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Allen NE, Canning CG, Almeida LRS, Bloem BR, Keus SH, Löfgren N, Nieuwboer A, Verheyden GS, Yamato TP, Sherrington C. Interventions for preventing falls in Parkinson's disease. Cochrane Database Syst Rev 2022; 6:CD011574. [PMID: 35665915 PMCID: PMC9169540 DOI: 10.1002/14651858.cd011574.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Natalie E Allen
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Colleen G Canning
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Lorena Rosa S Almeida
- Movement Disorders and Parkinson's Disease Clinic, Roberto Santos General Hospital, Salvador, Brazil
- Motor Behavior and Neurorehabilitation Research Group, Bahiana School of Medicine and Public Health, Salvador, Brazil
| | - Bastiaan R Bloem
- Raboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, Netherlands
| | - Samyra Hj Keus
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
- Quality and Improvement, OLVG, Amsterdam, Netherlands
| | - Niklas Löfgren
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- Department of Women's and Children's Health, Physiotherapy, Uppsala University, Uppsala, Sweden
| | - Alice Nieuwboer
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | | | - Tiê P Yamato
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | - Catherine Sherrington
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Ashburn A, Pickering R, McIntosh E, Hulbert S, Rochester L, Roberts HC, Nieuwboer A, Kunkel D, Goodwin VA, Lamb SE, Ballinger C, Seymour KC. Exercise- and strategy-based physiotherapy-delivered intervention for preventing repeat falls in people with Parkinson's: the PDSAFE RCT. Health Technol Assess 2020; 23:1-150. [PMID: 31339100 DOI: 10.3310/hta23360] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND People with Parkinson's disease are twice as likely to experience a fall as a healthy older person, often leading to debilitating effects on confidence, activity levels and quality of life. OBJECTIVE To estimate the effect of a physiotherapy programme for fall prevention among people with Parkinson's disease. DESIGN A multicentre, pragmatic, investigator-masked, individually randomised controlled trial (RCT) with prespecified subgroup analyses. SETTING Recruitment from NHS hospitals and clinics and community and social services in eight English regions with home-based interventions. PARTICIPANTS A total of 474 people with Parkinson's disease (i.e. Hoehn and Yahr scale stages 1-4) were recruited: 238 were assigned to a physiotherapy programme and 236 were assigned to usual care. Random allocation was 50 : 50. INTERVENTIONS All participants received routine care; the usual-care group received an information digital versatile disc (DVD) and a single advice session at trial completion. The intervention group had an individually tailored, progressive, home-based fall avoidance strategy training programme with balance and strengthening exercises: PDSAFE. MAIN OUTCOME MEASURES The primary outcome was the risk of repeat falling, collected by self-report monthly diaries between 0 and 6 months after randomisation. Secondary outcomes included near-falls, falls efficacy, freezing of gait (FoG), health-related quality of life, and measurements taken using the Mini-Balance Evaluation Systems Test (Mini-BESTest), the Chair Stand Test (CST), the Geriatric Depression Scale, the Physical Activity Scale for the Elderly and the Parkinson's Disease Questionnaire. RESULTS PDSAFE is the largest RCT of falls management among people with Parkinson's disease: 541 patients were screened for eligibility. The average age was 72 years, and 266 out of 474 (56%) participants were men. Of the 474 randomised participants, 238 were randomised to the intervention group and 236 were randomised to the control group. No difference in repeat falling within 6 months of randomisation was found [PDSAFE group to control group odds ratio (OR) 1.21, 95% confidence interval (CI) 0.74 to 1.98; p = 0.447]. An analysis of secondary outcomes demonstrated better balance (Mini-BESTest: mean difference 0.95, 95% CI 0.24 to 1.67; p = 0.009), functional strength (CST: p = 0.041) and falls efficacy (Falls Efficacy Scale - International: mean difference 1.6, 95% CI -3.0 to -0.19; p = 0.026) with near-falling significantly reduced with PDSAFE (OR 0.67, 95% CI 0.53 to 0.86; p = 0.001) at 6 months. Prespecified subgroup analysis (i.e. disease severity and FoG) revealed a PDSAFE differing effect; the intervention may be of benefit for people with moderate disease but may increase falling for those in the more severe category, especially those with FoG. LIMITATIONS All participants were assessed at primary outcome; only 73% were assessed at 12 months owing to restricted funding. CONCLUSIONS PDSAFE was not effective in reducing repeat falling across the range of people with Parkinson's disease in the trial. Secondary analysis demonstrated that other functional tasks and self-efficacy improved and demonstrated differential patterns of intervention impact in accordance with disease severity and FoG, which supports previous secondary research findings and merits further primary evaluation. FUTURE WORK Further trials of falls prevention on targeted groups of people with Parkinson's disease are recommended. TRIAL REGISTRATION Current Controlled Trials ISRCTN48152791. