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Domingos J, Dean J, Fernandes JB, Família C, Fernandes S, Godinho C. Exploring barriers and educational needs in implementing dual-task training for Parkinson's disease: insights from professionals. Front Med (Lausanne) 2024; 11:1325978. [PMID: 38646555 PMCID: PMC11032016 DOI: 10.3389/fmed.2024.1325978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 03/25/2024] [Indexed: 04/23/2024] Open
Abstract
Introduction There is growing evidence suggesting that dual-task training benefits people with Parkinson's disease (PD) on both physical and cognitive outcomes. However, there is no known data regarding professionals' educational needs and barriers to its implementation. This study aimed to explore the barriers and educational needs of healthcare and exercise professionals to integrate dual-task training into their practice with people with PD. Methods We conducted a study based on a web survey. Social media channels were used to recruit a convenience sample of exercise and healthcare professionals working with people with PD. Results Of the 185 eligible responses, the majority were physiotherapists (68.1%) followed by occupational therapists (10.8%). Most participants attended Parkinson specific training (88.6%) and employed the treatments set up in individual one on-one sessions (58.9%). We identified several barriers to dual-task training implementation, with lack of time (to prepare materials), staying creative and/ or accessing new ideas, unreliable tools for measuring gains, and insufficient expertise as the most referred by participants. The educational needs most referred included accessing examples of interventions in general, knowing what strategies to apply and their application for people with different symptoms. Discussion Our results highlight that professionals remain challenged to integrate dualtask training into PD clinical care mainly due to knowledge gaps, difficulties in accessing new ideas, and lack of time.
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Affiliation(s)
- Josefa Domingos
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Nijmegen, Netherlands
- Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, Almada, Portugal
| | - John Dean
- Triad Health, Aurora, CO, United States
| | - Júlio Belo Fernandes
- Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, Almada, Portugal
- Nurs* Lab, Almada, Portugal
| | - Carlos Família
- Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, Almada, Portugal
- Molecular Pathology and Forensic Biochemistry Laboratory (MPFBL), Caparica, Portugal
| | - Sónia Fernandes
- Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, Almada, Portugal
- Nurs* Lab, Almada, Portugal
| | - Catarina Godinho
- Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, Almada, Portugal
- Nurs* Lab, Almada, Portugal
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Kwon KY, You J, Kim RO, Lee EJ, Lee J, Kim I, Kim J, Koh SB. Association Between Baseline Gait Parameters and Future Fall Risk in Patients With De Novo Parkinson's Disease: Forward Versus Backward Gait. J Clin Neurol 2024; 20:201-207. [PMID: 38171499 PMCID: PMC10921052 DOI: 10.3988/jcn.2022.0299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 04/03/2023] [Accepted: 06/12/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND AND PURPOSE Falls are not uncommon even in patients with early stages of Parkinson's disease (PD). The aims of this study were to determine the relationships between gait parameters and falls and identify crucial gait parameters for predicting future falls in patients with de novo PD. METHODS We prospectively recruited patients with de novo PD, and evaluated their baseline demographics, global cognitive function on the Montreal Cognitive Assessment test, and parkinsonian motor symptoms including their subtypes. Both forward gait (FG) and backward gait (BG) were measured using the GAITRite system. The history of falls in consecutive patients with de novo PD was examined along with 1 year of follow-up data. RESULTS Among the 76 patients with de novo PD finally included in the study, 16 (21.1%) were classified as fallers. Fallers had slower gait and shorter stride for FG and BG parameters than did non-fallers, while stride-time variability was greater in fallers but only for BG. Multivariable logistic regression analysis revealed that slow gait was an independent risk factor in BG. CONCLUSIONS Among the patients with de novo PD, gait speed and stride length were more impaired for both FG and BG in fallers than in non-fallers. It was particularly notable that slow BG was significantly associated with future fall risk, indicating that BG speed is a potential biomarker for predicting future falls in patients with early-stage PD.
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Affiliation(s)
- Kyum-Yil Kwon
- Department of Neurology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jihwan You
- Department of Neurology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Rae On Kim
- Department of Neurology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Eun Ji Lee
- Department of Neurology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jungyeun Lee
- Department of Neurology and Parkinson's Disease Centre, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Ilsoo Kim
- Department of Neurology and Parkinson's Disease Centre, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jinhee Kim
- Department of Neurology, Na-Eun Hospital, Incheon, Korea
| | - Seong-Beom Koh
- Department of Neurology and Parkinson's Disease Centre, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.
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Alissa N, Rehan R, Al-Sharman A, Latrous M, Aburub AS, El-Salem K, Morris L, Khalil H. Cognitive status and sleep quality can explain the fear of falling and fall history in people with Parkinson's disease. Int J Rehabil Res 2023; 46:338-343. [PMID: 37581294 DOI: 10.1097/mrr.0000000000000596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
Fear of falling (FOF) is highly prevalent in people with Parkinson's disease (PwPD) and contributes to high fall risk. Studies reporting on the relationship between falls, FOF, and non-motor factors such as cognitive function and sleep quality in Parkinson's disease are limited. This study aimed to investigate (1) the relationship of cognitive function and sleep quality with FOF, and history of falls in PwPD; (2) differences in cognitive function and sleep quality between Parkinson's disease fallers and non-fallers; and (3) a cut-off score for cognitive function and sleep quality to discriminate Parkinson's disease fallers from non-fallers. Fifty PwPD were assessed for FOF [Falls Efficacy Scale-International (FES-I)], cognition [Montréal Cognitive Assessment (MOCA)], sleep quality [Pittsburgh Sleep Quality Index (PSQI)], and falls history. The MOCA is significantly associated with FES-I scores ( R2 = 0.429, P < 0.0001). Both MOCA ( P = 0.012) and PSQI ( P = 0.027) were associated with falls history even after adjusting for confounding factors (age, sex, L-dopa use, Parkinson's disease severity). Both MOCA and PSQI scores were able to distinguish fallers from non-fallers with cut-off scores of 15.5 and 7.5, respectively. Although our findings revealed that both cognitive function and sleep quality are important factors influencing falls and FOF in PwPD, it remains to be determined if addressing cognitive impairments and poor sleep quality may favorably impact balance before integrating such screenings into fall prevention programs.
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Affiliation(s)
- Nesreen Alissa
- Department of Physical Therapy and Rehabilitation Science, School of Medicine, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - Reem Rehan
- Department of Rehabilitation Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Alham Al-Sharman
- Department of Rehabilitation Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
- Department of Physical Therapy, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Mariem Latrous
- Department of Physical Therapy and Rehabilitation Science, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Ala' S Aburub
- Department of Rehabilitation Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
- Department of Physiotherapy, Israa University, Amman
| | - Khalid El-Salem
- Department of Neurosciences, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Linzette Morris
- Department of Physical Therapy and Rehabilitation Science, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Hanan Khalil
- Department of Physical Therapy and Rehabilitation Science, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
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van den Bergh R, Evers LJW, de Vries NM, Silva de Lima AL, Bloem BR, Valenti G, Meinders MJ. Usability and utility of a remote monitoring system to support physiotherapy for people with Parkinson's disease. Front Neurol 2023; 14:1251395. [PMID: 37900610 PMCID: PMC10601712 DOI: 10.3389/fneur.2023.1251395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/07/2023] [Indexed: 10/31/2023] Open
Abstract
Background Physiotherapy for persons with Parkinson's disease (PwPD) could benefit from objective and continuous tracking of physical activity and falls in daily life. Objectives We designed a remote monitoring system for this purpose and describe the experiences of PwPD and physiotherapists who used the system in daily clinical practice. Methods Twenty-one PwPD (15 men) wore a sensor necklace to passively record physical activity and falls for 6 weeks. They also used a smartphone app to self-report daily activities, (near-)falls and medication intake. They discussed those data with their PD-specialized physiotherapist (n = 9) during three regular treatment sessions. User experiences and aspects to be improved were gathered through interviews with PwPD and physiotherapists, resulting in system updates. The system was evaluated in a second pilot with 25 new PwPD (17 men) and eight physiotherapists. Results We applied thematic analysis to the interview data resulting in two main themes: usability and utility. First, the usability of the system was rated positively, with the necklace being easy to use. However, some PwPD with limited digital literacy or cognitive impairments found the app unclear. Second, the perceived utility of the system varied among PwPD. While many PwPD were motivated to increase their activity level, others were not additionally motivated because they perceived their activity level as high. Physiotherapists appreciated the objective recording of physical activity at home and used the monitoring of falls to enlarge awareness of the importance of falls for PwPD. Based on the interview data of all participants, we drafted three user profiles for PwPD regarding the benefits of remote monitoring for physiotherapy: for profile 1, a monitoring system could act as a flagging dashboard to signal the need for renewed treatment; for profile 2, a monitoring system could be a motivational tool to maintain physical activity; for profile 3, a monitoring system could passively track physical activity and falls at home. Finally, for a subgroup of PwPD the burdens of monitoring will outweigh the benefits. Conclusions Overall, both PwPD and physiotherapists underline the potential of a remote monitoring system to support physiotherapy by targeting physical activity and (near-)falls. Our findings emphasize the importance of personalization in remote monitoring technology, as illustrated by our user profiles.
