The effects of a mindfulness-based lifestyle program for adults with Parkinson's disease: a mixed methods, wait list controlled randomised control study

The Effect of Lifestyle Interventions on Anxiety, Depression and Stress: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

BACKGROUND/OBJECTIVES

Depression, anxiety, and stress are common mental health issues that affect individuals worldwide. This systematic review and meta-analysis examined the effectiveness of various lifestyle interventions including physical activity, dietary changes, and sleep hygiene in reducing the symptoms of depression, anxiety, and stress. Using stress as an outcome and conducting detailed subgroup analyses, this study provides novel insights into the differential effects of lifestyle interventions across diverse populations.

METHODS

Five databases were systematically searched: PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar, for gray literature searches. Keywords were used to search each database. The search period was from the conception of the databases until August 2023 and was conducted in English. For each analysis, Hedges' g was reported with a 95% confidence interval (CI) based on the random-effects method. Subgroups were analyzed and heterogeneity and publication bias were examined.

RESULTS

Ninety-six randomized clinical trial studies were included in this meta-analysis. Lifestyle interventions reduced depression (Hedges g -0.21, 95% confidence interval -0.26, -0.15; p < 0.001; I2 = 56.57), anxiety (Hedges g -0.24, 95% confidence interval -0.32, -0.15; p < 0.001; I2 = 59.25), and stress (-0.34, -0.11; p < 0.001; I2 = 61.40).

CONCLUSIONS

Lifestyle interventions offer a more accessible and cost-effective alternative to traditional treatments and provide targeted benefits for different psychological symptoms.

Mindfulness in Parkinson's disease: A French national survey and a pilot intervention feasibility trial using the MBSR program (M-Park)

BACKGROUND

Non-pharmacological complementary interventions, particularly mind-body practices, are of growing importance in the management of Parkinson's disease (PD). Among these, mindfulness meditation seems particularly effective, especially on anxiety and depression symptoms. However, current knowledge on mindfulness standardized programs in PD is still limited, particularly in France. Aiming at improving this knowledge we designed the M-PARK study in two phases. Phase 1 consisted in a French national survey to explore expectations, needs and initiatives for mindfulness meditation for PD patients. Phase 2 was a clinical trial with objectives to assess feasibility, acceptability and effects of a mindfulness (MBSR) program proposed to PD patients.

METHODS

In phase 1, online questionnaires were addressed to members of a French PD patient's association (France Parkinson) and French MBSR qualified instructors. In Phase 2, a clinical trial involving 30 PD patients consisted of a standard MBSR program with two additional evaluation visits one month before and after the program. Data collection included a global clinical evaluation, assessment of depression and anxiety symptoms, sleep, pain and quality of life and a face-to-face interview for qualitative assessment of the acceptability and lived experience during the program. Three MBSR programs were proposed to three groups of ten patients: two were online due to the pandemic situation, one proposed to patients with no or minor fluctuations (group 1) and one for patients with slight to moderate fluctuations (group 2), and the last one face-to-face for patients with no or minor fluctuations (group 3).

RESULTS

French survey: 209 responses were collected for the questionnaire sent to the members of the association France Parkinson; and 68 for the questionnaire sent to the instructors. Two-thirds of patients surveyed had heard of mindfulness meditation (66%), but were unaware of what this approach really consisted and how it could really help them. Few instructors (29%) had had to deal with patients with PD in their current practice. Yet 90% of patients surveyed indicated they were in favor of introducing this type of approach into their care.

CLINICAL TRIAL

The results indicated that the program is feasible and acceptable both online and face-to-face for patients with PD. Among the 30 patients enrolled, 25 completed the program. No unwanted effects related to mindfulness meditation practice were observed. The results showed a statistically significant reduction in anxiety symptoms, depressive symptoms, and improvement in quality of life. Furthermore, no statistically significant change was measured for pain or sleep quality. There was no striking difference in results observed between the patient groups. For the qualitative analysis, major themes highlighted were in relation with: (i) the lived experience during program; (ii) changes in the daily life; and (iii) disease-related changes. A large majority of patients who completed the program (24/25) described their participation as positive or very positive. They reported better management of stress and emotions, as well as greater autonomy in implementing new behavioral strategies, particularly in terms of self-care, acceptance, and de-identification from the disease.

CONCLUSION

Despite high expectations, PD patients are poorly informed about available mindfulness programs. This study however shows that these programs, whether offered online or face-to-face, are particularly beneficial, especially for anxiety and depressive symptoms, at least in mild-to-moderate stages of the disease.

Adapted Physical Activity Can Increase Life Appreciation in Patients with Parkinson's Disease

Objectives:This study aimed to measure the effect of a treatment of adapted physical activity (APA) on motor symptoms and on positive psychological resources in a group of patients with PD. Methods: 37 patients with PD (Mage= 71.5; 70.3% male) completed measures of disability level, motor performance, distress, well-being, and quality of life before and after participating in a program of APA (duration: 7 months). Analysis of variance - repeated measures was performed to evaluate the effect of APA on disability, distress, and well-being. Results: After intervention, patients reported significant improvements in their motor autonomy, disability level, psychological distress, and in life appreciation. Discussion: A brief physical activity program was beneficial not only to patients' motor functioning, but also to their mental health, by reducing distress and promoting life appreciation.

The Effects of Mindfulness-Based Interventions in People with Parkinson's Disease: A Systematic Review and Meta-Analysis

OBJECTIVES

To examine the effectiveness of mindfulness-based interventions (MBIs) on psychological symptoms, motor symptoms, and quality of life in patients with Parkinson's disease (PD).

METHODS

Published studies in Chinese and English languages, conducted from inception to March 2023, were identified by searching PubMed, Web of Science, Cochrane Library, CINAHL, PsycINFO, and two Chinese electronic databases. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines.

RESULTS

Twelve studies were selected for quantitative syntheses. The impact of MBIs on reducing depression and anxiety, and improving mindfulness and quality of life in PD patients was statistically significant compared to the control group. However, no statistically significant effect on motor symptoms was observed. Subgroup analysis indicated that participants from Asia, those who received face-to-face sessions, and those whose sessions lasted 1.5 hours showed a more positive effect than other subgroups.

CONCLUSIONS

Patients with PD may benefit from MBIs to improve psychological symptoms and quality of life. MBIs represent a pivotal non-pharmacological therapeutic approach in clinical practice.

CLINICAL IMPLICATIONS

MBIs confer positive improvements in psychological well-being and quality of life in PD patients. However, it remains challenging to conclusively determine their efficacy in addressing motor symptoms.

Psychosocial interventions affecting global perceptions of control in people with Parkinson's disease: a scoping review

PURPOSE

Perceived control is an important construct for the psychological well-being of people affected by chronic conditions, and higher perceived control is associated with better outcomes. Psychosocial interventions have been trialled in these populations to improve both global and specific perceptions of control. However, most interventions involving people with Parkinson's have focused on single-domain forms of control, while those addressing global perceived control are yet to be reviewed. This study aimed to identify and map the types of psychosocial interventions in individuals with Parkinson's which have included forms of global perceived control as an outcome.

MATERIALS AND METHODS

Scoping review based on a search across MEDLINE, PsycINFO, CINAHL, Academic Search Ultimate.

RESULTS

From an initial return of 4388 citations, 12 citations were eventually included. These consisted of 8 quantitative and 4 qualitative studies, and covered 4 overarching categories of psychosocial interventions. Mixed results were found for cognitive, educational, and physical interventions, while a randomised controlled trial on mindfulness-based lifestyle programme showed more preliminary positive evidence.

