Charting the progression of disability in Parkinson disease: study protocol for a prospective longitudinal cohort study

Distinct cortical and subcortical predictors of Purdue Pegboard decline in Parkinson's disease and atypical parkinsonism

Objective measures of disease progression are critically needed in research on Parkinson's disease (PD) and atypical Parkinsonism but may be hindered by both practicality and cost. The Purdue Pegboard Test (PPT) is objective, has high test-retest reliability, and has a low cost. The goals of this study were to determine: (1) longitudinal changes in PPT in a multisite cohort of patients with PD, atypical Parkinsonism, and healthy controls; (2) whether PPT performance reflects brain pathology revealed by neuroimaging; (3) quantify kinematic deficits shown by PD patients during PPT. Parkinsonian patients showed a decline in PPT performance that correlated with motor symptom progression, which was not seen in controls. Neuroimaging measures from basal ganglia were significant predictors of PPT performance in PD, whereas cortical, basal ganglia, and cerebellar regions were predictors for atypical Parkinsonism. Accelerometry in a subset of PD patients showed a diminished range of acceleration and irregular patterns of acceleration, which correlated with PPT scores.

Effects of a forced cycling program with cognitive stimulation on symptomatology, physical condition, and cognition in people diagnosed with Parkinson disease

BACKGROUND AND OBJECTIVES

Parkinson disease may present difficulties in performing dual tasks. The use of dual tasks during training can improve different abilities. Therefore, the objective of this study is creating a protocol, based on standard protocol items recommendations for interventional trials compliant, for a clinical trial study conduct, review, reporting, and interpretation. This protocol will provide the framework and a guide to a randomized double-blind study, that will be conducted to assess the influence of a cycling exercise program combined with a cognitive task, on cognitive and physical Parkinson disease aspects.

METHODS

Designed a protocol for a double-blind randomized study, where participants will perform a dual tasks intervention with cycling and a cognitive task. The revised version of the unified Parkinson disease rating scale, the Parkinson disease questionnaire, the timed up and go Test, the 30 seconds chair sit to stand test, the Stroop and the trail making test will be used to measure outcomes.

DISCUSSION

Research in Parkinson disease suggests that an improvement of motor and cognitive functions of Parkinson disease patients can be achieved by modifying different motor and cognitive pathways. The results of the present study will yield findings on both the physical and cognitive response to an intervention that combines a cognitive task with a motor task in Parkinson disease patients and will be essential tool for a better conducting of the clinical trial study.

The Effect of Non-Immersive Virtual Reality Exergames versus Traditional Physiotherapy in Parkinson's Disease Older Patients: Preliminary Results from a Randomized-Controlled Trial

(1) Background: Parkinson's disease (PD) is one of the most frequent causes of disability among older people. Recently, virtual reality and exergaming have been emerged as promising tools for gait and balance rehabilitation in PD patients. Our purpose is to evaluate an innovative treatment for older patients with PD, based on non-immersive virtual reality exergames, improving gait and balance and reducing falling risk. (2) Methods: Thirty PD patients were recruited and randomly divided into two groups, to receive a traditional rehabilitation (CG) or a technological rehabilitation (TG). (3) Results: A statistical improvement of balance at the end of treatments was observed in both groups (CG: 12.4 ± 0.7 vs. 13.5 ± 0.8, p = 0.017; TG: 13.8 ± 0.5 vs. 14.7 ± 0.4, p = 0.004), while the overall risk of falling was significantly reduced only in the TG (POMA Total: 24.6 ± 0.9 vs. 25.9 ± 0.7, p = 0.010). The results between groups shows that all POMA scores differ in a statistically significant manner in the TG, emphasizing improvement not only in balance but also in gait characteristics (9.7 ± 0.8 vs. 11.4 ± 0.2, p = 0.003). Moreover, TG also improves the psychological sphere, measured thorough MSC-(17.1 ± 0.4 vs. 16.5 ± 0.4, p = 0.034). Although an improvement in FES-I and Gait Speed can be observed, this increase does not turn out to be significant. (4) Conclusions: Results suggest how non-immersive virtual reality exergaming technology offers the opportunity to effectively train cognitive and physical domains at the same time.

Effects of Cycling Dual-Task on Cognitive and Physical Function in Parkinson’s Disease: A Randomized Double-Blind Pilot Study

(1) Background: Those with Parkinson’s disease (PD) may present difficulties in performing dual tasks (DT). The use of DT during training can improve different abilities. Therefore, the objective of this study is to verify the influence of a cycling exercise program combined with a cognitive task on cognitive and physical PD aspects; (2) Methods: A double-blind, randomized pilot study was undertaken. Participants performed a DT intervention composed of cycling and a cognitive task. The cycling parameters, MDS-UPDRS, PDQ-39, TUG Test, 30 s Chair Sit to Stand test and Stroop were used to measure outcomes; (3) Results: DT generated impairment in performing the cycling task, with significant differences in cycling parameters, active and passive distance (m), total work (W) and active speed (rpm). At the cognitive level, there was a trend of improvement in the group that performed the training with DT, which improved by 211%; (4) Conclusions: Combining cycling with a cognitive task caused impairment in the performance of the physical task and an improvement at the cognitive level. Therefore, combining cycling with a cognitive task in a presumably safer environment for patients with PD can be a good way to train these patients for the dual-task challenges with practical applications.

A Self-Reported Clinical Tool Predicts Falls in People with Parkinson's Disease

BACKGROUND

A 3-step clinical prediction tool including falling in the previous year, freezing of gait in the past month and self-selected gait speed <1.1 m/s has shown high accuracy in predicting falls in people with Parkinson's disease (PD). The accuracy of this tool when including only self-report measures is yet to be determined.

OBJECTIVES

To validate the 3-step prediction tool using only self-report measures (3-step self-reported prediction tool), and to externally validate the 3-step clinical prediction tool.

