RESUMO
BACKGROUND: Physical activity and exercise play a key role in managing Parkinson disease. This study aimed to: 1) determine if physiotherapy supported by telehealth helped people with Parkinson disease (PwP) to adhere to a home-based exercise program and maintain their physical activity; and 2) understand their experiences of using telehealth during the COVID-19 pandemic. METHODS: A mixed methods program evaluation involving a retrospective file audit from a student-run physiotherapy clinic and semi-structured interviews exploring participants' experiences of telehealth. Ninety-six people with mild to moderate disease received home-based telehealth physiotherapy for 21 weeks. The primary outcome was adherence to the prescribed exercise program. Secondary outcomes were measures of physical activity. Interviews were conducted with 13 clients and seven students and analysed thematically. RESULTS: Adherence to the prescribed exercise program was high. The mean (SD) proportion of prescribed sessions completed was 108% (46%). On average clients spent 29 (12) minutes per session, and 101 (55) minutes per week exercising. Physical activity levels were maintained, with clients taking 11,226 (4,832) steps per day on entry to telehealth, and 11,305 (4,390) steps per day on exit from telehealth. The semi-structured interviews identified important features of a telehealth service required to support exercise; a flexible approach of clients and therapists, empowerment, feedback, a therapeutic relationship, and mode of delivery. CONCLUSIONS: PwP were able to continue exercising at home and maintain their physical activity when physiotherapy was provided via telehealth. The flexible approach of both the client and the service was imperative.
Assuntos
COVID-19 , Doença de Parkinson , Telemedicina , Humanos , Pandemias , Doença de Parkinson/terapia , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , COVID-19/epidemiologia , Exercício FísicoRESUMO
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.
Assuntos
Fraturas Ósseas , Doença de Parkinson , Inibidores da Colinesterase , Exercício Físico , Humanos , Doença de Parkinson/complicações , Qualidade de VidaRESUMO
BACKGROUND: Cervical dystonia (CD) is an isolated, focal, idiopathic dystonia affecting the neck and upper back. CD is usually treated by botulinum neurotoxin (BoNT) injections into the dystonic muscles; however, about 20% of people will discontinue BoNT therapy. This systematic review aimed to determine the barriers to satisfaction and facilitators that could improve satisfaction with BoNT therapy for people with CD. METHODS: A database search for journal articles investigating satisfaction with BoNT treatment in CD identified seven qualitative studies and one randomised controlled trial. Results were grouped into "direct" and "indirect" barriers and facilitators. RESULTS: The most reported direct barrier to satisfaction with BoNT was treatment non-response, reported by up to 66% of participants. Other direct barriers included negative side effects, early wearing-off of treatment effect and inexperience of the treating physician. Indirect barriers included limited accessibility to treatment (including cost) and personal choice. Direct facilitators of satisfaction with BoNT included relief of symptoms and flexible re-treatment intervals. Indirect facilitators included easy accessibility to treatment. CONCLUSIONS: Despite BoNT having a discontinuation rate of only 20%, it appears a much greater proportion of people with CD are dissatisfied with this treatment. As BoNT is currently the main treatment offered to people with CD, efforts to improve treatment response rates, reduce side effects and make treatment more flexible and readily available should be adopted to improve the quality of life for people with CD.
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Toxinas Botulínicas Tipo A , Toxinas Botulínicas , Distúrbios Distônicos , Fármacos Neuromusculares , Torcicolo , Toxinas Botulínicas/uso terapêutico , Toxinas Botulínicas Tipo A/uso terapêutico , Distúrbios Distônicos/tratamento farmacológico , Humanos , Fármacos Neuromusculares/uso terapêutico , Satisfação Pessoal , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Torcicolo/tratamento farmacológicoRESUMO
OBJECTIVES: To explore the experiences of people with Parkinson's disease exercising and to determine if the location (home versus centre) or exercising in a group impacted on their experience. DESIGN: A qualitative study. PARTICIPANTS: Community-dwelling people with mild to moderate Parkinson's disease who had undertaken a 10-week exercise intervention. METHOD: Semi-structured interviews were conducted with 17 participants; nine participants had completed 10-weeks of predominately home-based exercise and eight participants had predominately centre-based excercise. Interviews were recorded, transcribed verbatim and analysed using inductive thematic analysis. RESULTS: Four key themes emerged. Two themes: 'targeted exercise is important when you have Parkinson's disease' and 'support helps me to gain the most from the exercise', were related to exercising with Parkinson's disease and were not specific to location. Two themes encompassed the perceptions when exercising at a centre in a group compared to exercising at home: 'the good and the bad of exercising in a group' and 'exercising at home, can I do it?' CONCLUSION: Experiences of people with Parkinson's disease when exercising were primarily influenced by the prescription of specific exercise and the support provided. There was no clear preference for the location of exercise but maintaining the motivation to exercise at home was challenging.