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Affiliation(s)
- Robin van den Bergh
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Nijmegen, Netherlands
| | - Luc J. W. Evers
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Nijmegen, Netherlands
- Radboud University, Institute for Computing and Information Sciences, Department of Data Science, Nijmegen, Netherlands
| | - Nienke M. de Vries
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Nijmegen, Netherlands
| | - Ana L. Silva de Lima
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Nijmegen, Netherlands
| | - Bastiaan R. Bloem
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Nijmegen, Netherlands
| | - Giulio Valenti
- Philips Research, Department of Connected Care and Remote Patient Management, Eindhoven, Netherlands
| | - Marjan J. Meinders
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Nijmegen, Netherlands
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Nijmegen, Netherlands
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Camicioli R, Morris ME, Pieruccini‐Faria F, Montero‐Odasso M, Son S, Buzaglo D, Hausdorff JM, Nieuwboer A. Prevention of Falls in Parkinson's Disease: Guidelines and Gaps. Mov Disord Clin Pract 2023; 10:1459-1469. [PMID: 37868930 PMCID: PMC10585979 DOI: 10.1002/mdc3.13860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/28/2023] [Accepted: 07/08/2023] [Indexed: 10/24/2023] Open
Abstract
Background People living with Parkinson's disease (PD) have a high risk for falls. Objective To examine gaps in falls prevention targeting people with PD as part of the Task Force on Global Guidelines for Falls in Older Adults. Methods A Delphi consensus process was used to identify specific recommendations for falls in PD. The current narrative review was conducted as educational background with a view to identifying gaps in fall prevention. Results A recent Cochrane review recommended exercises and structured physical activities for PD; however, the types of exercises and activities to recommend and PD subgroups likely to benefit require further consideration. Freezing of gait, reduced gait speed, and a prior history of falls are risk factors for falls in PD and should be incorporated in assessments to identify fall risk and target interventions. Multimodal and multi-domain fall prevention interventions may be beneficial. With advanced or complex PD, balance and strength training should be administered under supervision. Medications, particularly cholinesterase inhibitors, show promise for falls prevention. Identifying how to engage people with PD, their families, and health professionals in falls education and implementation remains a challenge. Barriers to the prevention of falls occur at individual, environmental, policy, and health system levels. Conclusion Effective mitigation of fall risk requires specific targeting and strategies to reduce this debilitating and common problem in PD. While exercise is recommended, the types and modalities of exercise and how to combine them as interventions for different PD subgroups (cognitive impairment, freezing, advanced disease) need further study.
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Affiliation(s)
- Richard Camicioli
- Department of Medicine (Neurology) and Neuroscience and Mental Health InstituteUniversity of AlbertaEdmontonAlbertaCanada
| | - Meg E. Morris
- La Trobe University, Academic and Research Collaborative in Health & HealthscopeMelbourneVictoriaAustralia
| | - Frederico Pieruccini‐Faria
- Gait and Brain Lab, Parkwood InstituteLawson Health Research InstituteLondonOntarioCanada
- Division of Geriatric Medicine, Department of Medicine, Schulich School of Medicine & DentistryWestern UniversityLondonOntarioCanada
| | - Manuel Montero‐Odasso
- Gait and Brain Lab, Parkwood InstituteLawson Health Research InstituteLondonOntarioCanada
- Division of Geriatric Medicine, Department of Medicine, Schulich School of Medicine & DentistryWestern UniversityLondonOntarioCanada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & DentistryWestern UniversityLondonOntarioCanada
| | - Surim Son
- Gait and Brain Lab, Parkwood InstituteLawson Health Research InstituteLondonOntarioCanada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & DentistryWestern UniversityLondonOntarioCanada
| | - David Buzaglo
- Center for the Study of Movement, Cognition and Mobility, Neurological InstituteTel Aviv Sourasky Medical CenterTel AvivIsrael
| | - Jeffrey M. Hausdorff
- Center for the Study of Movement, Cognition and Mobility, Neurological InstituteTel Aviv Sourasky Medical CenterTel AvivIsrael
- Department of Physical Therapy, Faculty of Medicine, Sagol School of NeuroscienceTel Aviv UniversityTel AvivIsrael
- Rush Alzheimer's Disease Center and Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Alice Nieuwboer
- Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy)KU LeuvenLeuvenBelgium
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Geritz J, Welzel J, Hansen C, Maetzler C, Hobert MA, Elshehabi M, Knacke H, Aleknonytė-Resch M, Kudelka J, Bunzeck N, Maetzler W. Cognitive parameters can predict change of walking performance in advanced Parkinson's disease - Chances and limits of early rehabilitation. Front Aging Neurosci 2022; 14:1070093. [PMID: 36620765 PMCID: PMC9813446 DOI: 10.3389/fnagi.2022.1070093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Links between cognition and walking performance in patients with Parkinson's disease (PD), which both decline with disease progression, are well known. There is lack of knowledge regarding the predictive value of cognition for changes in walking performance after individualized therapy. The aim of this study is to identify relevant predictive cognitive and affective parameters, measurable in daily clinical routines, for change in quantitative walking performance after early geriatric rehabilitation. Methods Forty-seven acutely hospitalized patients with advanced PD were assessed at baseline (T1) and at the end (T2) of a 2-week early rehabilitative geriatric complex treatment (ERGCT). Global cognitive performance (Montreal Cognitive Assessment, MoCA), EF and divided attention (Trail Making Test B minus A, delta TMT), depressive symptoms, and fear of falling were assessed at T1. Change in walking performance was determined by the difference in quantitative walking parameters extracted from a sensor-based movement analysis over 20 m straight walking in single (ST, fast and normal pace) and dual task (DT, with secondary cognitive, respectively, motor task) conditions between T1 and T2. Bayesian regression (using Bayes Factor BF10) and multiple linear regression models were used to determine the association of non-motor characteristics for change in walking performance. Results Under ST, there was moderate evidence (BF10 = 7.8, respectively, BF10 = 4.4) that lower performance in the ∆TMT at baseline is associated with lower reduction of step time asymmetry after treatment (R 2 adj = 0.26, p ≤ 0.008, respectively, R 2 adj = 0.18, p ≤ 0.009). Under DT walking-cognitive, there was strong evidence (BF10 = 29.9, respectively, BF10 = 27.9) that lower performance in the ∆TMT is associated with more reduced stride time and double limb support (R 2 adj = 0.62, p ≤ 0.002, respectively, R 2 adj = 0.51, p ≤ 0.009). There was moderate evidence (BF10 = 5.1) that a higher MoCA total score was associated with increased gait speed after treatment (R 2 adj = 0.30, p ≤ 0.02). Discussion Our results indicate that the effect of ERGT on change in walking performance is limited for patients with deficits in EF and divided attention. However, these patients also seem to walk more cautiously after treatment in walking situations with additional cognitive demand. Therefore, future development of individualized treatment algorithms is required, which address individual needs of these vulnerable patients.