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 36. See the NIHR Journals Library website for further project information. Sarah E Lamb is funded by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) at Oxford Health NHS Foundation Trust, the NIHR Oxford Biomedical Research Centre at the Oxford University Hospitals NHS Foundation Trust and CLAHRC Oxford. Victoria A Goodwin is supported by the NIHR Collaborations for Leadership in Applied Health Research and Care in the South West Peninsula (PenCLAHRC). Lynn Rochester is supported by the NIHR Newcastle Biomedical Research Centre based at Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University. The research was also supported by the NIHR Newcastle Clinical Research Facility Infrastructure funding. Helen C Roberts is supported by CLAHRC Wessex and the NIHR Southampton Biomedical Research Centre.
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Affiliation(s)
- Ann Ashburn
- Faculty of Health Science, University of Southampton, Southampton, UK
| | - Ruth Pickering
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Emma McIntosh
- Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Sophia Hulbert
- Faculty of Health Science, University of Southampton, Southampton, UK
| | - Lynn Rochester
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Helen C Roberts
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Alice Nieuwboer
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Dorit Kunkel
- Faculty of Health Science, University of Southampton, Southampton, UK
| | | | - Sarah E Lamb
- Oxford Clinical Trials Research Unit, University of Oxford Medical Sciences Division, Oxford, UK
| | - Claire Ballinger
- Wessex Public Involvement Network (PIN), University of Southampton, Southampton General Hospital, Southampton, UK
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Gunn H, Andrade J, Paul L, Miller L, Creanor S, Stevens K, Green C, Ewings P, Barton A, Berrow M, Vickery J, Marshall B, Zajicek J, Freeman J. A self-management programme to reduce falls and improve safe mobility in people with secondary progressive MS: the BRiMS feasibility RCT. Health Technol Assess 2020; 23:1-166. [PMID: 31217069 DOI: 10.3310/hta23270] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Balance, mobility impairments and falls are common problems for people with multiple sclerosis (MS). Our ongoing research has led to the development of Balance Right in MS (BRiMS), a 13-week home- and group-based exercise and education programme intended to improve balance and encourage safer mobility. OBJECTIVE This feasibility trial aimed to obtain the necessary data and operational experience to finalise the planning of a future definitive multicentre randomised controlled trial. DESIGN Randomised controlled feasibility trial. Participants were block randomised 1 : 1. Researcher-blinded assessments were scheduled at baseline and at 15 and 27 weeks post randomisation. As is appropriate in a feasibility trial, statistical analyses were descriptive rather than involving formal/inferential comparisons. The qualitative elements utilised template analysis as the chosen analytical framework. SETTING Four sites across the UK. PARTICIPANTS Eligibility criteria included having a diagnosis of secondary progressive MS, an Expanded Disability Status Scale (EDSS) score of between ≥ 4.0 and ≤ 7.0 points and a self-report of two or more falls in the preceding 6 months. INTERVENTIONS Intervention - manualised 13-week education and exercise programme (BRiMS) plus usual care. Comparator - usual care alone. MAIN OUTCOME MEASURES Trial feasibility, proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls), feasibility of the BRiMS programme (via process evaluation) and economic data. RESULTS A total of 56 participants (mean age 59.7 years, standard deviation 9.7 years; 66% female; median EDSS score of 6.0 points, interquartile range 6.0-6.5 points) were recruited in 5 months; 30 were block randomised to the intervention group. The demographic and clinical data were broadly comparable at baseline; however, the intervention group scored worse on the majority of baseline outcome measures. Eleven participants (19.6%) withdrew or were lost to follow-up. Worsening of MS-related symptoms unrelated to the trial was the most common reason (n = 5) for withdrawal. Potential primary and secondary outcomes and economic data had completion rates of > 98% for all