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Doença de Parkinson , Exercício Físico , Terapia por Exercício , Humanos , Motivação , Pesquisa QualitativaRESUMO
OBJECTIVE: To determine whether impairments across cognitive and affective domains provide additional information to sensorimotor deficits for fall prediction among various populations. DESIGN: We pooled data from 5 studies for this observational analysis of prospective falls. SETTING: Community or low-level care facility. PARTICIPANTS: Older people (N=1090; 74.0±9.4y; 579 female); 500 neurologically intact (NI) older people and 3 groups with neurologic disorders (cognitive impairment, n=174; multiple sclerosis (MS), n=111; Parkinson disease, n=305). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Sensorimotor function was assessed with the Physiological Profile Assessment, cognitive function with tests of executive function, affect with questionnaires of depression, and concern about falling with falls efficacy questionnaires. These variables were associated with fall incidence rates, obtained prospectively over 6-12 months. RESULTS: Poorer sensorimotor function was associated with falls (incidence rate ratio [95% CI], 1.46 [1.28-1.66]). Impaired executive function was the strongest predictor of falls overall (2.91 [2.27-3.73]), followed by depressive symptoms (2.07 [1.56-2.75]) and concern about falling (2.02 [1.61-2.55]). Associations were similar among groups, except for a weaker relationship with executive impairment in NI persons and a stronger relationship with concern about falling in persons with MS. Multivariable analyses showed that executive impairment, poorer sensorimotor performance, depressive symptoms, and concern about falling were independently associated with falls. CONCLUSIONS: Deficits in cognition (executive function) and affect (depressive symptoms) and concern about falling are as important as sensorimotor function for fall prediction. These domains should be included in fall risk assessments for older people and clinical groups.
Assuntos
Acidentes por Quedas/estatística & dados numéricos , Disfunção Cognitiva/fisiopatologia , Transtornos do Humor/fisiopatologia , Esclerose Múltipla/fisiopatologia , Doença de Parkinson/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Inquéritos e QuestionáriosRESUMO
OBJECTIVES: To investigate the feasibility and acceptability of a home-based exercise program monitored using telehealth for people with Parkinson's disease. DESIGN: Pilot randomised control trial. SETTING: University physiotherapy clinic, participants' homes. PARTICIPANTS: Forty people with mild to moderate Parkinson's disease, mean age 72 (6.9). INTERVENTION: In Block 1 (5 weeks) all participants completed predominantly centre-based exercise plus a self-management program. Participants were then randomised to continue the centre-based exercise (n = 20) or to a home-based program with telehealth (n = 20) for Block 2 (5 weeks). The exercises targeted balance and gait. OUTCOMES: The primary outcomes were the feasibility and acceptability of the intervention. Secondary outcomes were balance, gait speed and freezing of gait. RESULTS: Adherence was high in Block 1 (93%), and Block 2 (centre-based group = 93%, home-based group = 84%). In Block 2, the physiotherapist spent 6.4 hours providing telehealth to the home-based group (mean 10 (4) minutes per participant) and 32.5 hours delivering the centre-based exercise classes (98 minutes per participant). Participants reported that exercise was helpful, they could follow the home program and they would recommend exercising at home or in a group. However, exercising at home was less satisfying and there was a mixed response to the acceptability of the self-management program. There was no difference between groups in any of the secondary outcome measures (preferred walking speed mean difference -0.04 (95% CI: -0.12 to 0.05). CONCLUSION: Home-based exercise monitored using telehealth for people with Parkinson's disease is feasible and acceptable.