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Affiliation(s)
- Johanna Geritz
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany,Department of Psychology, University of Lübeck, Lübeck, Germany,*Correspondence: Johanna Geritz,
| | - Julius Welzel
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Clint Hansen
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Corina Maetzler
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Markus A. Hobert
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Morad Elshehabi
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Henrike Knacke
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | | | - Jennifer Kudelka
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Nico Bunzeck
- Department of Psychology, University of Lübeck, Lübeck, Germany,Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Lübeck, Germany
| | - Walter Maetzler
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
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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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Professionals' Self-Reported Difficulties towards Integrating Dual Task Training in Care for People with Parkinson's Disease. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031281. [PMID: 35162306 PMCID: PMC8835225 DOI: 10.3390/ijerph19031281] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 02/01/2023]
Abstract
Background: Despite the growing use of dual task training (DTT) in clinical practice with people with Parkinson Disease (PD), there is still limited evidence on how to best implement it. Data regarding professionals’ difficulties when integrating such practices are critical as a first step to generate further guidance on how to apply it. The aim of this study was to identify the difficulties perceived by professionals to integrate dual task in their practice. Methods: A descriptive, observational and cross-sectional study was conducted using a web-based survey. Convenience sampling was used to recruit exercise and healthcare professionals working with people with PD through various social media channels. Data were collected and then analyzed thematically using the method of constant comparisons. The study report follows the consolidated criteria for reporting qualitative research (COREQ) checklist. Results: Of the 205 eligible responses, 68.8% were Physiotherapist. The majority of the participants reported having Parkinson-specific training (91.7%) and 59.0% applied DTT in individual one-on-one sessions. We identified ten categories of difficulties faced by professionals. Conclusions: Professionals struggle to integrate DTT into PD clinical care. Challenges were identified and the most significant refer to difficulties in managing the chronicity of the disease and lack of patient compliance with home exercises. Understanding current challenges towards dual task exercise will help to reflect upon strategies to be applied effectively and safe.
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Gamified Dual-Task Training for Individuals with Parkinson Disease: An Exploratory Study on Feasibility, Safety, and Efficacy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312384. [PMID: 34886114 PMCID: PMC8657071 DOI: 10.3390/ijerph182312384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 12/02/2022]
Abstract
Objectives: The feasibility and safety of the use of neurorehabilitation technology (SMARTfit® Trainer system) by physical therapists in implementing a gamified physical-cognitive dual-task training (DTT) paradigm for individuals with Parkinson disease (IWPD) was examined. Additionally, the efficacy of this gamified DTT was compared to physical single-task training (STT), both of which were optimized using physio-motivational factors, on changes in motor and cognitive outcomes, and self-assessed disability in activities of daily living. Methods: Using a cross-over study design, eight participants with mild-to-moderate idiopathic PD (including one with mild cognitive impairment) completed both training conditions (i.e., gamified DTT and STT). For each training condition, the participants attended 2–3 sessions per week over 8.8 weeks on average, with the total amount of training being equivalent to 24 1 h sessions. A washout period averaging 11.5 weeks was inserted between training conditions. STT consisted of task-oriented training involving the practice of functional tasks, whereas for gamified DTT, the same task-oriented training was implemented simultaneously with varied cognitive games using an interactive training system (SMARTfit®). Both training conditions were optimized through continual adaptation to ensure the use of challenging tasks and to provide autonomy support. Training hours, heart rate, and adverse events were measured to assess the feasibility and safety of the gamified DTT protocol. Motor and cognitive function as well as perceived disability were assessed before and after each training condition. Results: Gamified DTT was feasible and safe for this cohort. Across participants, significant improvements were achieved in more outcome measures after gamified DTT than they were after STT. Individually, participants with specific demographic and clinical characteristics responded differently to the two training conditions. Conclusion: Physical therapists’ utilization of technology with versatile hardware configurations and customizable software application selections was feasible and safe for implementing a tailor-made intervention and for adapting it in real-time to meet the individualized, evolving training needs of IWPD. Specifically in comparison to optimized STT, there was a preliminary signal of efficacy for gamified DTT in improving motor and cognitive function as well as perceived disability in IWPD.
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10
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Huang Y, Canning CG, Song J, Clemson L, Allen NE. How does perceived fall risk influence decisions about whether to undertake activities in people with Parkinson's disease and their care partners? A qualitative study. Disabil Rehabil 2021; 44:6000-6008. [PMID: 34314280 DOI: 10.1080/09638288.2021.1955983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To explore how perceptions of fall risk influence decisions to undertake activities in people with Parkinson's disease who have fallen, along with their care-partners. MATERIALS AND METHODS This qualitative study used semi-structured interviews to collect data from eight people with moderate to severe Parkinson's Disease and freezing of gait (including those with cognitive impairments) and their care-partners. An inductive approach to thematic analysis was used to analyse the data. RESULTS Four main, interconnected themes emerged, and a framework was developed to illustrate these connections. Weighing up the risks and benefits reflected the constant tension between assessing the likelihood of falling and potential benefit of any activity; Being fearful heightened the perceived risk resulting in a tendency to avoid or modify activities; Desire to lead a normal life heightened the perceived benefit of any activity, leading towards risk taking behaviour; It's a part of Parkinson's provided the context in which the decision-making process took place, with the reality of a progressive disorder influencing choices and contributing to a belief that falls were inevitable. CONCLUSIONS There is a complex interaction between perceptions of fall risk and behaviour. An understanding of these interactions will assist therapists to tailor individualised fall prevention interventions.IMPLICATIONS FOR REHABILITATIONPeople are constantly weighing up the risks and benefits of activities while balancing fear of falling and a desire to lead a normal life in the context of Parkinson's disease.The resulting activity choices vary along a continuum from avoiding activities to taking risks, with a common approach to minimise the risk and then embrace the activity.Therapists can help people with Parkinson's and their care-partners to determine what level of risk is acceptable for them when balancing risk with quality of life.Understanding how people decide if they will undertake an activity that poses a risk of falling will allow therapists and patients to co-design fall prevention and management interventions based on the patient's values and priorities.
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Affiliation(s)
- Yingli Huang
- Discipline of Physiotherapy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Colleen G Canning
- Discipline of Physiotherapy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jooeun Song
- Discipline of Physiotherapy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Lindy Clemson
- Discipline of Occupational Therapy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Natalie E Allen
- Discipline of Physiotherapy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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11
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Mishra RK, Park C, Zhou H, Najafi B, Thrasher TA. Evaluation of Motor and Cognitive Performance in People with Parkinson's Disease Using Instrumented Trail-Making Test. Gerontology 2021; 68:234-240. [PMID: 33940574 DOI: 10.1159/000515940] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 03/16/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Parkinson's disease (PD) progressively impairs motor and cognitive performance. The current tools to detect decline in motor and cognitive functioning are often impractical for busy clinics and home settings. To address the gap, we designed an instrumented trail-making task (iTMT) based on a wearable sensor (worn on the shin) with interactive game-based software installed on a tablet. The iTMT test includes reaching to 5 indexed circles, a combination of numbers (1-3) and letters (A&B) randomly positioned inside target circles, in a sequential order, which virtually appears on a screen kept in front of the participants, by rotating one's ankle joint while standing and holding a chair for safety. By measuring time to complete iTMT task (iTMT time), iTMT enables quantifying cognitive-motor performance. PURPOSE This study's objective is to examine the feasibility of iTMT to detect early cognitive-motor decline in PDs. METHOD Three groups of volunteers, including 14 cognitively normal (CN) older adults, 14 PDs, and 11 mild cognitive impaireds (MCI), were recruited. Participants completed MoCA, 20 m walking test, and 3 trials of iTMT. RESULTS All participants enabled to complete iTMT with <3 min, indicating high feasibility. The average iTMT time for CN-Older, PD, and MCI participants were 20.9 ± 0.9 s, 32.3 ± 2.4 s, and 40.9 ± 4.5 s, respectively. After adjusting for age and education level, pairwise comparison suggested large effect sizes for iTMT between CN-older versus PD (Cohen's d = 1.7, p = 0.024) and CN-older versus MCI (d = 1.57, p < 0.01). Significant correlations were observed when comparing iTMT time with the gait speed (r = -0.4, p = 0.011) and MoCA score (r = -0.56, p < 0.01). CONCLUSION This study demonstrated the feasibility and early results supporting the potential application of iTMT to determine cognitive-motor and distinguishing individuals with MCI and PD from CN-older adults. Future studies are warranted to test the ability of iTMT to track its subtle changes over time.