CONCLUSIONS

Further rigorous research is required on the topic to build on these preliminary findings. In the meantime, clinicians may need to consider programmes which proved effective with populations similar to people with Parkinson's.IMPLICATIONS FOR REHABILITATIONPerceived control is a psychological construct important for people with chronic illnesses, which can be targeted by psychosocial interventions.This article reviewed psychosocial interventions targeting global forms of perceived control in Parkinson's.Mixed results were reported for the cognitive, educational, and physical interventions identified, while a randomised controlled trial on a mindfulness-based lifestyle programme showed more promising evidence.In the meantime, clinicians may need to consider programmes found to be effective with people with similar conditions to Parkinson's.

Perceived control as a predictor of medication adherence in people with Parkinson's: a large-scale cross-sectional study

PURPOSE

Medication adherence is a multi-faceted construct associated with several positive consequences in people with chronic conditions. However, non-adherence currently represents a major issue in Parkinson's, potentially due to low perceptions of control. This study investigated the predictive ability of several aspects of perceived control on adherence in people with Parkinson's, while accounting for previously established predictors such as depression and medication variables.

MATERIALS AND METHODS

An online cross-sectional survey was carried out with 1210 adults with Parkinson's from 15 English-speaking countries. Demographic and clinical questions, as well as measures of depression, aspects of perceived control, and medication adherence were included. Pearson's correlations and a 4-block hierarchical regression analysis were performed to assess the relationship between the variables.

RESULTS

Perceived control explained a slightly higher amount of variance in medication adherence compared to medication variables when entered in the last block. Unexpectedly, depression was not significantly related with adherence. Internal locus of control was an independent negative predictor of adherence, while external dimensions of locus of control emerged as independent positive predictors.

CONCLUSIONS

In people with Parkinson's, perceptions of control may have a larger impact on adherence compared to medication variables. Implications for clinical practice and future research are discussed.Implications for RehabilitationPerceived control and depression are considered important constructs for medication adherence in Parkinson's, which in turn is often problematic for affected individuals.The specific predictive value of different aspects of perceived control on medication adherence in Parkinson's is currently unclear.This large-scale study found that perceptions of control may have a larger impact on adherence compared to medication variables, while depression was unrelated to it.A need for psychologically-informed interventions, person-centred approaches to medication management, and Parkinson-specific measures of adherence are highlighted.

Intervention components in the self-management of Parkinson's: a mixed-methods synthesis of qualitative and quantitative evidence

INTRODUCTION

Self-management interventions consist of multiple components to support people in the management of medical, emotional, and behavioural aspects of their condition, and aim to improve quality of life, function, and other outcomes. A systematic review of self-management interventions in Parkinson's showed no conclusive evidence for effectiveness of specific self-management approaches in Parkinson's to date but identified several potentially useful components.

AIM

To identify the key required components for self-management in people with Parkinson's by synthesising evidence from a body of primary qualitative evidence and systematic reviews, and to explore which of these key components should be incorporated into trials of self-management in Parkinson's.

METHOD

A mixed-methods synthesis was conducted. We combined data from two primary qualitative studies and a systematic review of qualitative studies that focused on self-management in Parkinson's to identify key intervention components. These were then mapped onto the results of a systematic review of Randomised Controlled Trials (RCTs) using matrices. First, data were extracted from the qualitative studies with people with Parkinson's and healthcare professionals on the key self-management components in this population. Second, a matrix table was created to map the identified Parkinson's specific self-management components against potential effectiveness from published RCTs of self-management interventions.

RESULTS

Synthesis of qualitative data identified 15 potential self-management components. These 15 components included components needed to start self-managing (e.g., information, skill acquirement) and components needed to maintain self-managing (e.g., self-motoring, increasing motivation). From 18 RCTs, interventions varied in how many components were included (range 1-10). Trials reporting significant beneficial effects of their intervention included a higher number of components (4 or more self-management components) than trials without significant findings (1-3 self-management components).

CONCLUSION

Fifteen key self-management components were identified that should be incorporated into interventions or programs of self-management in Parkinson's. No current trial has incorporated all aspects, but a higher number of these key components appears to make trials of self-management interventions more likely to be successful.

A general clinical overview of the non-motor symptoms in Parkinson's disease: Neuropsychiatric symptoms

The heterogeneity of non-motor features observed in people with Parkinson's disease (PD) is often dominated by one or more symptoms belonging to the neuropsychiatric spectrum, such as cognitive impairment, psychosis, depression, anxiety, and apathy. Due to their high prevalence in people with PD (PwP) and their occurrence in every stage of the disease, from the prodromal to the advanced stage, it is not surprising that PD can be conceptualised as a complex neuropsychiatric disorder. Despite progress in understanding the pathophysiological mechanisms underlying the neuropsychiatric signs and symptoms in PD, and better identification and diagnosis of these symptoms, effective treatments are still a major unmet need. The impact of these symptoms on the quality of life of PwP and caregivers, as well as their contribution to the overall non-motor symptom burden can be greater than that of motor symptoms and require a personalised, holistic approach. In this chapter, we provide a general clinical overview of the major neuropsychiatric symptoms of PD.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Systematic Review of Psychotherapy Approaches for Anxiety in Parkinson's Disease

OBJECTIVES

Anxiety is common in Parkinson's disease (PD), negatively impacting daily functioning and quality of life in PD patients and their families. This systematic review evaluates the effectiveness of different psychotherapeutic approaches for reducing anxiety in PD and provides recommendations for clinical practise.

METHODS

Following PRISMA guidelines, 36 studies were included and risk of bias was evaluated.

RESULTS

We identified cognitive behavioral therapy (CBT), mindfulness-based therapies, acceptance and commitment therapy, and psychodrama psychotherapies. There is good evidence-base for anxiety reduction using CBT approaches, but with mixed results for mindfulness-based therapies. Other therapeutic approaches were under researched. Most randomized control trials examined anxiety as a secondary measure. There was a paucity of interventions for anxiety subtypes. Secondarily, studies revealed the consistent exclusion of PD patients with cognitive concerns, an importance of care partner involvement, and a growing interest in remote delivery of psychotherapy interventions.

CONCLUSIONS

Person-centered anxiety interventions tailored for PD patients, including those with cognitive concerns, and trials exploring modalities other than CBT, warrant future investigations.

CLINICAL IMPLICATIONS

Practitioners should consider PD-specific anxiety symptoms and cognitive concerns when treating anxiety. Key distinctions between therapeutic modalities, therapy settings and delivery methods should guide treatment planning.

Mindfulness or meditation therapy for Parkinson's disease: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Parkinson's disease (PD) is the second most common neurodegenerative disorder worldwide. Mindfulness and meditation therapies have been demonstrated as effective alternative treatments for patients with neurological disorders. However, the effects of mindfulness and meditation therapies on PD remain unclear. This meta-analysis investigated the effects of mindfulness and meditation therapies in PD patients.

METHODS

A literature search was conducted using PubMed, Embase, Cochrane Library, and ClinicalTrials.gov for randomized controlled trials comparing mindfulness and meditation therapies with control treatments in patients with PD.

RESULTS

Nine articles involving eight trials were included, with a total of 337 patients. Our meta-analysis revealed that mindfulness and meditation therapies significantly improved Unified Parkinson's Disease Rating Scale-Part III score (mean difference [MD] = -6.31, 95% confidence interval [95% CI] = -8.57 to -4.05) and cognitive function (standard mean difference [SMD] = 0.62, 95% CI = 0.23 to 1.02). However, no significant differences were discovered between mindfulness therapies and control in gait velocity (MD = 0.05, 95% CI = -0.23 to 0.34), Parkinson's Disease Questionnaire-39 Summary Index (MD = 0.51, 95% CI = -1.12 to 2.14), activities of daily living (SMD = -1.65, 95% CI = -3.74 to 0.45), depression (SMD = -0.43, 95% CI = -0.97 to 0.11), anxiety (SMD = -0.80, 95% CI = -1.78 to 0.19), pain (SMD = 0.79, 95% CI = -1.06 to 2.63), or sleep disturbance (SMD = -0.67, 95% CI = -1.58 to 0.24).