Assuntos
Terapia por Exercício , Serviços de Assistência Domiciliar , Doença de Parkinson/reabilitação , Autogestão , Telemedicina , Idoso , Estudos de Viabilidade , Feminino , Marcha , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Doença de Parkinson/complicações , Doença de Parkinson/fisiopatologia , Projetos PilotoRESUMO
BACKGROUND: Previous investigations of falls predictors in people with Parkinson's disease (PD) have used various statistical methods and categorization of falls outcomes. The impact of methodological differences on falls predictors has not been investigated. OBJECTIVES: To describe similarities and differences in predictors modelled for fall rates [negative binomial (NB), Poisson Inverse Gaussian (PIG) and quantile regression] and previously-reported predictors of time to second fall (Cox regression), i.e. past falls, motor fluctuations, disability, levodopa dose and balance impairment. To investigate whether predictors from quantile regression vary across subsets of fallers based on fall frequency. METHODS: Participants with PD (n = 229) were followed-up for 12 months. NB and PIG regression were used to determine predictors of fall rates, with the best fitting model reported. Quantile regression was used to determine predictors at higher (62nd, 70th, 80th) percentiles of the falls distribution. Univariate and multivariate analyses were performed. RESULTS: Predictors of fall rates were the same in NB and PIG multivariate models, with the PIG model fitting our data better. Past falls, disability and levodopa dose were associated with fall rates from PIG and quantile regression. Freezing of gait was associated with fall rates from PIG regression. Disease severity predicted less (70th percentile, approximately 2-4) and more (80th percentile, approximately ≥ 5) frequent falls, and anteroposterior stability also predicted less frequent falls (p < 0.05), from quantile regression. CONCLUSIONS: Not all predictors of time to second fall were predictors of fall rates. Quantile regression revealed some divergent predictors depending on the percentile of fall frequency examined.
Assuntos
Acidentes por Quedas , Doença de Parkinson , Idoso , Idoso de 80 Anos ou mais , Feminino , Marcha , Transtornos Neurológicos da Marcha/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Doença de Parkinson/complicações , Equilíbrio Postural , Índice de Gravidade de DoençaRESUMO
There is evidence from observational studies for a role of a number of environmental exposures and lifestyle habits in modulating the risk for Parkinson's disease. Environmental and lifestyle associations, if causal, represent opportunities for Parkinson's disease prevention or disease modification at individual and population levels. In the past decade, additional evidence has been published that improves causal inference and/or enhances our understanding of the complexity of these associations. A number of gene-environment interactions have been elucidated, and our understanding of the roles of physical activity, pesticide and other chemical exposures, dietary habits, emotional stress, head injury, and smoking has been refined. In the next decade, better techniques will help us to close the gaps in our knowledge, including taking into account Parkinson's disease heterogeneity and gene and risk factor interactions in observational studies. To do this, larger datasets, global consortia, genomewide environment interaction studies, prospective studies throughout the lifespan, and improvements in the methodology of clinical trials of physical activity will be key. Despite the caveats of observational studies, a number of low-risk and potentially high-yield recommendations for lifestyle modification could be made to minimize the individual and societal burdens of Parkinson's disease, including dietary modifications, increasing physical activity, and head injury avoidance. Furthermore, a reduction in pesticide use could have a major impact on global health related to and beyond Parkinson's disease. Given the increasing prevalence of this disorder, formulating and promoting these recommendations should be a high priority. © 2019 International Parkinson and Movement Disorder Society.
