkinson's disease (PD) is the second most prevalent neurodegenerative disorder, impairing balance and motor function. Virtual reality (VR) and motor imagery (MI) are emerging techniques for rehabilitating people with PD. VR and MI combination have not been studied in PD patients. This study was conducted to investigate the combined effects of VR and MI techniques on the balance, motor function, and activities of daily living (ADLs) of patients with PD.

Methods

This study was a single-centered, two-armed, parallel-designed randomized controlled trial. A total of 44 patients of either gender who had idiopathic PD were randomly allocated into two groups using lottery methods. Both groups received Physical therapy (PT) treatment, while the experimental group (N: 20) received VR and MI in addition to PT. Both groups received assigned treatment for three days a week on alternate days for 12 weeks. The Unified Parkinson’s Disease Rating Scale (UPDRS) (parts II and III), Berg Balance Scale (BBS), and Activities-specific Balance Confidence (ABC) Scale were used as outcome measures for motor function, balance, and ADLs. The baseline, 6^th, and 12^th weeks of treatment were assessed, with a 16^th week follow-up to measure retention. The data was analysed using SPSS 24.

Results

The experimental group showed significant improvement in motor function than the control group on the UPDRS part III, with 32.45±3.98 vs. 31.86±4.62 before and 15.05±7.16 vs. 25.52±7.36 at 12-weeks, and a p-value < 0.001. At 12 weeks, the experimental group's BBS scores improved from 38.95±3.23 to 51.36±2.83, with p-value < 0.001. At 12 weeks, the experimental group's balance confidence improved considerably, from 59.26±5.87to 81.01±6.14, with a p-value of < 0.001. The experimental group's ADL scores improved as well, going from 22.00±4.64 to 13.07±4.005 after 12 weeks, with a p-value of < 0.001.

Conclusion

VR with MI techniques in addition to routine PT significantly improved motor function, balance, and ADLs in PD patients compared to PT alone.

Trial registration

IRCT20200221046567N1. Date of registration: 01/04/2020

A Randomized Controlled Trial of Motor Imagery Combined with Virtual Reality Techniques in Patients with Parkinson's Disease

Background: Parkinson’s disease is the second most common neurological disease, affecting balance, motor function, and activities of daily living. Virtual reality and motor imagery are two emerging approaches for the rehabilitation of patients with Parkinson’s disease. This study aimed to determine the combined effects of virtual reality and motor imagery techniques with routine physical therapy on the motor function components of individuals with Parkinson’s disease. Methods: The study was a prospective, two-arm, parallel-design randomized controlled trial. Forty-four patients with idiopathic Parkinson’s disease were randomly assigned to one of two groups. Virtual reality and motor imagery were given together with physical therapy in the experimental group (N: 20), while physical therapy treatment alone was given in the control group (N: 21). Both groups received allocated treatment for 12 weeks, 3 days a week, on alternate days. Motor function was assessed at baseline, six weeks, twelve weeks, and sixteen weeks after discontinuing treatment with the Unified Parkinson’s Disease Rating Scale part III. SPSS 24 was used to analyze the data. Results: Study results indicate that the experimental group showed significant improvements in the motor function components: tremor at rest at the 6th week (p = 0.028), 12th week (p = 0.05), and 16th week (p = 0.001), rigidity at the 6th week (p = 0.03), 12th week (p = 0.000), and 16th week (p = 0.001), posture at the 12th week (p = 0.005) and 16th week (p = 0.004), and gait at the 6th week with a p-value of (p = 0.034). Conclusions: This study demonstrated that virtual reality and motor imagery training in combination with routine physical therapy can significantly improve resting tremors, rigidity, posture, gait, and body bradykinesia in individuals with PD in comparison to patients receiving only routine physical therapy.

