Cognition and Activity of Daily Living Function in people with Parkinson's disease

The ability to perform activities of daily living (ADL) function is a multifaceted construct that reflects functionality in different daily life situations. The loss of ADL function due to cognitive impairment is the core feature for the diagnosis of Parkinson's disease dementia (PDD). In contrast to Alzheimer's disease, ADL impairment in PD can be compromised by various factors, including motor and non-motor aspects. This narrative review summarizes the current state of knowledge on the association of cognition and ADL function in people with PD and introduces the concept of "cognitive ADL" impairment for those problems in everyday life that are associated with cognitive deterioration as their primary cause. Assessment of cognitive ADL impairment is challenging because self-ratings, informant-ratings, and performance-based assessments seldomly differentiate between "cognitive" and "motor" aspects of ADL. ADL function in PD is related to multiple cognitive domains, with attention, executive function, and memory being particularly relevant. Cognitive ADL impairment is characterized by behavioral anomalies such as trial-and-error behavior or task step omissions, and is associated with lower engagement in everyday behaviors, as suggested by physical activity levels and prolonged sedentary behavior. First evidence shows that physical and multi-domain interventions may improve ADL function, in general, but the evidence is confounded by motor aspects. Large multicenter randomized controlled trials with cognitive ADL function as primary outcome are needed to investigate which pharmacological and non-pharmacological interventions can effectively prevent or delay deterioration of cognitive ADL function, and ultimately the progression and conversion to PDD.

Optimal dosage ranges of various exercise types for enhancing timed up and go performance in Parkinson's disease patients: a systematic review and Bayesian network meta-analysis

Objective

To examine the dose-response relationship between specific types of exercise for alleviating Timed up and Go (TUG) in Parkinson's disease PD.

Design

Systematic review and Bayesian network meta-analysis.

Data sources

PubMed, Medline, Embase, PsycINFO, Cochrane Library, and Web of Science were searched from inception until February 5th, 2024.

Study analysis

Data analysis was conducted using R software with the MBNMA package. Effect sizes of outcome indicators were expressed as mean deviation (MD) and 95% confidence intervals (95% CrI). The risk of bias in the network was evaluated independently by two reviewers using ROB2.

Results

A total of 73 studies involving 3,354 PD patients. The text discusses dose-response relationships in improving TUG performance among PD patients across various exercise types. Notably, Aquatic (AQE), Mix Exercise (Mul_C), Sensory Exercise (SE), and Resistance Training (RT) demonstrate effective dose ranges, with AQE optimal at 1500 METs-min/week (MD: -8.359, 95% CI: -1.398 to -2.648), Mul_C at 1000 METs-min/week (MD: -4.551, 95% CI: -8.083 to -0.946), SE at 1200 METs-min/week (MD: -5.145, 95% CI: -9.643 to -0.472), and RT at 610 METs-min/week (MD: -2.187, 95% CI: -3.161 to -1.278), respectively. However, no effective doses are found for Aerobic Exercise (AE), Balance Gait Training (BGT), Dance, and Treadmill Training (TT). Mind-body exercise (MBE) shows promise with an effective range of 130 to 750 METs-min/week and an optimal dose of 750 METs-min/week (MD: -2.822, 95% CI: -4.604 to -0.996). According to the GRADE system, the included studies' overall quality of the evidence was identified moderate level.

Conclusion

This study identifies specific exercise modalities and dosages that significantly enhance TUG performance in PD patients. AQE emerges as the most effective modality, with an optimal dosage of 1,500 METs-min/week. MBE shows significant benefits at lower dosages, catering to patients with varying exercise capacities. RT exhibits a nuanced "U-shaped" dose-response relationship, suggesting an optimal range balancing efficacy and the risk of overtraining. These findings advocate for tailored exercise programs in PD management, emphasizing personalized prescriptions to maximize outcomes.Systematic Review Registration: International Prospective Register of Systematic Reviews (PROSPERO) (CRD42024506968).

Comparing the effects of aquatic-based exercise and land-based exercise on balance in older adults: a systematic review and meta-analysis

BACKGROUND

Balance plays a crucial role in the daily activities of older adults. Aquatic-based exercises (AE) are widely conducted as an alternative to land-based exercises (LE). Previous studies have compared AE and LE as effective ways to improve balance and have yielded inconsistent results. Therefore, this review aimed to compare the effects of AE and LE on balance function in older adults.

METHODS

Electronic databases, including PubMed, Web of Science, Scopus, and Embase, were searched. Randomized controlled trials published from January 2003 to June 2023 were included following predetermined criteria. Data extraction was carried out by two independent reviewers. Data synthesis was conducted using RevMan 5.3 software. The fixed-effect model or random-effect model was chosen based on the results of the heterogeneity test. Meta-analysis for the effect sizes of balance outcomes was calculated as standardized mean difference (SMD) with 95% confidence intervals (CI). The quality of the included studies was evaluated using the Physiotherapy Evidence Database (PEDro) scale. This review was registered at PROSPERO CRD42023429557.

RESULTS

A total of 29 studies involving 1486 older adults (with an average age of 66.2 years) were included. Meta-analysis results indicated that AE could improve balance ability based on two tests: the Berg balance scale (BBS: SMD = 1.13, 95% CI 0.25 to 2.00, p = 0.01, I2 = 94%) and the 30-s chair stand test (30 CST: SMD = 2.02, 95% CI 0.50 to 3.54, p = 0.009, I2 = 96%). However, there were no significant differences between the AE group and the LE group in terms of the 6-min walking test (6 MWT: SMD = 0.13, 95% CI -0.16 to 0.43, p = 0.38, I2 = 62%) and time up to go test (TUGT: SMD = 0.44, 95% CI -0.44 to 0.91, p = 0.07, I2 = 85%). Older adults with different health conditions have different gains in different balance measurements after AE intervention and LE intervention.

CONCLUSIONS

Although this was influenced by participant health status, transfer effects, sample size, and other factors, AE offers better benefits than LE for improving balance function in older adults.

Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis

BACKGROUND

Physical exercise is effective in managing Parkinson's disease (PD), but the relative benefit of different exercise types remains unclear.

OBJECTIVES

To compare the effects of different types of physical exercise in adults with PD on the severity of motor signs, quality of life (QoL), and the occurrence of adverse events, and to generate a clinically meaningful treatment ranking using network meta-analyses (NMAs).

SEARCH METHODS

An experienced information specialist performed a systematic search for relevant articles in CENTRAL, MEDLINE, Embase, and five other databases to 17 May 2021. We also searched trial registries, conference proceedings, and reference lists of identified studies up to this date.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing one type of physical exercise for adults with PD to another type of exercise, a control group, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. A third author was involved in case of disagreements. We categorized the interventions and analyzed their effects on the severity of motor signs, QoL, freezing of gait, and functional mobility and balance up to six weeks after the intervention using NMAs. Two review authors independently assessed the risk of bias using the risk of bias 2 (RoB 2) tool and rated the confidence in the evidence using the CINeMA approach for results on the severity of motor signs and QoL. We consulted a third review author to resolve any disagreements. Due to heterogeneous reporting of adverse events, we summarized safety data narratively and rated our confidence in the evidence using the GRADE approach.

MAIN RESULTS

We included 154 RCTs with a total of 7837 participants with mostly mild to moderate disease and no major cognitive impairment. The number of participants per study was small (mean 51, range from 10 to 474). The NMAs on the severity of motor signs and QoL included data from 60 (2721 participants), and 48 (3029 participants) trials, respectively. Eighty-five studies (5192 participants) provided safety data. Here, we present the main results. We observed evidence of beneficial effects for most types of physical exercise included in our review compared to a passive control group. The effects on the severity of motor signs and QoL are expressed as scores on the motor scale of the Unified Parkinson's Disease Rating Scale (UPDRS-M) and the Parkinson's Disease Questionnaire 39 (PDQ-39), respectively. For both scales, higher scores denote higher symptom burden. Therefore, negative estimates reflect improvement (minimum clinically important difference: -2.5 for UPDRS-M and -4.72 for PDQ-39). Severity of motor signs The evidence from the NMA (60 studies; 2721 participants) suggests that dance and gait/balance/functional training probably have a moderate beneficial effect on the severity of motor signs (dance: mean difference (MD) -10.18, 95% confidence interval (CI) -14.87 to -5.36; gait/balance/functional training: MD -7.50, 95% CI -11.39 to -3.48; moderate confidence), and multi-domain training probably has a small beneficial effect on the severity of motor signs (MD -5.90, 95% CI -9.11 to -2.68; moderate confidence). The evidence also suggests that endurance, aqua-based, strength/resistance, and mind-body training might have a small beneficial effect on the severity of motor signs (endurance training: MD -5.76, 95% CI -9.78 to -1.74; aqua-based training: MD -5.09, 95% CI -10.45 to 0.40; strength/resistance training: MD -4.96, 95% CI -9.51 to -0.40; mind-body training: MD -3.62, 95% CI -7.24 to 0.00; low confidence). The evidence is very uncertain about the effects of "Lee Silverman Voice training BIG" (LSVT BIG) and flexibility training on the severity of motor signs (LSVT BIG: MD -6.70, 95% CI -16.48 to 3.08; flexibility training: MD 4.20, 95% CI -1.61 to 9.92; very low confidence). Quality of life The evidence from the NMA (48 studies; 3029 participants) suggests that aqua-based training probably has a large beneficial effect on QoL (MD -15.15, 95% CI -23.43 to -6.87; moderate confidence). The evidence also suggests that mind-body, gait/balance/functional, and multi-domain training and dance might have a small beneficial effect on QoL (mind-body training: MD -7.22, 95% CI -13.57 to -0.70; gait/balance/functional training: MD -6.17, 95% CI -10.75 to -1.59; multi-domain training: MD -5.29, 95% CI -9.51 to -1.06; dance: MD -3.88, 95% CI -10.92 to 3.00; low confidence). The evidence is very uncertain about the effects of gaming, strength/resistance, endurance, and flexibility training on QoL (gaming: MD -8.99, 95% CI -23.43 to 5.46; strength/resistance training: MD -6.70, 95% CI -12.86 to -0.35; endurance training: MD -6.52, 95% CI -13.74 to 0.88; flexibility training: MD 1.94, 95% CI -10.40 to 14.27; very low confidence). Adverse events Only 85 studies (5192 participants) provided some kind of safety data, mostly only for the intervention groups. No adverse events (AEs) occurred in 40 studies and no serious AEs occurred in four studies. AEs occurred in 28 studies. The most frequently reported events were falls (18 studies) and pain (10 studies). The evidence is very uncertain about the effect of physical exercise on the risk of adverse events (very low confidence). Across outcomes, we observed little evidence of differences between exercise types.