Assuntos
Meio Ambiente , Interação Gene-Ambiente , Estilo de Vida , Doença de Parkinson/etiologia , Exposição Ambiental , Humanos , Doença de Parkinson/genéticaRESUMO
BACKGROUND: There is compelling evidence that physical activity has many physical and mental health benefits and can delay the development of disability in older age. However, uptake of this health behaviour is sub-optimal in working women in their middle age. This trial aims to establish the impact of a low-dose information program, incorporating follow-up support using behaviour change techniques, compared with a wait-list control group, on physical activity among women aged 50+ years. METHODS: 100 female university or health service employees aged 50 years and over who are not sufficiently active according to national guidelines will be recruited and randomised to: [1] attend one information session at the worksite with follow-up email support and provision of resources including use of an activity tracker (Fitbit) for 3 months and free trial class at the university sports facility, or [2] a wait-list control to receive the intervention after the 3-month follow-up period. The primary outcome will be the proportion of people achieving 10,000 steps/day at 3 months post randomisation. Secondary outcomes will include the proportion of people achieving national guideline-recommended physical activity levels, the average self-reported hours of physical activity per week, perceived benefits of and barriers to exercise participation, physical functioning, and mood. Analyses will be planned, conducted while masked to group allocation and will use an intention-to-treat approach. DISCUSSION: This randomised controlled trial will evaluate the impact of a simple intervention using behaviour change techniques to increase physical activity participation in insufficiently active working women over the age of 50. TRIAL REGISTRATION: ACTRN12617000485336 , prospectively registered, approved 04/04/2017.
Assuntos
Exercício Físico/psicologia , Promoção da Saúde/métodos , Saúde Ocupacional , Austrália , Feminino , Seguimentos , Humanos , Disseminação de Informação , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Projetos de Pesquisa , Apoio Social , UniversidadesRESUMO
OBJECTIVES: To determine whether 12-week home-based exergame step training can improve stepping performance, gait and complementary physical and neuropsychological measures associated with falls in Parkinson's disease. DESIGN: A single-blinded randomised controlled trial. SETTING: Community (experimental intervention), university laboratory (outcome measures). SUBJECTS: Sixty community-dwelling people with Parkinson's disease. INTERVENTIONS: Home-based step training using videogame technology. MAIN MEASURES: The primary outcomes were the choice stepping reaction time test and Functional Gait Assessment. Secondary outcomes included physical and neuropsychological measures associated with falls in Parkinson's disease, number of falls over six months and self-reported mobility and balance. RESULTS: Post intervention, there were no differences between the intervention ( n = 28) and control ( n = 25) groups in the primary or secondary outcomes except for the Timed Up and Go test, where there was a significant difference in favour of the control group ( P = 0.02). Intervention participants reported mobility improvement, whereas control participants reported mobility deterioration-between-group difference on an 11-point scale = 0.9 (95% confidence interval: -1.8 to -0.1, P = 0.03). Interaction effects between intervention and disease severity on physical function measures were observed ( P = 0.01 to P = 0.08) with seemingly positive effects for the low-severity group and potentially negative effects for the high-severity group. CONCLUSION: Overall, home-based exergame step training was not effective in improving the outcomes assessed. However, the improved physical function in the lower disease severity intervention participants as well as the self-reported improved mobility in the intervention group suggest home-based exergame step training may have benefits for some people with Parkinson's disease.
Assuntos
Acidentes por Quedas/prevenção & controle , Terapia por Exercício/métodos , Marcha/fisiologia , Serviços de Assistência Domiciliar/organização & administração , Doença de Parkinson/reabilitação , Jogos de Vídeo , Idoso , Austrália , Feminino , Humanos , Vida Independente , Masculino , Pessoa de Meia-Idade , Doença de Parkinson/diagnóstico , Equilíbrio Postural/fisiologia , Estudos Prospectivos , Valores de Referência , Medição de Risco , Índice de Gravidade de Doença , Método Simples-Cego , Resultado do TratamentoRESUMO
Falls are a major determinant of poor quality of life, immobilization, and reduced life expectancy in people affected by Parkinson's disease (PD) and in older adults more generally. Although many questions remain, recent research has advanced the understanding of this complex problem. The goal of this review is to condense new knowledge of falls in PD from prodromal to advanced disease, taking into account risk factors, assessment, and classification as well as treatment. The fundamental steps of clinical and research-based approaches to falls are described, namely, the identification of fall risk factors, clinical and instrumental methods to evaluate and classify fall risk, and the latest evidence to reduce or delay falls in PD. We summarize recent developments, the direction in which the field should be heading, and what can be recommended at this stage. We also provide a practical algorithm for clinicians.© 2017 International Parkinson and Movement Disorder Society.