CONCLUSION

Mindfulness and meditation therapies may serve as complementary and alternative treatments for PD patients.

Occupational Therapist-Led Mindfulness Training Program for Older Adults Living with Early Cognitive Decline in Primary Care: A Pilot Randomized Controlled Trial

Background

Community-dwelling older adults with early cognitive deficits experience less efficiency in performing everyday life tasks, resulting in decreased satisfaction and other adverse psychological outcomes. Mindfulness training has been linked to cognitive and psychological improvements and, most recently, has been identified as a potential intervention supporting performance of everyday life activities.

Objective

This study aimed to evaluate whether mindfulness practice can improve perceived performance and satisfaction with everyday life activity and secondary psychological outcomes.

Methods

This study is a pilot randomized controlled trial (RCT) in an interprofessional primary care team practice in Toronto, Ontario, Canada. The participants were 27 older adults aged 60 years of age or older living with early cognitive deficits. Participants were randomized into an 8-Week mindfulness training program (n = 14) group or a Wait-List Control (WLC; n = 13) group compared at baseline, post-intervention and 4-weeks follow-up. MANOVAs with post-hoc independent t-tests were used to compare between groups at different time points.

Results

There was a significant improvement in anxiety for the intervention group compared to the WLC group at post-intervention; Time-2 (mean difference = 3.90; CI = 0.04-7.75; p = 0.04) with large effect size (d = 0.80).

Conclusion

Mindfulness training significantly improved anxiety scores for patients with early cognitive deficits post-intervention. Further work is required to test the sustainability of reduced anxiety over time, but this study demonstrated that MBSR is a promising primary care intervention for those living with early cognitive deficits. This study warrants the pursuit of a future study in exploring how long the reduced anxiety effects would be sustained.

Modulating arousal to overcome gait impairments in Parkinson's disease: how the noradrenergic system may act as a double-edged sword

In stressful or anxiety-provoking situations, most people with Parkinson's disease (PD) experience a general worsening of motor symptoms, including their gait impairments. However, a proportion of patients actually report benefits from experiencing-or even purposely inducing-stressful or high-arousal situations. Using data from a large-scale international survey study among 4324 people with PD and gait impairments within the online Fox Insight (USA) and ParkinsonNEXT (NL) cohorts, we demonstrate that individuals with PD deploy an array of mental state alteration strategies to cope with their gait impairment. Crucially, these strategies differ along an axis of arousal-some act to heighten, whereas others diminish, overall sympathetic tone. Together, our observations suggest that arousal may act as a double-edged sword for gait control in PD. We propose a theoretical, neurobiological framework to explain why heightened arousal can have detrimental effects on the occurrence and severity of gait impairments in some individuals, while alleviating them in others. Specifically, we postulate that this seemingly contradictory phenomenon is explained by the inherent features of the ascending arousal system: namely, that arousal is related to task performance by an inverted u-shaped curve (the so-called Yerkes and Dodson relationship). We propose that the noradrenergic locus coeruleus plays an important role in modulating PD symptom severity and expression, by regulating arousal and by mediating network-level functional integration across the brain. The ability of the locus coeruleus to facilitate dynamic 'cross-talk' between distinct, otherwise largely segregated brain regions may facilitate the necessary cerebral compensation for gait impairments in PD. In the presence of suboptimal arousal, compensatory networks may be too segregated to allow for adequate compensation. Conversely, with supraoptimal arousal, increased cross-talk between competing inputs of these complementary networks may emerge and become dysfunctional. Because the locus coeruleus degenerates with disease progression, finetuning of this delicate balance becomes increasingly difficult, heightening the need for mental strategies to self-modulate arousal and facilitate shifting from a sub- or supraoptimal state of arousal to improve gait performance. Recognition of this underlying mechanism emphasises the importance of PD-specific rehabilitation strategies to alleviate gait disability.

A Pilot Study of Telehealth Mindfulness-Based Cognitive Therapy for Depression in Parkinson's Disease

Introduction: Parkinson's disease (PD) is characterized by high-rates of depression with limited evidence-based treatment options to improve mood. Objective: To expand therapeutic options, we evaluated the feasibility and effect of a telehealth mindfulness-based cognitive therapy intervention adapted for PD (MBCT-PD) in a sample of participants with DSM-5 depressive disorders. Methods: Fifteen participants with PD and clinically-significant depression completed 9 sessions of MBCT-PD. Depression, anxiety, and quality of life were evaluated at baseline, endpoint, and 1-month follow-up. Results: Telehealth MBCT-PD was feasible and beneficial. Completion rates exceeded 85% and treatment satisfaction rates were high. Notable improvements were observed for depression, anxiety, and quality of life over the course of the trial. Conclusion: Telehealth MBCT-PD shows promise and warrants further evaluation via randomized clinical trial with more diverse participants. Such research holds the potential to expand the range of therapeutic options for depression in PD, thereby setting the stage for personalized care.

A randomized clinical trial of mindfulness meditation versus exercise in Parkinson's disease during social unrest

Clinical practice guidelines support resilience training and exercise for patients with Parkinson's disease (PD). This assessor-blinded, randomized clinical trial aimed to compare the effects of a modified mindfulness meditation program versus stretching and resistance training exercise (SRTE) in patients with mild-to-moderate PD. A total of 126 potential participants were enrolled via convenience sampling, of which 68 eligible participants were randomized 1:1 to receive eight weekly 90-min sessions of mindfulness meditation or SRTE. Compared to the SRTE group, generalized estimating equation analyses revealed that the mindfulness group had significantly better improvement in outcomes, particularly for improving depressive symptoms (d, -1.66; 95% CI, -3.31 to -0.02) at week 8 and maintaining emotional non-reactivity at week 20 (d, 2.08; 95% CI, 0.59 to 3.56). Both groups demonstrated significant immediate, small-moderate effects on cognition (effect size [d] = 0.36-0.37, p = 0.006-0.011). Compared with the SRTE, mindfulness meditation appeared to be a feasible and promising strategy for managing depressive symptoms and maintaining emotional stability, with comparable benefits on cognitive performance. To combat the psychospiritual and cognitive sequelae of social unrest and COVID-19 pandemic, the integration of mindfulness training into motor-oriented PD rehabilitation protocols is recommended to strengthen the resilience and minimize the psycho-cognitive comorbidities among patients with mild-to-moderate PD.Trial Registration: HKU Clinical Trials Registry identifier: HKUCTR-2681.

Online Mindfulness-Based Cognitive Therapy for People with Parkinson’s Disease and Their Caregivers: a Pilot Study

Anxiety and depression are common non-motor symptoms of Parkinson’s disease (PD). Caregivers of people with PD may experience severe caregiver burden. This study explored the feasibility and potential benefits of an online mindfulness-based cognitive therapy (MBCT) intervention for improving anxiety and depressive symptoms in people with PD and their caregivers (ClinicalTrials.gov NCT04469049, 7/8/2020). People with PD or parkinsonism and anxiety and/or depressive symptoms and caregivers of people with PD participated in one of three online MBCT groups. Demographic variables, pre- and post-MBCT behavioral measures (GAD-7, PHQ-9, Five Facet Mindfulness Questionnaire — FFMQ-15, Caregiver Self-Assessment Questionnaire — CSAQ), and satisfaction surveys were collected. Descriptive statistics were used to summarize data. Pre- and post-MBCT behavioral scores were compared using mixed-effect models. Fifty-six potential participants were assessed for eligibility. Twenty-eight entered MBCT groups; all but one completed the intervention. The overall sample analyzed (22 people with PD, 4 caregivers) showed significant GAD-7 and PHQ-9 score reductions and FFMQ-15 total and observing and non-reactivity subscale score increases (all p’s < 0.05). Participants with PD and anxiety symptoms (n = 14) had a significant GAD-7 score reduction; those with PD and depressive symptoms (n = 12) had a significant PHQ-9 score reduction (both p’s < 0.05). Participants with PD also had a significant FFMQ-15 observing subscale score increase (p < 0.05). The caregiver sample was too small to be analyzed separately. Online MBCT is feasible (as measured by high attendance, completion rate, and participant satisfaction) and may be effective in improving anxiety and depressive symptoms in people with PD.