A theoretical framework for addressing fear of falling avoidance behavior in Parkinson's disease

Postural instability in Parkinson's disease (PD) is associated with several downstream consequences that ultimately lead to a greater risk of falling. Among the prominent downstream consequences is fear of falling (FOF), which is both common and problematic in PD. It can lead to a vicious cycle of FOF avoidance behavior that results in more sedentary behavior, physical deconditioning, and weakening of already impaired balance systems. This, in turn, may make the person with PD more susceptible to a future fall even with benign daily tasks. While FOF activity avoidance can be adaptive (appropriate), it can also be maladaptive (inappropriate or exaggerated). When this adaptive and maladaptive FOF avoidance behavior is contextualized to gait/balance performance, it provides a theoretical framework that can be used by clinicians to match patterns of behavior to a concordant treatment approach. In the theoretical framework proposed in this perspective, four different patterns related to FOF avoidance behavior and gait/balance performance are suggested: appropriate avoiders, appropriate non-avoiders, inappropriate avoiders, and inappropriate non-avoiders. For each of the four FOF avoidance behavior patterns, this paper also provides suggested treatment focuses, approaches and recommendations.

The effect of Tai Chi on functional mobility, balance and falls in Parkinson's disease: A systematic review and meta-analysis of systematic reviews

BACKGROUND

The aim of the study was to evaluate the effect of Tai Chi on functional mobility, balance and falls in Parkinson's disease.

MATERIALS AND METHODS

A comprehensive literature search was conducted to identify the systematic reviews and meta-analyses up to the end of October 2021. 601 studies were identified, and 16 of them were included in our study.

RESULTS

According to our meta-analysis; there was a significant effect of Tai Chi on balance (SMD, -0.777 95% CI -0.921 to -0.633; p = 0.000), functional mobility (SMD, -0.719 95% CI -0.944 to -0.494; p = 0.000), and falls (SMD, -0.456 95% CI -0.668 to -0.245; p = 0.000) in PD.

CONCLUSION

Our systematic review and meta-analysis found significant effects of Tai Chi on functional mobility, balance and falls in patients with PD.

Stability Evaluation of Brain Changes in Parkinson's Disease Based on Machine Learning

Structural MRI (sMRI) has been widely used to examine the cerebral changes that occur in Parkinson's disease (PD). However, previous studies have aimed for brain changes at the group level rather than at the individual level. Additionally, previous studies have been inconsistent regarding the changes they identified. It is difficult to identify which brain regions are the true biomarkers of PD. To overcome these two issues, we employed four different feature selection methods [ReliefF, graph-theory, recursive feature elimination (RFE), and stability selection] to obtain a minimal set of relevant features and nonredundant features from gray matter (GM) and white matter (WM). Then, a support vector machine (SVM) was utilized to learn decision models from selected features. Based on machine learning technique, this study has not only extended group level statistical analysis with identifying group difference to individual level with predicting patients with PD from healthy controls (HCs), but also identified most informative brain regions with feature selection methods. Furthermore, we conducted horizontal and vertical analyses to investigate the stability of the identified brain regions. On the one hand, we compared the brain changes found by different feature selection methods and considered these brain regions found by feature selection methods commonly as the potential biomarkers related to PD. On the other hand, we compared these brain changes with previous findings reported by conventional statistical analysis to evaluate their stability. Our experiments have demonstrated that the proposed machine learning techniques achieve satisfactory and robust classification performance. The highest classification performance was 92.24% (specificity), 92.42% (sensitivity), 89.58% (accuracy), and 89.77% (AUC) for GM and 71.93% (specificity), 74.87% (sensitivity), 71.18% (accuracy), and 71.82% (AUC) for WM. Moreover, most brain regions identified by machine learning were consistent with previous findings, which means that these brain regions are related to the pathological brain changes characteristic of PD and can be regarded as potential biomarkers of PD. Besides, we also found the brain abnormality of superior frontal gyrus (dorsolateral, SFGdor) and lingual gyrus (LING), which have been confirmed in other studies of PD. This further demonstrates that machine learning models are beneficial for clinicians as a decision support system in diagnosing PD.

Dance Is an Accessible Physical Activity for People with Parkinson's Disease

OBJECTIVE

To evaluate the outcomes of face-to-face, digital, and virtual modes of dancing for people living with Parkinson's disease (PD).

DESIGN

Systematic review informed by Cochrane and PRIMSA guidelines. Data Sources. Seven electronic databases were searched: AMED, Cochrane, PEDro, CINHAL, PsycINFO, EMBASE, and MEDLINE.