Assuntos
Acidentes por Quedas , Doença de Parkinson/fisiopatologia , Acidentes por Quedas/prevenção & controle , Acidentes por Quedas/estatística & dados numéricos , Humanos , Doença de Parkinson/complicaçõesRESUMO
BACKGROUND AND PURPOSE: Flexed truncal posture is common in people with Parkinson disease (PD); however, little is known about the mechanisms responsible or its effect on physical performance. This cross-sectional study aimed to establish the reliability of a truncal posture measurement and explore relationships between PD impairments and truncal posture, as well as truncal posture and balance and mobility. METHODS: A total of 82 people with PD participated. Truncal posture was measured in standing as the distance between vertebra C7 and a wall. Univariate and multivariate regression analyses were performed with truncal posture and impairments, including global axial symptoms, tremor, bradykinesia, rigidity, freezing of gait (FOG), reactive stepping and executive function, as well as truncal posture with balance and mobility measures. RESULTS: The truncal posture measure had excellent test-retest reliability (ICC3,1 0.79, 95% CI 0.60-0.89, P < 0.001). Global axial symptoms had the strongest association with truncal posture (adjusted R = 0.08, P = 0.01), although the majority of the variance remains unexplained. Post hoc analysis revealed that several impairments were associated with truncal posture only in those who did not report FOG. Flexed truncal posture was associated with poorer performance of most balance and mobility tasks after adjustment for age, gender, disease severity, and duration (adjusted R = 0.24-0.33, P < 0.001-0.03). DISCUSSION AND CONCLUSIONS: The C7 to wall measurement is highly reliable in people with PD. Global axial symptoms were independently associated with truncal posture. Greater flexed truncal posture was associated with poorer balance and mobility. Further studies are required to elucidate the mechanisms responsible for flexed truncal posture and the impact on activity.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A164).
Assuntos
Disfunção Cognitiva/fisiopatologia , Transtornos Neurológicos da Marcha/fisiopatologia , Doença de Parkinson/fisiopatologia , Doença de Parkinson/psicologia , Equilíbrio Postural/fisiologia , Postura/fisiologia , Atividades Cotidianas , Idoso , Disfunção Cognitiva/psicologia , Estudos Transversais , Função Executiva/fisiologia , Feminino , Marcha/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Limitação da Mobilidade , Reprodutibilidade dos TestesRESUMO
OBJECTIVE: The aim of this study was to determine the cost-effectiveness of a 6-month minimally supervised exercise program for people with PD. METHODS: An economic analysis was conducted alongside a randomized, controlled trial in which 231 people age 40 years and over with PD were randomized into a usual care control group or an exercise group. Cost-effectiveness was estimated using incremental cost per fall prevented (using falls calendars) as the primary analysis and cost per extra person avoiding mobility deterioration (defined as an improvement or no change in the 12-point Short Physical Performance Battery Score between baseline and 6 month). A cost-utility analysis using the Short Form-6D was also performed. Uncertainty was represented using cost-effectiveness scatter plots and acceptability curves. Planned subgroup analyses for the low-disease-severity group were also undertaken. RESULTS: All results are reported in Australian dollars ($A). The average cost of the intervention was $A1,010 per participant. Incremental cost-effectiveness of the program relative to usual care was $A574 per fall prevented, $A9,570 per extra person avoiding mobility deterioration, and $A338,800 per quality-adjusted life year gained. The intervention had an 80% probability of being cost-effective, relative to the control, at a threshold of $A2,000 per fall prevented. Subgroup analyses for the low-disease-severity group indicate the program to be dominant, that is, less costly and more effective than usual care for all health outcomes. CONCLUSION: The exercise intervention appeared cost-effective with regard to fall prevention in the whole sample and cost saving in the low disease severity group, when compared with usual care.