AUTHORS' CONCLUSIONS

We found evidence of beneficial effects on the severity of motor signs and QoL for most types of physical exercise for people with PD included in this review, but little evidence of differences between these interventions. Thus, our review highlights the importance of physical exercise regarding our primary outcomes severity of motor signs and QoL, while the exact exercise type might be secondary. Notably, this conclusion is consistent with the possibility that specific motor symptoms may be treated most effectively by PD-specific programs. Although the evidence is very uncertain about the effect of exercise on the risk of adverse events, the interventions included in our review were described as relatively safe. Larger, well-conducted studies are needed to increase confidence in the evidence. Additional studies recruiting people with advanced disease severity and cognitive impairment might help extend the generalizability of our findings to a broader range of people with PD.

Effect of aquatic exercise programs according to the International Classification of Functionality, Disability and Health domains in individuals with Parkinson's disease: a systematic review and meta-analysis with GRADE quality assessment

PURPOSE

To investigate the effects of aquatic exercise programs (AEP) in body structure and function, activity, and participation outcomes in individuals with Parkinson's disease (PD) with mild to moderate disability levels.

METHODS

Six databases were searched from inception until November 2022. Randomized clinical trials that used AEP alone, AEP combined and/or compared two types of AEP were included. The quality of evidence was assessed by the GRADE approach and the standardized mean differences (SMD) were calculated the meta-analysis.

RESULTS

Twelve studies (n = 380) were included. AEP alone was superior to active control in improving body structure and function outcome: postural balance (low evidence, SMD = 0.47, p = 0.02). No statistically significant differences were found for the other body structure and function outcomes: lower limb muscle strength (p = 0.14) and depressive symptoms (p = 0.79), activity outcomes: mobility (p = 0.32) and participation outcomes: quality of life (p = 0.05). AEP combined showed no statistically significant difference for the outcomes of body structure and function: postural balance (p = 0.11) and activity: mobility (p = 0.21) when compared to active control.

CONCLUSION

AEP showed positive effects on body structure and function outcome (postural balance) in individuals with PD with mild to moderate disability levels while, no significant improvements were noticed for activity and participation outcomes.IMPLICATIONS FOR REHABILITATIONOur findings indicate that aquatic exercise programs (AEP) lead to significant improvements on body structure and function (i.e., postural balance) in individuals with Parkinson's disease (PD).The AEP evaluated in this study implemented postural balance, gait, single and double training, as well as aerobic exercises, trunk mobility exercises, and Ai Chi.The average duration, frequency, and total time implemented were 50 minutes, three times a week, for seven weeks, respectively.Considering the potential benefits identified in this study, AEP can be recommended as an adjunct treatment strategy for individuals with PD.Additionally, the use of the International Classification of Functionality, Disability and Health on the development of rehabilitation treatment plans is advised.

Self-directed physical activity interventions for motor symptoms and quality of life in early and mid-stage Parkinson's disease: A systematic review and meta-analysis

BACKGROUND

Self-directed physical activity (SDPA) has been found in previous research to alleviate some of the symptoms of early and mid-stage Parkinson's disease (PD) patients. So, this study aimed to determine the impact of SDPA on these patients in the areas of motor symptoms, and quality of life (QoL).

METHOD

PubMed, Embase, the Cochrane Library, the Web of Science, Scopus, and ProQuest were all searched. The risk-of-bias tool of Cochrane for randomized trials, Version 2 (RoB 2), was also used to assess the credibility of studies in terms of their procedures.

RESULTS

15 eligible studies were analyzed. SDPA improved motor function and mobility, including timed up and go (TUG) test [standardized mean difference (SMD), -0.55 (95% CI, -0.91 - -0.18), p = 0.003], 6-minute walking (6MW) test [1.11 (0.75 - 1.47), p < 0.00001], stride length [0.45 (0.18 - 0.72), p = 0.001], gait velocity [0.42 (0.04 - 0.81 p = 0.03], Unified Parkinson's Disease Rating Scale Part-III (UPDRS-III) [-0.76 (-1.18 - -0.33), p = 0.0005] and enhanced Berg Balance Scale (BBS) [0.88 (0.50 - 1.27), p < 0.00001]). Despite engaging in SDPA, there was no significant improvement observed in freezing of gait (FOG) [0.23 (-0.11 - 0.56), p = 0.18] as well as the Parkinson's Disease Questionnaire-39 (PDQ-39) [0.04 (-0.55 - 0.62), p = 0.90]).

CONCLUSION

The motor symptoms of those with early to mid-stage PD improved with SDPA, however the research found no enhancement in FOG or QoL.

Clair KA, Toledo S, York MK, Todaro R, Yarab N, Wallock K. Delivering Multidisciplinary Rehabilitation Care in Parkinson's Disease: An International Consensus Statement

BACKGROUND

Parkinson's disease (PD) is a complex neurodegenerative disorder impacting everyday function and quality of life. Rehabilitation plays a crucial role in improving symptoms, function, and quality of life and reducing disability, particularly given the lack of disease-modifying agents and limitations of medications and surgical therapies. However, rehabilitative care is under-recognized and under-utilized in PD and often only utilized in later disease stages, despite research and guidelines demonstrating its positive effects. Currently, there is a lack of consensus regarding fundamental topics related to rehabilitative services in PD.

OBJECTIVE

The goal of the international Parkinson's Foundation Rehabilitation Medicine Task Force was to develop a consensus statement regarding the incorporation of rehabilitation in PD care.

METHODS

The Task Force, comprised of international multidisciplinary experts in PD and rehabilitation and people directly affected by PD, met virtually to discuss topics such as rehabilitative services, existing therapy guidelines and rehabilitation literature in PD, and gaps and needs. A systematic, interactive, and iterative process was used to develop consensus-based statements on core components of PD rehabilitation and discipline-specific interventions.

RESULTS

The expert-based consensus statement outlines key tenets of rehabilitative care including its multidisciplinary approach and discipline-specific guidance for occupational therapy, physical therapy, speech language pathology/therapy, and psychology/neuropsychology across all PD stages.

CONCLUSIONS

Rehabilitative interventions should be an essential component in the comprehensive treatment of PD, from diagnosis to advanced disease. Greater education and awareness of the benefits of rehabilitative services for people with PD and their care partners, and further evidence-based and scientific study are encouraged.

Motor symptoms of Parkinson's disease are affected by temperature: A controlled pilot study

PURPOSE

The motor symptoms (MS) of Parkinson's disease (PD) have been affecting the quality of life in patients. In clinical practice, most patients with PD report that MS are more severe in winter than in summer, and hyperthermic baths (HTB) could temporarily improve MS. The study aimed to evaluate the effects of seasonal variation and aquatic thermal environment of HTB on the MS of PD.

PATIENTS AND METHODS

A cross-sectional study of 203 Chinese Han patients was performed. Univariate and multivariate analyses were performed to analyze seasonal variation in MS relative to baseline data (sex, age at onset, duration, season of birth, Hoehn and Yahr stage, family history, levodopa equivalent dose, and the effect of HTB on MS). Ten subjects participated in the HTB study, and one patient dropped out. The paired Wilcoxon rank test was used to assess the differences in the Movement Disorder Society-United Parkinson's disease Rating Scale (MDS-UPDRS) part III motor examination total scores and the modified Webster Symptoms Score between non-HTB and before HTB and between non-HTB and after HTB.

RESULTS

The improvement of MS after HTB was an independent risk factor for seasonal variation in MS (OR, 25.203; 95% CI, 10.951-58.006; p = .000). Patients with PD had significant improvements in the MDS-UPDRS part III motor examination total scores, especially in bradykinesia (p = .043), rigidity (p = .008), posture (p = .038), and rest tremor amplitude (p = .047).

CONCLUSION

Seasonal variation in temperature and water temperature of HTB may affect MS in some patients with PD. Simple HTB could be recommended as physiotherapy for patients with PD who report temperature-sensitive MS.