METHODS

Eligible studies were randomised controlled trials (RCT) and other trials with quantitative data. The PEDro scale evaluated risk of bias for RCTs. Joanna Briggs Institute instruments were used to critically appraise non-RCTs. The primary outcome was the feasibility of dance interventions, and the secondary outcomes included gait, balance, quality of life, and disability.

RESULTS

The search yielded 8,327 articles after duplicates were removed and 38 met the inclusion criteria. Seven were at high risk of bias, 20 had moderate risk of bias, and 11 had low risk of bias. There was moderately strong evidence that dance therapy was beneficial for balance, gait, quality of life, and disability. There was good adherence to digital delivery of dance interventions and, for people with PD, online dance was easy to access.

CONCLUSION

Dancing is an accessible form of exercise that can benefit mobility and quality of life in people with PD. The COVID-19 pandemic and this review have drawn attention to the benefits of access to digital modes of physical activity for people living with chronic neurological conditions.

The Effect of a Single Session of Non-Invasive Brain Stimulation on Balance in Healthy Individuals: A Systematic Review and Best Evidence Synthesis

Aim: To evaluate the effects of a single session of non-invasive brain stimulation (NIBS) on postural balance. Introduction: The NIBS has been used widely in improving balance. However, the effect of a single session of NIBS on balance in healthy individuals has not been systemically reviewed. Methods: A systematic literature review and best evidence synthesis were conducted, according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, to determine the effects of different NIBS techniques on balance function in healthy individuals. The methodological quality of included articles was assessed by the risk of bias, and the Downs and Black tool. Data were analyzed by using the best evidence synthesis. Thirty-five articles were included that used the following NIBS techniques: anodal transcranial direct current stimulation (a-tDCS), cathodal transcranial direct current stimulation (c-tDCS), continuous theta burst stimulation (cTBS), and repetitive transcranial magnetic stimulation (rTMS) on primary motor cortex (M1), supplementary motor area (SMA), dorsolateral prefrontal cortex (DLPFC), and cerebellum on balance. Results: Strong evidence showed that a-tDCS of M1, SMA improve balance in healthy participants, and the a-tDCS of DLPFC induces improvement only in dual task balance indices. Also, the findings indicate that cerebellar a-tDCS might significantly improve balance, if at least 10 min cerebellar a-tDCS with an intensity of ≥1 mA, over or maximum 1.5 cm below the inion, is used. Strong evidence showed that c-tDCS, cTBS, and rTMS are not effective on the balance. Conclusion: According to the results, the a-tDCS may be a useful technique to improve balance in healthy adults.

Positive impact of short-term gait rehabilitation in Parkinson patients: a combined approach based on statistics and machine learning

Parkinson's disease is the second most common neurodegenerative disorder in the world. Assumed that gait dysfunctions represent a major motor symptom for the pathology, gait analysis can provide clinicians quantitative information about the rehabilitation outcome of patients. In this scenario, wearable inertial systems for gait analysis can be a valid tool to assess the functional recovery of patients in an automatic and quantitative way, helping clinicians in decision making. Aim of the study is to evaluate the impact of the short-term rehabilitation on gait and balance of patients with Parkinson's disease. A cohort of 12 patients with Idiopathic Parkinson's disease performed a gait analysis session instrumented by a wearable inertial system for gait analysis: Opal System, by APDM Inc., with spatial and temporal parameters being analyzed through a statistic and machine learning approach. Six out of fourteen motion parameters exhibited a statistically significant difference between the measurements at admission and at discharge of the patients, while the machine learning analysis confirmed the separability of the two phases in terms of Accuracy and Area under the Receiving Operating Characteristic Curve. The rehabilitation treatment especially improved the motion parameters related to the gait. The study shows the positive impact on the gait of a short-term rehabilitation in patients with Parkinson's disease and the feasibility of the wearable inertial devices, that are increasingly spreading in clinical practice, to quantitatively assess the gait improvement.