METHODS

The clinical tool was used with 137 individuals with PD. Participants also answered a question about self-reported gait speed, enabling scoring of the self-reported tool, and were followed-up for 6 months. An intraclass correlation coefficient (ICC2,1) was calculated to evaluate test-retest reliability of the 3-step self-reported prediction tool. Multivariate logistic regression models were used to evaluate the performance of both tools and their discriminative ability was determined using the area under the curve (AUC).

RESULTS

Forty-two participants (31%) reported ≥1 fall during follow-up. The 3-step self-reported tool had an ICC2,1 of 0.991 (95% CI 0.971-0.997; P < 0.001) and AUC = 0.68; 95% CI 0.59-0.77, while the 3-step clinical tool had an AUC = 0.69; 95% CI 0.60-0.78.

CONCLUSIONS

The 3-step self-reported prediction tool showed excellent test-retest reliability and was validated with acceptable accuracy in predicting falls in the next 6 months. The 3-step clinical prediction tool was externally validated with similar accuracy. The 3-step self-reported prediction tool may be useful to identify people with PD at risk of falls in e/tele-health settings.

Understanding physical activity in Veterans with Parkinson disease: A mixed-methods approach

INTRODUCTION

Physical activity is critical in Parkinson disease (PD) management, but barriers and motivators of activity in Veterans with PD may be unique. We examined activity habits, including barriers and motivators, in this population.

METHODS

Participants completed the Physical Activity Scale in the Elderly (PASE). Compliance with American Heart Association (AHA) recommendations was assessed. Veterans also completed the Exercise Perceptions Questionnaire (EPQ), assessing knowledge, barriers, and motivators of activity. Free-text barriers/motivators were analyzed by the overlapping clusters method.

RESULTS

Seventy-five Veterans were recruited; mean age (standard deviation [SD]) was 70.5 (8.2) years and mean disease duration (SD) was 5.4 (5.2) years. Raw median PASE was 120.4 (interquartile range [IQR] 68.8-165.7); age-adjusted median PASE was 135.3. Only 9 Veterans (14.3%) were AHA-compliant. There were trends toward negative association between PASE and UPDRS-3 (r = -0.24, p = 0.06) and between PASE and PDQ-8 (r = -0.23, p = 0.08). Sixty-three subjects (84%) completed the EPQ; 27 (42.9%) preferred scheduled exercise, and only 33 (53.2%) reported that they preferred to exercise with others. Common themes of 46 free-text responses included desire to improve PD symptoms (n = 15, 32.6%) and social engagement (n = 12, 26.1%).

CONCLUSIONS

Self-reported activity in Veterans with PD is low, with less than 15% of subjects meeting recommended activity targets. Qualitative analysis of barriers and motivators revealed that although many Veterans enjoy the social aspects of group exercise, they may not feel comfortable in general exercise classes aimed at younger participants without chronic illnesses. These data will be useful in designing Veteran- and/or PD-specific interventions to increase activity levels.

Predictors of self-perceived stigma in Parkinson's disease

OBJECTIVE

The burden of PD extends beyond physical limitations and includes significant psychosocial adjustments as individuals undergo changes to their self-perception and how others perceive them. There is limited quantitative evidence of the factors that contribute to self-perceived stigma, which we addressed in the present study.

METHODS

In 362 individuals with PD (157 women, 205 men), self-perceived stigma was measured by the four-item stigma subscale of the Parkinson's Disease Questionnaire (PDQ-39). Hierarchical linear modeling was used to assess predictors of stigma including demographics (age, gender) and disease characteristics: duration, stage (Hoehn & Yahr Scale), motor severity (Unified Parkinson's Disease Rating Scale, UPDRS, Part 3), activities of daily living (UPDRS Part 2), and depression (Geriatric Depression Scale). Predictor variables were chosen based on their significant correlations with the stigma subscale. Further analyses were conducted for men and women separately.

RESULTS

For the total sample, the full model accounted for 14% of the variance in stigma perception (p < .001). Younger age and higher depression scores were the only significant predictors (both p < .001). This pattern was also seen for the men in the sample. For the women, only depression was a significant predictor. Depression mediated the relation between stigma and activities of daily living.

CONCLUSIONS

Younger age (men) and depression (men and women) were the primary predictors of self-perceived stigma in PD. Disease characteristics (motor and ADL) did not contribute to stigma perception. Depression is a potential treatment target for self-perceived stigma in PD.

Prática mental após fisioterapia mantém mobilidade funcional de pessoas com doença de Parkinson

RESUMO O objetivo deste estudo foi avaliar a prática mental após a fisioterapia motora para manutenção dos efeitos obtidos na mobilidade funcional de pessoas com doença de Parkinson (DP). Este ensaio clínico randomizado controlado, com cegamento simples, incluiu 14 sujeitos com DP nos estágios de 1 a 3 (escala de Hoehn & Yahr), com idade entre 45 e 72 anos. Após a avaliação inicial com o Timed Up & Go (TUG), Dynamic Gait Index (DGI) e Falls Efficacy Scale - International Brazil (FES-I Brasil), os sujeitos realizaram 15 sessões de fisioterapia motora. Foram reavaliados e divididos randomicamente em Grupo Controle (GC) e Grupo Prática Mental (GPM). Após a alocação, o GPM foi submetido a 10 sessões de prática mental associada a orientações de exercícios domiciliares. O GC foi orientado apenas a realizar os exercícios domiciliares. Em seguida, os grupos foram novamente reavaliados. Verificou-se que o GPM continuou apresentando redução na média de tempo do TUG na segunda reavaliação (p=0,05). Na segunda reavaliação do DGI, o GPM manteve a mesma média de escore da primeira reavaliação e o GC apresentou declínio da média. Não foram verificadas diferenças significativas na comparação intergrupos dos escores na FES-I Brasil. A prática mental foi capaz de manter os ganhos obtidos pela fisioterapia na mobilidade funcional de pacientes com DP.