Lifestyle medicine for anxiety symptoms: A meta-analysis of randomized controlled trials

BACKGROUND

Lifestyle medicine (LM) is gaining increasing attention as a treatment option for anxiety, but the current state of evidence has not yet been systematically examined.

METHODS

Six electronic databases were systematically searched from inception to February 2022. Randomized controlled trials (RCTs) comparing the effects of multicomponent LM interventions on anxiety symptoms with either care-as-usual, waitlist, no intervention, or attention control group on anxiety symptoms were identified.

RESULTS

A total of 53 RCTs with 18,894 participants were included for qualitative synthesis, in which 45 RCTs with data available were included for meta-analysis. Multicomponent LM intervention was significantly more effective than the control groups in reducing anxiety symptoms at immediate posttreatment (d = 0.19, p < .001) and at short-term follow-up (d = 0.29, p < .001). However, no significant difference at medium-term was found (p = .14), whereas more studies are needed to study the long-term effects. The subgroup analyses suggested that baseline anxiety symptoms was a significant moderator, suggesting that those with moderate level of baseline anxiety symptoms appeared to have greater improvements (d = 0.66, p < .05).

LIMITATIONS

Minimal anxiety symptoms at baseline contributed to the floor effect and influenced the degree of improvement. The included RCTs had a high risk of bias in general with potential publication bias detected.

CONCLUSION

The findings of this meta-analysis provided support for the positive effects of multicomponent LM interventions for anxiety symptoms. Future research is needed to determine the long-term effects of multicimponent LM and the optimal baseline anxiety severity.

Occupational Therapy Practice Guidelines for People With Parkinson's Disease

IMPORTANCE

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION AND RECOMMENDATIONS

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

Randomized Controlled Trial of Cognitive-Behavioral and Mindfulness-Based Stress Reduction on the Quality of Life of Patients With Crohn Disease

BACKGROUND

Patients with Crohn disease have debilitating psychological symptoms, mental fatigue, and poor quality of life. Psychological intervention may improve these symptoms.

METHODS

We performed a randomized parallel-group physician-blinded trial of cognitive-behavioral and mindfulness-based stress reduction (COBMINDEX) on quality of life and psychological symptoms in adults with mild-moderate Crohn disease. COBMINDEX was taught by social workers in one-on-one video conferences over 3 months; quotidian home practice was mandated.

RESULTS

Fifty-five COBMINDEX and 61 waitlist control patients completed the study; mean age was 33 years and 65% of participants were women. At 3 months, COBMINDEX patients had significantly reduced disease activity (per Harvey-Bradshaw Index score, C-reactive protein level, and calprotectin level), increased quality of life (Short Inflammatory Bowel Disease Questionnaire [SIBDQ] score increased from baseline 41 to 50; P < 0.001), decreased psychological symptoms (Global Severity Index [GSI], 0.98-0.70; P < 0.001), reduced fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue, 26-33; P < 0.001), and increased mindfulness disposition (Freiburg Mindfulness Inventory, 33-38; P < 0.001). Waitlist patients had a significant but small change in Harvey-Bradshaw Index, SIBDQ, and GSI scores, without improvement in fatigue or mindfulness. There were significant correlations (0.02 > P < 0.002) in COBMINDEX patients between baseline SIBDQ, GSI, Freiburg Mindfulness Inventory, and Functional Assessment of Chronic Illness Therapy-Fatigue scores with a relative change (baseline to 3 months) of the SIBDQ score, but none among waitlist patients. Predictors of relative change of the SIBDQ score in COBMINDEX patients included the GSI score (90% quantile; coefficient 0.52; P < 0.001), somatization (90%; 0.20; P = 0.001), depression (75%; 0.16; P = 0.03), and phobic anxiety (75%; 0.31; P = 0.008).

CONCLUSIONS

COBMINDEX was effective in increasing patients' quality of life and reducing psychological symptoms and fatigue. Patients with severe baseline psychological symptoms benefited the most from COBMINDEX.

Goal management training and psychoeducation / mindfulness for treatment of executive dysfunction in Parkinson’s disease: A feasibility pilot trial

Introduction

As there is currently no pharmacological treatment for Parkinson’s Disease Mild Cognitive Impairment (PD-MCI) with executive dysfunctions, specific cognitive interventions must be investigated. Most previous studies have tested bottom-up cognitive training programs but have not shown very good results.

Objectives

The aim of this study was to test ease of implementation, differential safety and preliminary efficacy of two top-down (strategy-learning) home-based, individualized, cognitive interventions: Goal Management Training (GMT), adapted for PD-MCI (Adapted-GMT), and a psychoeducation program combined with mindfulness exercises (PSYCH-Mind).

Methods

This was a single-blind block-randomized between-group comparative study. Twelve PD-MCI with mild executive dysfunctions were divided in four blocks and randomly assigned to any of the two interventions. The participants were included if they had PD-MCI diagnosis (no dementia), with stabilized medication. Both groups (Adapted-GMT and PSYCH-mind) received five intervention sessions each lasting 60–90 minutes for five weeks. Measures were collected at baseline, mid-point, one-week, four-week and 12-week follow-ups. Executive functions were assessed with the Dysexecutive questionnaire (DEX) and the Zoo Map Test (ZMT). Quality of life (QoL) and psychiatric symptoms were also evaluated. Repeated measures ANCOVAs (mixed linear analysis) were applied to all outcomes.

Results

There was one drop out, and both interventions were feasible and acceptable. Despite the small sample size limiting statistical power, patients of both groups significantly improved executive functions per the DEX-patient (Time: F(4,36) = 2.96, p = 0.033, CI95%: 10.75–15.23) and DEX-caregiver scores (Time: F(4,36) = 6.02, p = 0.017, CI95%: 9.63–17.23). Both groups significantly made fewer errors between measurement times on the ZMT (Time: F(3,36) = 16.66, p = 0.001, CI95%: 1.07–2.93). However, QoL significantly increased only in PSYCH-Mind patients at four-week follow-up (interaction Time*Group: F(4,36) = 5.31, p = 0.002, CI95%: 15.33–25.61).

Conclusion

Both interventions were easily implemented and proved to be safe. Because both interventions are arguably cost-effective, these pilot findings, although promising, need to be replicated in large samples.

ClinicalTrials.gov Identifier

NCT04636541.

My Healthy Brain: Rationale and Case Report of a Virtual Group Lifestyle Program Targeting Modifiable Risk Factors for Dementia

Nearly half of dementia cases may be explained by modifiable lifestyle risk factors. Multidomain interventions are needed to bypass cognitive decline (CD) and aging-related barriers to sustained healthy lifestyles in at-risk older adults. We iteratively developed  My Healthy Brain, a group-based lifestyle program (8 weeks, 90 min sessions) delivered via live video that applies behavioral principles to target multiple risk factors for dementia. We describe the program structure, virtual delivery, and outcomes for a group of older adults with subjective CD or mild cognitive impairment and lifestyle risk factors (e.g., sedentary, poor sleep or diet). We also conducted a group exit interview to qualitatively assess participant experiences and elicit feedback to improve My Healthy Brain. This case report demonstrates that delivering evidence-based brain health education and behavior change skills in a group setting via live video is feasible, acceptable, and has the potential to improve lifestyle, cognitive, and psychosocial outcomes in older adults with CD.