Test-Retest Reliability of the Timed Up and Go Test in Subjects with Parkinson's Disease: Implications for Longitudinal Assessments

BACKGROUND

Despite the frequent use of the Timed Up and Go (TUG) test in clinical trials, evaluation of longitudinal test-retest reliability is generally lacking and still inconclusive for patients with Parkinson's disease (PD).

OBJECTIVE

We aimed to further investigate long-term reliability and sensitivity of the TUG test among this population. Furthermore, we explored alternative assessment strategies of the test aimed at elucidating whether the inclusion or combination of timed trials may have potential implications on outcome measure.

METHODS

Relative and absolute reliability of the TUG performance were obtained in forty-three subjects with PD over three timed trials in two different testing sessions separated by a two-months period.

RESULTS

Our results reported excellent intra-session and moderate inter-session reliability coefficients. The use of different assessment strategies of the TUG was found to have an important impact on outcome measure, highlighting the averaging of several timed trials in each testing session as a recommended alternative to minimize measurement error and increase reliability in longitudinal assessments. Nevertheless, beyond acceptable reliability, poor trial-to-trial stability of the measure appears to exist, since the ranges of expected variability upon retesting were wide and the incidence of spurious statistical effects was not negligible, especially in longitudinal repeated testing.

CONCLUSION

Limitations may exist in the interpretation of the TUG outputs as part of longitudinal assessments aimed at evaluating treatment effectiveness in PD population. Researchers and practitioners should be aware of these concerns to prevent possible misrepresentations of functional ability in patients for a particular intervention.

Protective effect of Actinidia arguta in MPTP-induced Parkinson's disease model mice

Parkinson's disease (PD) is a neurodegenerative disease characterized by the progressive degeneration of dopaminergic neurons in the substantia nigra. Oxidative stress-induced neuronal death has been identified as one of the major causes of nigrostriatal degeneration in PD. The fruit of Actinidia arguta (A. arguta), known as sarunashi in Japan, has been reported to show beneficial health effects such as antioxidant, anti-inflammatory, anti-mutagenic, and anticholinergic effects. In this study, we investigated the neuroprotective effects of A. arguta in 1-methyl-4-phenyl-1,2,3,6-tetrahydropypridine (MPTP)-induced PD model mice. A. arguta juice was administered to 7-week-old C57BL/6J mice continuously for 10 days before the first MPTP injection. The degeneration of dopaminergic neurons in the substantia nigra was induced by MPTP (30 mg/kg, i. p.) once daily for five consecutive days. We found that the administration of A. arguta ameliorated MPTP-induced motor impairment and suppressed the MPTP-induced reductions of tyrosine hydroxylase-positive neurons and tyrosine hydroxylase protein expression in the substantia nigra. Our findings suggest that taking A. arguta could provide neuroprotection that delays or prevents the neurodegenerative process of PD.

Is Aquatic Therapy Optimally Prescribed for Parkinson's Disease? A Systematic Review and Meta-Analysis

BACKGROUND

Aquatic therapy offers an alternative physiotherapy approach to managing the motor and non-motor symptoms associated with Parkinson's disease (PD).

OBJECTIVE

This review examined exercise prescription for aquatic therapy in PD and evaluated if aquatic therapy is as effective as land-based physiotherapy for improving movement, disability and wellbeing in people living with PD.

METHODS

A systematic search of eight databases was conducted to identify suitable randomized controlled trials from inception until August 2019. Aquatic therapy prescription data and outcomes of interest included gait, balance, motor disability, mobility, falls, mood, cognitive function and health related quality of life data was extracted and synthesised. A meta-analysis was performed where appropriate.

RESULTS

Fourteen studies involving 472 participants (Hoehn & Yahr scale I-IV) met the inclusion criteria. Eight were of modest quality, scoring 70-80% on the PEDro scale. Seven studies were included in the meta-analysis. Exercise prescription was highly variable and often insufficiently dosed. Similar gains were shown for aquatic therapy and land exercises for balance, motor disability or quality of life. A statistically significant difference was found for mobility as measured using the TUG (-1.5 s, 95 % CI -2.68 to -0.32; p = 0.01, I2 = 13%), in favor of aquatic therapy.