Multi-modal Brain MRI in Subjects with PD and iRBD

Idiopathic rapid eye movement sleep behavior disorder (iRBD) is a condition that often evolves into Parkinson's disease (PD). Therefore, by monitoring iRBD it is possible to track the neurodegeneration of individuals who may progress to PD. Here we aimed at piloting the characterization of brain tissue properties in mid-brain subcortical regions of 10 healthy subjects, 8 iRBD, and 9 early-diagnosed PD. We used a battery of magnetic resonance imaging (MRI) contrasts at 3 T, including adiabatic and non-adiabatic rotating frame techniques developed by our group, along with diffusion tensor imaging (DTI) and resting-state fMRI. Adiabatic T_1ρ and T_2ρ, and non-adiabatic RAFF4 (Relaxation Along a Fictitious Field in the rotating frame of rank 4) were found to have lower coefficient of variations and higher sensitivity to detect group differences as compared to DTI parameters such as fractional anisotropy and mean diffusivity. Significantly longer T_1ρ were observed in the amygdala of PD subjects vs. controls, along with a trend of lower functional connectivity as measured by regional homogeneity, thereby supporting the notion that amygdalar dysfunction occurs in PD. Significant abnormalities in reward networks occurred in iRBD subjects, who manifested lower network strength of the accumbens. In agreement with previous studies, significantly longer T_1ρ occurred in the substantia nigra compacta of PD vs. controls, indicative of neuronal degeneration, while regional homogeneity was lower in the substantia nigra reticulata. Finally, other trend-level findings were observed, i.e., lower RAFF4 and T_2ρ in the midbrain of iRBD subjects vs. controls, possibly indicating changes in non-motor features as opposed to motor function in the iRBD group. We conclude that rotating frame relaxation methods along with functional connectivity measures are valuable to characterize iRBD and PD subjects, and with proper validation in larger cohorts may provide pathological signatures of iRBD and PD.

Inventory of real world data sources in Parkinson's disease

Background

Real world data have an important role to play in the evaluation of epidemiology and burden of disease; and in assisting health-care decision-makers, especially related to coverage and payment decisions. However, there is currently no overview of the existing longitudinal real world data sources in Parkinson’s disease (PD) in the USA. Such an assessment can be very helpful, to support a future effort to harmonize real world data collection and use the available resources in an optimal way.

Methods

The objective of this comprehensive literature review is to systematically identify and describe the longitudinal, real world data sources in PD in the USA, and to provide a summary of their measurements (categorized into 8 main dimensions: motor and neurological functions, cognition, psychiatry, activities of daily living, sleep, quality of life, autonomic symptoms and other). The literature search was performed using MEDLINE, EMBASE and internet key word search.

Results

Of the 53 data sources identified between May and August 2016, 16 were still ongoing. Current medications (81%) and comorbidities (79%) were frequently collected, in comparison to medical imaging (36%), genetic information (30%), caregiver burden (11%) and healthcare costs (2%). Many different measurements (n = 108) were performed and an interesting variability among used measurements was revealed.

Conclusions

Many longitudinal real world data sources on PD exist. Different types of measurements have been performed over time. To allow comparison and pooling of these multiple data sources, it will be essential to harmonize practices in terms of types of measurements.

Are the average gait speeds during the 10meter and 6minute walk tests redundant in Parkinson disease?

We investigated the relationships between average gait speed collected with the 10Meter Walk Test (Comfortable and Fast) and 6Minute Walk Test (6MWT) in 346 people with Parkinson disease (PD) and how the relationships change with increasing disease severity. Pearson correlation and linear regression analyses determined relationships between 10Meter Walk Test and 6MWT gait speed values for the entire sample and for sub-samples stratified by Hoehn & Yahr (H&Y) stage I (n=53), II (n=141), III (n=135) and IV (n=17). We hypothesized that redundant tests would be highly and significantly correlated (i.e. r>0.70, p<0.05) and would have a linear regression model slope of 1 and intercept of 0. For the entire sample, 6MWT gait speed was significantly (p<0.001) related to the Comfortable 10 Meter Walk Test (r=0.75) and Fast 10Meter Walk Test (r=0.79) gait speed, with 56% and 62% of the variance in 6MWT gait speed explained, respectively. The regression model of 6MWT gait speed predicted by Comfortable 10 Meter Walk gait speed produced slope and intercept values near 1 and 0, respectively, especially for participants in H&Y stages II-IV. In contrast, slope and intercept values were further from 1 and 0, respectively, for the Fast 10Meter Walk Test. Comfortable 10 Meter Walk Test and 6MWT gait speeds appeared to be redundant in people with moderate to severe PD, suggesting the Comfortable 10 Meter Walk Test can be used to estimate 6MWT distance in this population.

Two-Year Trajectory of Fall Risk in People With Parkinson Disease: A Latent Class Analysis

OBJECTIVE

To examine fall risk trajectories occurring naturally in a sample of individuals with early to middle stage Parkinson disease (PD).

DESIGN

Latent class analysis, specifically growth mixture modeling (GMM), of longitudinal fall risk trajectories.

SETTING

Assessments were conducted at 1 of 4 universities.

PARTICIPANTS

Community-dwelling participants with PD of a longitudinal cohort study who attended at least 2 of 5 assessments over a 2-year follow-up period (N=230).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Fall risk trajectory (low, medium, or high risk) and stability of fall risk trajectory (stable or fluctuating). Fall risk was determined at 6 monthly intervals using a simple clinical tool based on fall history, freezing of gait, and gait speed.

RESULTS

The GMM optimally grouped participants into 3 fall risk trajectories that closely mirrored baseline fall risk status (P=.001). The high fall risk trajectory was most common (42.6%) and included participants with longer and more severe disease and with higher postural instability and gait disability (PIGD) scores than the low and medium fall risk trajectories (P<.001). Fluctuating fall risk (posterior probability <0.8 of belonging to any trajectory) was found in only 22.6% of the sample, most commonly among individuals who were transitioning to PIGD predominance.