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Affiliation(s)
- Ram Kinker Mishra
- Michael E. DeBakey Department of Surgery, Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Baylor College of Medicine, Houston, Texas, USA, .,Department of Health and Human Performance, Center for Neuromotor and Biomechanics Research, University of Houston, Houston, Texas, USA,
| | - Catherine Park
- Michael E. DeBakey Department of Surgery, Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Baylor College of Medicine, Houston, Texas, USA
| | - He Zhou
- Michael E. DeBakey Department of Surgery, Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Baylor College of Medicine, Houston, Texas, USA
| | - Bijan Najafi
- Michael E. DeBakey Department of Surgery, Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Baylor College of Medicine, Houston, Texas, USA
| | - T Adam Thrasher
- Department of Health and Human Performance, Center for Neuromotor and Biomechanics Research, University of Houston, Houston, Texas, USA
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12
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van den Heuvel L, Dorsey RR, Prainsack B, Post B, Stiggelbout AM, Meinders MJ, Bloem BR. Quadruple Decision Making for Parkinson's Disease Patients: Combining Expert Opinion, Patient Preferences, Scientific Evidence, and Big Data Approaches to Reach Precision Medicine. JOURNAL OF PARKINSONS DISEASE 2021; 10:223-231. [PMID: 31561387 PMCID: PMC7029360 DOI: 10.3233/jpd-191712] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Clinical decision making for Parkinson’s disease patients is supported by a combination of three distinct information resources: best available scientific evidence, professional expertise, and the personal needs and preferences of patients. All three sources have clear value but also share several important limitations, mainly regarding subjectivity, generalizability and variability. For example, current scientific evidence, especially from controlled clinical trials, is often based on selected study populations, making it difficult to translate the outcome to the care for individual patients in everyday clinical practice. Big data, including data from real-life unselected Parkinson populations, can help to bridge this information gap. Fine-grained patient profiles created from big data have the potential to aid in identifying therapeutic approaches that will be most effective given each patient’s individual characteristics, which is particularly important for a disorder characterized by such tremendous interindividual variability as Parkinson’s disease. In this viewpoint, we argue that big data approaches should be acknowledged and harnessed, not to replace existing information resources, but rather as a fourth and complimentary source of information in clinical decision making, helping to represent the full complexity of individual patients. We introduce the ‘quadruple decision making’ model and illustrate its mode of action by showing how this can be used to pursue precision medicine for persons living with Parkinson’s disease.
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Affiliation(s)
- Lieneke van den Heuvel
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Ray R Dorsey
- Department of Neurology, University of Rochester Medical Centre, Rochester, NY, USA
| | - Barbara Prainsack
- Department of Political Science, University of Vienna, AT; and Department of Global Health & Social Medicine, King's College London, London, UK
| | - Bart Post
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Anne M Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marjan J Meinders
- Radboud University Medical Centre, Radboud Institute for Health Sciences; Scientific Centre for Quality of Healthcare, Nijmegen, The Netherlands
| | - Bastiaan R Bloem
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
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13
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Capato TTC, de Vries NM, IntHout J, Barbosa ER, Nonnekes J, Bloem BR. Multimodal Balance Training Supported by Rhythmical Auditory Stimuli in Parkinson's Disease: A Randomized Clinical Trial. JOURNAL OF PARKINSONS DISEASE 2021; 10:333-346. [PMID: 31884492 PMCID: PMC7029328 DOI: 10.3233/jpd-191752] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background: Balance impairment in Parkinson’s disease (PD) improves only partially with dopaminergic medication. Therefore, non-pharmacological interventions such as physiotherapy are important elements in clinical management. External cues are often applied to improve gait, but their effects on balance control are unclear. Objective/Methods: We performed a prospective, single-blind, randomized clinical trial to study the effectiveness of balance training with and without rhythmical auditory cues. We screened 201 volunteers by telephone; 154 were assigned randomly into three groups: (1) multimodal balance training supported by rhythmical auditory stimuli (n = 56) (RAS-supported multimodal balance training); (2) regular multimodal balance training without rhythmical auditory stimuli (n = 50); and (3) control intervention involving a general education program (n = 48). Training was performed for 5 weeks, two times/week. Linear mixed models were used for all outcomes. Primary outcome was the Mini-BESTest (MBEST) score immediately after the training period. Assessments were performed by a single, blinded assessor at baseline, immediately post intervention, and after one and 6-months follow-up. Results: Immediately post intervention, RAS-supported multimodal balance training was more effective than regular multimodal balance training on MBEST (difference 3.5 (95% Confidence Interval (CI) 2.2; 4.8)), p < 0.001). Patients allocated to both active interventions improved compared to controls (MBEST estimated mean difference versus controls 6.6 (CI 5.2; 8.0), p < 0.001 for RAS-supported multimodal balance training; and 3.0 (CI 2.7; 5.3), p < 0.001 for regular multimodal balance training). Improvements were retained at one-month follow-up for both active interventions, but only the RAS-supported multimodal balance training group maintained its improvement at 6 months. Conclusion: Both RAS-supported multimodal balance training and regular multimodal balance training improve balance, but RAS-supported multimodal balance training–adding rhythmical auditory cues to regular multimodal balance training–has greater and more sustained effects.
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Affiliation(s)
- Tamine T C Capato
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands.,Department of Neurology, University of São Paulo, Movement Disorder Center, São Paulo, Brazil
| | - Nienke M de Vries
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands
| | - Joanna IntHout
- Department for Health Evidence, Radboud University Medial Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Egberto R Barbosa
- Department of Neurology, University of São Paulo, Movement Disorder Center, São Paulo, Brazil
| | - Jorik Nonnekes
- Department of Rehabilitation, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Bastiaan R Bloem
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands
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14
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Pasman EP, McKeown MJ, Garg S, Cleworth TW, Bloem BR, Inglis JT, Carpenter MG. Brain connectivity during simulated balance in older adults with and without Parkinson's disease. Neuroimage Clin 2021; 30:102676. [PMID: 34215147 PMCID: PMC8102637 DOI: 10.1016/j.nicl.2021.102676] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 04/02/2021] [Accepted: 04/10/2021] [Indexed: 11/07/2022]
Abstract
Individuals with Parkinson's disease often experience postural instability, a debilitating and largely treatment-resistant symptom. A better understanding of the neural substrates contributing to postural instability could lead to more effective treatments. Constraints of current functional neuroimaging techniques, such as the horizontal orientation of most MRI scanners (forcing participants to lie supine), complicates investigating cortical and subcortical activation patterns and connectivity networks involved in healthy and parkinsonian balance control. In this cross-sectional study, we utilized a newly-validated MRI-compatible balance simulator (based on an inverted pendulum) that enabled participants to perform balance-relevant tasks while supine in the scanner. We utilized functional MRI to explore effective connectivity underlying static and dynamic balance control in healthy older adults (n = 17) and individuals with Parkinson's disease while on medication (n = 17). Participants performed four tasks within the scanner with eyes closed: resting, proprioceptive tracking of passive ankle movement, static balancing of the simulator, and dynamic responses to random perturbations of the simulator. All analyses were done in the participant's native space without spatial transformation to a common template. Effective connectivity between 57 regions of interest was computed using a Bayesian Network learning approach with false discovery rate set to 5%. The first 12 principal components of the connection weights, binomial logistic regression, and cross-validation were used to create 4 separate models: contrasting static balancing vs {rest, proprioception} and dynamic balancing vs {rest, proprioception} for both controls and individuals with Parkinson's disease. In order to directly compare relevant connections between controls and individuals with Parkinson's disease, we used connections relevant for predicting a task in either controls or individuals with Parkinson's disease in logistic regression with Least Absolute Shrinkage and Selection Operator regularization. During dynamic balancing, we observed decreased connectivity between different motor areas and increased connectivity from the brainstem to several cortical and subcortical areas in controls, while individuals with Parkinson's disease showed increased connectivity associated with motor and parietal areas, and decreased connectivity from brainstem to other subcortical areas. No significant models were found for static balancing in either group. Our results support the notion that dynamic balance control in individuals with Parkinson's disease relies more on cortical motor areas compared to healthy older adults, who show a preference of subcortical control during dynamic balancing.
