A Mixed Methods Approach to Explore the Experience of Pain and Its Management in People with Parkinson's Disease.

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.

Implementing digital devices to increase mobility training for people receiving inpatient rehabilitation: protocol for a feasibility hybrid type II randomized controlled trial.

BACKGROUND: People with mobility limitations can benefit from rehabilitation programs incorporating intensive, repetitive, and task-specific exercises using digital devices such as virtual reality gaming systems, tablet and smartphone applications, and wearable devices. The Activity and MObility UsiNg Technology (AMOUNT) rehabilitation trial (n = 300) showed improvements in mobility in people using these types of digital devices in addition to their usual rehabilitation care when the intervention was provided by an additional study-funded physiotherapist. However, it is not clear if this intervention can be implemented by hospital physiotherapists with a usual clinical load. The AMOUNT Implementation trial aims to explore the feasibility of conducting a large-scale implementation trial. METHODS: A pragmatic, assessor blinded, feasibility hybrid type II randomized controlled trial will be undertaken at a public hospital in Australia. There will be two phases. Phase I (Implementation phase) will involve implementing the digital devices into physiotherapy practice. Physiotherapists from the rehabilitation ward will receive a multifaceted implementation strategy guided by the Capabilities, Opportunities, Motivation-Behaviour (COM-B) theoretical model. The implementation strategy includes identifying and training a clinical champion; providing digital devices and education and training; facilitating use of the devices through clinical reasoning sessions and journal clubs; and audit and feedback of exercise dosage documentation. Phase II (Trial phase) will involve randomising 30 eligible inpatients from the same ward into either usual care or usual care plus an additional 30 min or more of exercises using digital devices. This intervention will be provided by the physiotherapists who took part in the implementation phase. We will collect data on feasibility, implementation, and patient-level clinical outcomes. The three primary outcome measures are the extent to which physiotherapists document the dosage of exercises provided to participants (feasibility criteria: exercise practice sheets complete for ≥85% of all participants); ability to recruit participants; and fidelity to the protocol of using digital devices to prescribe exercises (feasibility criteria: average of ≥ 30mins per day for > 50% intervention participants). DISCUSSION: This feasibility study will provide important information to guide the planning and conduct of a future large-scale implementation trial. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry; ACTRN12621000938808; registered 19/07/2021. Trial sponsor: Prince of Wales Hospital. 320-346 Barker Street, Randwick, NSW, 2031, Australia. PROTOCOL VERSION: 6.2 7th April 2021.

Injury severity, age and pre-injury exercise history predict adherence to a home-based exercise programme in adults with traumatic brain injury.

PURPOSE: To explore factors that may influence exercise adherence in adults with traumatic brain injury (TBI) within the International Classification of Functioning, Disability and Health (ICF) theoretical model. PARTICIPANTS: Thirty participants with TBI who had been randomized to a home-based exercise programme in a recently conducted randomized controlled trial. METHODS: Impairments in body functions, environmental factors and personal factors were explored as predictors for exercise adherence. Significant variables were entered into binary logistic regression analyses to determine their combined power to predict exercise adherence. RESULTS: Greater injury severity, older age and a pre-injury exercise history of walking or jogging positively influenced exercise adherence. As a combined set the three predictor variables accurately classified 82% of participants as adherent or non-adherent and were able to explain 49% of the variance (sensitivity = 67%; specificity = 89%). CONCLUSION: These results demonstrate people with severe injuries are able to exercise independently and suggest that in order to maximize adherence to an exercise programme, clinicians need to consider exercise history when prescribing the type of exercise. The results also provide factors within the ICF theoretical model to investigate in a large-scale study of exercise adherence after TBI.

The Associations Between Physical Activity, Sleep, and Mood with Pain in People with Parkinson's Disease: An Observational Cross-Sectional Study.