CONCLUSION

Aquatic therapy had positive outcomes for gait, balance and mobility that were comparable to land-based physiotherapy in the early stages of PD. The optimal dosage, content and duration of aquatic interventions for PD could not be confirmed in this meta-analysis. Many trials appeared to be under-dosed and therapy duration was low, ranging from 3-11 weeks.

Community aquatic therapy for Parkinson's disease: an international qualitative study

PURPOSE

To explore the opinions of people living with Parkinson's disease about access to and participation in community aquatic therapy.

METHODS

Focus groups and individual interviews were conducted with people living with Parkinson's disease in Ireland (n = 24) and Australia (n = 10). All discussions were audio-recorded, transcribed verbatim, and thematically analysed.

RESULTS

Four main themes were identified. Primarily, participants were optimistic about their reasons for choosing aquatic therapy and found it beneficial to their health and well-being. Optimal components of aquatic therapy identified were access to individually tailored aquatic programs, completed as a minimum once a week, at a moderate to high-intensity level, and guided by a credentialed instructor. Fear was a significant barrier for a small proportion of participants and was linked to water competence, past experiences, and fall risk associated with the aquatic environment. Participants identified a strong need for education and increased awareness about aquatic therapy benefits to promote greater engagement.

CONCLUSION

Aquatic therapy is a popular exercise choice for people with Parkinson's disease, especially in the early to middle disease stages. Considering the views of people living with Parkinson's disease can aid the design and implementation of interventions and future aquatic research internationally.Implications for RehabilitationAquatic therapy is emerging as an effective physiotherapy approach for managing motor and non-motor symptoms in Parkinson's disease.Little is known regarding community-based aquatic therapy programs from the perspectives of people living with Parkinson's disease internationally.People with Parkinson's disease may benefit from timely information about the unique benefits, prerequisites, and local aquatic therapy facilities to promote greater uptake of aquatic programs.Tailored aquatic therapy interventions delivered within a group setting by a credentialed healthcare professional may increase long-term adherence.

Reliability of measurement using Image J for reach distance and movement angles in the functional reach test

[Purpose] The purpose of this study was to examine the test-retest reliability and minimal detectable change (MDC) of reach distance and movement angle analyses using Image J. [Participants and Methods] Thirty-eight healthy young males performed the functional reach test (FRT) twice, and their reach movements were recorded using a digital video camera. Image J was used to combine the digital photographs taken at the start position and maximum reach and to measure each movement. The measurements recorded were the movement distance of the third metacarpal bone (reach distance), anterior-superior iliac spine, and trochanter major, and the angles recorded were the acromion-malleolus lateralis, acromion-trochanter major, and trochanter major-malleolus lateralis. The reliability of all the measurements was analyzed using intraclass correlation coefficients (ICCs), Bland-Altman plots, and MDCs. [Results] The ICCs (1, 1) were >0.80 for all the outcomes. The Bland-Altman analysis revealed no systematic bias in any outcome. The MDC of reach distance was 18.3 mm. [Conclusion] Measurement using Image J for reach distance and movement angles in the FRT showed acceptable high test-retest reliability. Measurement of the FRT and the MDC calculated in this study could be used as a reference for further research.

Quantifying upper limb motor impairment in people with Parkinson's disease: a physiological profiling approach

BACKGROUND

Upper limb motor impairments, such as slowness of movement and difficulties executing sequential tasks, are common in people with Parkinson's disease (PD).

OBJECTIVE

To evaluate the validity of the upper limb Physiological Profile Assessment (PPA) as a standard clinical assessment battery in people with PD, by determining whether the tests, which encompass muscle strength, dexterity, arm stability, position sense, skin sensation and bimanual coordination can (a) distinguish people with PD from healthy controls, (b) detect differences in upper limb test domains between "off" and "on" anti-Parkinson medication states and (c) correlate with a validated measure of upper limb function.

METHODS

Thirty-four participants with PD and 68 healthy controls completed the upper limb PPA tests within a single session.

RESULTS

People with PD exhibited impaired performance across most test domains. Based on validity, reliability and feasibility, six tests (handgrip strength, finger-press reaction time, 9-hole peg test, bimanual pole test, arm stability, and shirt buttoning) were identified as key tests for the assessment of upper limb function in people with PD.