Hydrodynamic Flow Characteristics of a Recirculating Pool: Examining the Ecological Validity for Training and Testing

ABSTRACT

Krajewski, KT, Beethe, AZ, Dever, DE, Johnson, CD, Nindl, BC, Lovalekar, MT, Flanagan, SD, and Connaboy, C. Hydrodynamic flow characteristics of a recirculating pool: examining the ecological validity for training and testing. J Strength Cond Res 37(10): 2023-2031, 2023-Recirculating swimming flumes (RSFs) with elliptical multifeature designs have grown in popularity due to their multifunctionality for rehabilitation and training. Because of their smaller footprint, laboratories have adopted their use to investigate swimming and underwater treadmill running. However, little is known about the hydrodynamic characteristics of these RSFs and how they might influence outcomes. The purpose was to determine hydrodynamic flow characteristics of an RSF at the manufacturers' set "speeds" around the centroid of flow projection. Hydrodynamic velocity profiles were collected through a 3D profiling velocimeter, sampling at 200 Hz in an RSF. Data were collected 0.5 and 1.5 m from the projection channel at designated flume "speeds" of 30-95 (+99) in 5-unit increments. Velocity data were collected for 1 minute per trial (location × speed) to determine mean flow velocity (MFV) for 10, 20, 30, and 40 cm2 cross-sectional areas (CSAs). A two-way ANOVA was conducted comparing CSAs from the surface by distance from the current channel (4 × 2). Separate ANOVAs were conducted to assess differences in MFV across each CSA. Significant differences between flow CSAs indicated that MFV is less for a larger area at the same speed, indicative of variable and turbulent flow characteristics across the respective CSAs. Mean flow velocity was further diminished by distance from the flow channel as supported by the main effect, thus exposing an individual to variant flow velocities simultaneously. Limited stability of the flow velocity centroid could affect swim mechanics making the movement pattern no longer analogous to traditional pool and open water swimming, rather resembling swimming upstream in a river with turbulent flow.

Effectiveness of the aquatic physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in healthy community-dwelling older adults: A systematic review and meta-analysis

BACKGROUND

Opting to use aquatic or land-based physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in community-dwelling older adults (CDOAs) is still a questionable clinical decision for physiotherapists.

OBJECTIVE

Assess the quality of evidence from randomized or quasi-randomized controlled trials that used aquatic physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in CDOAs.

METHODS

Articles were surveyed in the following databases: MEDLINE/PubMed, EMBASE, SCOPUS, LILACS, Web of Science, CENTRAL (Cochrane Central Register of Controlled Trials), PEDro, CINAHL, SciELO and Google Scholar, published in any language, up to July 31, 2023. Two independent reviewers extracted the data and assessed evidence quality. The risk of bias of the trials was evaluated by the Cochrane tool and evidence quality by GRADE approach. Review Manager software was used to conduct the meta-analyses.

RESULTS

3007 articles were identified in the searches, remaining 33 studies to be read in full, with 11 trials being eligible for this systematic review. The trials included presented low evidence quality for the balance, gait, quality of life and fear of falling. Land-based and aquatic physical therapy exercises improved the outcomes analyzed; however, aquatic physical therapy exercises were more effective in improving balance, gait, quality of life and reducing fear of falling in CDOAs. The meta-analysis showed that engaging in aquatic physical therapy exercises increases the functional reach, through of the anterior displacement of the center of pressure of CDOAs by 6.36cm, compared to land-based physical therapy exercises, assessed by the Functional Reach test: [CI:5.22 to 7.50], (p<0.00001), presenting low quality evidence.

CONCLUSIONS

Aquatic physical therapy exercises are more effective than their land-based counterparts in enhancing balance, gait, quality of life and reducing the fear of falling in CDOAs. However, due to methodological limitations of the trials, this clinical decision remains inconclusive. It is suggested that new trials be conducted with greater methodological rigor, in order to provide high-quality evidence on the use of the aquatic physical therapy exercises to improve the outcomes analyzed in CDOAs.

Comparative efficacy of 24 exercise types on postural instability in adults with Parkinson's disease: a systematic review and network meta-analysis

OBJECTIVE

To compare, rank and evaluate the 24 exercise types that improve postural instability in patients with Parkinson's disease (PD).

METHODS

We searched the data in PubMed, MEDLINE, Embase, PsycINFO, Cochrane library, and Web of Science from their inception date to January 23, 2023. Randomized controlled trials (RCTs) that aimed at determining the effectiveness of physical activity interventions on postural instability in adults with PD. This review focused on different balance outcome categories: (a) balance test batteries (BBS); (b) static steady-state balance (sSSB); (c) dynamic steady-state balance (dSSB); (d) proactive balance (PB); (e) reactive balance (RB).

RESULTS

Among 10,474 records, 199 studies (patients = 9523) were eligible for qualitative synthesis. The random-effects NMA model revealed that the following exercise training modalities had the highest p score of being best when compared with control group: body-weight support treadmill training (BWS_TT) for BBS (p score = 0.97; pooled standardised mean difference (95% CI): 1.56 (0.72 to 2.39)) and dSSB (1.00; 1.53 (1.07 to 2.00)), aquatic exercise (AQE) for sSSB (0.85; 0.94 (0.33 to 1.54)), Pilates for PB (0.95; 1.42 (0.59 to 2.26)). Balance and gait training with the external cue or attention (BGT_ECA) and robotic assisted gait balance (RA_GT) had similar superior effects in improving RB. The confidence in evidence was often low according to Confidence in Network Meta-Analysis.

CONCLUSIONS

There is low quality evidence that BWS_TT, AQE, Pilates, BGT_ECA and RA_GT are possibly the most effective treatments, pending outcome of interest, for adults with PD.

Effects of aquatic exercise on the improvement of lower-extremity motor function and quality of life in patients with Parkinson's disease: A meta-analysis

Objective: To systematically evaluate the effect of aquatic exercise interventions on the improvement of lower-extremity motor function and quality of life in patients with Parkinson's disease. Methods: Two researchers independently searched the literature using the PubMed, Web of Science, Embase, and Cochrane Library databases. The search period was from the establishment of the database to December 2021. The subject heading search included "hydrotherapy," "hydro therapies," "hydro therapeutics," "water therapy," "aquatic exercise therapy," "aquatic therapy," "water-based exercise," "Parkinson," "Parkinson disease," "Parkinson's disease," "Parkinson's syndrome," "primary Parkinsonism," "paralysis agitans," and "randomized controlled trial (RCT)." Result: A total of 698 articles were retrieved from the four databases by searching for subject headings, and 10 RCT articles were finally included. The balance ability of aquatic exercise in patients with Parkinson's disease (weighted mean differences [WMD] = 2.234, 95% CI: 1.112-3.357, Z = 3.9, p < 0.01), walking ability (WMD = -0.911, 95% CI: -1.581 to -0.241, Z = 2.67, p < 0.01), and quality of life (WMD = -5.057, 95% CI: -9.610 to -0.504, Z = 2.18, p = 0.029) were improved, but there was no significant difference in motor function (WMD = -0.328, 95% CI: -1.781 to 1.125, Z = 0.44, p = 0.658). Conclusion: Compared with conventional rehabilitation therapy, aquatic exercise can effectively improve balance, walking ability, and quality of life in patients with Parkinson's disease. However, it had no obvious effect on improving motor function. This study was limited by the number and quality of the included studies, and more high-quality studies are needed to verify this. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022365103.

Improvement of Balance, Motor Aspects, and Activities of Daily Living in Parkinson's Disease after a Sequential Multimodal Aquatic- and Land-Based Intervention Program

Parkinson's disease (PD) is a neurodegenerative, with heterogeneous clinical conditions and motor changes that reduce functioning. Postural instability is one of the motor aspects of disease progression, with a potential increase in the risk of falls, consequently affecting the activities of daily living (ADL). The objective of this study was to verify the influence of a multimodal intervention program (MIP) sequentially applied in aquatic- (AEs) and land-based environments (LEs) on balance, postural control, motor activities, and ADL in people with PD. It is an interventional clinical study with patients in stages 1 to 4 in the Hoehn and Yahr scale, assessed with Berg Balance Scale (BBS), Mini-Balance Evaluation System Test (Mini-BESTest), Unified Parkinson's Disease Rating Scale (UPDRS) II and III, Dynamic Gait Index (DGI), and quiet stance (QS) analysis in a force platform. The MIP was conducted sequentially with aquatic- (AIs) and land-based interventions (LIs) for 12 weeks each, twice a week, each session lasting 1 hour, and a 12-week interval between interventions. The comparison analysis was made with Friedman ANOVA, and the multiple comparisons with Wilcoxon signed-rank, Bonferroni correction, and effect size (r). The sample comprised 18 people with PD (66.83 ± 11.74 years). The AI and the full intervention (FI) had a large effect according to BBS. With Mini-BESTest, the LI and FI had a large effect. According to UPDRS II, the MIP improved ADL after LI, with a medium effect, and the motor aspects of UPDRS III improved after LI and FI, with a large effect. DGI was not sensitive in the analyses, with a ceiling effect after FI. No differences were identified in QS analyses. This research identified improved balance, ADL, and motor aspects in people with PD after sequential MIP in AI and LI, indicating that land-based and aquatic interventions are complementary and advantageous to people with PD.

Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis

BACKGROUND

Physical exercise is effective in managing Parkinson's disease (PD), but the relative benefit of different exercise types remains unclear.

OBJECTIVES

To compare the effects of different types of physical exercise in adults with PD on the severity of motor signs, quality of life (QoL), and the occurrence of adverse events, and to generate a clinically meaningful treatment ranking using network meta-analyses (NMAs).