BACKGROUND: Pain is common in Parkinson's disease (PD). In general and chronic pain populations, physical inactivity, poor sleep, and anxiety are associated with worse pain. However, little is known about these potential predictors of pain in PD. OBJECTIVE: This cross-sectional observational study investigated associations between measures of physical activity, sleep, and mood with pain in people with PD. METHODS: Pain was measured using the King's PD Pain Scale and the Brief Pain Inventory (pain severity and interference) in 52 participants with PD. Independent variables were categorised by demographics (age, gender), disease severity (MDS-UPDRS) and duration, central sensitization (Central Sensitization Inventory), physical activity (Incidental and Planned Exercise Questionnaire), sleep (Pittsburgh Sleep Quality Index), and mood (Hospital Anxiety and Depression Scale). RESULTS: Univariate regression analyses showed that increased disease severity, longer disease duration, greater central sensitization, increased physical activity, poor sleep, anxiety, and depression were associated with worse pain in one or more pain measures (p < 0.05). Multivariate regression models accounted for 56% of the variance in the King's Pain Scale, 25% pain severity and 36% in pain interference. Poor sleep independently contributed to worse pain scores in all models (ß 0.3-0.4, p < 0.05). CONCLUSION: Increased physical activity, poor sleep, anxiety, and depression are associated with worse pain scores in people with PD. For optimal management of pain in people with PD, sleep and mood may need to be addressed. Further, the nature of the relationship between physical activity and pain in PD requires further investigation.

A Comparison of Activity Monitor Data from Devices Worn on the Wrist and the Waist in People with Parkinson's Disease.

BACKGROUND: It is unclear if it is appropriate for people with Parkinson's disease (PD) to wear activity monitors on the wrist because of the potential influence of impairments on the data. OBJECTIVE: The objective of this study was to determine (1) whether activity monitor data collected from devices worn at the wrist and waist are comparable and (2) the contribution of PD impairments to any differences in step and activity counts at the wrist and waist. METHODS: A total of 46 community-dwelling people with PD wore an accelerometer at the wrist and waist simultaneously for 1 week. Motor impairments (rigidity, bradykinesia, tremor, dyskinesia) were assessed using the Movement Disorders Society Unified Parkinson's Disease Rating Scale part III (motor examination) and part IV (motor complications). RESULTS: Higher values were recorded by the wrist monitor for steps/day (wrist, 9236 [standard deviation (SD) 3812]; waist, 5324 [SD 2800]; difference 3912; P < 0.001) and activity counts/day (wrist, 872,590 [SD 349,148]; waist, 186,491 [SD 101,989]; difference 686,099; P < 0.001). However, the wrist and waist values were strongly correlated (steps, r = 0.89; counts, r = 0.74; P ≤ 0.001). Increased tremor and dyskinesia explained 19% of the variation in the difference in average steps/day, and these variables plus reduced bradykinesia explained 24% of the variation in the difference in average activity counts/day. CONCLUSION: Wrist monitors are likely to overestimate activity, particularly in people with tremor and dyskinesia. Nonetheless, activity monitors can be worn on the wrist if the aim is to monitor change rather than accurately record activity.

Relationship between lower limb coordination and walking speed after stroke: an observational study.

BACKGROUND: Although lower limb muscle strength is associated with walking performance in people after stroke, even when there is good strength, walking speed may remain slower than normal, perhaps due to incoordination. OBJECTIVE: The aim of this study was to examine the relationship between walking speed and lower limb coordination in people with good strength after stroke. METHODS: An observational study was conducted with 30 people with stroke and 30 age-matched controls. Inclusion criteria for stroke were good lower limb strength (i.e., ≥Grade 4) and walking speed at >0.6m/s without aids in bare feet (with recruitment stratified so that walking speed was evenly represented across the range). Walking performance was measured as speed during the 10-m Walk Test and distance during the 6-min Walk Test. Coordination was measured using the Lower Extremity Motor Coordination Test and reported in taps/s. RESULTS: Stroke survivors walked at 1.00 (SD 0.26) m/s during the10-m Walk Test (64% of normal), walked 349 (SD 94) m during the 6-min Walk Test (68% of normal), and performed the Lower Extremity Motor Coordination Test at 1.20 (SD 0.34) taps/s with the affected side (64% of normal). Lower Extremity Motor Coordination Test scores for the affected side were statistically significantly correlated with walking performance in the 10-m Walk Test (r=0.42, p=0.02) and the 6-min Walk Test (r=0.50, p=0.01). CONCLUSION: Coordination was related to walking performance, suggesting that loss of coordination may contribute to slow walking in this group of stroke survivors with good strength. TRIAL REGISTRATION: ANZCTR12614000856617 (www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366827).