Assuntos
Acidentes por Quedas/prevenção & controle , Análise Custo-Benefício , Terapia por Exercício/economia , Terapia por Exercício/métodos , Doença de Parkinson/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Inquéritos Epidemiológicos , Humanos , Masculino , Entrevista Psiquiátrica Padronizada , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de SaúdeRESUMO
OBJECTIVE: This study aimed to: 1) examine the severity and frequency of pain and the extent to which pain interferes with work and 2) explore the contributions of motor impairments to pain in people with Parkinson's disease (PD). METHOD: Pain severity, frequency and the impact of pain on work were determined using subscores from the SF-36TM, Parkinson's Disease Questionnaire and SF-12v2TM, respectively, in 231 people with Parkinson's disease. Motor impairments were measured using the Unified Parkinson's Disease Rating Scale. Freezing of gait was determined as its presence or absence in the last month. Associations between impairments and pain were examined using logistic regression. RESULTS: Pain was reported by 187 (81%) participants, with 91 (39%) reporting pain of moderate severity or worse. Pain interfered with work to some extent in 158 (68%) participants. After adjusting for age and gender, increased rigidity was associated with higher pain frequency and more pain that interfered with work (for both models, Odds Ratio = 1.14, 95% confidence interval 1.0-1.3). Tremor was not associated with any measures of pain and motor impairments were not associated with pain severity. CONCLUSIONS: Most people with PD experience pain at least monthly and pain interferes with daily activities. PD impairments are associated with more frequent pain and pain that interferes with work, with rigidity having the strongest association. Development of Parkinson's disease-specific pain assessments and further investigation into the association between PD impairments and pain is warranted.
Assuntos
Transtornos das Habilidades Motoras/diagnóstico , Transtornos das Habilidades Motoras/epidemiologia , Dor/diagnóstico , Dor/epidemiologia , Doença de Parkinson/diagnóstico , Doença de Parkinson/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Tremor/diagnóstico , Tremor/epidemiologiaRESUMO
OBJECTIVE: To measure the strength of the major muscle groups of the affected and intact lower limbs in people with stroke compared with age-matched controls. DESIGN: Cross-sectional study. SETTING: University laboratory. PARTICIPANTS: Ambulatory stroke survivors (n=60; mean age, 69±11y), who had had a stroke between 1 and 6 years previously, and age-matched controls (n=35; mean age, 65±9y) (N=95). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The maximum isometric strength of 12 muscle groups (hip flexors and extensors, hip adductors and abductors, hip internal rotators and external rotators, knee flexors and extensors, ankle dorsiflexors and plantarflexors, ankle invertors and evertors) of both lower limbs was measured using handheld dynamometry. All strength measurements were taken in standardized positions by 1 rater. RESULTS: The affected lower limb of the participants with stroke was significantly weaker than that of the control participants for all muscle groups (P<.01). Strength (adjusted for age, sex, and body weight) was 48% (range, 34%-62%) of that of the control participants. The most severely affected muscle groups were hip extensors (34% of controls), ankle dorsiflexors (35%), and hip adductors (38%), and the least severely affected muscle groups were ankle invertors (62%), ankle plantarflexors (57%), and hip flexors (55%). The intact lower limb of the participants with stroke was significantly weaker than that of the control participants for all muscle groups (P<.05) except for ankle invertors (P=.25). Strength (adjusted for age, sex, and body weight) was 66% (range, 44%-91%) of that of the control participants. The most severely affected muscle groups were hip extensors (44% of controls), ankle dorsiflexors (52%), and knee flexors (54%). CONCLUSIONS: Ambulatory people with chronic stroke have a marked loss of strength in most of the major muscle groups of both lower limbs compared with age-matched controls.
Assuntos
Extremidade Inferior/fisiopatologia , Força Muscular/fisiologia , Músculo Esquelético/fisiopatologia , Acidente Vascular Cerebral/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Doença Crônica , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dinamômetro de Força Muscular , Sobreviventes , CaminhadaRESUMO
OBJECTIVE: To determine whether EMG-triggered electrical stimulation applied to multiple muscles daily is a feasible intervention and to determine its effect on strength and activity in very weak stroke patients. DESIGN: A prospective, randomized trial with blinded assessment. SETTING: Metropolitan mixed acute and rehabilitation units. PARTICIPANTS: Thirty-three people within four weeks of a stroke with less than Grade 3 strength in three out of four muscle groups (shoulder flexors, elbow extensors, wrist and finger extensors and thumb abductors) of the affected arm. INTERVENTIONS: Participants were randomly allocated to receive EMG-triggered electrical stimulation to the four muscle groups of the affected arm plus usual therapy five times a week for four weeks, or usual therapy only. MAIN MEASURES: Feasibility of the intervention was measured by examining compliance with the trial protocol. Strength was measured using manual muscle testing summed across muscle groups (0-20). Activity was measured using the Motor Assessment Scale, summed upper limb items (0-18). RESULTS: The experimental group received 87% of the intervention. Following the intervention period, there was no difference between the groups for strength (mean between-group difference, 0 out of 20, 95% confidence interval (CI) -3 to 3, p = 0.91) or activity (mean between-group difference 1 out of 18, 95% CI -2 to 4, p = 0.44). CONCLUSIONS: It is feasible to apply EMG-triggered electrical stimulation to multiple muscles of the upper limb in very weak people early after stroke. However, it does not appear to improve strength or activity beyond usual arm therapy that contains strengthening.