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Affiliation(s)
- Elizabeth P Pasman
- School of Kinesiology, University of British Columbia, Vancouver, BC, Canada
| | | | - Saurabh Garg
- Pacific Parkinson's Research Centre, Vancouver, BC, Canada
| | - Taylor W Cleworth
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Bastiaan R Bloem
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands
| | - J Timothy Inglis
- School of Kinesiology, University of British Columbia, Vancouver, BC, Canada; Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada; International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
| | - Mark G Carpenter
- School of Kinesiology, University of British Columbia, Vancouver, BC, Canada; Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada; International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada.
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15
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Shepherd V. How nurses can support the inclusion in research of older people who lack capacity to consent. Nurs Older People 2021; 33:26-31. [PMID: 33084258 DOI: 10.7748/nop.2020.e1267] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2020] [Indexed: 11/09/2022]
Abstract
Research is important because it underpins evidence-based care. However, people who lack capacity to consent are often excluded from research, due partly to ethical concerns and practical challenges, and partly to a lack of awareness among professionals of the legal framework that supports their inclusion. The COVID-19 pandemic, which has extensively affected care home residents, has reinforced the importance of including older people with cognitive impairment in research. Nurses who care for older people with impaired cognition have an important role in ensuring these people have the opportunity to contribute to and benefit from research. This article discusses some of the challenges associated with the inclusion in research of older people who lack capacity to consent, including the involvement of relatives and friends in decision-making. The article describes the findings of recent research and shares resources with the aim of supporting nurses to ensure that older people in their care who lack capacity can participate in research.
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16
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Kiesmann M, Sauleau E, Perisse J, Jehl C, Konrad S, Karcher P, Fleury MC, Rohmer D, Sauer A, Ehret M, Vogel T, Kaltenbach G, Schmitt E. Parkinsonian gait in elderly people: Significance of the threshold value of two and more falls per year. Rev Neurol (Paris) 2020; 177:385-393. [PMID: 33032799 DOI: 10.1016/j.neurol.2020.06.012] [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] [Received: 03/24/2020] [Revised: 05/11/2020] [Accepted: 06/12/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Parkinsonism in the elderly presents a major risk factor for recurrent falls (2 and more falls per year), which is associated with increased morbidity. The main objective was to investigate explanatory variables relating to the risk of being recurrent fallers (RF) in persons with parkinsonian gait. METHODS Seventy-nine among 172 eligible persons were enrolled in this prospective study, the findings of which were analyzed at 12 months. Motor and non-motor features, as well as follow-up interviews to identify falls, loss of ability to walk, fluctuating cognition, traumatic falls, all-cause hospitalizations and deaths were collated and results compared between non RF (zero and one fall per year) and RF. Bayesian model averaging was used to predict the probability of patients being RF from their medical history as well as from cognitive assessment, gait velocity, vision and posture. RESULTS N=79, 0.58 men, 50% had Parkinson's disease, 14% other neurodegenerative parkinsonian syndrome, 23% vascular parkinsonism and 13% Lewy body disease, 58% were RF. Median age 81.2 years and median MMSE 25/30. A history of falls and of hallucinations, median odds ratio respectively 9.06 (CI 2.34-38.22), 4.21 (CI 1.04-18.67) were associated with the highest odds ratios along with fluctuating cognition and abnormal posture. Two or more falls a year was a relevant threshold to distinguish a population with a high risk of comorbidity. CONCLUSION The whole history of falls, hallucinations and fluctuating cognition can be considered predictive of recurrent falls in elderly people with parkinsonian gait and provide a tracking tool for patient management.
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Affiliation(s)
- M Kiesmann
- Geriatric Department, University Hospitals of Strasbourg, Strasbourg, France
| | - E Sauleau
- Biostatistical Laboratory, iCube - CNRS UMR 7357, Department of Public Health, methods in clinical research, University of Strasbourg, Strasbourg, France
| | - J Perisse
- Geriatric Department, University Hospitals of Strasbourg, Strasbourg, France
| | - C Jehl
- Geriatric Department, University Hospitals of Strasbourg, Strasbourg, France
| | - S Konrad
- Geriatric Department, University Hospitals of Strasbourg, Strasbourg, France
| | - P Karcher
- Geriatric Department, University Hospitals of Strasbourg, Strasbourg, France
| | - M C Fleury
- Neurology Department, University Hospitals of Strasbourg, Strasbourg, France
| | - D Rohmer
- Otorhinolaryngology Department, University Hospitals of Strasbourg, Strasbourg, France
| | - A Sauer
- Ophthalmology Department, University Hospitals of Strasbourg and University of Strasbourg, Strasbourg, France
| | - M Ehret
- Otorhinolaryngology Department, University Hospitals of Strasbourg, Strasbourg, France
| | - T Vogel
- Geriatric Department, University Hospitals of Strasbourg, Strasbourg, France; EA-3072, University of Strasbourg, Strasbourg, France
| | - G Kaltenbach
- Geriatric Department, University Hospitals of Strasbourg, Strasbourg, France
| | - E Schmitt
- Geriatric Department, University Hospitals of Strasbourg, Strasbourg, France; EA-3072, University of Strasbourg, Strasbourg, France.
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17
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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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18
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Longitudinal prediction of falls and near falls frequencies in Parkinson's disease: a prospective cohort study. J Neurol 2020; 268:997-1005. [PMID: 32970193 PMCID: PMC7914172 DOI: 10.1007/s00415-020-10234-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 11/05/2022]
Abstract
Introduction and objective Several prediction models for falls/near falls in Parkinson’s disease (PD) have been proposed. However, longitudinal predictors of frequency of falls/near falls are poorly investigated. Therefore, we aimed to identify short- and long-term predictors of the number of falls/near falls in PD. Methods A prospective cohort of 58 persons with PD was assessed at baseline (mean age and PD duration, 65 and 3.2 years, respectively) and 3.5 years later. Potential predictors were history of falls and near falls, comfortable gait speed, freezing of gate, dyskinesia, retropulsion, tandem gait (TG), pain, and cognition (Mini-Mental State Exam, MMSE). After each assessment, the participants registered a number of falls/near falls during the following 6 months. Multivariate Poisson regression was used to identify short- and long-term predictors of a number of falls/near falls. Results Baseline median (q1–q3) motor (UPDRS) and MMSE scores were 10 (6.75–14) and 28.5 (27–29), respectively. History of falls was the only significant short-time predictor [incidence rate ratio (IRR), 15.17] for the number of falls/near falls during 6 months following baseline. Abnormal TG (IRR, 3.77) and lower MMSE scores (IRR, 1.17) were short-term predictors 3.5 years later. Abnormal TG (IRR, 7.79) and lower MMSE scores (IRR, 1.49) at baseline were long-term predictors of the number of falls/near falls 3.5 years later. Conclusion Abnormal TG and MMSE scores predict the number of falls/near falls in short and long term, and may be indicative of disease progression. Our observations provide important additions to the evidence base for clinical fall prediction in PD.