those assessed. However, the overall return rate for the patient-reported falls diary was 62%. After adjusting for baseline score, the differences between the groups (intervention compared with usual care) at week 27 for the potential primary outcomes were MS Walking Scale (12-item) version 2 -7.7 [95% confidence interval (CI) -17.2 to 1.8], MS Impact Scale (29-item) version 2 (MSIS-29vs2) physical 0.6 (95% CI -7.8 to 9) and MSIS-29vs2 psychological -0.4 (95% CI -9.9 to 9) (negative score indicates improvement). After the removal of one outlier, a total of 715 falls were self-reported over the 27-week trial period, with substantial variation between individuals (range 0-93 falls). Of these 715 falls, 101 (14%) were reported as injurious. Qualitative feedback indicated that trial processes and participant burden were acceptable, and participants highlighted physical and behavioural changes that they perceived to result from undertaking BRiMS. Engagement varied, influenced by a range of condition- and context-related factors. Suggestions to improve the utility and accessibility of BRiMS were highlighted. CONCLUSIONS The results suggest that the trial procedures are feasible and acceptable, and retention, programme engagement and outcome completion rates were sufficient to satisfy the a priori progression criteria. Challenges were experienced in some areas of data collection, such as completion of daily diaries. FUTURE WORK Further development of BRiMS is required to address logistical issues and enhance user-satisfaction and adherence. Following this, a definitive trial to assess the clinical effectiveness and cost-effectiveness of the BRiMS intervention is warranted. TRIAL REGISTRATION Current Controlled Trials ISRCTN13587999. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 27. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hilary Gunn
- School of Health Professions, Faculty of Health and Human Sciences, Peninsula Allied Health Centre, University of Plymouth, Plymouth, UK
| | - Jackie Andrade
- School of Psychology, Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK
| | - Lorna Paul
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Linda Miller
- Douglas Grant Rehabilitation Unit, Ayrshire Central Hospital, Irvine, UK
| | - Siobhan Creanor
- Peninsula Clinical Trials Unit at Plymouth University (PenCTU), Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK.,Medical Statistics Group, Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Kara Stevens
- Medical Statistics Group, Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Colin Green
- University of Exeter Medical School, Health Economics Group, University of Exeter, Exeter, UK
| | - Paul Ewings
- National Institute for Health Research (NIHR) Research Design Service (South West), Musgrove Park Hospital, Taunton, UK
| | - Andrew Barton
- National Institute for Health Research (NIHR) Research Design Service, Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Margie Berrow
- Peninsula Clinical Trials Unit at Plymouth University (PenCTU), Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Jane Vickery
- Peninsula Clinical Trials Unit at Plymouth University (PenCTU), Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | | | - John Zajicek
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Jennifer Freeman
- School of Health Professions, Faculty of Health and Human Sciences, Peninsula Allied Health Centre, University of Plymouth, Plymouth, UK
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Rowsell A, Ashburn A, Fitton C, Goodwin VA, Hulbert S, Lamb SE, McIntosh E, Nieuwboer A, Pickering R, Rochester L, Chivers-Seymour K, Ballinger C. Participant expectations and experiences of a tailored physiotherapy intervention for people with Parkinson's and a history of falls. Disabil Rehabil 2020; 44:727-735. [PMID: 32573284 DOI: 10.1080/09638288.2020.1779824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Purpose: People with Parkinson's are twice as likely to fall as older people within the general population. This longitudinal qualitative study was part of a larger programme of research including a randomised controlled trial to test the effectiveness of a tailored physiotherapy intervention. Specific qualitative aims focused on a subsample of trial participants in the intervention arm of the trial, and comprised the following:To explore the expectations of participants about the intervention.To investigate participants' experiences of the intervention, and its perceived impacts.To understand the facilitators and barriers to engagement.Methods: Two semi-structured interviews were completed with a theoretical sample of people with Parkinson's from the intervention arm, initially after randomisation but before the intervention commenced, and then again six months later.Results: Forty-two participants out of a large clinical trial were interviewed initially, with 