Assuntos
Terapia por Estimulação Elétrica/métodos , Eletromiografia/métodos , Debilidade Muscular/reabilitação , Treinamento Resistido/métodos , Reabilitação do Acidente Vascular Cerebral , Extremidade Superior/fisiopatologia , Idoso , Terapia por Estimulação Elétrica/instrumentação , Estudos de Viabilidade , Feminino , Humanos , Masculino , Força Muscular/fisiologia , Debilidade Muscular/etiologia , Músculo Esquelético/fisiopatologia , Propriocepção/fisiologia , Estudos Prospectivos , Acidente Vascular Cerebral/fisiopatologiaRESUMO
OBJECTIVE: To determine the effects of leg muscle power training in people with Parkinson's disease. DESIGN: Randomized controlled trial. SETTING: University laboratory (outcome measures and experimental intervention), community (control intervention). SUBJECTS: Community-dwelling people with Parkinson's disease. INTERVENTIONS: Leg muscle power training using pneumatic variable resistance equipment (experimental) was compared with low intensity sham exercise (control). Both groups exercised twice weekly for 12 weeks. MAIN MEASURES: Primary outcomes were peak power of four leg muscle groups. Secondary outcomes were measures of muscle strength, mobility, balance and falls. RESULTS: Exercise adherence was high in both groups. Leg muscle power was significantly better in the experimental group than the control group in all four primary outcome measures at 12 weeks after adjusting for baseline values: leg extensors (57.9 watts, 95% confidence interval (CI) 22.0-93.7, p = 0.002); knee flexors (29.6 watts, 95% CI 7.4-51.8, p = 0.01); hip flexors (68.1 watts, 95% CI 19.6-116.5, p = 0.007); and hip abductors (37.4 watts, 95% CI 19.9-54.9, p < 0.001). The experimental group performed significantly better on tests of leg muscle strength (p < 0.001 to 0.07) and showed trends toward better performance in the Timed Up and Go (p = 0.13) and choice stepping reaction time (p = 0.11). There was a non-significant reduction in the rate of falls in the experimental group compared with the control group (incidence rate ratio 0.84, p = 0.76). CONCLUSIONS: This programme significantly improved muscle power in all trained muscle groups.
Assuntos
Acidentes por Quedas/estatística & dados numéricos , Extremidade Inferior/fisiopatologia , Força Muscular/fisiologia , Doença de Parkinson/reabilitação , Equilíbrio Postural/fisiologia , Treinamento Resistido/métodos , Acidentes por Quedas/prevenção & controle , Idoso , Feminino , Humanos , Extremidade Inferior/fisiologia , Masculino , New South Wales , Doença de Parkinson/complicaçõesRESUMO
Introduction: Pain in Parkinson's disease (PD) is common but poorly understood, with most research to date taking a mechanistic approach. This mixed methods study takes a broader biopsychosocial approach to assess and describe contributors of pain and explore pain management and the relationship between pain and physical activity in people with PD (PwPD) and chronic pain. Methods: A structured survey evaluated respondents' contributors of pain using standardized, self-report assessments of the following: pain, peripheral neuropathy, central nociplastic change, emotional dysregulation or pathology, and maladaptive cognitions. Semistructured individual interviews were conducted with purposively sampled survey participants and analyzed using inductive thematic analysis. Results: Eighty-nine PwPD (mean age 67 years, 55% female) completed the survey. The most common pain contributors were maladaptive cognitions (62%), central nociplastic change (49%), and emotional dysregulation (44%). Approaches to pain management and the response to physical activity were variable within and across individuals with different pain contributors. Four themes emerged from interviews with 24 participants: (1) causative perceptions of pain are diverse; (2) sense of control influences disease acceptance and exercise self-efficacy; (3) belief in the value of therapy; and (4) pain as the unspoken PD symptom. Physical activity was used by PwPD for pain management; however, the relationship between pain and physical activity varied based on sense of control. Conclusions: Clinicians should screen for pain and assess its contributors to provide individualized, multidimensional pain management that considers the biological, psychological, and social factors of pain in PwPD. It is plausible that such an approach would promote a better sense of control for PwPD.