Systematic Review for the Medical Applications of Meditation in Randomized Controlled Trials

Background: Meditation has been increasingly adapted for healthy populations and participants with diseases. Its beneficial effects are still challenging to determine due to the heterogeneity and methodological obstacles regarding medical applications. This study aimed to integrate the features of therapeutic meditation in randomized controlled trials (RCTs). Methods: We conducted a systematic review of RCTs with meditation for populations with diseases using the PubMed database through June 2021. We analyzed the characteristics of the diseases/disorders, participants, measurements, and their overall benefits. Results: Among a total of 4855 references, 104 RCTs were determined and mainly applied mindfulness-based (51 RCTs), yoga-based (32 RCTs), and transcendental meditation (14 RCTs) to 10,139 patient-participants. These RCTs were conducted for participants with a total of 45 kinds of disorders; the most frequent being cancer, followed by musculoskeletal and connective tissue diseases and affective mood disorder. Seven symptoms or signs were frequently assessed: depressive mood, feeling anxious, quality of life, stress, sleep, pain, and fatigue. The RCTs showed a higher ratio of positive outcomes for sleep (73.9%) and fatigue (68.4%). Conclusions: This systematic review produced the comprehensive features of RCTs for therapeutic meditation. These results will help physicians and researchers further study clinical adaptations in the future as reference data.

Systematic review and meta-analysis of clinical effectiveness of self-management interventions in Parkinson's disease

BACKGROUND

Parkinson's disease is a complex neurodegenerative condition with significant impact on quality of life (QoL), wellbeing and function. The objective of this review is to evaluate the clinical effectiveness of self-management interventions for people with Parkinson's disease, taking a broad view of self-management and considering effects on QoL, wellbeing and function.

METHODS

Systematic searches of four databases (MEDLINE, Embase, PsycINFO, Web of Science) were conducted for studies evaluating self-management interventions for people with Parkinson's disease published up to 16th November 2020. Original quantitative studies of adults with idiopathic Parkinson's disease were included, whilst studies of atypical Parkinsonism were excluded. Full-text articles were independently assessed by two reviewers, with data extracted by one reviewer and reliability checked by a second reviewer, then synthesised through a narrative approach and, for sufficiently similar studies, a meta-analysis of effect size was conducted (using a random-effects meta-analysis with restricted maximum likelihood method pooled estimate). Interventions were subdivided into self-management components according to PRISMS Taxonomy. Risk of bias was examined with the Cochrane Risk of Bias 2 (RoB2) tool or ROBIN-I tool as appropriate.

RESULTS

Thirty-six studies were included, evaluating a diverse array of interventions and encompassing a range of study designs (RCT n = 19; non-randomised CT n = five; within subject pre- and post-intervention comparisons n = 12). A total of 2884 participants were assessed in studies across ten countries, with greatest output from North America (14 studies) and UK (six studies). Risk of bias was moderate to high for the majority of studies, mostly due to lack of participant blinding, which is not often practical for interventions of this nature. Only four studies reported statistically significant improvements in QoL, wellbeing or functional outcomes for the intervention compared to controls. These interventions were group-based self-management education and training programmes, either alone, combined with multi-disciplinary rehabilitation, or combined with Cognitive Behaviour Therapy; and a self-guided community-based exercise programme. Four of the RCTs evaluated sufficiently similar interventions and outcomes for meta-analysis: these were studies of self-management education and training programmes evaluating QoL (n = 478). Meta-analysis demonstrated no significant difference between the self-management and the control groups with a standardised mean difference (Hedges g) of - 0.17 (- 0.56, 0.21) p = 0.38. By the GRADE approach, the quality of this evidence was deemed "very low" and the effect of the intervention is therefore uncertain. Components more frequently observed in effective interventions, as per PRISMS taxonomy analysis, were: information about resources; training or rehearsing psychological strategies; social support; and lifestyle advice and support. The applicability of these findings is weakened by the ambiguous and at times overlapping nature of self-management components.

CONCLUSION

Approaches and outcomes to self-management interventions in Parkinson's disease are heterogenous. There are insufficient high quality RCTs in this field to show effectiveness of self-management interventions in Parkinson's disease. Whilst it is not possible to draw conclusions on specific intervention components that convey effectiveness, there are promising findings from some studies, which could be targeted in future evaluations.

Prevalence and Cumulative Incidence of Caregiver-Reported Aggression in Advanced Parkinson Disease and Related Disorders

Objective

To estimate the point prevalence and cumulative incidence of caregiver-reported aggressive behaviors among people living with advanced Parkinson disease and related disorders (PDRDs) and secondarily examine variables associated with aggression.

Methods

Caregivers from a clinical trial of outpatient palliative care for PDRD were surveyed about patient aggression at baseline and every 3 months over 12 months. Baseline responses were used for point prevalence. Cumulative incidence was calculated using responses from caregivers with no reported baseline aggression and available data at all other time points. Measures of disease severity, quality of life, mood, and caregiver burden were included in correlation and relative risk models, adjusting for age, sex, and diagnosis.

Results

Of 170 caregivers, 31 (18.2%) reported physical aggression, and 18 (10.6%) reported sexual aggression. Twelve-month cumulative incidence for physical and sexual aggression was 21.1% (23/109) and 16.0% (19/119), respectively. Physical aggression cumulative incidence was associated with patient depression (r = 0.37), patient-perceived quality of life (r = -0.26), caregiver burden (r = 0.26), caregiver-perceived patient quality of life (r = -0.26), and caregiver anxiety (r = 0.20). Age, sex, cognitive impairment, and dementia were not associated with aggression. No variables were associated with cumulative sexual aggression.

Conclusion

There was a high prevalence and incidence of aggression in our PDRD cohort. This is an understudied issue in PDRD, and our findings highlight the need for increased awareness among neurologists. Providers should consider assessing for aggression when discussing neuropsychiatric symptoms or screening for caregiver burden. Future research should examine the relationship between aggression and patient and caregiver health outcomes.

Trial Registration Information

Clinical trial registration number: NCT02533921.

Pilot Study of Mindfulness Training on the Self-Awareness of Motor Symptoms in Parkinson's Disease - A Randomized Controlled Trial

Objective: This study aims to evaluate feasibility and effects of a newly developed mindfulness intervention tailored to specific needs of patients with Parkinson’s disease (PD).

Background: The phenomenon of impaired self-awareness of motor symptoms (ISAm) in PD might be reduced by increasing patients’ mindfulness. A PD-specific mindfulness intervention has been developed and evaluated as a potential treatment option: IPSUM (“Insight into Parkinson’s Disease Symptoms by using Mindfulness”).

Methods: IPSUM’s effectiveness is evaluated by comparing an intervention with a waitlist-control group. Applying a pre-post design, patients were assessed before, directly after and 8weeks after treatment. The primary outcome was the change in a quantitative ISAm score from baseline to post-assessment. Secondary outcome measures were PD-related affective changes and neuropsychological test performance. Feasibility was evaluated via feedback forms.

Results: In total, 30 non-depressed and non-demented PD patients were included (intervention: n=14, waitlist-control: n=16). ISAm score did not change significantly, but the training group showed greater performance in sustained attention and language tasks over time. Additional changes included greater mindfulness as well as less sleeping problems and anxiety. Cognitive disturbances, apathy, and sleeping problems worsened only in the waitlist-control group. Patients’ feedback regarding the training concept and material was excellent.

Conclusion: Insight into Parkinson’s Disease Symptoms by using Mindfulness has not been capable of reducing ISAm in PD patients but appears to be a feasible and effective concept to, among others, support mental health in the mid-term. It has to be noted though that the study was stopped beforehand because of the SARS CoV-2 pandemic. The lack of findings might therefore be caused by a lack of statistical power. The need for further research to better understand the mechanisms of ISAm and its connection to mindfulness in PD is highlighted.

Health Promotion and Wellness in Neurologic Physical Therapy: Strategies to Advance Practice

BACKGROUND AND PURPOSE

Neurologic physical therapy (PT) can assist people with neurologic conditions and injuries to optimize their health and well-being by addressing barriers at the individual, relationship, community, and societal levels. The purpose of this special interest article is to provide consensus-driven strategies to address barriers to implementing health promotion and wellness (HPW)-related neurologic PT practice.