37 agreeing to a second interview at six months. Prior experience of rehabilitation plus information accessed through the trial consent procedure informed participants' realistic expectations. Most found the level of the intervention acceptable, and perceived a range of benefits. However, views about equipment provided were more equivocal. The biggest barriers to participation were time and motivation, whilst social support facilitated engagement with the intervention.Conclusions: This study is the first to capture expectations about participation in a programme of exercises and strategies. It highlights that previous challenges to engagement in physical exercises and activities are not a barrier to future participation and provides new insights into the role of equipment and technology in programmes of physical activity for people with Parkinson's. The challenge of ensuring that programmes of exercise and strategies become an embedded feature of everyday life is highlighted, particularly alongside busy social engagements and leisure pursuits.Implications for rehabilitationFor people with Parkinsons, a programme of exercises and strategies has the potential to reduce the risk of falls amongst those with a history of falling.Adherence to such programmes can prove challenging for a variety of reasons, even when participants have realistic expectations about the commitment and effort needed.Clear explanations about the role of equipment and technology within such programmes could enhance adherence.In order to further individualise programmes of exercise for people with Parkinsons, choice regarding social support, reminders and integration into everyday activities should be explored.
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Affiliation(s)
- Alison Rowsell
- Health Sciences, University of Southampton, Southampton, UK
| | - Ann Ashburn
- Health Sciences, University of Southampton, Southampton, UK
| | - Carolyn Fitton
- Health Sciences, University of Southampton, Southampton, UK
| | | | | | - Sarah E Lamb
- Institute for Health Research, University of Exeter, Exeter, UK
| | - Emma McIntosh
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Alice Nieuwboer
- Rehabilitation Sciences, University of Leuven, Leuven, Belgium
| | - Ruth Pickering
- Biomedical Research Centre, University of Southampton, Southampton, UK
| | - Lynn Rochester
- Translational and Clinical Research Institute, University of Newcastle, Newcastle, UK
| | | | - Claire Ballinger
- Biomedical Research Centre, University of Southampton, Southampton, UK
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Morris R, Martini DN, Smulders K, Kelly VE, Zabetian CP, Poston K, Hiller A, Chung KA, Yang L, Hu SC, Edwards KL, Cholerton B, Grabowski TJ, Montine TJ, Quinn JF, Horak F. Cognitive associations with comprehensive gait and static balance measures in Parkinson's disease. Parkinsonism Relat Disord 2019; 69:104-110. [PMID: 31731260 DOI: 10.1016/j.parkreldis.2019.06.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/19/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Gait and balance impairments are cardinal features of Parkinson's disease (PD) that require cognitive input. However, the extent to which specific gait and balance characteristics relate to cognition in PD is unclear. In addition, independent models of gait and balance have not been developed from the same cohort. We aimed to i) develop models of gait and balance in a large PD cohort and ii) determine which gait and balance characteristics best related to cognition. METHODS One hundred and ninety-eight people with PD were recruited to the Pacific Udall Center. Using six inertial sensors (APDM, Inc.), comprehensive gait measurements were collected over a 2-min continuous walk and comprehensive static balance measures were collected during a 60-second standing task. Six domains of cognition were assessed: global cognition, attention, executive function, language, memory, and visuospatial function. Correlations and hierarchical linear regression determined independent associations. RESULTS Principal components analysis identified a gait model containing four domains accounting for 80.1% of total variance: pace/turning, rhythm, variability, and trunk. The balance model contained four independent domains accounting for 84.5% of total variance: sway area/jerkiness, sway velocity, sway frequency anteroposterior, and sway frequency mediolateral. Gait domains of pace/turning and variability were strongly associated with attention and executive function. Sway area and jerkiness of balance associated with attention and visuospatial function. CONCLUSIONS Gait and balance characteristics were associated with specific types of cognition. The specific relationships between gait or balance with cognitive functions suggests shared cerebral cortical circuitry for mobility and cognitive functions.