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Cheng KL, Lin LH, Chen PC, Chiang PL, Chen YS, Chen HL, Chen MH, Chou KH, Li SH, Lu CH, Lin WC. Reduced Gray Matter Volume and Risk of Falls in Parkinson's Disease with Dementia Patients: A Voxel-Based Morphometry Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17155374. [PMID: 32722623 PMCID: PMC7432132 DOI: 10.3390/ijerph17155374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 01/10/2023]
Abstract
Purpose: Risk of falls is a common sequela affecting patients with Parkinson’s disease (PD). Although motor impairment and dementia are correlated with falls, associations of brain structure and cognition deficits with falls remain unclear. Material and Methods: Thirty-five PD patients with dementia (PDD), and 37 age- and sex-matched healthy subjects were recruited for this study. All participants received structural magnetic resonance imaging (MRI) scans, and disease severity and cognitive evaluations. Additionally, patient fall history was recorded. Regional structural differences between PDD with and without fall groups were performed using voxel-based morphometry processing. Stepwise logistic regression analysis was used to predict the fall risk in PDD patients. Results: The results revealed that 48% of PDD patients experienced falls. Significantly lower gray matter volume (GMV) in the left calcarine and right inferior frontal gyrus in PDD patients with fall compared to PDD patients without fall were noted. The PDD patients with fall exhibited worse UPDRS-II scores compared to PDD patients without fall and were negatively correlated with lower GMV in the left calcarine (p/r = 0.004/−0.492). Furthermore, lower GMV in the left calcarine and right inferior frontal gyrus correlated with poor attention and executive functional test scores. Multiple logistic regression analysis showed that the left calcarine was the only variable (p = 0.004, 95% CI = 0.00–0.00) negatively associated with the fall event. Conclusions: PDD patients exhibiting impaired motor function, lower GMV in the left calcarine and right inferior frontal gyrus, and notable cognitive deficits may have increased risk of falls.
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Affiliation(s)
- Kai-Lun Cheng
- Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
- School of Medical Imaging and Radiological Sciences, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Veterinary Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Li-Han Lin
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (L.-H.L.); (P.-L.C.); (Y.-S.C.); (H.-L.C.); (M.-H.C.)
| | - Po-Cheng Chen
- Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan;
| | - Pi-Ling Chiang
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (L.-H.L.); (P.-L.C.); (Y.-S.C.); (H.-L.C.); (M.-H.C.)
| | - Yueh-Sheng Chen
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (L.-H.L.); (P.-L.C.); (Y.-S.C.); (H.-L.C.); (M.-H.C.)
| | - Hsiu-Ling Chen
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (L.-H.L.); (P.-L.C.); (Y.-S.C.); (H.-L.C.); (M.-H.C.)
| | - Meng-Hsiang Chen
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (L.-H.L.); (P.-L.C.); (Y.-S.C.); (H.-L.C.); (M.-H.C.)
| | - Kun-Hsien Chou
- Brain Research Center, National Yang-Ming University, Taipei 112, Taiwan;
- Institute of Neuroscience, National Yang-Ming University, Taipei 112, Taiwan
| | - Shau-Hsuan Li
- Department of Oncology and Hematology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan;
| | - Cheng-Hsien Lu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan;
| | - Wei-Che Lin
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (L.-H.L.); (P.-L.C.); (Y.-S.C.); (H.-L.C.); (M.-H.C.)
- Correspondence: ; Tel.: +886-7-731-7123
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20
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Domingos J, Radder D, Riggare S, Godinho C, Dean J, Graziano M, de Vries NM, Ferreira J, Bloem BR. Implementation of a Community-Based Exercise Program for Parkinson Patients: Using Boxing as an Example. JOURNAL OF PARKINSONS DISEASE 2020; 9:615-623. [PMID: 31282426 PMCID: PMC6839476 DOI: 10.3233/jpd-191616] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Persons with Parkinson's disease (PD) benefit from continuous exercise through participation in community-based exercise programs. However, community programs often lack PD-specific knowledge needed to provide safe and adequately dosed exercise. OBJECTIVE To evaluate the acceptability and safety of a PD-specific boxing program in the community. METHODS We developed specific educational resources to facilitate the boxing instructors. We also organized an educational and practical workshop for patients (n = 26) and instructors (n = 10), and assessed: (a) participants' satisfaction; (b) instructors' appreciation of the educational resources; and (c) numbers of patients interested in participating in the boxing program. After 18 months, patients and instructors completed a questionnaire evaluating: (a) participants' satisfaction; (b) adverse events; (c) facilitators and barriers; and (d) proportion of participants at follow-up. RESULTS Twenty-six persons with PD (62% men) and 10 boxing instructors participated in the workshop. 81% of patients and 80% of instructors were very satisfied. Instructors found the educational materials "very helpful" (60%) or "helpful" (40%). Patients expressed a clear interest (54%) or possible interest (46%) in the program. We initiated classes with 10 participants. At 18-months follow-up, the program consisted of four boxing sessions/week, led by three instructors, with 40 participants. Seventeen patients responded to the questionnaire at follow-up. Participants were "very satisfied" (53%), "satisfied" (35%) and neither satisfied nor unsatisfied (12%) with the program. Adverse effects were mild (e.g., muscle aches). Transportation and physical disability were the main barriers for participation. CONCLUSIONS The boxing program was well-received, with increasing numbers of participants at 18 months. The educational resources can support boxing instructors participating in current and future boxing classes being delivered in the community.
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Affiliation(s)
- Josefa Domingos
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands.,Department of Sport and Health, Laboratory of Motor Behavior, Faculty of Human Kinetics, University of Lisbon, Portugal
| | - Danique Radder
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Sara Riggare
- Department for Learning, Health Informatics Centre, Informatics, Management, and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Catarina Godinho
- Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz, Monte de Caparica, Portugal
| | | | | | - Nienke M de Vries
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Joaquim Ferreira
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Portugal.,CNS - Campus Neurológico Sénior, Torres Vedras, Portugal
| | - Bastiaan R Bloem
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
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21
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Silva de Lima AL, Borm C, Vries NMD, Bloem BR. Falling among people with Parkinson's disease: motor, non-motor, or both? ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 77:759-760. [PMID: 31826130 DOI: 10.1590/0004-282x20190164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/21/2019] [Indexed: 11/22/2022]
Affiliation(s)
- Ana Lígia Silva de Lima
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Center of Expertise for Parkinson & Movement Disorders; Department of Neurology, Nijmegen, The Netherlands
| | - Carlijn Borm
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Center of Expertise for Parkinson & Movement Disorders; Department of Neurology, Nijmegen, The Netherlands
| | - Nienke M de Vries
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Center of Expertise for Parkinson & Movement Disorders; Department of Neurology, Nijmegen, The Netherlands
| | - Bastiaan R Bloem
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Center of Expertise for Parkinson & Movement Disorders; Department of Neurology, Nijmegen, The Netherlands
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22
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Poli A, Kelfve S, Motel-Klingebiel A. A research tool for measuring non-participation of older people in research on digital health. BMC Public Health 2019; 19:1487. [PMID: 31703655 PMCID: PMC6842243 DOI: 10.1186/s12889-019-7830-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 10/22/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Healthcare services are being increasingly digitalised in European countries. However, in studies evaluating digital health technology, some people are less likely to participate than others, e.g. those who are older, those with a lower level of education and those with poorer digital skills. Such non-participation in research - deriving from the processes of non-recruitment of targeted individuals and self-selection - can be a driver of old-age exclusion from new digital health technologies. We aim to introduce, discuss and test an instrument to measure non-participation in digital health studies, in particular, the process of self-selection. METHODS Based on a review of the relevant literature, we designed an instrument - the NPART survey questionnaire - for the analysis of self-selection, covering five thematic areas: socioeconomic factors, self-rated health and subjective overall quality of life, social participation, time resources, and digital skills and use of technology. The instrument was piloted on 70 older study persons in Sweden, approached during the recruitment process for a trial study. RESULTS Results indicated that participants, as compared to decliners, were on average slightly younger and more educated, and reported better memory, higher social participation, and higher familiarity with and greater use of digital technologies. Overall, the survey questionnaire was able to discriminate between participants and decliners on the key aspects investigated, along the lines of the relevant literature. CONCLUSIONS The NPART survey questionnaire can be applied to characterise non-participation in digital health research, in particular, the process of self-selection. It helps to identify underrepresented groups and their needs. Data generated from such an investigation, combined with hospital registry data on non-recruitment, allows for the implementation of improved sampling strategies, e.g. focused recruitment of underrepresented groups, and for the post hoc adjustment of results generated from biased samples, e.g. weighting procedures.