SUMMARY OF KEY POINTS

Environmental scan, literature review, and expert input were used to determine barriers and develop strategies. Barriers include lack of time; low knowledge, self-efficacy, and awareness; client complexity; and lack of HPW resources; as well as concerns regarding payment and scope of practice. Four key strategies emerged: (1) develop and disseminate a consensus-based scope of practice for HPW in neurologic PT; (2) increase knowledge of resources related to HPW; (3) promote delivery models for HPW-related neurologic PT; and (4) encourage advocacy, community building and partnership along the continuum of care.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Clinicians should practice to their full scope of HPW-related PT practice. This includes optimizing movement, including physical activity and fitness, as well as reinforcing the importance of healthy sleep, nutrition, stress, and smoking cessation. These activities address primary, secondary, and tertiary prevention. Clinicians are encouraged to report their experiences with HPW-focused delivery models and outcomes. Additional research is needed to understand the full impact of HPW on PT practice (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A364).

Psychological interventions for people with Parkinson's disease in the early 2020s: Where do we stand?

PURPOSE

To explore the heterogeneity of the literature on psychological interventions for psychological difficulties in people with Parkinson's disease (PD).

METHODS

A scoping review was performed across five major databases (MEDLINE Complete, PsycINFO, CINAHL, Academic Search Ultimate, and Cochrane Library) up to June 2020.

RESULTS

From an initial return of 4911 citations, 56 studies were included, of which 21 were RCTs. A relatively wide range of therapeutic models have been adopted with people with PD, from common therapies such as cognitive behavioural therapy (CBT) and mindfulness, to less frequent approaches, for example, acceptance and commitment therapy (ACT) and psychodrama. The clinical implications of the findings are discussed, and suggestions are provided for future research on intervention studies and key psychological outcomes.

CONCLUSIONS

CBT appears to be effective in treating depression and sleep disorders in people with PD, while psychoeducation programmes alone should be avoided. The use of CBT to improve anxiety, quality of life, and impulse control, as well mindfulness-based interventions, should be undertaken with some caution because of insufficient research and inconsistent results. As we enter the new decade, more high-quality evidence is required for psychological interventions in people with PD in general and to corroborate preliminary positive findings on the adoption of less frequent approaches such as ACT.

PRACTITIONER POINTS

Parkinson's disease is a progressive neurodegenerative condition associated with several psychological difficulties which be targeted by psychological interventions. Currently, cognitive behavioural therapy (CBT) can be recommended to treat depression and sleep disorders in people with Parkinson's, while psychoeducation alone should be avoided. Caution is advised regarding the use of CBT and mindfulness-based interventions to improve anxiety, quality of life, and impulse control. Further evidence is required for less common approaches, such as acceptance and commitment therapy, psychodrama, and EMDR.

Psychotherapy for the Treatment of Anxiety and Depression in Patients with Parkinson Disease: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Anxiety and depression are major psychiatric nonmotor symptoms (NMSs) of Parkinson disease (PD). Although several studies have investigated the effects of psychotherapeutic interventions, particularly cognitive-behavioral therapy (CBT), for alleviating anxiety and depression in patients with PD, the findings have been inconclusive because of the small sample size and the lack of a unified protocol for such treatments. Thus, the present meta-analysis of randomized controlled trials (RCTs) was conducted to assess the effect of psychotherapy on PD-related anxiety and depression.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Relevant RCTs were extracted from PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library databases. This study was registered in PROSPERO under the number CRD 42020165052.

MEASURES

The primary and secondary outcomes were changes in the anxiety score and depressive symptoms, respectively.

RESULTS

Fourteen RCTs including 507 patients with PD were analyzed. The interventions were classified as CBT and non-CBT. CBT significantly reduced anxiety at the end of the study (standardized mean difference = -0.85, 95% confidence interval = -1.12 to -0.58, P < .001, I² = 0%), whereas non-CBT did not. Greater heterogeneity in the effects of non-CBT treatment was observed. CBT was significantly beneficial for depression (standardized mean difference = -0.83, 95% confidence interval = -1.26 to -0.40, P < .001, I² = 55%). Despite the greater heterogeneity in the effects, non-CBT interventions were also effective in alleviating depressive symptoms.

CONCLUSION AND IMPLICATIONS

CBT is effective for the management of anxiety and depression in patients with PD. Routine treatment for patients with this condition is strongly recommended.

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

IMPORTANCE

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

OBJECTIVE

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

DATA SOURCES

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

FINDINGS

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

CONCLUSIONS AND RELEVANCE

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

The Relationship Between Anxiety Disorders and Parkinson's Disease: Clinical and Therapeutic Issues

PURPOSE OF REVIEW

This paper seeks to describe anxiety's different symptomatologic presentations in Parkinson's disease (PD), its longitudinal course and predictors, as well as its motor and non-motor correlates. It also reviews the available screening tools and different treatment modalities.

RECENT FINDINGS

In PD, longitudinal predictors of anxiety are mostly non-motor non-dopaminergic symptoms. The longitudinal course of anxiety is mainly a stable one. The Parkinson Anxiety Scale and the Geriatric Anxiety Scale are the 2 recommended screening tools. A third of PD patients suffer from an anxiety disorder at any time point. It can precede or follow PD motor symptoms. Anxiety is associated with demographic, disease-related motor and non-motor features. There is a lack of studies evaluating psychotropic treatment of anxiety in PD. Adjustment of dopaminergic treatment is indicated when anxiety is associated with motor fluctuations. DBS can be useful as well as CBT and body-mind interventions.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Patient or Public Contribution

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

Stress and Mindfulness in Parkinson's Disease: Clinical Effects and Potential Underlying Mechanisms

Patients with Parkinson's disease (PD) are very vulnerable to the negative effects of psychological distress: neuropsychiatric symptoms, such as anxiety and depression, are highly prevalent in PD; motor symptoms (such as tremor) typically worsen in stressful situations; and dopaminergic medication is less effective. Furthermore, animal studies of PD suggest that chronic stress may accelerate disease progression. Adequate self-management strategies are therefore essential to reduce the detrimental effects of chronic stress on PD. Mindfulness-based interventions encourage individuals to independently self-manage and adapt to the challenges created by their condition. In PD, emerging clinical evidence suggests that mindfulness-based interventions may reduce psychological distress and improve clinical symptoms, but insight into the underlying mechanisms is lacking. In this viewpoint, we provide a systematic overview of existing mindfulness trials in PD. Furthermore, we discuss the cerebral mechanisms involved in acute and chronic stress, and the impact of mindfulness-based interventions on these networks. In addition, we delineate a hypothetical mechanistic framework of how chronic stress may increase the susceptibility for neuropsychiatric symptoms in PD and may potentially even influence disease progression. We end with offering recommendations for future research. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Improving Self-Awareness of Motor Symptoms in Patients With Parkinson's Disease by Using Mindfulness - A Study Protocol for a Randomized Controlled Trial

Objective

This study aims to increase self-awareness in patients with Parkinson’s disease (PD) using a newly developed mindfulness-based intervention, tailored for the specific needs of PD patients. Its impact on self-awareness and patients’ daily lives is currently being evaluated.

Background

Recently, the phenomenon of impaired self-awareness for motor symptoms (ISAm) and some non-motor symptoms has been described in PD. ISAm can negatively influence patients’ daily lives, e.g., by affecting therapy adherence, and is therefore the main focus of this study. The main goal is the development of IPSUM (“Insight into Parkinson’s Disease Symptoms by using Mindfulness”), a PD-specific intervention for increasing patients’ mindfulness and thereby reducing ISAm.