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Affiliation(s)
- Rosie Morris
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Douglas N Martini
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Katrijn Smulders
- Sint Maartenskliniek Research Department, Nijmegen, the Netherlands
| | - Valerie E Kelly
- Department of Rehabilitation, University of Washington School of Medicine, Seattle, WA, USA
| | - Cyrus P Zabetian
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA; Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Kathleen Poston
- Department of Neurology and Neurological Sciences, Stanford School of Medicine, Palo Alto, CA, USA
| | - Amie Hiller
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Kathryn A Chung
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Laurice Yang
- Department of Neurology and Neurological Sciences, Stanford School of Medicine, Palo Alto, CA, USA
| | - Shu-Ching Hu
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA; Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Karen L Edwards
- Department of Epidemiology, University of California, Irvine, CA, USA
| | - Brenna Cholerton
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Thomas J Grabowski
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
| | - Thomas J Montine
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Joseph F Quinn
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA; Portland Veterans Affairs Health Care System, Portland, OR, USA
| | - Fay Horak
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA; Portland Veterans Affairs Health Care System, Portland, OR, USA.
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Chivers Seymour K, Pickering R, Rochester L, Roberts HC, Ballinger C, Hulbert S, Kunkel D, Marian IR, Fitton C, McIntosh E, Goodwin VA, Nieuwboer A, Lamb SE, Ashburn A. Multicentre, randomised controlled trial of PDSAFE, a physiotherapist-delivered fall prevention programme for people with Parkinson's. J Neurol Neurosurg Psychiatry 2019; 90:774-782. [PMID: 30944149 PMCID: PMC6585265 DOI: 10.1136/jnnp-2018-319448] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 02/06/2019] [Accepted: 02/09/2019] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To estimate the effect of a physiotherapist-delivered fall prevention programme for people with Parkinson's (PwP). METHODS People at risk of falls with confirmed Parkinson's were recruited to this multicentre, pragmatic, investigator blind, individually randomised controlled trial with prespecified subgroup analyses. 474 PwP (Hoehn and Yahr 1-4) were randomised: 238 allocated to a physiotherapy programme and 236 to control. All participants had routine care; the control group received a DVD about Parkinson's and single advice session at trial completion. The intervention group (PDSAFE) had an individually tailored, progressive home-based fall avoidance strategy training programme with balance and strengthening exercises. The primary outcome was risk of repeat falling, collected by self-report monthly diaries, 0-6 months after randomisation. Secondary outcomes included Mini-BESTest for balance, chair stand test, falls efficacy, freezing of gait, health-related quality of life (EuroQol EQ-5D), Geriatric Depression Scale, Physical Activity Scale for the Elderly and Parkinson's Disease Questionnaire, fractures and rate of near falling. RESULTS Average age is 72 years and 266 (56%) were men. By 6 months, 116 (55%) of the control group and 125 (61.5%) of the intervention group reported repeat falls (controlled OR 1.21, 95% CI 0.74 to 1.98, p=0.447). Secondary subgroup analyses suggested a different response to the intervention between moderate and severe disease severity groups. Balance, falls efficacy and chair stand time improved with near falls reduced in the intervention arm. CONCLUSION PDSAFE did not reduce falling in this pragmatic trial of PwP. Other functional tasks improved and reduced fall rates were apparent among those with moderate disease. TRIAL REGISTRATION NUMBER ISRCTN48152791.