CONCLUSIONS

Regardless of their baseline characteristics, most participants had clear and stable fall risk trajectories over 2 years. Further investigation is required to determine whether interventions to improve gait and balance may improve fall risk trajectories in people with PD.

Detecting and predicting balance decline in Parkinson disease: a prospective cohort study

BACKGROUND

The natural progression of balance decline in individuals with Parkinson disease (PD) is not well understood.

OBJECTIVES

We aimed to: 1) compare the utility of three standardized clinical measures for detecting balance decline over 1-year, 2) identify components of balance susceptible to decline, and 3) identify factors useful for predicting future balance decline.

METHODS

Eighty people with PD (59% male; mean age 68.2 ± 9.3; Hoehn & Yahr range I-IV) completed Balance Evaluation Systems Test (BESTest), Mini-BESTest, and Berg Balance Scale (BBS) assessments. Baseline predictor variables included the MDS-UPDRS III sub-score, presence of freezing, 6-month fall history, age, gender, and physical activity. Balance and MDS-UPDRS III assessments were repeated at 6 (n = 51) and 12 months (n = 44).

RESULTS

BESTest and Mini-BESTest score declined over 6 and 12 months (P < 0.01). Postural responses, stability limits, and sensory orientation were most susceptible to decline. BBS score did not change (P > 0.01). MDS-UPDRS III score was unchanged over 6 months (P > 0.01), but declined over 12 months (P < 0.01). Change in BESTest score over 6 months was related to baseline MDS-UPDRS III, H&Y, freezing, and fall history (P < 0.05). Change in BESTest score over 12 months was related to baseline MDS-UPDRS III and freezing (P < 0.05). Change in Mini-BESTest over 12 months was related to baseline MDS-UPDRS III and age (P < 0.05).

CONCLUSIONS

The BESTest and Mini-BESTest were responsive to balance decline in individuals with PD and helped to identify decline in underlying balance components. Disease severity and freezing most consistently predicted balance decline in persons with PD.

Dynamic High-Cadence Cycling Improves Motor Symptoms in Parkinson's Disease

RATIONALE

Individuals with Parkinson's disease (PD) often have deficits in kinesthesia. There is a need for rehabilitation interventions that improve these kinesthetic deficits. Forced (tandem) cycling at a high cadence improves motor function. However, tandem cycling is difficult to implement in a rehabilitation setting.

OBJECTIVE

To construct an instrumented, motored cycle and to examine if high cadence dynamic cycling promotes improvements in motor function.

METHOD

This motored cycle had two different modes: dynamic and static cycling. In dynamic mode, the motor maintained 75-85 rpm. In static mode, the rider determined the pedaling cadence. UPDRS Motor III and Timed Up and Go (TUG) were used to assess changes in motor function after three cycling sessions.

RESULTS

Individuals in the static group showed a lower cadence but a higher power, torque and heart rate than the dynamic group. UPDRS score showed a significant 13.9% improvement in the dynamic group and only a 0.9% improvement in the static group. There was also a 16.5% improvement in TUG time in the dynamic group but only an 8% improvement in the static group.

CONCLUSION

These findings show that dynamic cycling can improve PD motor function and that activation of proprioceptors with a high cadence but variable pattern may be important for motor improvements in PD.

Balance differences in people with Parkinson disease with and without freezing of gait

BACKGROUND

Freezing of gait (FOG) is a relatively common and remarkably disabling impairment associated with Parkinson disease (PD). Laboratory-based measures indicate that individuals with FOG (PD+FOG) have greater balance deficits than those without FOG (PD-FOG). Whether such differences also can be detected using clinical balance tests has not been investigated. We sought to determine if balance and specific aspects of balance, measured using Balance Evaluation Systems Test (BESTest), differs between PD+FOG and PD-FOG. Furthermore, we aimed to determine if time-efficient clinical balance measures (i.e. Mini-BESTest, Berg Balance Scale (BBS)) could detect balance differences between PD+FOG and PD-FOG.

METHODS

Balance of 78 individuals with PD, grouped as either PD+FOG (n=32) or PD-FOG (n=46), was measured using the BESTest, Mini-BESTest, and BBS. Between-groups comparisons were conducted for these measures and for the six sections of the BESTest using analysis of covariance. A PD composite score was used as a covariate.

RESULTS

Controlling for motor sign severity, PD duration, and age, PD+FOG had worse balance than PD-FOG when measured using the BESTest (p=0.008, F=7.35) and Mini-BESTest (p=0.002, F=10.37), but not the BBS (p=0.27, F=1.26). BESTest section differences were noted between PD+FOG and PD-FOG for reactive postural responses (p<0.001, F=14.42) and stability in gait (p=0.003, F=9.18).

CONCLUSIONS

The BESTest and Mini-BESTest, which specifically assessed reactive postural responses and stability in gait, were more likely than the BBS to detect differences in balance between PD+FOG and PD-FOG. Because it is more time efficient to administer, the Mini-BESTest may be the preferred tool for assessing balance deficits associated with FOG.

Toward Understanding Ambulatory Activity Decline in Parkinson Disease

BACKGROUND

Declining ambulatory activity represents an important facet of disablement in Parkinson disease (PD).

OBJECTIVE

The primary study aim was to compare the 2-year trajectory of ambulatory activity decline with concurrently evolving facets of disability in a small cohort of people with PD. The secondary aim was to identify baseline variables associated with ambulatory activity at 1- and 2-year follow-up assessments.

DESIGN

This was a prospective, longitudinal cohort study.

METHODS

Seventeen people with PD (Hoehn and Yahr stages 1-3) were recruited from 2 outpatient settings. Ambulatory activity data were collected at baseline and at 1- and 2-year annual assessments. Motor, mood, balance, gait, upper extremity function, quality of life, self-efficacy, and levodopa equivalent daily dose data and data on activities of daily living also were collected.