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Affiliation(s)
- Arianna Poli
- Division Ageing and Social Change (ASC), Linköping University, Kungsgatan 40, 601 74 Norrköping, Sweden
| | - Susanne Kelfve
- Division Ageing and Social Change (ASC), Linköping University, Kungsgatan 40, 601 74 Norrköping, Sweden
- Aging Research Center (ARC), Karolinska Institutet & Stockholm University, Gävlegatan 16, 113 30 Stockholm, Sweden
| | - Andreas Motel-Klingebiel
- Division Ageing and Social Change (ASC), Linköping University, Kungsgatan 40, 601 74 Norrköping, Sweden
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23
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Bloem BR, Ypinga JHL, Willis A, Canning CG, Barker RA, Munneke M, De Vries NM. Using Medical Claims Analyses to Understand Interventions for Parkinson Patients. JOURNAL OF PARKINSONS DISEASE 2019; 8:45-58. [PMID: 29254108 PMCID: PMC5836412 DOI: 10.3233/jpd-171277] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The scientific evidence to support the value of a range of non-pharmacological interventions for people with Parkinson’s disease (PD) is increasing. However, showing unequivocally that specific interventions are better than usual care is not straightforward because of generic drawbacks of clinical trials. Here, we address these challenges, specifically related to the context of evaluating complex non-pharmacological interventions for people with PD. Moreover, we discuss the potential merits of undertaking “real world” analyses using medical claims data. We illustrate this approach by discussing an interesting recent publication in The Lancet Neurology, which used such an approach to demonstrate the value of specialized physiotherapy for PD patients, over and above usual care physiotherapy.
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Affiliation(s)
- Bastiaan R Bloem
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
| | - Jan H L Ypinga
- Department Care Purchasing, CZ Groep, Goes, The Netherlands
| | - Allison Willis
- Departments of Neurology and of Biostatistics, Epidemiology and Informatics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Colleen G Canning
- Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, Australia
| | - Roger A Barker
- Department of Clinical Neurosciences, John van Geest Centre for Brain Repair, University of Cambridge, UK
| | - Marten Munneke
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
| | - Nienke M De Vries
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
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24
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Abstract
Parkinson's disease (PD) and other synucleinopathies, namely dementia with Lewy bodies (DLB) and multiple system atrophy (MSA), are common degenerative neurological disorders that share synuclein pathology. Although certain cardinal features of parkinsonism, including bradykinesia and rigidity, respond well to levodopa, axial features, such as gait and balance impairment, are less reliably responsive to dopaminergic therapy and surgical interventions. Consequently, falls are common in PD and other synucleinopathies and are a major contributor toward injury and loss of independence. This underscores the need for appropriate fall risk assessment and implementation of preventative measures in all patients with parkinsonism. The aim of this review is therefore to explore modifiable and non-modifiable risk factors for falls in synucleinopathies. We next review and evaluate the evidence for pharmacological, nonpharmacological, and surgical approaches for fall prevention, and emphasize individualized and multifaceted approaches.
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25
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Silva de Lima AL, Smits T, Darweesh SKL, Valenti G, Milosevic M, Pijl M, Baldus H, de Vries NM, Meinders MJ, Bloem BR. Home-based monitoring of falls using wearable sensors in Parkinson's disease. Mov Disord 2019; 35:109-115. [PMID: 31449705 PMCID: PMC7003816 DOI: 10.1002/mds.27830] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/02/2019] [Accepted: 07/15/2019] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Falling is among the most serious clinical problems in Parkinson's disease (PD). We used body-worn sensors (falls detector worn as a necklace) to quantify the hazard ratio of falls in PD patients in real life. METHODS We matched all 2063 elderly individuals with self-reported PD to 2063 elderly individuals without PD based on age, gender, comorbidity, and living conditions. We analyzed fall events collected at home via a wearable sensor. Fall events were collected either automatically using the wearable falls detector or were registered by a button push on the same device. We extracted fall events from a 2.5-year window, with an average follow-up of 1.1 years. All falls included were confirmed immediately by a subsequent telephone call. The outcomes evaluated were (1) incidence rate of any fall, (2) incidence rate of a new fall after enrollment (ie, hazard ratio), and (3) 1-year cumulative incidence of falling. RESULTS The incidence rate of any fall was higher among self-reported PD patients than controls (2.1 vs. 0.7 falls/person, respectively; P < .0001). The incidence rate of a new fall after enrollment (ie, hazard ratio) was 1.8 times higher for self-reported PD patients than controls (95% confidence interval, 1.6-2.0). CONCLUSION Having PD nearly doubles the incidence of falling in real life. These findings highlight PD as a prime "falling disease." The results also point to the feasibility of using body-worn sensors to monitor falls in daily life. © 2019 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Ana Lígia Silva de Lima
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
| | - Tine Smits
- Philips Research, Department Personal Health, Eindhoven, the Netherlands
| | - Sirwan K L Darweesh
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands.,Department of Epidemiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Giulio Valenti
- Philips Research, Department Personal Health, Eindhoven, the Netherlands
| | - Mladen Milosevic
- Philips Research North America, Acute Care Solutions Department, Cambridge, Massachusetts, USA
| | - Marten Pijl
- Philips Research, Department Personal Health, Eindhoven, the Netherlands
| | - Heribert Baldus
- Philips Research, Department Personal Health, Eindhoven, the Netherlands
| | - Nienke M de Vries
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
| | - Marjan J Meinders
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands.,Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Nijmegen, the Netherlands
| | - Bastiaan R Bloem
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
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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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27
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Avanzino L, Lagravinese G, Abbruzzese G, Pelosin E. Relationships between gait and emotion in Parkinson's disease: A narrative review. Gait Posture 2018; 65:57-64. [PMID: 30558947 DOI: 10.1016/j.gaitpost.2018.06.171] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 06/26/2018] [Accepted: 06/28/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Disturbance of gait is a key feature of Parkinson's disease (PD) and has a negative impact on quality of life. Deficits in cognition and sensorimotor processing impair the ability of people with PD to walk quickly, efficiently and safely. Recent evidence suggests that emotional disturbances may also affect gait in PD. RESEARCH QUESTION We explored if there were relationships between walking ability, emotion and cognitive impairment in people with PD. METHODS The literature was firstly reviewed for unimpaired individuals. The recent experimental evidence for the influence of emotion on gait in people with PD was then explored. The contribution of affective disorders to continuous gait disorders was investigated, particularly for bradykinetic and hypokinetic gait. In addition, we investigated the influence of emotional processing on episodic gait disturbances, such as freezing of gait. Potential effects of pharmacological, surgical and physical therapy interventions were also considered. RESULTS Emerging evidence showed that emotional disturbances arising from affective disorders such as anxiety and depression, in addition to cognitive impairment, could contribute to gait disorders in some people with PD. An analysis of the literature indicated mixed evidence that improvements in affective disorders induced by physical therapy, pharmacological management or surgery improve locomotion in PD. SIGNIFICANCE When assessing and treating gait disorders in people with PD, it is important to take into the account non-motor symptoms such as anxiety, depression and cognitive impairment, in addition to the motor sequalae of this progressive neurological condition.