SEARCH METHODS

An experienced information specialist performed a systematic search for relevant articles in CENTRAL, MEDLINE, Embase, and five other databases to 17 May 2021. We also searched trial registries, conference proceedings, and reference lists of identified studies up to this date.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing one type of physical exercise for adults with PD to another type of exercise, a control group, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. A third author was involved in case of disagreements.  We categorized the interventions and analyzed their effects on the severity of motor signs, QoL, freezing of gait, and functional mobility and balance up to six weeks after the intervention using NMAs. Two review authors independently assessed the risk of bias using the risk of bias 2 (RoB 2) tool and rated the confidence in the evidence using the CINeMA approach for results on the severity of motor signs and QoL. We consulted a third review author to resolve any disagreements. Due to heterogeneous reporting of adverse events, we summarized safety data narratively and rated our confidence in the evidence using the GRADE approach.

MAIN RESULTS

We included 156 RCTs with a total of 7939 participants with mostly mild to moderate disease and no major cognitive impairment. The number of participants per study was small (mean 51, range from 10 to 474). The NMAs on the severity of motor signs and QoL included data from 71 (3196 participants), and 55 (3283 participants) trials, respectively. Eighty-five studies (5192 participants) provided safety data. Here, we present the main results. We observed evidence of beneficial effects for most types of physical exercise included in our review compared to a passive control group. The effects on the severity of motor signs and QoL are expressed as scores on the motor scale of the Unified Parkinson Disease Rating Scale (UPDRS-M) and the Parkinson's Disease Questionnaire 39 (PDQ-39), respectively. For both scales, higher scores denote higher symptom burden. Therefore, negative estimates reflect improvement (minimum clinically important difference: -2.5 for UPDRS-M and -4.72 for PDQ-39). Severity of motor signs The evidence from the NMA (71 studies; 3196 participants) suggests that dance has a moderate beneficial effect on the severity of motor signs (mean difference (MD) -10.32, 95% confidence interval (CI) -15.54 to -4.96; high confidence), and aqua-based, gait/balance/functional, and multi-domain training might have a moderate beneficial effect on the severity of motor signs (aqua-based: MD -7.77, 95% CI -13.27 to -2.28; gait/balance/functional: MD -7.37, 95% CI -11.39 to -3.35; multi-domain: MD -6.97, 95% CI -10.32 to -3.62; low confidence). The evidence also suggests that mind-body training and endurance training might have a small beneficial effect on the severity of motor signs (mind-body: MD -6.57, 95% CI -10.18 to -2.81; endurance: MD -6.43, 95% CI -10.72 to -2.28; low confidence). Flexibility training might have a trivial or no effect on the severity of motor signs (MD 2.01, 95% CI -4.82 to 8.98; low confidence). The evidence is very uncertain about the effects of strength/resistance training and "Lee Silverman Voice training BIG" (LSVT BIG) on the severity of motor signs (strength/resistance: MD -6.97, 95% CI -11.93 to -2.01; LSVT BIG: MD -5.49, 95% CI -14.74 to 3.62; very low confidence). Quality of life The evidence from the NMA (55 studies; 3283 participants) suggests that aqua-based training probably has a large beneficial effect on QoL (MD -14.98, 95% CI -23.26 to -6.52; moderate confidence). The evidence also suggests that endurance training might have a moderate beneficial effect, and that gait/balance/functional and multi-domain training might have a small beneficial effect on QoL (endurance: MD -9.16, 95% CI -15.68 to -2.82; gait/balance/functional: MD -5.64, 95% CI -10.04 to -1.23; multi-domain: MD -5.29, 95% CI -9.34 to -1.06; low confidence). The evidence is very uncertain about the effects of mind-body training, gaming, strength/resistance training, dance, LSVT BIG, and flexibility training on QoL (mind-body: MD -8.81, 95% CI -14.62 to -3.00; gaming: MD -7.05, 95% CI -18.50 to 4.41; strength/resistance: MD -6.34, 95% CI -12.33 to -0.35; dance: MD -4.05, 95% CI -11.28 to 3.00; LSVT BIG: MD 2.29, 95% CI -16.03 to 20.44; flexibility: MD 1.23, 95% CI -11.45 to 13.92; very low confidence). Adverse events Only 85 studies (5192 participants) provided some kind of safety data, mostly only for the intervention groups. No adverse events (AEs) occurred in 40 studies and no serious AEs occurred in four studies. AEs occurred in 28 studies. The most frequently reported events were falls (18 studies) and pain (10 studies). The evidence is very uncertain about the effect of physical exercise on the risk of adverse events (very low confidence). Across outcomes, we observed little evidence of differences between exercise types.

AUTHORS' CONCLUSIONS

We found evidence of beneficial effects on the severity of motor signs and QoL for most types of physical exercise for people with PD included in this review, but little evidence of differences between these interventions. Thus, our review highlights the importance of physical exercise regarding our primary outcomes severity of motor signs and QoL, while the exact exercise type might be secondary. Notably, this conclusion is consistent with the possibility that specific motor symptoms may be treated most effectively by PD-specific programs. Although the evidence is very uncertain about the effect of exercise on the risk of adverse events, the interventions included in our review were described as relatively safe. Larger, well-conducted studies are needed to increase confidence in the evidence. Additional studies recruiting people with advanced disease severity and cognitive impairment might help extend the generalizability of our findings to a broader range of people with PD.

Can spa rehabilitative interventions play a role for patients suffering from neurodegenerative disorders at the early stages? A scoping review

The global burden of neurodegenerative disorders is significantly increasing as life expectancy rises but currently there is no cure for these conditions. An extensive search on MEDLINE (PubMed) and PEDro databases was conducted selecting clinical trials, Randomized Controlled Trials, and longitudinal studies published in the last 20 years in order to highlight what evidence there is for a role of spa rehabilitative interventions for patients with neurodegenerative diseases, in terms of motor function, symptoms, and quality of life (QoL) improvement and cost-effectiveness. A total of 225 publications were analyzed. Only three manuscripts were selected for review because they matched the inclusion criteria. These studies demonstrated statistically significant differences in the outcomes evaluated among patients affected by Parkinson's disease after thermal rehabilitative treatments: motor function, balance, QoL, and psychological well-being statistically improved. In addition, rehabilitation in the spa setting seemed to be cost-effective for these patients. However, further studies are needed to define the role of spa rehabilitative interventions for these patients as the literature is still limited.

Effects of an Aquatic Physical Exercise Program on Ventilatory Parameters in People with Parkinson’s Disease

Problems in the respiratory system are the main cause of death in Parkinson’s disease (PD). Ventilatory limitations can also be part of a vicious cycle involving physical-functional limitations (e.g., walking difficulties) and the patients’ perception of fatigue. The objective of this study was to analyze the effects of an aquatic physical exercise intervention program on ventilatory parameters, perception of fatigue, and gait capacity in participants with PD. This quasi-experimental study had a single group with repeated measures in four assessments, proposing an aquatic physical exercise intervention program. The inclusion criteria encompassed being in levels 1 to 4 on the Hoehn and Yahr scale and having a medical certificate for the activities. Assessments took place at 3-month intervals between them—the first period was the control, the second following the intervention, and the third period was the follow-up. The intervention had 25 biweekly sessions over 3 months. A total of 13 people (71.3 ± 5.61 years old) participated in the intervention, without significant differences in the control period. Between the intervention assessments, they had statistically significant differences in MIP, MEP, FVC, Tiffeneau index, MVV, and fatigue. The study demonstrated that the aquatic physical exercise intervention was effective for ventilatory outcomes and fatigue in people with PD.

Interventions for preventing falls in Parkinson's disease

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

Effects of Ten Different Exercise Interventions on Motor Function in Parkinson’s Disease Patients—A Network Meta-Analysis of Randomized Controlled Trials

Objective: The aim of this study was to evaluate ten exercise interventions (YOGA: yoga training, RT: resistance training, AQU: aquatic training, TAI: Taiji Qigong training, TRD: treadmill training, VR: virtual reality training, DANCE: musical dance training, WKT: walking training, CYC: cycling training, BDJ: Baduanjin Qigong training) on motor function in Parkinson’s disease (PD) patients. Design: Through searching PubMed, Embase, Cochrane Library, Web of Science, and CNKI, only randomized controlled trials (RCTs) were collected to study the effects of the ten exercise interventions on motor function in patients with Parkinson’s disease. The included studies were evaluated for methodological quality by the Cochrane bias risk assessment tool. Results: The RCTs were collected between the earliest available date and April 2022. Sixty RCTs were included and the total sample size used in the study was 2859. The results of the network meta-analysis showed that DANCE can significantly improve patients’ Berg Balance Scale (BBS) (SUCRA = 78.4%); DANCE can significantly decline patients’ Unified Parkinson’s Disease Rating Scale score (UPDRS) (SUCRA = 72.3%) and YOGA can significantly decline patients’ Timed-Up-and-Go score (TUGT) (SUCRA = 78.0%). Conclusion: Based on the network meta-analysis and SUCRA ranking, we can state that dance, yoga, virtual reality training and resistance training offers better advantages than other exercise interventions for patients’ motor function.

Occupational Therapy Practice Guidelines for People With Parkinson's Disease

IMPORTANCE

Occupational therapy practitioners address the occupational performance and participation needs of people with Parkinson's disease (PD) and their care partners.