RESULTS

Participants displayed significant 1- and 2-year declines in the amount and intensity of ambulatory activity concurrently with increasing levodopa equivalent daily dose. Worsening motor symptoms and slowing of gait were apparent only after 2 years. Concurrent changes in the remaining clinical variables were not observed. Baseline ambulatory activity and physical performance variables had the strongest relationships with 1- and 2-year mean daily steps.

LIMITATIONS

The sample was small and homogeneous.

CONCLUSIONS

Future research that combines ambulatory activity monitoring with a broader and more balanced array of measures would further illuminate the dynamic interactions among evolving facets of disablement and help determine the extent to which sustained patterns of recommended daily physical activity might slow the rate of disablement in PD.

External validation of a simple clinical tool used to predict falls in people with Parkinson disease

BACKGROUND

Assessment of fall risk in an individual with Parkinson disease (PD) is a critical yet often time consuming component of patient care. Recently a simple clinical prediction tool based only on fall history in the previous year, freezing of gait in the past month, and gait velocity <1.1 m/s was developed and accurately predicted future falls in a sample of individuals with PD.

METHODS

We sought to externally validate the utility of the tool by administering it to a different cohort of 171 individuals with PD. Falls were monitored prospectively for 6 months following predictor assessment.

RESULTS

The tool accurately discriminated future fallers from non-fallers (area under the curve [AUC] = 0.83; 95% CI 0.76-0.89), comparable to the developmental study.

CONCLUSION

The results validated the utility of the tool for allowing clinicians to quickly and accurately identify an individual's risk of an impending fall.

Dance for people with Parkinson disease: what is the evidence telling us?

OBJECTIVES

(1) To appraise and synthesize the literature on dance interventions for individuals with Parkinson disease (PD); (2) to provide information regarding the frequency, intensity, duration, and type of dance used in these programs; and (3) to inform the development of future studies evaluating dance interventions in this population.

DATA SOURCES

Eight databases (MEDLINE, Cumulative Index to Nursing and Allied Health Literature [CINAHL], the Allied and Complementary Medicine Database [AMED], SPORTDiscus, PubMed, PubMed Central, Sage, and ScienceDirect) were electronically searched in April 2014. The references lists from the included articles were also searched.

STUDY SELECTION

Studies retrieved during the literature search were reviewed by 2 reviewers independently. Suitable articles were identified by applying inclusion criteria.

DATA EXTRACTION

Data regarding participants and the frequency, intensity, duration, and type of dance form used were extracted. The effect that each dance program had on defined outcomes and the feasibility of each program were also reviewed.

DATA SYNTHESIS

Thirteen articles were identified. The quality of studies varied, and methodological limitations were evident in some. The evidence evaluated suggests that two 1-hour dance classes per week over 10 to 13 weeks may have beneficial effects on endurance, motor impairment, and balance.

CONCLUSIONS

Dance may be helpful for some people with PD. This article provides preliminary information to aid clinicians when implementing dance programs for people with PD. Higher-quality multicenter studies are needed to determine the effect of other dance genres and the optimal therapy volume and intensity.

Two-year exercise program improves physical function in Parkinson's disease: the PRET-PD randomized clinical trial

Background. The progressive resistance exercise (PRE) in Parkinson's disease trial (PRET-PD) showed that PRE improved the motor signs of PD compared to a modified Fitness Counts (mFC) program. It is unclear how long-term exercise affects physical function in these individuals. Objective. To examine the effects of long-term PRE and mFC on physical function outcome measures in individuals with PD. Methods. A preplanned secondary analysis was conducted using data from the 38 patients with idiopathic PD who completed the PRET-PD trial. Participants were randomized into PRE or mFC groups and exercised 2 days/week up to 24 months. Blinded assessors obtained functional outcomes on and off medication at baseline, 6 and 24 months with the Modified Physical Performance Test, 5 times sit to stand test, Functional Reach Test, Timed Up and Go, Berg Balance Scale, 6 minute walk test (6MWT), and 50-ft walking speed (walk speed). Results. The groups did not differ on any physical function measure at 6 or 24 months (Ps > .1). Across time, all physical function measures improved from baseline to 24 months when tested on medication (Ps < .0001), except for 6MWT (P = .068). Off medication results were similar except that the 6MWT was now significant. Conclusions. Twenty-four months of supervised and structured exercise (either PRE or mFC) is effective at improving functional performance outcomes in individuals with moderate PD. Clinicians should strive to include structured and supervised exercise in the long-term plan of care for individuals with PD.

Dance for Parkinson's: a new framework for research on its physical, mental, emotional, and social benefits

Parkinson's is a neurodegenerative disease commonly associated with symptoms such as tremor, rigidity, bradykinesia, freezing during gait, motor control deficits and instability. These physical symptoms can cause a myriad of psychological problems including depression, feelings of loneliness, and low self-esteem. Current research suggests pharmacological interventions do not sufficiently address all symptoms and thus alternative therapies have been deemed an important part of treatment for people with Parkinson's. Dance has shown to be a beneficial activity for this population. Upon reviewing recent dance for Parkinson's studies it is clear that there are developing trends with respect to overall approach. The tendency to place more emphasis on changes to clinical signs is creating a gap whereby research neglects to look at how dance is influencing a particular individual in all aspects of their life. There is a need for a framework that allows for and encourages the analysis of the dancing experience for people with Parkinson's on a variety of levels including physically, mentally, emotionally, and socially. With such a framework it would be possible to triangulate the information gathered to draw stronger conclusions that are more meaningful to the people with Parkinson's. This paper would like to propose the use of the World Health Organization's International Classification of Functioning, Disability, and Health as a possible framework for dance for Parkinson's research.