CONCLUSIONS

The upper limb PPA provides a valid, quick and simple means of quantifying specific upper limb impairments in people with PD. These findings indicate clinical assessments should prioritise tests of muscle strength, unilateral movement and dexterity, bimanual coordination, arm stability and functional tasks in people with PD as these domains are the most commonly and significantly impaired.

Enablers to Exercise Participation in Progressive Supranuclear Palsy: Health Professional Perspectives

Background: People living with progressive supranuclear palsy (PSP) can experience considerable difficulties with movement, walking, balance, and oculomotor control. The role of exercises and physical activities in mitigating the motor and non-motor symptoms of PSP remains uncertain. Aims: The aim of this study was to identify the perspectives and beliefs of health professionals about the benefits, enablers, and barriers to participation in exercise and physical activity across the course of disease progression of PSP. Methods: Qualitative methods, within a phenomenological framework, were used to obtain nursing and allied health professional perspectives and recommendations. Focus group and in-depth interview questions were derived from a systematic review on exercise for PSP. Expert opinions also guided the interviews, which were audio-recorded, transcribed verbatim, and de-identified. Two researchers independently conducted a thematic analysis. Results: Nineteen health professionals participated from the disciplines of nursing, physiotherapy, occupational therapy, and speech pathology. Four main themes emerged: (i) exercise and physical activities are important for living well with PSP; (ii) provision of information about the benefits of exercise and physical activities facilitates uptake; (iii) interdisciplinary teams work together to improve outcomes; and (iv) care partners can assist with the implementation of exercise and physical activities. Conclusion: Health professionals advocated physical therapies for people living with PSP. The expectation is that structured exercises and physical activities can help to optimize health and well-being, enabling people to continue to participate in social roles. The actual merits of such interventions must now be tested in large-scale controlled clinical trials.

Design and Development of a Virtual Reality-Based Mobility Training Game for People With Parkinson's Disease

People with Parkinson's disease (PD) commonly have gait impairments that reduce their ability to walk safely in the community. These impairments are characterized, in part, by a compromised ability to turn and negotiate both predictable and unpredictable environments. Here, we describe the development and usability assessment of a virtual reality training application, Wordplay VR, that allows people with PD to practice skills such as turning, obstacle avoidance, and problem-solving during over-ground walking in a game-based setting. Nine people with PD completed three sessions with Wordplay VR, and each session was directed by their personal physical therapist. Our outcome measures included perceived sense of presence measured using the International Test Commission–Sense of Presence Inventory (ITC-SOPI), levels of motivation using the Intrinsic Motivation Inventory (IMI), overall system usability using the System Usability Scale (SUS), and setup time by the physical therapists. Both the people with PD and the physical therapists rated their sense of presence in the training system positively. The system received high ratings on the interest and value subscales of the IMI, and the system was also rated highly on usability, from the perspective of both the patient during gameplay and the therapist while controlling the experience. These preliminary results suggest that the application and task design yielded an experience that was motivating and user-friendly for both groups. Lastly, with repeated practice over multiple sessions, therapists were able to reduce the time required to help their patients don the headset and sensors and begin the training experience.

Effects of rhythmic auditory stimulation on functionality in Parkinson’s disease

Abstract Introduction: Functionality is affected by the clinical characteristics and progression of Parkinson’s disease (PD). Objective: Assess the effects of a therapeutic exercise program associated with music-based rhythmic auditory stimulation (RAS) on the Activities and Participation Profile (APP) related to mobility of people with PD. Methods: Intervention study investigating people with moderate PD recruited from the Hospital das Clínicas of the Federal University of Pernambuco and the Parkinson’s Disease Association of Pernambuco. The APP related to mobility of the participants was assessed based on the International Classification of Functioning Disability and Health (ICF). The APP contains 23 activity/participation items scored from 0 (no problem) to 4 (complete problem). The intervention consisted of 10 outpatient sessions of a therapeutic exercise program associated with music-based RAS, applied using a smartphone application (ParkinSONS®), performed twice a week, with an average duration of 50 minutes per session. Given the metric nature of the variable and its non-normal distribution, Wilcoxon’s test was applied, considering p < 0.05. Results: In the sample of 8 patients, there was a significant decline in APP scores after intervention (p = 0.018*), indicating a positive change. Scores for all the APP activities decreased following the intervention, except for “transferring oneself to the left side while lying down”. Conclusion: In this study, a therapeutic exercise program associated with music-based RAS had a positive effect on the APP related to mobility of people with moderate PD.