OBJECTIVE

This Practice Guideline is informed by systematic reviews on the use of occupational therapy interventions to promote participation in occupations for people with PD and to facilitate their caregivers' participation in the caregiver role. This guideline is meant to support practitioners' clinical decision making when working with people with PD and their care partners.

METHOD

We examined and synthesized the results of four systematic reviews and integrated those results into clinical recommendations for practice.

RESULTS

Thirty-three articles from the systematic reviews served as the basis for the clinical recommendations in this Practice Guideline. Clinical recommendations are provided for interventions that have strong or moderate supporting evidence.

CONCLUSION AND RECOMMENDATIONS

Multidisciplinary, tailored, goal-oriented intervention is recommended for people with PD. Various forms of exercise can be used to improve activities of daily living and instrumental activities of daily living performance and social participation, and interventions should incorporate health behavior change techniques to support adequate physical activity levels in daily life. Mindfulness meditation and exercise can be used to support sleep, and task-oriented training can be used to improve performance of specific tasks. Occupational therapy practitioners should incorporate self-management, coaching, compensatory, cognitive-behavioral, and other approaches into multicomponent treatment plans depending on the client's needs and goals. Additional potentially appropriate intervention approaches or areas to address are discussed on the basis of existing or emerging evidence and expert opinion. What This Article Adds: This Practice Guideline provides a summary and applications of the current evidence supporting occupational therapy intervention for people with PD. It includes case examples and suggested decision-making algorithms to support practitioners in addressing client goals.

Effect of Intensive Rehabilitation Program in Thermal Water on a Group of People with Parkinson's Disease: A Retrospective Longitudinal Study

The main objective of this study is to test the effect of thermal aquatic exercise on motor symptoms and quality of life in people with Parkinson's Disease (PD). Fourteen participants with diagnosis of idiopathic PD completed the whole rehabilitation session and evaluation protocol (Hoehn and Yahr in OFF state: 2-3; Mini Mental State Examination >24; stable pharmacological treatment in the 3 months prior participating in the study). Cognitive and motor status, functional abilities and quality of life were assessed at baseline and after an intensive rehabilitation program in thermal water (12 sessions of 45 min in a 1.4 m depth pool at 32-36 ∘C). The Mini Balance Evaluation System Test (Mini-BESTest) and the PD Quality of Life Questionnaire (PDQ-39) were considered as main outcomes. Secondary assessment measures evaluated motor symptoms and quality of life and psychological well-being. Participants kept good cognitive and functional status after treatment. Balance of all the participants significantly improved (Mini-BESTest: p<0.01). The PDQ-39 significantly improved after rehabilitation (p=0.038), with significance being driven by dimensions strongly related to motor status. Thermal aquatic exercise may represent a promising rehabilitation tool to prevent the impact of motor symptoms on daily-life activities of people with PD. PDQ-39 improvement foreshows good effects of the intervention on quality of life and psychological well-being.

Rehabilitation in movement disorders: From basic mechanisms to clinical strategies

Movement disorders encompass a variety of conditions affecting the nervous system at multiple levels. The pathologic processes underlying movement disorders alter the normal neural functions and could lead to aberrant neuroplastic changes and to clinical phenomenology that is not expressed only through mere motor symptoms. Given this complexity, the responsiveness to pharmacologic and surgical therapies is often disappointing. Growing evidence supports the efficacy of neurorehabilitation for the treatment of movement disorders. Specific form of training involving both goal-based practice and aerobic training could drive and modulate neuroplasticity in order to restore the circuitries dysfunctions and to achieve behavioral gains. This chapter provides an overview of the alterations expressed in some movement disorders in terms of clinical signs and symptoms and plasticity, and suggests which ones and why tailored rehabilitation strategies should be adopted for the management of the different movement disorders.

Evidence-Based Aquatic Therapy Guidelines for Parkinson's Disease: An International Consensus Study

BACKGROUND

Aquatic therapy is one therapy option for people living with Parkinson's disease (PD). However, the optimal prescription, dosage, and delivery remain unclear.

OBJECTIVE

i) To generate consensus statements, ii) to establish evidence-based clinical practice aquatic therapy guidelines for PD.

METHODS

Seventy-three international experts were invited to participate in a 3-step modified Delphi study. Gaps in the aquatic therapy evidence, patient preferences, and stakeholder engagement were considered when developing the initial list of 43-statements identified by the research development group. Practice experts rated each statement on an 11-point Likert scale. Consensus for inclusion was set at a priori of ≥70% of respondents scoring an item ≥7. Two rounds of Delphi questionnaires were completed online, and the expert comments were analyzed using content analysis. An online consensus meeting with an expert subgroup (n = 10) then advised on the guideline's acceptability and debated items until consensus for inclusion was reached.

RESULTS

Fifty experts participated in the Delphi round one (83% response rate) and 45 in round two (90% response rate), representing 15 countries. In round one, 35 statements met the criteria for consensus. Content analysis informed the revised statements in round two, where 12 of the remaining 16 statements met consensus. The final agreed aquatic therapy guidelines include key information about dosage, content, safety, contraindications, and the optimal aquatic therapy delivery throughout the disease course.

CONCLUSION

Stakeholders, including international practice experts, informed a rigorous evidence-based approach to integrate the best available evidence, patient preferences, and practice expertise to inform these guidelines.

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

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

Interventions Within the Scope of Occupational Therapy to Improve Activities of Daily Living, Rest, and Sleep in People With Parkinson's Disease: A Systematic Review

IMPORTANCE

People with Parkinson's disease (PD) commonly experience difficulty in performing activities of daily living (ADLs), which affects their perceived quality of life.

OBJECTIVE

To examine the evidence for the effectiveness of interventions within the scope of occupational therapy to improve performance and participation in ADLs, rest, and sleep in adults with PD.

DATA SOURCES

Databases searched were MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane Collection. Included articles were published between January 2011 and December 2018. Study Selection and Data Collection: Articles describing Level 1b, 2b, and 3b studies that examined outcomes related to ADLs, rest, and sleep in people with PD were included following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

FINDINGS

Forty-five articles (10 Level 1b, 27 Level 2b, and 8 Level 3b) met the inclusion criteria.

CONCLUSIONS AND RELEVANCE

Strong strength of evidence was found to support inpatient multidisciplinary intensive rehabilitation treatment (MIRT) to improve ADLs, and moderate strength of evidence that MIRT improves sleep performance. Low strength of evidence was present for outpatient occupational therapy to improve ADL and sleep outcomes. Low strength of evidence was found for resistance exercise programs to improve ADLs, but moderate strength of evidence indicates that multimodal exercise programs and targeted exercise programs can improve ADLs. Low to moderate strength of evidence suggested that alternative therapies and cognitive-behavioral therapy have a positive impact on ADLs and sleep. These results can be used to inform evidence-based occupational therapy practice. What This Article Adds: This article provides information for practitioners on the effectiveness of interventions within the scope of occupational therapy practice to improve ADLs and sleep.

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.

Perceptions of aquatic physiotherapy and health-related quality of life among people with Parkinson's disease

Background

Enablers for people with Parkinson's disease (PD) participating in aquatic physiotherapy have been identified, and exercise improves health‐related quality of life (HRQoL) but it is unclear whether all enablers and barriers for aquatic physiotherapy specific to the PD population have been explored.

Objective

To describe HRQoL in people with PD who have undertaken aquatic physiotherapy, and explore their perceptions and attitudes regarding the programme.

Methods

Twenty‐one participants who participated in a pilot trial on aquatic physiotherapy were included. Participants completed a survey regarding their experiences. The Parkinson's Disease Questionnaire‐39 (PDQ‐39) and Personal Well‐being Index‐Adult (PWI) were used to quantify HRQoL, whilst focus groups were conducted to explore their perceptions and attitudes. Descriptive statistics were used to summarize HRQoL scores. Focus group data were analysed using the deductive coding method.

Results

Most participants felt that the aquatic programme was worthwhile (n = 20/21, 95%). However, they had poor overall well‐being (mean 41.6, SD 13.5) and HRQoL (mean 31.0, SD 13.2) as measured by the PWI and PDQ‐39. Several barriers to aquatic therapy including safety when getting dressed, fatigue and transport were identified although many enablers were also identified, including an improvement in function, less falls and group socialization.

Conclusions

Aquatic physiotherapy was well‐accepted. Participants felt their function improved and felt safe in the water. HRQoL is lower in individuals with PD when compared to Australian norms; thus, interventions to optimize HRQoL need to be explored further.

Patient or Public Contribution

Patients participated in the aquatic intervention, survey and focus groups.

Aquatic exercise associated or not with grape juice consumption-modulated oxidative parameters in Parkinson disease patients: A randomized intervention study

Parkinson's disease (PD) is a neurodegenerative disorder with significant motor disabilities and cognitive decline. Importantly, the imbalance of oxidative stress is related to PD physiopathology and progression. This study aimed to evaluate the impact of grape juice consumption associated with an aquatic exercise protocol on oxidative stress parameters and cognitive function in individuals with PD. The participants were randomized into two groups: grape juice group (GJG) and control group (CG) and were submitted to 4 weeks of an aquatic intervention (twice a week, approximately 60 minutes/session). The GJG also consumed 400 ml of grape juice per day (integral and conventional) during this period. Cognitive function was assessed by the Montreal Cognitive Assessment (MoCa) questionnaire. For the analysis of oxidative stress markers, specifically lipid oxidative damage (TBARS), proteins (Carbonil), acid uric and the activity of antioxidant enzymes (superoxide dismutase, glutathione peroxidase and catalase), blood collection were done before and after intervention. No changes were observed in cognitive function after intervention in both groups. Regarding biomarkers, a reduction of antioxidant enzymes, thiobarbituric acid reactive substances (TBARS) and uric acid was observed in both groups. However, only the GJG showed a significant reduction on protein oxidation levels after intervention. In conclusion, the consumption of grape juice associated with an aquatic exercise protocol might be consider an effective alternative to reduce the oxidative damage in PD, reinforcing the importance of this intervention in promoting beneficial impact in this population.