Muscle strength and executive function as complementary parameters for the assessment of impairment in Parkinson's disease

OBJECTIVE

To evaluate the relationship between the quantitative results of functional and cognitive performance of patients with Parkinson's disease (PD) and disease severity; and to study the relationship between patients' functional and cognitive capacity and motor impairment (Unified Parkinson's Disease Rating Scale - UPDRS III).

METHOD

Twenty-nine subjects clinically diagnosed with PD were classified into three groups according to disease severity using the modified Hoehn and Yahr Scale (H&Y). They were submitted to functional (Senior Fitness Test) and neuropsychological tests. Stepwise regression analysis showed a significant association between H&Y and upper limb strength (r² =0.30; p=0.005) and executive function (r² =0.37; p=0.004). In relation to UPDRS III, there was a significant association between lower limb strength (r² =0.27; p=0.010) and global cognitive status (r² =0.24; p=0.024).

CONCLUSION

The implementation of simple tests of functional capacity associated with neuropsychological testing can help to assess disease severity and motor impairment, and can be used to monitor the response to treatment in PD.

Predictors of gait speeds and the relationship of gait speeds to falls in men and women with Parkinson disease

Gait difficulties and falls are commonly reported in people with Parkinson disease (PD). Reduction in gait speed is a major characteristic of Parkinsonian gait, yet little is known about its underlying determinants, its ability to reflect an internal reservation about walking, or its relationship to falls. To study these issues, we selected age, disease severity, and nonmotor factors (i.e., depression, quality of life, balance confidence, and exercise beliefs and attitudes) to predict self-selected (SELF), fast-as-possible (FAST), and the difference (DIFF) between these walking speeds in 78 individuals with PD. We also examined gender differences in gait speeds and evaluated how gait speeds were related to a retrospective fall report. Age, disease severity, and balance confidence were strong predictors of SELF, FAST, and, to a lesser extent, DIFF. All three parameters were strongly associated with falling. DIFF was significantly greater in men compared to women and was significantly associated with male but not female fallers. The results supported the clinical utility of using a suite of gait speed parameters to provide insight into the gait difficulties and differentiating between fallers in people with PD.

An exploratory study of activity in veterans with Parkinson's disease

Movement disorder specialists have limited information on the specifics of how patients with Parkinson’s disease (PD) spend their time. We deemed it important to examine the relationships among activity and daily energy expenditure (DEE), non-motor symptoms, and body mass index in veterans with PD who were outpatients at a Veterans Affairs medical center. In this exploratory study, we mailed demographic and activity questionnaires and gathered data on 100 patients. Activity was categorized into five domains and three intensity levels, and DEE was measured in kilocalories. Light activities accounted for 64.9% of DEE (9.1 h), moderate activities for 32.9% (2.1 h), and vigorous activities for 2.2% (0.1 h) of DEE. Television viewing comprised 10.6% (2.5 h) of the day. The effects of non-motor symptoms were significantly associated with more time spent on activities of daily life (ADL). Patients rated fatigue and pain as having the greatest impact on their daily activities. The overweight/obese group of PD patients expended more overall DEE (p = 0.044) and more DEE on social activities (p = 0.024) and light intensity activities (p = 0.021) than did the underweight/normal group. Leisure activities for both groups changed from active to passive. Veterans with PD primarily expended DEE on ADL, TV viewing, and light intensity activities. Television viewing time may have been under reported. Movement disorder specialists can be more proactive in referring patients to physical therapy and encouraging their participation in community exercise and support groups.

Measures of fine motor skills in people with tremor disorders: appraisal and interpretation

People with Parkinson's disease, essential tremor, or other movement disorders involving tremor have changes in fine motor skills that are among the hallmarks of these diseases. Numerous measurement tools have been created and other methods devised to measure such changes in fine motor skills. Measurement tools may focus on specific features - e.g., motor skills or dexterity, slowness in movement execution associated with parkinsonian bradykinesia, or magnitude of tremor. Less obviously, some tools may be better suited than others for specific goals such as detecting subtle dysfunction early in disease, revealing aspects of brain function affected by disease, or tracking changes expected from treatment or disease progression. The purpose of this review is to describe and appraise selected measurement tools of fine motor skills appropriate for people with tremor disorders. In this context, we consider the tools' content - i.e., what movement features they focus on. In addition, we consider how measurement tools of fine motor skills relate to measures of a person's disease state or a person's function. These considerations affect how one should select and interpret the results of these tools in laboratory and clinical contexts.

Barriers to exercise in people with Parkinson disease

BACKGROUND

Exercise is known to reduce disability and improve quality of life in people with Parkinson disease (PD). Although barriers to exercise have been studied in older adults, barriers in people with chronic progressive neurological diseases, such as PD, are not well defined.

OBJECTIVE

The purpose of this study was to identify perceived barriers to exercise in people with PD.

DESIGN

The study had a cross-sectional design.

METHODS

People who had PD, dwelled in the community, and were at stage 2.4 on the Hoehn and Yahr scale participated in this cross-sectional study (N=260; mean age=67.7 years). Participants were divided into an exercise group (n=164) and a nonexercise group (n=96). Participants self-administered the barriers subscale of the Physical Fitness and Exercise Activity Levels of Older Adults Scale, endorsing or denying specific barriers to exercise participation. Multivariate logistic regression analysis was used to examine the contribution of each barrier to exercise behavior, and odds ratios were reported.

RESULTS

Three barriers were retained in the multivariate regression model. The nonexercise group had significantly greater odds of endorsing low outcome expectation (ie, the participants did not expect to derive benefit from exercise) (odds ratio [OR]=3.93, 95% confidence interval [CI]=2.08-7.42), lack of time (OR=3.36, 95% CI=1.55-7.29), and fear of falling (OR=2.35, 95% CI=1.17-4.71) than the exercise group.

LIMITATIONS

The cross-sectional nature of this study limited the ability to make causal inferences.