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Affiliation(s)
| | - Ruth Pickering
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Lynn Rochester
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Helen C Roberts
- Faculty of Medicine, University of Southampton, Southampton, UK
| | | | - Sophia Hulbert
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Dorit Kunkel
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Ioana R Marian
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Carolyn Fitton
- School of Health Sciences, University of Southampton, Southampton, UK
| | | | | | - Alice Nieuwboer
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Sarah E Lamb
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Ann Ashburn
- School of Health Sciences, University of Southampton, Southampton, UK
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Henderson EJ, Morgan GS, Amin J, Gaunt DM, Ben-Shlomo Y. The minimum clinically important difference (MCID) for a falls intervention in Parkinson's: A delphi study. Parkinsonism Relat Disord 2018; 61:106-110. [PMID: 30455158 DOI: 10.1016/j.parkreldis.2018.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/19/2018] [Accepted: 11/05/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Falls are common in Parkinson's disease so any intervention that reduced falls risk would be of value. One potential intervention is the use of cholinesterase inhibitor (ChEi) drugs. OBJECTIVE To establish the minimum clinically important difference (MCID) for fall rates to inform the effect estimate for sample size calculations of future clinical trials. METHODS We performed a Delphi study assembling a panel of experts in Parkinson's disease from academic and clinical medicine in order to reach a consensus of opinion. Responses from a panel were summarised and resent to the group, until consensus was reached. RESULTS 780 clinicians, who had been caring for people with Parkinson's for an average of 14 years, were contacted via three routes. The median (Interquartile range (IQR)) MCID after round 1 was 25% (IQR 20-30%) which equates to the prevention of 5 (IQR 4-6) falls per year. Increasing consensus after round two confirmed the MCID of 25%, narrowing the (IQ) range to 20%-25%. This was unchanged when the panel were shown the number of participants that would need to be recruited to a clinical trial in order to achieve this difference. CONCLUSIONS We have established that an expert panel of PD specialists consider that an intervention that demonstrated a 25% (IQR 20-25%) relative reduction in falls rate would be clinically meaningful. This estimate can be used to help determine the sample size for any future clinical trial.
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Affiliation(s)
- Emily J Henderson
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, United Kingdom; Royal United Hospitals NHS Foundation Trust Bath, BA1 3NG, United Kingdom.
| | - Gemma S Morgan
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, United Kingdom
| | - Jigisha Amin
- Faculty of Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, United Kingdom
| | - Daisy M Gaunt
- Bristol Randomised Trials Collaboration (BRTC), Department of Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, United Kingdom
| | - Yoav Ben-Shlomo
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, United Kingdom
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Comparison of alternative falls data collection methods in the Prevention of Falls Injury Trial (PreFIT). J Clin Epidemiol 2018; 106:32-40. [PMID: 30266633 DOI: 10.1016/j.jclinepi.2018.09.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/28/2018] [Accepted: 09/18/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Prospective, monthly diaries are recommended for collecting falls data but are burdensome and expensive. The aim of the article was to compare characteristics of fallers and estimates of fall rates by method of data collection. STUDY DESIGN AND SETTING A methodology study nested within a large cluster randomized controlled trial. We randomized 9,803 older adults from 63 general practices across England to receive one of three fall prevention interventions. Participants provided a retrospective report of falls in postal questionnaires mailed every 4 months. A separate randomization allocated participants to receive prospective monthly falls diaries for one simultaneous 4-month period. RESULTS Falls diaries were returned by 7,762 of 9,375 (83%); of which 6,306 (67%) participants reported the same number of falls on both data sources. Diary nonresponders were older and had poorer levels of physical and mental health. Analysis of time points where both data sources were available showed the falls rate on diaries was consistently higher than on the questionnaire (mean rate: 0.16 vs. 0.12 falls per person-month observation). Diary allocation was associated with a higher rate of withdrawal from the main trial. CONCLUSION Diary completion was associated with sample attrition. We found on average a 32% difference in falls rates between the two data sources. Retrospective and prospective falls data are not consistently reported when collected simultaneously.