Methods

The effectiveness of IPSUM is evaluated by comparison of an intervention group with a waitlist-control group. A pre-post design with an additional 8-week follow-up measurement is applied, resulting in three measurement points: before, directly after and 8 weeks after completing the intervention protocol. In total, up to 180 non-depressed PD patients without severe cognitive impairment (non-demented) will be included. The primary outcome is a quantitative score for measuring ISAm. Secondary outcome measures are affective changes, neuropsychological performance and self-awareness of cognition. At pre- and post-measurement an fMRI scan is performed to connect behavioral and neurobiological findings. At post- and follow-up-measurement each patient will take part in a semi-structured interview to explore IPSUM’s impact on self-awareness and patients’ everyday lives.

Results

The conception of the intervention protocol is finished, the resulting 8-week program is presented in detail. It has successfully been tested in the first group of patients, their feedback so far was quite promising. Recruitment is ongoing and a first interim analysis will be performed once 30 patients have completed IPSUM.

Conclusion

For the first time, the intervention protocol of IPSUM has successfully been tested in a group of PD patients. As the study goes on, more quantitative data is collected for statistical analyses to evaluate its effectiveness. More qualitative data is collected to evaluate feasibility and effectiveness. We hope for this intervention to be capable of reducing the patients’ ISAm and improving their quality of life on many levels.

Mindfulness-based lifestyle programs for the self-management of Parkinson's disease in Australia

Despite emerging evidence suggesting positive outcomes of mindfulness training for the self-management of other neurodegenerative diseases, limited research has explored its effect on the self-management of Parkinson's disease (PD). We aimed to characterize the experiences of individuals participating in a facilitated, group mindfulness-based lifestyle program for community living adults with Stage 2 PD and explore how the program influenced beliefs about self-management of their disease. Our longitudinal qualitative study was embedded within a randomized controlled trial exploring the impact of a 6-week mindfulness-based lifestyle program on patient-reported function. The study was set in Melbourne, Australia in 2012-2013. We conducted semi-structured interviews with participants before, immediately after, and 6 months following participation in the program. Sixteen participants were interviewed prior to commencing the program. Of these, 12 were interviewed shortly after its conclusion, and 9 interviewed at 6 months. Prior to the program, participants felt a lack of control over their illness. A desire for control and a need for alternative tools for managing the progression of PD motivated many to engage with the program. Following the program, where participants experienced an increase in mindfulness, many became more accepting of disease progression and reported improved social relationships and self-confidence in managing their disease. Mindfulness-based lifestyle programs have the potential for increasing both participants' sense of control over their reactions to disease symptoms as well as social connectedness. Community-based mindfulness training may provide participants with tools for self-managing a number of the consequences of Stage 2 PD.

Report from a multidisciplinary meeting on anxiety as a non-motor manifestation of Parkinson's disease

Anxiety is a severe problem for at least one-third of people living with Parkinson's disease (PD). Anxiety appears to have a greater adverse impact on quality of life than motor impairment. Despite its high prevalence and impact on daily life, anxiety is often undiagnosed and untreated. To better address anxiety in PD, future research must improve knowledge about the mechanism of anxiety in PD and address the lack of empirical evidence from clinical trials. In response to these challenges, the Parkinson's Foundation sponsored an expert meeting on anxiety on June 13th and 14th 2018. This paper summarizes the findings from that meeting informed by a review of the existing literature and discussions among patients, caregivers, and an international, clinician-scientist, expert panel working group. The goal is to provide recommendations to improve our understanding and treatment of anxiety in PD.

Treatment of psychiatric disturbances in hypokinetic movement disorders

Introduction: We reviewed studies that assessed the treatment of psychiatric disturbances in Parkinson's disease and atypical parkinsonisms. Neuropsychiatric disturbances in these conditions are frequent and have a profound impact on quality of life of patients and of their caregivers. It is therefore important to be familiar with the appropriate pharmacological and non-pharmacological interventions for treating these disorders. Areas covered: The authors searched for papers in English in Pubmed using the following keywords: Parkinson's disease, multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, Lewy body dementia, depression, apathy, anxiety, fatigue, sleep disorders, obsessive compulsive disorders, psychosis, hallucinations, delusions, impulse control disorders. Expert opinion: In Parkinson's disease, depression may benefit from the optimization of dopaminergic therapy, from the use of antidepressants acting on both the serotoninergic and noradrenergic pathways and from cognitive behavioral therapy. Psychosis in Parkinson's disease may improve with the use of clozapine; the serotonin inverse agonist pimavanserin has been shown to be effective. Treatment of impulse control disorders is primarily based on the removal of dopamine agonists. No controlled studies have investigated the treatment of neuropsychiatric disorders in multiple system atrophy, progressive supranuclear palsy or corticobasal degeneration. Acethylcholinesterase inhibitors may be used to treat hallucinations in Lewy body dementia.

Nonpharmacologic Interventions for the Self-Management of Anxiety in Parkinson's Disease: A Comprehensive Review

Anxiety in Parkinson's disease (aPD) is underdiagnosed, undertreated, and understudied. As many as 50% of persons diagnosed with Parkinson's disease (PD) are reported to suffer from anxiety. Current treatment is largely pharmacologic, which can result in a myriad of undesirable and unsafe side effects. The aim of this paper is to examine intervention studies of self-managed nonpharmacological strategies for the treatment of anxiety. A comprehensive review was conducted on experimental or quasi-experimental trials that included self-management approaches for the nonpharmacologic treatment of anxiety as a primary or secondary aim or outcome measure. Thirteen studies were identified from four databases. Study quality demonstrated variability in design and delivery of self-managed interventions; sample sizes were small; anxiety was most commonly a secondary aim; and the use of anxiety measures varied widely. Statistical significance was evident in slightly more than 50% of the anxiety intervention studies. A common element in the interventions in all studies was the focused use of breath. Further research is needed to determine the feasibility of using focused breathing, alone, as an intervention for the self-management of anxiety in Parkinson's disease.

Modified Mindfulness-Based Cognitive Therapy for Depressive Symptoms in Parkinson's Disease: a Pilot Trial

Background: Mindfulness-based cognitive therapy (MBCT) has evidence of efficacy in a range of populations, but few studies to date have reported on MBCT for treatment of anxious and depressive symptoms in Parkinson's disease (PD). Aims: The aim of this study was to examine the efficacy of modified MBCT in reducing symptoms of anxiety and depression and improving quality of life in PD. Method: Thirty-six individuals with PD were randomly assigned to either modified MBCT or a waitlist control. Changes in symptoms of anxiety, depression and quality of life were compared at group level using generalized linear mixed models and at individual level using reliable change analysis. Results: At post-treatment, there was a significant reduction in depressive symptoms for people undertaking modified MBCT at both group and individual levels compared with controls. There was no significant effect on anxiety or quality of life at the group level, although significantly more people had reliable improvement in anxiety after modified MBCT than after waitlist. Significantly more waitlist participants had reliable deterioration in symptoms of anxiety and depression than those completing modified MBCT. Most participants stayed engaged in modified MBCT, with only three drop-outs. Discussion: This proof-of-concept study demonstrates the potential efficacy of modified MBCT as a treatment for depressive symptoms in Parkinson's disease and suggests further research is warranted.

Mindfulness and physical disease: a concise review

Many of today's most common, chronic, and costly diseases-from high blood pressure, to chronic pain-are related to stress. Mindfulness, considered a state, a trait, and a training, might help treat or prevent stress-related physical symptoms. A concise review of current scientific evidence shows that both higher levels of trait mindfulness as well as mindfulness training are associated with better psychological well-being, coping, and quality of life. Effects on objective measures of disease, however, are often non-significant or await replication. Larger trials with active control groups, clear diagnostic criteria, objective outcome measures, and longer-term follow-up are needed to generate better quality evidence. Yet, many studies do support integrating mindfulness into health care as part of self-care and disease management.