CONCLUSIONS

Low outcome expectation from exercise, lack of time to exercise, and fear of falling appear to be important perceived barriers to engaging in exercise in people who have PD, are ambulatory, and dwell in the community. These may be important issues for physical therapists to target in people who have PD and do not exercise regularly. The efficacy of intervention strategies to facilitate exercise adherence in people with PD requires further investigation.

Comparative utility of the BESTest, mini-BESTest, and brief-BESTest for predicting falls in individuals with Parkinson disease: a cohort study

BACKGROUND

The newly developed brief-balance evaluation system test (brief-BESTest) may be useful for measuring balance and predicting falls in individuals with Parkinson disease (PD).

OBJECTIVES

The purposes of this study were: (1) to describe the balance performance of those with PD using the brief-BESTest, (2) to determine the relationships among the scores derived from the 3 versions of the BESTest (i.e., full BESTest, mini-BESTest, and brief-BESTest), and (3) to compare the accuracy of the brief-BESTest with that of the mini-BESTest and BESTest in identifying recurrent fallers among people with PD.

DESIGN

This was a prospective cohort study.

METHODS

Eighty participants with PD completed a baseline balance assessment. All participants reported a fall history during the previous 6 months. Fall history was again collected 6 months (n=51) and 12 months (n=40) later.

RESULTS

At baseline, participants had varying levels of balance impairment, and brief-BESTest scores were significantly correlated with mini-BESTest (r=.94, P<.001) and BESTest (r=.95, P<.001) scores. Six-month retrospective fall prediction accuracy of the Brief-BESTest was moderately high (area under the curve [AUC]=0.82, sensitivity=0.76, and specificity=0.84). Prospective fall prediction accuracy over 6 months was similarly accurate (AUC=0.88, sensitivity=0.71, and specificity=0.87), but was less sensitive over 12 months (AUC=0.76, sensitivity=0.53, and specificity=0.93).

LIMITATIONS

The sample included primarily individuals with mild to moderate PD. Also, there was a moderate dropout rate at 6 and 12 months.

CONCLUSIONS

All versions of the BESTest were reasonably accurate in identifying future recurrent fallers, especially during the 6 months following assessment. Clinicians can reasonably rely on the brief-BESTest for predicting falls, particularly when time and equipment constraints are of concern.

Community-based exercise and wellness program for people diagnosed with Parkinson disease: experiences from a 10-month trial

OBJECTIVE

This study considered whether a therapy community could create an infrastructure for developing and maintaining a service delivery model grounded in a clinic-based physiotherapy model. A longitudinal clinical study was conducted to assess the abilities of participants with Parkinson disease in a 10-month community exercise program.

METHODS

Fifteen individuals averaging stage 3 on the Hoehn and Yahr scale, 6 years since Parkinson disease diagnosis, and 72 years old, participated.

RESULTS

Graphical analysis of ambulation endurance demonstrated the strongest improvement over time (11%). Walking speeds, balance, and mobility showed a maintenance effect over the 10 months. The total unified Parkinson disease rating scale, activities of daily living subscale, and motor subscale remained statistically unchanged in the study. Scores on the unified Parkinson disease rating scale mentation, behavior, and mood subscale improved by 38%. None of the scores met or exceeded the minimal detectable change, MDC95 but two scores demonstrated more than 10% change.

CONCLUSION

This clinical study implemented previous short-term research findings into an ongoing community wellness program for individuals with Parkinson disease. No community-based studies have demonstrated an ability to maintain a group for an extended time frame. Group exercise including forward and backward treadmill training, designed and monitored by a physical therapist, may improve or maintain functional outcomes.

Symptoms and quality of life in late stage Parkinson syndromes: a longitudinal community study of predictive factors

BACKGROUND

Palliative care is increasingly offered earlier in the cancer trajectory but rarely in Idiopathic Parkinson's Disease(IPD), Progressive Supranuclear Palsy(PSP) or Multiple System Atrophy(MSA). There is little longitudinal data of people with late stage disease to understand levels of need. We aimed to determine how symptoms and quality of life of these patients change over time; and what demographic and clinical factors predicted changes.

METHODS

We recruited 82 patients into a longitudinal study, consenting patients with a diagnosis of IPD, MSA or PSP, stages 3-5 Hoehn and Yahr(H&Y). At baseline and then on up to 3 occasions over one year, we collected self-reported demographic, clinical, symptom, palliative and quality of life data, using Parkinson's specific and generic validated scales, including the Palliative care Outcome Scale (POS). We tested for predictors using multivariable analysis, adjusting for confounders.

FINDINGS

Over two thirds of patients had severe disability, over one third being wheelchair-bound/bedridden. Symptoms were highly prevalent in all conditions - mean (SD) of 10.6(4.0) symptoms. More than 50% of the MSA and PSP patients died over the year. Over the year, half of the patients showed either an upward (worsening, 24/60) or fluctuant (8/60) trajectory for POS and symptoms. The strongest predictors of higher levels of symptoms at the end of follow-up were initial scores on POS (AOR 1.30; 95%CI:1.05-1.60) and being male (AOR 5.18; 95% CI 1.17 to 22.92), both were more predictive than initial H&Y scores.

INTERPRETATION

The findings point to profound and complex mix of non-motor and motor symptoms in patients with late stage IPD, MSA and PSP. Symptoms are not resolved and half of the patients deteriorate. Palliative problems are predictive of future symptoms, suggesting that an early palliative assessment might help screen for those in need of earlier intervention.

Capturing ambulatory activity decline in Parkinson's disease

BACKGROUND AND PURPOSE

Relatively little is known about the natural evolution of physical activity-related participation restrictions associated with Parkinson's disease (PD). We examined this issue prospectively, using continuous monitoring technology to capture the free-living ambulatory activity of persons with PD engaging in life situations. We specifically sought (1) to explore natural, long-term changes in daily ambulatory activity and (2) to compare the responsiveness of ambulatory activity parameters to clinical measures of gait and disease severity.