The Proprioceptive Neuromuscular Facilitation Concept in Parkinson Disease: A Systematic Review and Meta-Analysis

Objective

The aim of this review was to evaluate the effects of proprioceptive neuromuscular facilitation (PNF) in individuals with Parkinson disease.

Methods

This was a systematic review. We searched for articles with the keywords "Proprioceptive neuromuscular facilitation" and "Parkinson's disease." The databases searched were Scopus, ScienceDirect, Springer, Web of Science, LILACS (Latin American and Caribbean Health Sciences Literature), CINAHL (Cumulative Index to Nursing and Allied Health Literature), the Cochrane Library, PEDro (Physiotherapy Evidence Database), SciELO (Scientific Electronic Library Online), Ovid, and PubMed, in addition to reference lists of relevant articles. All scientific articles published before November 2019 that addressed rehabilitative outcomes of PNF for individuals with Parkinson disease were considered. Two investigators independently screened studies according to the eligibility criteria.

Results

Of the 674 articles found, 6 were selected. The PEDro scores of 2 articles were 3 points, and the others scored 7, 8, and 9 points. The meta-analysis investigated 3 articles with the same outcomes: walking speed, stride length, and cadence. We found a statistical difference between PNF and other therapies for gait speed (M = 0.28, 95% confidence interval = 0.21-0.34, P < .001).

Conclusion

Based on the meta-analysis, we found that PNF is similar or superior to other therapies as relates to gait speed. The efficacy of PNF for indications of Parkinson disease, however, requires further investigation, as a sufficient number of qualified, well-designed, randomized controlled studies is lacking.

Changes in Step Characteristics Over a Known Outdoor Surface Transition: The Effect of Parkinson Disease

The factors that contribute to the difficulties persons with Parkinson Disease (PwPD) have when negotiating transitions in walking surfaces are not completely known. The authors investigated if PwPD adjusted their step characteristics when negotiating a familiar outdoor surface transition between synthetic concrete and synthetic turf. Force plate and motion capture data were collected for 10 participants with mild to moderate Parkinson disease and 5 healthy older control participants ambulating bidirectionally across the transition between synthetic concrete and synthetic turf. Between groups, PwPD had a significantly higher minimum toe clearance (P = .007) for both directions of travel compared with the healthy control group. Within groups, PwPD significantly increased their hip (P < .001) and ankle (P = .016) range of motion walking from concrete to turf, while the healthy control participants significantly increased their minimum toe clearance (P = .013), margin of stability (P = .019), hip (P < .001) and ankle (P = .038) range of motion, and step length (P < .001). Walking from turf to concrete, both the Parkinson disease group (P = .014) and the healthy control group (P < .001) increased their knee range of motion. Both groups adjusted their step characteristics when negotiating known surface transitions, indicating that surface transitions result in step changes regardless of health status. However, PwPD exhibited overcompensations, particularly in their minimum toe clearance.

Physiotherapy in Parkinson's Disease: A Meta-Analysis of Present Treatment Modalities

BACKGROUND

Physiotherapy is a commonly prescribed intervention for people with Parkinson's disease (PD). Conventional types of physiotherapy have been studied extensively, while novel modalities are being developed and evaluated.

OBJECTIVE

To evaluate the effectiveness of conventional and more recent physiotherapy interventions for people with PD. The meta-analysis performed as part of the 2014 European Physiotherapy Guideline for PD was used as the starting point and updated with the latest evidence.