A scoping review of the nature of physiotherapists' role to avoid fall in people with Parkinsonism

BACKGROUND

Parkinson's disease (PD) is considered a neurological disease with a high prevalence rate among population. One of its main problems is recurrent fall which has numerous contributing factors such as history of fall, fear of falling, gait deficits, impaired balance, poor functional mobility, and muscle weakness.

OBJECTIVE

To review and explore the focus/nature of interventions which target the role of physiotherapy preventing fall in patients with PD.

METHOD

A scoping review was led dependent on Arksey and O'Malley as discussed by Wood et al. (2002). This paper based on this structure to perceive intervention studies have been embraced in physiotherapy to prevent fall after Parkinson's disease. The search included various databases. The referencing arrangements of every pertinent paper were additionally filtered for more studies.

FINDINGS

A total of 173 articles were included, 39 of which met the eligibility criteria. Fifteen studies reported on the direct impact of physiotherapy on fall, while the rest examined the impacts of physiotherapy on factors that are associated with fall. Different outcomes, interventions types, and duration were used in these studies. Findings showed a favorable result of physiotherapy on fall and near fall incidence, balance, gait, functional mobility, muscle strength, and fear of falling.

CONCLUSION

Physiotherapy has the possibility to decrease fall incidence and fall risk in people with PD. However, the heterogeneity in the patients' selection, intervention studies, outcome measures chosen, time since the onset of disease, variation in intensity, and duration of treatment between included studies make the comparisons difficult. Consequently, more studies are needed on best intervention.

A systematic review and meta-analysis comparing the effect of aquatic and land exercise on dynamic balance in older adults

BACKGROUND

Balance impairments are the leading causes of falls in older adults. Aquatic-based exercises have been broadly practiced as an alternative to land-based exercises; however, the effects on dynamic balance have not been comprehensively reviewed and compared to land exercises. Thus, the purpose of this systematic review and meta-analysis was to compare the effectiveness of aquatic exercises (AE) to land exercises (LE) on dynamic balance in older adults.

METHODS

Electronic databases (PubMed, MEDLINE, CINAHL, SPORTDiscus, psycINFO), from inception to November 2019, were searched. Studies met the following eligibility criteria: Randomized controlled trials, English language, older adults aged 65 years or older, a minimum of one AE and LE group, at least one assessment for dynamic balance. For the meta-analysis, the effect sizes of dynamic balance outcomes were calculated using a standardized mean difference (SMD) and a 95% confidence interval (CI).

RESULTS

A total of 11 trials met the inclusion criteria, and 10 studies were eligible for the meta-analysis. The meta-analysis presented that older adults in AE groups demonstrated comparable enhancements in dynamic steady-state balance (SMD = - 0.24; 95% CI, -.81 to .34), proactive balance (SMD = - 0.21; 95% CI, -.59 to .17), and balance test batteries (SMD = - 0.24; 95% CI, -.50 to .03) compared with those in LE groups.

CONCLUSIONS

AE and LE have comparable impacts on dynamic balance in older adults aged 65 years or older. Thus, this review provides evidence that AE can be utilized as a reasonable alternative to LE to improve dynamic balance and possibly reduce the risk of falls.

Effect of exercise and grape juice on epigenetic modulation and functional outcomes in PD: A randomized clinical trial

OBJECTIVE

This study aimed to investigate the impact of an aquatic physical training program associated with grape juice (Vitis labrusca) consumption on functional outcomes, Brain-Derived Neurotrophic Factor (BDNF) and global histone H4 acetylation levels in peripheral blood from individuals with Parkinson's disease.

METHODS

Nineteen participants were randomized to Aquatic Exercise (AQ, n = 9) and Aquatic Exercise + Grape Juice (AQ+GJ, n = 10) groups and performed to 4 weeks of an aquatic intervention (twice a week, approximately 60 min/session). The AQ+GJ groups also consumed 400 mL of grape juice per day during this period. Functional capacity (six-min walk test, 6MWT), mobility (The Timed Up and Go, TUG) and the risk of falls (Berg Balance Scale, BBS) were evaluated before and after intervention. In addition, blood collections were carried out for biomarker analysis (e.g. BDNF and global histone H4).

RESULTS

The aquatic exercise program induced functional improvement in individuals with Parkinson's disease, specifically ameliorating their mobility and functional capacity. In addition, enhanced levels of BDNF and histone H4 acetylation were found after the intervention. Grape juice consumption did not potentiate these effects, since any significant differences between the AQ and AQ+GJ groups were not found in all analysed variables.

CONCLUSIONS

The present study provides important insights about aquatic exercise-modulated BDNF levels in individuals with Parkinson's disease in combination with functional improvements, suggesting that histone acetylation status may interact to dictate the molecular mechanisms involved in this response. Parkinson disease, aquatic exercise, BDNF, epigenetic, grape juice.

Effects of water-based exercise on functioning and quality of life in people with Parkinson's disease: a systematic review and meta-analysis

AIM

To investigate the effects of the water-based exercise on balance, mobility, mobility and functional independence, functional performance, fear of falling and quality of life in people with Parkinson's disease.

METHODS

We searched pubmed/MEDLINE, Cochrane Central Register of Controlled Trials, PEDro data base and SciELO to June 2020 for randomised controlled trials that investigated the effects of water-based exercise in people with Parkinson's disease. Two comparisons were made: water-based exercise versus usual care and water-based exercise versus land-exercise. The main outcomes were Balance, Confidence, Mobility, Unified Parkinson's Disease Rating Scale and quality of life. Mean differences (MD) with 95% confidence interval (CI) were calculated, and heterogeneity was assessed using the I² test.

RESULTS

Fifteen randomised controlled trials were found (435 people). Compared to usual care, water-based exercise resulted in improvement in balance MD (9.1, 95% CI: 6.5, 11.8, N = 45). Water-based exercise resulted in improvement in balance MD (3.1, 95% CI: 1.2, 5.0, N = 179), mobility MD (-2.2, 95% CI: -3.3, -1.0, N = 197) and quality of life MD (-5.5, 95% CI: -11, -0.07, N = 98) compared to land-based exercise, but without significant difference in functional performance MD (0.01, 95% CI: -2.6 to 2.7, N = 69). Land-based exercise resulted in improvement in fear of falling MD (-3.5, 95% CI: -5.6, -1.3, N = 58) compared to water-based exercise.

CONCLUSION

Water-based exercise was more efficient than land-based exercise and/or usual care in improving balance, mobility and quality of life in people with Parkinson's disease.

Additional Physical Interventions to Conventional Physical Therapy in Parkinson's Disease: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Parkinson’s disease (PD) represents the second most common neurodegenerative disease. Currently, conventional physical therapy is complemented by additional physical interventions with recreational components, improving different motor conditions in people with PD. This review aims to evaluate the effectiveness of additional physical interventions to conventional physical therapy in Parkinson’s disease. A systematic review and meta-analysis of randomized controlled trials were performed. The literature search was conducted in PubMed, Physiotherapy Evidence Database (PEDro), Scopus, SciELO and Web of Science. The PEDro scale was used to evaluate the methodological quality of the studies. A total of 11 randomized controlled trials were included in this review. Five of them contributed information to the meta-analysis. The statistical analysis showed favorable results for dance-based therapy in motor balance: (Timed Up and Go: standardized mean difference (SMD) = −1.16; 95% Confidence Interval (CI):(−2.30 to −0.03); Berg Balance Scale: SMD = 4.05; 95%CI:(1.34 to 6.75)). Aquatic interventions showed favorable results in balance confidence (Activities-Specific Balance Confidence: SMD=10.10; 95%CI:(2.27 to 17.93)). The results obtained in this review highlight the potential benefit of dance-based therapy in functional balance for people with Parkinson’s disease, recommending its incorporation in clinical practice. Nonetheless, many aspects require clarification through further research and high-quality studies on this subject.

Motor-cognitive approach and aerobic training: a synergism for rehabilitative intervention in Parkinson's disease

Parkinson's disease (PD) results in a complex deterioration of motor behavior. Effective pharmacological or surgical treatments addressing the whole spectrum of both motor and cognitive symptoms are lacking. The cumulative functional impairment may have devastating socio-economic consequences on both patients and caregivers. Comprehensive models of care based on multidisciplinary approaches may succeed in better addressing the overall complexity of PD. Neurorehabilitation is a highly promising non-pharmacological intervention for managing PD. The scientific rationale beyond rehabilitation and its practical applicability remain to be established. In the present perspective, we aim to discuss the current evidence supporting integrated motor-cognitive and aerobic rehabilitation approaches for patients with PD while suggesting a practical framework to optimize this intervention in the next future.

Effects of land- and water-based exercise programmes on postural balance in individuals with COPD: additional results from a randomised clinical trial

OBJECTIVE

To investigate the effects of water-based exercise training on postural balance in individuals with chronic obstructive pulmonary disease (COPD), and compare the effects of two similar protocols of land- and water-based exercise programmes on postural balance in this population.