METHODS

Thirty-three persons with PD participated (Hoehn and Yahr range of 1-3). Participants wore a step activity monitor for up to 7 days at baseline and again at 1-year follow-up. Mean daily values were calculated for parameters indicative of amount, intensity, frequency, and duration of ambulatory activity. Clinical measures included the Unified Parkinson Disease Rating Scale, the 6-Minute Walk, and Maximal Gait Speed. Parametric tests for paired samples were used to investigate changes in ambulatory activity parameters and clinical measures.

RESULTS

Participants had significant declines in the amount and intensity of daily ambulatory activity but not in its frequency and duration (P < 0.007). Declines occurred in the absence of changes in clinical measures of gait or disease severity. The greatest 1-year decline occurred in the number of daily minutes participants spent engaging in at least moderate-intensity ambulatory activity.

CONCLUSION

Continuous monitoring of ambulatory activity beyond mere step counts may serve as a distinct and important means of quantifying declining ambulatory behavior associated with disease progression or improved ambulatory behavior resulting from rehabilitation and medical and/or surgical interventions in persons with PD.

Motor and cognitive impairments in Parkinson disease: relationships with specific balance and mobility tasks

BACKGROUND

Balance and mobility problems are common for people with Parkinson disease (PD).

OBJECTIVE

To determine the relationships of motor and cognitive impairments with specific balance and mobility task performance.

METHODS

A total of 82 community-dwelling people with idiopathic PD were tested "on" medication. Impairments measured included leg extensor and hip abductor muscle power, freezing of gait, dyskinesia, and executive function. Balance and mobility were classified into tasks requiring anticipatory control with a change in base of support, anticipatory control without a change in support, and reactive adjustments in response to external perturbations. Associations between impairments and tasks were examined using univariable and multivariable linear regression models.

RESULTS

Univariable models revealed that muscle power was significantly related to balance and mobility, explaining 7% to 33% of the variability in task performance. Freezing of gait, dyskinesia, and executive function were not consistently related to task performance. Multivariable models that included all impairments plus disease severity, age, gender, and height explained 5% to 43% of the variability in balance and mobility tasks. Leg muscle power was the only impairment with a consistent association with performance of tasks involving anticipatory control with a change in base of support (β = 0.2 to 0.5), but the association of each muscle group was specific to individual tasks.

CONCLUSION

Information gained from this study about the relationships between impairments and specific balance and mobility tasks may be able to guide the development of interventional strategies for people with PD.

Factors associated with exercise behavior in people with Parkinson disease

BACKGROUND

The benefits of exercise for reducing disability in people with Parkinson disease (PD) are becoming more evident. Optimal benefit, however, requires regular and sustained participation. Factors associated with engaging in regular exercise have received little scientific scrutiny in people with PD.

OBJECTIVE

The purpose of this study was to explore factors associated with exercise behavior in patients with PD using the International Classification of Functioning, Disability and Health (ICF) as a guiding framework.

DESIGN

This was a cross-sectional study.

METHODS

The participants in this study were 260 patients with PD from 4 institutions. Participants were designated as "exercisers" or "nonexercisers" based on responses to the Stages of Readiness to Exercise Questionnaire. Exercise status was validated using the Physical Activity Scale for the Elderly and an activity monitor. Factors potentially associated with exercise behavior included measures of body structure and function, activity, participation, environmental factors, and personal factors. Their relative contributions were analyzed using logistic regression and quantified with odds ratios.

RESULTS

One hundred sixty-four participants (63%) were designated as exercisers. Participants with high self-efficacy were more than twice as likely to engage in regular exercise than those with low self-efficacy (adjusted odds ratio=2.34, 95% confidence interval=1.30-4.23). College educated and older participants also were more likely to exercise. Disabling influences of impairments, activity limitations, and participation restrictions were not associated with exercise behavior.

LIMITATIONS

The cross-sectional nature of the study limited the ability to make causal inferences.

CONCLUSIONS

Self-efficacy, rather than disability, appears to be strongly associated with whether ambulatory, community-dwelling people with PD exercise regularly. The results of this study suggest that physical therapists should include strategies to increase exercise self-efficacy when designing patient intervention programs for patients with PD.

Accuracy of fall prediction in Parkinson disease: six-month and 12-month prospective analyses

Introduction. We analyzed the ability of four balance assessments to predict falls in people with Parkinson Disease (PD) prospectively over six and 12 months. Materials and Methods. The BESTest, Mini-BESTest, Functional Gait Assessment (FGA), and Berg Balance Scale (BBS) were administered to 80 participants with idiopathic PD at baseline. Falls were then tracked for 12 months. Ability of each test to predict falls at six and 12 months was assessed using ROC curves and likelihood ratios (LR). Results. Twenty-seven percent of the sample had fallen at six months, and 32% of the sample had fallen at 12 months. At six months, areas under the ROC curve (AUC) for the tests ranged from 0.8 (FGA) to 0.89 (BESTest) with LR+ of 3.4 (FGA) to 5.8 (BESTest). At 12 months, AUCs ranged from 0.68 (BESTest, BBS) to 0.77 (Mini-BESTest) with LR+ of 1.8 (BESTest) to 2.4 (BBS, FGA). Discussion. The various balance tests were effective in predicting falls at six months. All tests were relatively ineffective at 12 months. Conclusion. This pilot study suggests that people with PD should be assessed biannually for fall risk.

Advancing nursing science through health trajectory research: an introduction

The Minnesota Center for Health Trajectory Research has focused on developing ways to better understand how interventions influence health trajectories during transitional, acute, or chronic health challenges across the life span. The health trajectory perspective advances nursing science by providing a person-centered point of view that emphasizes change in health over time within individuals, families, groups, or communities. Theoretical considerations and statistical modeling approaches used in studying health trajectories, along with exemplars from nursing research studies from this special issue of Nursing Research, are highlighted.