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Affiliation(s)
- Laura Avanzino
- Department of Experimental Medicine, Section of Human Physiology and Centro Polifunzionale di Scienze Motorie, University of Genoa, Genoa, Italy; Ospedale Policlinico San Martino, IRCCS, Genoa, Italy
| | - Giovanna Lagravinese
- Department of Experimental Medicine, Section of Human Physiology and Centro Polifunzionale di Scienze Motorie, University of Genoa, Genoa, Italy
| | - Giovanni Abbruzzese
- Ospedale Policlinico San Martino, IRCCS, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Unit, University of Genoa, Italy
| | - Elisa Pelosin
- Ospedale Policlinico San Martino, IRCCS, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Unit, University of Genoa, Italy.
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Chomiak T, Watts A, Burt J, Camicioli R, Tan SN, McKeown MJ, Hu B. Differentiating cognitive or motor dimensions associated with the perception of fall-related self-efficacy in Parkinson's disease. NPJ Parkinsons Dis 2018; 4:26. [PMID: 30155514 PMCID: PMC6102294 DOI: 10.1038/s41531-018-0059-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 05/28/2018] [Accepted: 06/07/2018] [Indexed: 12/18/2022] Open
Abstract
In Parkinson's disease (PD), concurrent declines in cognitive and motor domain function can severely limit an individual's ability to conduct daily tasks. Current diagnostic methods, however, lack precision in differentiating domain-specific contributions of cognitive or motor impairments based on a patients' clinical manifestation. Fear of falling (FOF) is a common clinical manifestation among the elderly, in which both cognitive and motor impairments can lead to significant barriers to a patients' physical and social activities. The present study evaluated whether a set of analytical and machine-learning approaches could be used to help delineate boundary conditions and separate cognitive and motor contributions to a patient's own perception of self-efficacy and FOF. Cognitive and motor clinical scores, in conjunction with FOF, were collected from 57 Parkinson's patients during a multi-center rehabilitation intervention trial. Statistical methodology was used to extract a subset of uncorrelated cognitive and motor components associated with cognitive and motor predictors, which were then used to independently identify and visualize cognitive and motor dimensions associated with FOF. We found that a central cognitive process, extracted from tests of executive, attentional, and visuoperceptive function, was a unique and significant independent cognitive predictor of FOF in PD. In addition, we provide evidence that the approaches described here may be used to computationally discern specific types of FOF based on separable cognitive or motor models. Our results are consistent with a contemporary model that the deterioration of a central cognitive mechanism that modulates self-efficacy also plays a critical role in FOF in PD.
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Affiliation(s)
- Taylor Chomiak
- Division of Translational Neuroscience, Department of Clinical Neurosciences, Hotchkiss Brain Institute, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1 Canada
| | - Alexander Watts
- Division of Translational Neuroscience, Department of Clinical Neurosciences, Hotchkiss Brain Institute, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1 Canada
| | - Jacqueline Burt
- Department of Medicine, Division of Neurology, Clinical Sciences Building, University of Alberta, Edmonton, AB T6G 2R7 Canada
| | - Richard Camicioli
- Department of Medicine, Division of Neurology, Clinical Sciences Building, University of Alberta, Edmonton, AB T6G 2R7 Canada
| | - Sun Nee Tan
- Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 1Z3 Canada
| | - Martin J. McKeown
- Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 1Z3 Canada
| | - Bin Hu
- Division of Translational Neuroscience, Department of Clinical Neurosciences, Hotchkiss Brain Institute, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1 Canada
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Abstract
Parkinson disease (PD) is a complex, multisystem disorder with both neurologic and systemic nonmotor manifestations. It is neurodegenerative in nature in which disordered balance, gait, and falls are universal problems that can be present at initial diagnosis, and which progress over time. Freezing of gait is a particularly debilitating feature of PD that becomes more prevalent over time with disease progression, being present in approximately 7% after 2 years of disease and 28% after 5 years. Approximately 60% of people with PD fall each year, with around 70% of fallers falling recurrently, and some recurrent fallers falling multiple times per week. Many risk factors for falls in people with PD have been identified; these include a history of falls, freezing of gait, and abnormalities in measures of balance, leg muscle strength, mobility, cognition, and fear of falling. Therapies for improving physical function and mobility include levodopa, cholinesterase inhibitors, methylphenidate, deep-brain stimulation, cuing for freezing of gait, and exercise. This chapter reviews the clinical, pathologic, and physiologic correlates of gait disturbance and falls in PD, as well as the evidence for medical and nonmedical interventions.
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Affiliation(s)
- Samuel D Kim
- Movement Disorders Unit, Department of Neurology, Westmead Hospital and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Natalie E Allen
- Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Colleen G Canning
- Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Victor S C Fung
- Movement Disorders Unit, Department of Neurology, Westmead Hospital and Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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Gaßner H, Marxreiter F, Steib S, Kohl Z, Schlachetzki JCM, Adler W, Eskofier BM, Pfeifer K, Winkler J, Klucken J. Gait and Cognition in Parkinson's Disease: Cognitive Impairment Is Inadequately Reflected by Gait Performance during Dual Task. Front Neurol 2017; 8:550. [PMID: 29123499 PMCID: PMC5662548 DOI: 10.3389/fneur.2017.00550] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/28/2017] [Indexed: 01/20/2023] Open
Abstract
Introduction Cognitive and gait deficits are common symptoms in Parkinson’s disease (PD). Motor-cognitive dual tasks (DTs) are used to explore the interplay between gait and cognition. However, it is unclear if DT gait performance is indicative for cognitive impairment. Therefore, the aim of this study was to investigate if cognitive deficits are reflected by DT costs of spatiotemporal gait parameters. Methods Cognitive function, single task (ST) and DT gait performance were investigated in 67 PD patients. Cognition was assessed by the Montreal Cognitive Assessment (MoCA) followed by a standardized, sensor-based gait test and the identical gait test while subtracting serial 3’s. Cognitive impairment was defined by a MoCA score <26. DT costs in gait parameters [(DT − ST)/ST × 100] were calculated as a measure of DT effect on gait. Correlation analysis was used to evaluate the association between MoCA performance and gait parameters. In a linear regression model, DT gait costs and clinical confounders (age, gender, disease duration, motor impairment, medication, and depression) were correlated to cognitive performance. In a subgroup analysis, we compared matched groups of cognitively impaired and unimpaired PD patients regarding differences in ST, DT, and DT gait costs. Results Correlation analysis revealed weak correlations between MoCA score and DT costs of gait parameters (r/rSp ≤ 0.3). DT costs of stride length, swing time variability, and maximum toe clearance (|r/rSp| > 0.2) were included in a regression analysis. The parameters only explain 8% of the cognitive variance. In combination with clinical confounders, regression analysis showed that these gait parameters explained 30% of MoCA performance. Group comparison revealed strong DT effects within both groups (large effect sizes), but significant between-group effects in DT gait costs were not observed. Conclusion These findings suggest that DT gait performance is not indicative for cognitive impairment in PD. DT effects on gait parameters were substantial in cognitively impaired and unimpaired patients, thereby potentially overlaying the effect of cognitive impairment on DT gait costs. Limits of the MoCA in detecting motor-function specific cognitive performance or variable individual response to the DT as influencing factors cannot be excluded. Therefore, DT gait parameters as marker for cognitive performance should be carefully interpreted in the clinical context.
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Affiliation(s)
- Heiko Gaßner
- Department of Molecular Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Franz Marxreiter
- Department of Molecular Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Simon Steib
- Institute for Sport Science and Sport, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Zacharias Kohl
- Department of Molecular Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Johannes C M Schlachetzki
- Department of Molecular Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Werner Adler
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Bjoern M Eskofier
- Chair for Machine Learning and Data Analytics, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Klaus Pfeifer
- Institute for Sport Science and Sport, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Jürgen Winkler
- Department of Molecular Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Jochen Klucken
- Department of Molecular Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Burk JA. Reducing falls in a model of impaired cognitive control of movement (Commentary on Kucinski et al.). Eur J Neurosci 2016; 45:215-216. [PMID: 27868266 DOI: 10.1111/ejn.13466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Joshua A Burk
- Department of Psychology, College of William & Mary, Williamsburg, VA, 23187, USA
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