METHODS

We performed a systematic search in PubMed, CINAHL, Embase, and Web of Science. Randomized controlled trials comparing any physiotherapy intervention with no intervention or sham treatment were included. Trials were classified into 12 categories: conventional physiotherapy, resistance training, treadmill training, strategy training, dance, martial arts, aerobic exercises, hydrotherapy, balance and gait training, dual tasking, exergaming, and Nordic walking. Outcomes included motor symptoms, balance, gait, and quality of life, and are presented as standardized mean differences. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to systematically appraise methodological quality.

RESULTS

A total of 191 trials with 7998 participants were included. Conventional physiotherapy significantly improved motor symptoms, gait, and quality of life. Resistance training improved gait. Treadmill training improved gait. Strategy training improved balance and gait. Dance, Nordic walking, balance and gait training, and martial arts improved motor symptoms, balance, and gait. Exergaming improved balance and quality of life. Hydrotherapy improved balance. Finally, dual task training did not significantly improve any of the outcomes studied.

CONCLUSIONS

This meta-analysis provides a comprehensive overview of the evidence for the effectiveness of different physiotherapy interventions in the management of PD, allowing clinicians and patients to make an evidence-based decision for specific treatment modalities. Further work is needed to directly compare the relative efficacy of the various treatments.

NEURO-FUZZY SYSTEM FOR DETECTING PD PATIENTS BASED ON EUCLID DISTANCE, FFT, AND PCA

This study proposes a method to distinguish between healthy people and Parkinson’s disease patients using sole pressure sensor data, neural network with weighted fuzzy membership (NEWFM), and preprocessing techniques. The preprocessing techniques include fast Fourier transform (FFT), Euclidean distance, and principal component analysis (PCA), to remove noise in the data for performance enhancement. To make the features usable as inputs for NEWFM, the Euclidean distances between the left and right sole pressure sensor data were used at the first step. In the second step, the frequency scales of the Euclidean distances extracted in the first step were divided into individual scales by the FFT using the Hamming method. In the final step, 1–15 dimensions were extracted as the features of NEWFM from the individual scales by the FFT extracted in the second step by the PCA. An accuracy of 75.90% was acquired from the eight dimensions as the inputs of NEWFM.

Feasibility of Music-Assisted Treadmill Training in Parkinson's Disease Patients With and Without Deep Brain Stimulation: Insights From an Ongoing Pilot Randomized Controlled Trial

Background: Music-assisted treadmill training (MATT) is a new therapeutic approach for Parkinson's disease (PD) patients, combining treadmill training with rhythmic auditory cueing and visual feedback. PD studies have shown larger positive effects on motor outcomes than usual treadmill training. However, effects on cognition, in contrast, are less clear. Existing studies provided intensive training protocols and included only stable medicated patients. Thus, a pilot randomized controlled trial was designed to analyze the feasibility of a shorter training protocol as well as preliminary effects on cognition, motor function, and patient-centered outcomes in a rehabilitation setting where PD patients with and without deep brain stimulation (DBS) undergo adaptation of medication and DBS settings. Here, we present the results from the feasibility analysis of the still ongoing trial. Methods: Non-demented PD patients with and without DBS were recruited during their inpatient rehabilitation and randomized to an experimental group (EG; 20 min MATT) or an active control group (CG; 20 min bike ergometer training). The trainings took place for 8 consecutive days and were added to the usual rehabilitation. Feasibility was assessed with the following parameters: patients' study protocol acceptance, study protocol transferability into clinical routine, training-induced adverse events, and patients' training perception. Results: Thirty-two patients (EG: n = 15; CG: n = 17; 72% DBS) were included. The study protocol was well-accepted (inclusion rate: 84%). It was transferable into clinical routines; dropout rates of 40% (EG) and 18% (CG) were observed. However, an in-depth analysis of the dropout cohort did not reveal intervention-related dropout reasons. The MATT and the standard ergometer training showed no adverse events and were positively perceived by PD patients with and without DBS. Conclusion: MATT was shown to be a feasible, safe, and enjoyable treatment option in PD patients with and without DBS. Furthermore, the dropout cohort analysis revealed some exciting first insights into possible dropout reasons that go beyond the form of intervention. Therefore, research would benefit from a common practice of dropout analyses, as this would enhance our understanding of patients' therapy adherence and expectations.