Remote delivery of psychological interventions for Parkinson's disease

ABSTRACTObjective:Over two-thirds of Parkinson's disease (PD) patients experience comorbid neuropsychiatric symptoms, which adversely impact their quality of life and often require intervention. There is a preference for non-pharmacological, psychological approaches in addressing these symptoms. Given mobility limitations, travel burden, and cost, accessibility to psychological treatment can be problematic in this population. There has been a recent shift toward delivering care via telehealth in PD. Accordingly, this review aimed to examine remotely delivered psychological interventions for PD patients.Results:Most of the telehealth studies for PD involved Cognitive Behavioral Therapy (CBT) based anxiety and depression telephone interventions with relatively short (one month) follow-up periods.Conclusion:Although a preliminary work indicates efficacy, future studies should demonstrate the non-inferiority of these telehealth programs compared to face-to-face delivery, and examine the long-term outcomes of remotely delivered therapy. Video-conferencing (VC) appears to be a promising modality to overcome noted limitations of telephone delivery, and has demonstrated efficacy for PD speech programs. Further research should be conducted evaluating telehealth VC modalities for delivery of psychotherapy including CBT, as well as mindfulness-based therapy and acceptance and commitment therapy for remote treatment of depression and anxiety in PD.

Use and perceived effectiveness of complementary therapies in Parkinson's disease

INTRODUCTION

Complementary therapies are commonly used by people with Parkinson's disease to relieve symptoms not fully addressed by pharmacologic and rehabilitation therapies currently available through medical clinics and programs. Three prior surveys in the US have shown that 40-85% of patients have used complementary therapies. We were interested in understanding what complementary therapies (CTs) our patients had used, to treat what symptoms, and whether they felt that the treatments were effective.

METHODS

Patients scheduled for a return visit to a center neurologist were mailed a survey and instructed to bring the completed survey to their clinic visit. The survey contained questions on CTs used, effectiveness, and for what symptoms was the CT helpful. Willingness to participate in CT research was also included in the survey.

RESULTS

272 of 435 people with Parkinson's disease who completed the survey (62.5%) had tried some kind of CT, including a higher proportion of women than men (75.7% vs 53.8%; p < 0.01). Massage was the most frequently used therapy followed by yoga, Tai Chi, meditation and acupuncture. A high proportion of patients found the CT to be effective, for instance meditation was viewed as helpful by 85% of patients. Almost 2/3 of patients said they would be willing to participate in a research study of a CT.

CONCLUSIONS

Complementary therapies are frequently used by people with Parkinson's disease coming to our center, and are viewed to be helpful for both motor and non-motor symptoms. Formal research assessments of therapies such as meditation are warranted.

Implementation of a multidisciplinary psychoeducational intervention for Parkinson's disease patients and carers in the community: study protocol

Background

Parkinson’s disease progressively limits patients at different levels and as a result family members play a key role in their care. However, studies show lack of an integrative approach in Primary Care to respond to the difficulties and psychosocial changes experienced by them. The aim of this study is to evaluate the effects of a multidisciplinary psychoeducational intervention focusing on improving coping skills, the psychosocial adjustment to Parkinson’s disease and the quality of life in patients and family carers in a Primary Care setting.

Methods

This quasi-experimental study with control group and mixed methods was designed to evaluate a multidisciplinary psychoeducational intervention. Based on the study power calculations, 100 people with Parkinson’s disease and 100 family carers will be recruited and assigned to two groups. The intervention group will receive the ReNACE psychoeducational intervention. The control group will be given a general educational programme. The study will be carried out in six community-based health centres. The results obtained from the two groups will be collected for evaluation at three time points: at baseline, immediately after the intervention and at 6 months post-intervention. The results will be measured with these instruments: the Quality of Life Scale PDQ-39 for patients and the Scale of Quality of Life of Care-givers SQLC for family carers, and for all participants the Psychosocial Adjustment to Illness scale and the Brief COPE Inventory. Focus groups will be organised with some patients and family carers who will have received the ReNACE psychoeducational intervention and also with the healthcare professionals involved in its development.

Discussion

An important gap exists in the knowledge and application of interventions with a psychosocial approach for people with PD and family carers as a whole. This study will promote this comprehensive approach in Primary Care, which will clearly contribute in the existing knowledge and could reduce the burden of PD for patients and family carers, and also in other long-term conditions.

Trial registration

NCT03129425 (ClinicalTrials.gov). Retrospectively registered on April 26, 2017.

Falling upward with Parkinson's disease

Falls can injure, even kill. No one with Parkinson’s disease (PD) wants to fall by accident. However, the potential nastiness of falls does not preclude a more nuanced understanding of the personal meaning that falls can have. Rather than view falls as a problem to fear and manage solely by preventing and repairing harm, people with PD and those who care for them may recast falls as a mixed blessing. Falls may be a resource, skill, and catalyst for personal growth. We discuss how falls may give rise to opportunities in interrelated domains: capabilities, credo, character, creativity, chronemics, and connectedness. Clinicians could incorporate a positive focus across these domains to help people with PD to ‘fall upward’ in the sense of flourish.

Complementary and Alternative Medicine and Exercise in Nonmotor Symptoms of Parkinson's Disease

The use of complementary and alternative medicine (CAM) therapy in nonmotor symptoms (NMS) for Parkinson disease (PD) is growing worldwide. Well-performed, systematic evidence-based research is largely lacking in this area and many studies include various forms of CAM with small patient numbers and a lack of standardization of the approaches studied. Taichi, Qigong, dance, yoga, mindfulness, acupuncture, and other CAM therapies are reviewed and there is some evidence for the following: Taichi in sleep and PDQ39; dance in cognition, apathy, and a mild trend to improved fatigue; yoga in PDQ39; and acupuncture in depression, PDQ39, and sleep. Exercise including occupational therapy (OT) and physical therapy (PT) has been studied in motor symptoms of PD and balance but only with small studies with a mounting evidence base for use of exercise in NMS of PD including PDQ39, sleep, fatigue, depression, and some subsets of cognition. Studies of OT and PT largely show some benefit to depression, apathy, and anxiety. Sustainability of an improvement has not been shown given short duration of follow up. Finding optimal control groups and blind for these interventions is also an issue. This is a very important area of study since patients want to be self-empowered and they want guidance on which form of exercise is the best. Additionally, evidence for PT and OT in NMS would give added weight to get these interventions covered through medical insurance.

Mindfulness-based stress reduction in Parkinson's disease: a systematic review

BACKGROUND

Mindfulness based stress reduction (MBSR) is increasingly being used to improve outcomes such as stress and depression in a range of long-term conditions (LTCs). While systematic reviews on MBSR have taken place for a number of conditions there remains limited information on its impact on individuals with Parkinson's disease (PD).

METHODS

Medline, Central, Embase, Amed, CINAHAL were searched in March 2016. These databases were searched using a combination of MeSH subject headings where available and keywords in the title and abstracts. We also searched the reference lists of related reviews. Study quality was assessed based on questions from the Cochrane Collaboration risk of bias tool.

RESULTS

Two interventions and three papers with a total of 66 participants were included. The interventions were undertaken in Belgium (n = 27) and the USA (n = 39). One study reported significantly increased grey matter density (GMD) in the brains of the MBSR group compared to the usual care group. Significant improvements were reported in one study for a number of outcomes including PD outcomes, depression, mindfulness, and quality of life indicators. Only one intervention was of reasonable quality and both interventions failed to control for potential confounders in the analysis. Adverse events and reasons for drop-outs were not reported. There was also no reporting on the costs/benefits of the intervention or how they affected health service utilisation.

CONCLUSION

This systematic review found limited and inconclusive evidence of the effectiveness of MBSR for PD patients. Both of the included interventions claimed positive effects for PD patients but significant outcomes were often contradicted by other results. Further trials with larger sample sizes, control groups and longer follow-ups are needed before the evidence for MBSR in PD can be conclusively judged.