DESIGN

Randomised clinical trial.

SETTING

University-based, outpatient, physical therapy clinic.

SUBJECTS

Fifty individuals with COPD.

INTERVENTIONS

Participants were assigned at random to the land group (LG; n=27) or the water group (WG; n=23), and underwent high-intensity endurance and strength training three times per week for 3months.

MAIN OUTCOME MEASURES

Functional balance was assessed by the timed up and go test (TUG), and static balance was assessed with a force platform in the following conditions: standing with feet hip-width apart and eyes open; standing with feet hip-width apart and eyes closed; standing on a short base; and one-legged stance.

RESULTS

Seventeen subjects completed the intervention in the LG {nine males, mean age 64 [standard deviation (SD) 8] years, mean forced expiratory volume in 1 second (FEV₁) 48 (SD 17) %predicted} compared with 14 subjects in the WG [nine males, mean age 65 (SD 8) years, FEV₁ 51 (SD 15) %predicted]. Water-based exercise training had a positive effect on functional balance [TUG: mean difference -1.17 (-1.93 to -0.41 95% confidence interval) seconds; P=0.006], whereas static balance remained unaltered for both groups. There was no between-group difference in postural balance after exercise training; however, a higher proportion of participants who had a clinically relevant improvement in the TUG were in the WG (LG 35%, WG 64%; P<0.001).

CONCLUSION

Functional balance improved after 3months of high-intensity exercise training performed in water. Despite the environment, non-specific training seems to be insufficient to improve static balance.

CLINICAL TRIAL REGISTRATION NUMBER

clinicalTrials.gov NCT01691131.

Aquatic exercise program-modulated oxidative stress markers in patients with Parkinson's disease

Parkinson’s disease is a neurodegenerative disease. Oxidative stress, i.e., the imbalance between the generation of reactive oxygen species and the antioxidant defense capacity of the body, plays an important role in the pathogenesis of this disease. Physical exercise can regulate oxidative stress. The purpose of this study was to analyze the short- and long-term effects of an aquatic exercise program on oxidative stress levels in patients with Parkinson’s disease. The aquatic exercise program was carried out during 1 month with two sessions per week (1 hour/session). Blood samples were collected at four different time points: pre-intervention, immediately, 48 hours, and 30 days after the first session of aquatic exercise program. Our results revealed that water-based programs modulated antioxidant enzyme activity, increased superoxide dismutase activity, reduced catalase activity, and increased the ratio of superoxide dismutase activity to catalase activity in patients with Parkinson’s disease. Compared with pre-intervention and 48 hours after the first session of aquatic exercise program, superoxide dismutase activity was higher and catalase activity was lower immediately and 30 days after the first session. Our results demonstrated that aquatic exercise program could modulate oxidative stress, mainly by the effect of antioxidant enzyme activity. These results could better help understand the target of oxidative stress in Parkinson’s disease. This study was approved by the Ethics Committee of Centro Universitário Metodista IPA (approval No. 1.373.911) on August 9, 2019 and registered with REBEC (registration number: RBR-6NJ4MK).

The effect of balance training with Tetra-ataxiometric posturography on balance function in patients with parkinsonism

BACKGROUND

Balance impairment is a major clinical concern in patients with parkinsonism. Balance training with tetra-ataxiometric posturography (Tetrax) is known to improve balance function through visual biofeedback effects.

OBJECTIVE

In this study, we evaluated the effects of balance training with Tetrax in patients with parkinsonism.

METHODS

Patients with parkinsonism (idiopathic Parkinson's disease, multiple systemic atrophy, and multiple systemic atrophy) who were able to stand with or without an assistive device were recruited for the study. Twenty patients with parkinsonism were randomly assigned to one of the following two groups: (1) the Tetrax group, in which patients received Tetrax biofeedback balance training for 30 min/day for 2 weeks (10 sessions); and (2) the control group, in which patients received conventional balance training for 30 min/day for 2 weeks (10 sessions). One day before and after training, we measured patients' balance parameters using the Berg balance scale (BBS) and fall index (FI).

RESULTS

The BBS and FI scores of the Tetrax group showed significant improvements after compared to before training. However, the scores in the control group were not significantly changed after vs. before conventional balance training.

CONCLUSIONS

For patients with parkinsonism, Tetrax biofeedback balance training had a positive effect on balance function.

Treatment options for postural instability and gait difficulties in Parkinson's disease

Introduction: Gait and balance disorders in Parkinson's disease (PD) represent a major therapeutic challenge as frequent falls and freezing of gait impair quality of life and predict mortality. Limited dopaminergic therapy responses implicate non-dopaminergic mechanisms calling for alternative therapies.Areas covered: The authors provide a review that encompasses pathophysiological changes involved in axial motor impairments in PD, pharmacological approaches, exercise, and physical therapy, improving physical activity levels, invasive and non-invasive neurostimulation, cueing interventions and wearable technology, and cognitive interventions.Expert opinion: There are many promising therapies available that, to a variable degree, affect gait and balance disorders in PD. However, not one therapy is the 'silver bullet' that provides full relief and ultimately meaningfully improves the patient's quality of life. Sedentariness, apathy, and emergence of frailty in advancing PD, especially in the setting of medical comorbidities, are perhaps the biggest threats to experience sustained benefits with any of the available therapeutic options and therefore need to be aggressively treated as early as possible. Multimodal or combination therapies may provide complementary benefits to manage axial motor features in PD, but selection of treatment modalities should be tailored to the individual patient's needs.

Exercise in the Aquatic Environment for Patients With Chronic Spinal Cord Injury and Invasive Appliances: Successful Integration and Therapeutic Interventions

OBJECTIVE

Our primary objectives of this initial "proof-of-principle" trial were to evaluate the interventions used in skilled aquatic therapy and to identify any clinical benefits for individuals with spinal cord injuries who use invasive appliances including pressure injury dressings, suprapubic catheters, indwelling catheters, colostomy bags, and tracheostomy tubes.

DESIGN

This is a retrospective chart review of patients with chronic spinal cord injuries using invasive appliances who had also undergone skilled aquatic therapy.

RESULTS

Forty-nine patients with traumatic spinal cord injuries demonstrated scores showing statistically significant improvement using their total mobility and self-care of the Spinal Cord Independence Measure III (P ≤ 0.021, 0.039, 0.021) scores. Forty-five patients with traumatic spinal cord injuries demonstrated significant improvement of ASIA Impairment Scale motor scores (P ≤ 0.002) and nine patients with traumatic spinal cord injuries walked longer distances in 6-min walk test (P ≤ 0.011). The Spinal Cord Independence Measure III efficiency was 0.26 per hour (95% confidence interval = 0.037-0.475). There was one reported unplanned bowel evacuation that occurred but did not prevent future therapy. All patients successfully completed a sequence of aquatic therapy.

CONCLUSIONS

Spinal cord injury patients with various invasive appliances can safely participate in specialized aquatic therapy without complications and seem to achieve clinically significant benefits. We recommend that spinal cord injury rehabilitation centers seek out and connect with opportunities for aquatic therapy within their institutions and communities.

Impact of water therapy on pain management in patients with fibromyalgia: current perspectives

Exercise-related interventions have been recommended as one of the main components in the management of fibromyalgia syndrome (FMS). Water therapy, which combines water's physical properties and exercise benefits, has proven effective in improving the clinical symptoms of FMS, especially pain, considered the hallmark of this syndrome. However, to our knowledge, the mechanisms underlying water therapy effects on pain are still scarcely explored in the literature. Therefore, this narrative review aimed to present the current perspectives on water therapy and the physiological basis for the mechanisms supporting its use for pain management in patients with FMS. Furthermore, the effects of water therapy on the musculoskeletal, neuromuscular, cardiovascular, respiratory, and neuroendocrine systems and inflammation are also addressed. Taking into account the aspects reviewed herein, water therapy is recommended as a nonpharmacologic therapeutic approach in the management of FMS patients, improving pain, fatigue, and quality of life. Future studies should focus on clarifying whether mechanisms and long-lasting effects are superior to other types of nonpharmacological interventions, as well as the economic and societal impacts that this intervention may present.

Cost-effectiveness of hydrotherapy versus land-based therapy in patients with musculoskeletal disorders in Singapore

BACKGROUND

The study evaluated the cost-effectiveness of hydrotherapy versus land-based therapy in patients with musculoskeletal disorders (MSDs) in Singapore.

METHODS

A decision-analytic model was constructed to compare the cost-effectiveness of hydrotherapy to land-based therapy over 3 months from societal perspective. Target population comprised patients with low back pain (LBP), osteoarthritis (OA), rheumatoid arthritis (RA), total hip replacement (THR) and total knee replacement (TKR). Subgroup analyses were carried out to determine the cost-effectiveness of hydrotherapy in individual MSDs. Relative treatment effects were obtained through a systematic review of published data.

RESULTS

Compared to land-based therapy, hydrotherapy was associated with an incremental cost-effectiveness ratio (ICER) of SGD 27 471 per quality-adjusted life-year (QALY) gained, which was below the willingness-to-pay threshold of SGD 70 000 per QALY (one gross domestic product per capita in Singapore in 2015). For the respective MSDs, hydrotherapy were dominant (more effective and less costly) in THR and TKR, cost-effective for LBP and RA, and not cost-effective for OA. Treatment adherence and cost of hydrotherapy were key drivers to the ICER values.