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Hulbert S, Rochester L, Nieuwboer A, Goodwin V, Fitton C, Chivers-Seymour K, Ashburn A. "Staying safe" - a narrative review of falls prevention in people with Parkinson's - "PDSAFE". Disabil Rehabil 2018; 41:2596-2605. [PMID: 29774765 DOI: 10.1080/09638288.2018.1471167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Parkinson's disease demonstrates a spectrum of motor and non-motor symptoms. Falling is common and disabling. Current medical management shows minimal impact to reduce falls or fall-related risk factors, such as deficits in gait, strength, and postural instability. Despite evidence supporting rehabilitation in reducing fall risk factors, the most appropriate intervention to reduce overall fall rate remains inconclusive. This article aims to 1) synthesise current evidence and conceptual models of falls rehabilitation in Parkinson's in a narrative review; and based on this evidence, 2) introduce the treatment protocol used in the falls prevention and multi-centre clinical trial "PDSAFE". Method: Search of four bibliographic databases using the terms "Parkinson*" and "Fall*" combined with each of the following; "Rehab*, Balanc*, Strength*, Strateg*and Exercis*" and a framework for narrative review was followed. A total of 3557 papers were identified, 416 were selected for review. The majority report the impact of rehabilitation on isolated fall risk factors. Twelve directly measure the impact on overall fall rate. Discussion: Results were used to construct a narrative review with conceptual discussion based on the "International Classification of Functioning", leading to presentation of the "PDSAFE" intervention protocol. Conclusions: Evidence suggests training single, fall risk factors may not affect overall fall rate. Combining with behavioural and strategy training in a functional, personalised multi-dimensional model, addressing all components of the "International Classification of Functioning" is likely to provide a greater influence on falls reduction. "PDSAFE" is a multi-dimensional, physiotherapist delivered, individually tailored, progressive, home-based programme. It is designed with a strong evidence-based approach and illustrates a model for the clinical delivery of the conceptual theory discussed. Implications for Rehabilitation Parkinson's disease demonstrates a spectrum of motor and non-motor symptoms, where falling is common and disabling. Current medical and surgical management have minimal impact on falls, rehabilitation of falls risk factors has strong evidence but the most appropriate intervention to reduce overall fall rate remains inconclusive. Addressing all components of the International Classification of Function in a multifactorial model when designing falls rehabilitation interventions may be more effective at reducing fall rates in people with Parkinson's than treating isolated risk factors. The clinical model for falls rehabilitation in people with Parkinson's should be multi-dimensional.
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Affiliation(s)
- Sophia Hulbert
- Faculty of Health Sciences, University Hospital Southampton, University of Southampton , Southampton , UK
| | - Lynn Rochester
- Campus for Ageing and Vitality, Clinical Ageing Research Unit, Newcastle University , Newcastle upon Tyne , UK
| | | | - Vicki Goodwin
- NIHR CLAHRC South West Peninsula, University of Exeter , Exeter , UK
| | - Carolyn Fitton
- Faculty of Health Sciences, University Hospital Southampton, University of Southampton , Southampton , UK
| | - Kim Chivers-Seymour
- Faculty of Health Sciences, University Hospital Southampton, University of Southampton , Southampton , UK
| | - Ann Ashburn
- Faculty of Health Sciences, University Hospital Southampton, University of Southampton , Southampton , UK
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