RESUMO
Falls are a major cause of morbidity in Parkinson's disease (PD). The objective of this study was to identify predictors of falls in PD and develop a simple prediction tool that would be useful in routine patient care. Potential predictor variables (falls history, disease severity, cognition, leg muscle strength, balance, mobility, freezing of gait [FOG], and fear of falling) were collected for 205 community-dwelling people with PD. Falls were monitored prospectively for 6 months using monthly falls diaries. In total, 125 participants (59%) fell during follow-up. A model that included a history of falls, FOG, impaired postural sway, gait speed, sit-to-stand, standing balance with narrow base of support, and coordinated stability had high discrimination in identifying fallers (area under the receiver-operating characteristic curve [AUC], 0.83; 95% confidence interval [CI], 0.77-0.88). A clinical tool that incorporated 3 predictors easily determined in a clinical setting (falling in the previous year: odds ratio [OR], 5.80; 95% CI, 3.00-11.22; FOG in the past month: OR, 2.39; 95% CI, 1.19-4.80; and self-selected gait speed < 1.1 meters per second: OR, 1.86; 95% CI, 0.96-3.58) had similar discrimination (AUC, 0.80; 95% CI, 0.73-0.86) to the more complex model (P = 0.14 for comparison of AUCs). The absolute probability of falling in the next 6 months for people with low, medium, and high risk using the simple, 3-test tool was 17%, 51%, and 85%, respectively. In people who have PD without significant cognitive impairment, falls can be predicted with a high degree of accuracy using a simple, 3-test clinical tool. This tool enables individualized quantification of the risk of falling. © 2013 Movement Disorder Society.
Assuntos
Acidentes por Quedas , Doença de Parkinson/complicações , Equilíbrio Postural/fisiologia , Transtornos de Sensação/diagnóstico , Transtornos de Sensação/etiologia , Adulto , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Probabilidade , Curva ROC , Índice de Gravidade de DoençaRESUMO
OBJECTIVE: To investigate the feasibility and effectiveness of an active exercise program for cervical dystonia. DESIGN: Pilot randomized controlled, single-blind trial of a 12-week intervention followed by a four-week follow-up period. SETTING: Supervised physiotherapy and outcome measurement sessions were conducted in a hospital outpatient physiotherapy setting. Participants also performed exercises at home. SUBJECTS: Twenty participants with idiopathic cervical dystonia were randomized into an experimental (n = 9) or control (n = 11) group. Two participants from the experimental group and one from the control group dropped out. INTERVENTIONS: The experimental group undertook a semi-supervised active exercise program aimed at correcting the dystonic head position, plus relaxation. The control group performed relaxation only. MAIN OUTCOME MEASURES: Feasibility of the intervention was assessed by recording adherence, muscle soreness, and adverse events. The primary outcome measure was blinded analysis of the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) score. RESULTS: The active exercise program was feasible and safe, with participants in the experimental group completing 84% of prescribed training sessions in the 12-week intervention period. There were no adverse events in either group, while mild muscle soreness was reported by 66% of the experimental group. There was no significant difference between groups at post-test or follow-up. The difference between groups of -1.9 (95% confidence interval (CI) -9.0-5.2) on the TWSTRS demonstrates a trend towards greater improvement for the experimental group. CONCLUSION: Active exercise for people with cervical dystonia is feasible and can be completed with good adherence and no adverse effects.