CONCLUSIONS

Hydrotherapy was a cost-effective rehabilitation compared to land-based therapy for a population with MSDs in Singapore. However, the benefit of hydrotherapy was not observed in patients with OA.

Land Plus Aquatic Therapy Versus Land-Based Rehabilitation Alone for the Treatment of Freezing of Gait in Parkinson Disease: A Randomized Controlled Trial

BACKGROUND

Freezing of gait (FOG) is one of the most disabling symptoms of Parkinson disease (PD). Different land-based rehabilitation approaches based on motor and cognitive strategies can be effective in treating FOG. Although there are data about the efficacy of aquatic therapy in ameliorating this phenomenon, no study has explored the combined effect of land-based therapies plus aquatic therapy in patients with PD who have FOG.

OBJECTIVE

The objective was to investigate the effectiveness of a multidisciplinary, intensive, motor-cognitive rehabilitation treatment (MIRT) in improving FOG and whether implementation with aquatic therapy (MIRT-AT) adds further benefits.

DESIGN

The design consisted of a single-blind, parallel-group, 1:1 allocation ratio, randomized trial.

SETTING

The Department of Parkinson Disease, Movement Disorders and Brain Injury Rehabilitation at "Moriggia-Pelascini" Hospital (Gravedona ed Uniti, Como, Italy) was used as the setting.

PARTICIPANTS

Sixty hospitalized patients with PD who had FOG in Hoehn and Yahr stage 2 or 5-3 were included.

INTERVENTION

Sixty patients with PD + FOG were randomly assigned to 2 groups: 30 underwent a 4-week MIRT and 30 underwent a 4-week MIRT-AT.

MEASUREMENTS

The primary outcome measure was the Freezing of Gait Questionnaire; secondary outcome measures were total Unified Parkinson Disease Rating Scale (UPDRS), UPDRS II, UPDRS III, Berg Balance Scale, Timed Up and Go Test, and 6-Minute Walk Test. These measures were assessed both at admission and discharge.

RESULTS

Participants in the 2 groups had similar age, sex distribution, Hoehn and Yahr stage, and most-affected side. At baseline, no difference in outcome measures was observed between the 2 groups. After treatment, a significant time effect was observed for all variables in both groups. No significant time × group interaction was observed. A between-group analysis showed nonsignificant differences between values at T1 and values at T0 for all variables.

LIMITATIONS

The limitations were the lack of a control group and follow-up.

CONCLUSIONS

We showed that a multidisciplinary, intensive, and goal-based rehabilitation treatment, such as MIRT, improves FOG in patients with PD. Although aquatic therapy could be considered a useful approach for treating FOG, it does not add further benefits to this kind of motor-cognitive rehabilitation.

Aquatic exercise improves motor impairments in people with Parkinson's disease, with similar or greater benefits than land-based exercise: a systematic review

QUESTIONS

What are the effects of aquatic exercise on disease severity, (non-)motor impairments, activity performance, fear of falling, and quality of life in people with Parkinson's disease (PD)? Does aquatic exercise have greater effects on these outcomes than other forms of exercise in people with PD?

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

PARTICIPANTS

People with idiopathic PD.

INTERVENTION

Supervised aquatic exercise programs ≥ 2 weeks.

OUTCOMES MEASURES

The primary outcomes were disease severity, motor impairments, activity performance, and fear of falling. The secondary outcomes were non-motor impairments and quality of life.

RESULTS

Of the 129 identified records, seven trials met the inclusion criteria and six were meta-analysed (159 participants). One trial assessed the effect of aquatic exercise compared with control and found a significant improvement in the Unified Parkinson's Disease Rating Scale Part III (MD -4.6, 95% CI -7.5 to -1.7) in favour of aquatic exercise. Six studies compared aquatic exercise with land-based exercise after intervention (mean 7.2 weeks of training (SD 2.2); 159 participants). The effect of aquatic exercise was superior to land-based exercise on the Berg Balance Scale (MD 2.7, 95% CI 1.6 to 3.9), the Falls Efficacy Scale (MD -4.0, 95% CI -6.1 to -1.8) and the 39-item Parkinson's Disease Questionnaire (MD -6.0, 95% CI -11.3 to -0.6), with no other significant effects identified. The significant benefit on the Berg Balance Scale was maintained at the follow-up assessment (MD 6.3, 95% CI 2.1 to 10.5, 54 participants).

CONCLUSION

Aquatic exercise improves motor impairments in people with PD significantly more than no intervention. It also has slightly to moderately greater benefits than land-based exercise on balance capacity, fear of falling, and health-related quality of life. On other outcomes, the benefits of aquatic exercise are similar to those of land-based exercise.

TRIAL REGISTRATION

PROSPERO CRD42017077370.

Sardinian Folk Dance for Individuals with Parkinson's Disease: A Randomized Controlled Pilot Trial

OBJECTIVES

Among different exercise models proposed for individuals with Parkinson's disease (IwPD), the popularity of traditional forms of dance is increasing. The aim of this study was to evaluate the effects of Sardinian folk dance (Ballu Sardu, BS) on functional performance and motor and nonmotor symptoms in IwPD.

DESIGN

Single-blind, randomized controlled pilot trial.

SETTINGS

Outpatient health clinic.

SUBJECTS AND INTERVENTIONS

Twenty IwPD (13M, 7F; 67.4 ± 6.1 years) were randomly assigned to BS (n = 10) or usual care (n = 10). The dance program consisted of two sessions/week, 90-min/class, for 12 weeks.

OUTCOME MEASURES

Motor and nonmotor symptoms, as well as functional performance, were evaluated using different questionnaires and tests such as the Unified Parkinson's Disease Rating Scale Part-III (UPDRS-III), 6-min walking test (6MWT), Berg Balance Scale (BBS), Timed Up-and-Go (TUG) test, Five Times Sit-to-Stand Test (FTSST), Back Scratch Test (BST), Sit-and-Reach Test (SRT), instrumented gait analysis, Parkinson's Disease Fatigue Scale (PFS-16), Beck Depression Inventory, Starkstein Apathy Scale (SAS), and Montreal Cognitive Assessment (MOCA) scale.

RESULTS

Repeated-measures analysis of variance revealed significant Time × Group interactions for UPDRS-III and functional variables such as the 6MWT, BBS, FTSST, TUG (all, p < 0.001), BST (p = 0.04), and gait analysis parameters (stride length, p = 0.031; gait speed, p = 0.049; and gait fatigue index (GFI), p = 0.005). For nonmotor symptoms, significant Time × Group interactions for depression (p < 0.001), apathy (p = 0.016), and MOCA scores (p = 0.012) were observed. Of note, for GFI and SAS, the BS group only showed a trend toward improvement, while the condition of the controls worsened significantly. No between-group differences were observed for SRT and PFS-16.

CONCLUSIONS

BS is an enjoyable activity, which has been proved to be superior to usual care alone in inducing changes in different motor and nonmotor symptoms associated with PD. Results show that BS can be considered a safe tool for contrasting impairments observed in IwPD due to the intrinsic nature of the neurodegenerative disease.

Is the aquatic thermal environment a suitable place for providing rehabilitative treatment for person with Parkinson's disease? A retrospective study

Many authors showed that aquatic physiotherapy could improve quality of life and reduce postural instability and risk of falling in elderly subjects. The aim of this research was to explore if the thermal aquatic environment is a suitable place for rehabilitative training in person with Parkinson disease (PwP) with results comparable to the standard physiotherapy. A retrospective study was conducted on a database of 14 persons with Parkinson who were admitted to a thermal aquatic rehabilitation to undergo treatments made to improve gait and balance impairments. The rehabilitation training consisted of 45-min sessions conducted twice a week, on non-consecutive days, over 4 weeks of functional re-education and kinesitherapy in the thermal pool. Educational and prevention instructions were also given to the patients during each session. Additionally, nutrition (diet), health education, and cognitive behavioral advice were given to our patients by therapists. The clinical characteristics of the sample were age 66 ± 9, disease duration 7 ± 5, and Hoehn and Yahr 1.5 ± 0.5. The statistical analysis showed a statistically significant improvement for the UPDRS p = 0.0005, for The Berg Balance Scale p = 0.0078, for the PDQ8 p = 0.0039, Tinetti p = 0.0068, and for Mini BESTest p = 0.0002. Our data suggest that this intervention could become a useful strategy in the rehabilitation program of PwP. The simplicity of treatment and the lack of side effects endorse the use of thermal aquatic environment for the gait and balance recovery in PwP.

Analyses of Baropodometry Protocols Through Bibliometric Research

The posture of the foot is an important and complex aspect of the human body that implies a constant and coherent adaptation, and keeps the body segments in alignment. Baropodometry is a quantitative exam that evaluates the distribution of pressures at different points in the plantar region and the foot contact area. The objective of the study was to know evaluation protocols that used Barapodometry and to verify which variables were observed after the examination. It was analyzed 43 publications, between 2014 and November 2017, indexed in the Web of Science database and / or IEEE. It was verified that the year with the most publications was 2016 and the language with the highest incidence was English. Italy was the country with the highest number of articles published. In relation to the profile of the participants the most studied were those affected by Parkinson's Disease; the most used positioning protocol was bipodal barefoot support with separated feet with open eyes and then closed and arms along the body, the analyzes performed after the examination were on the stabilization area and anteroposterior and lateral velocity of balance. It was concluded that the examination can be effective in the diagnosis of disorders of static and dynamic equilibrium in the different disorders.