Exercise-induced hypoalgesia is present in people with Parkinson's disease: Two observational cross-sectional studies.

BACKGROUND: Exercise is prescribed for people with Parkinson's disease to address motor and non-motor impairments, including pain. Exercise-induced hypoalgesia (i.e., an immediate reduction in pain sensitivity following exercise) is reported in the general population; however, the immediate response of pain sensitivity to exercise in people with Parkinson's disease is unknown. The purpose of this study was to investigate if exercise-induced hypoalgesia is present following isometric and aerobic exercise in people with Parkinson's disease, and if so, if it varies with the dose of aerobic exercise. METHODS: Thirty people with idiopathic Parkinson's disease and pain-free age-matched controls completed two observational studies evaluating the response to: (a) right arm isometric exercise; and (b) treadmill walking at low and moderate intensities. Pressure pain thresholds were measured over biceps brachii and quadriceps muscles immediately before and after exercise, with increased thresholds after exercise indicating exercise-induced hypoalgesia. RESULTS: Pressure pain thresholds increased in the Parkinson's disease group at all tested sites following all exercise bouts (e.g., isometric exercise, right bicep 29%; aerobic exercise, quadriceps, moderate intensity 8.9%, low intensity 7.1% (p ≤ 0.008)), with no effect of aerobic exercise dose (p = 0.159). Similar results were found in the control group. CONCLUSIONS: Overall, people with Parkinson's disease experienced an exercise-induced hypoalgesia response similar to that of the control group, the extent of which did not vary between mild and moderate doses of aerobic exercise. Further research is warranted to investigate potential longer term benefits from exercise in the management of pain in this population. SIGNIFICANCE: Isometric and aerobic exercise reduces pain sensitivity in people with Parkinson's disease. As exercise is important for people with Parkinson's disease, these results provide assurance that people with Parkinson's disease and pain can exercise without an immediate increase in pain sensitivity. The reduction in pain sensitivity with both modes and with low and moderate intensities of aerobic exercise suggests that people with Parkinson's disease can safely choose the mode and intensity of exercise that best suits their needs.

Do people with intellectual disability use Nintendo Wii when placed in their home as part of a physiotherapy program? An observational study.

PURPOSE: To examine how much, and in what way, Nintendo Wii™ (Wii) is used when prescribed as part of a home-physiotherapy program for people with intellectual disability. METHODS: Twenty people with intellectual disability were recruited. The following parameters were recorded about play patterns over a 12-week period: frequency, duration, perceived exertion, play position, play mode, initiation of play and games from Wii Sports and Wii Fit Plus. RESULTS: Participants used the Wii for a median of 101 min per week (interquartile range [IQR]: 50-172) in weeks one and two across a median of three days per week (IQR: 3-4), decreasing down to a median of 35 min per week (IQR: 0-141) in weeks 11 and 12 across a median of one day per week (IQR: 0-3). CONCLUSIONS: Usage of the Wii drops off rapidly when it is placed in the homes of people with intellectual disability as part of a physiotherapy program. Implications for Rehabilitation Usage of the Nintendo Wii drops off rapidly when it is placed in the homes of people with intellectual disability and they are instructed to use it as part of a home physiotherapy program. Games commonly played include bowling and boxing in Wii Sport, and penguin slide, ski jump and tight rope walk in Wii Fit Plus. Physiotherapists should use person and family centred practice to ensure that Nintendo Wii is a suitable intervention for the person with an intellectual disability and provide support to encourage ongoing usage.

Validity of the Fitbit activity tracker for measuring steps in community-dwelling older adults.

BACKGROUND: Commercially available activity monitors, such as the Fitbit, may encourage physical activity. However, the accuracy of the Fitbit in older adults remains unknown. This study aimed to determine (1) the criterion validity of Fitbit step counts compared to visual count and ActiGraph accelerometer step counts and (2) the accuracy of ActiGraph step counts compared to visual count in community-dwelling older people. METHODS: Thirty-two community-dwelling adults aged over 60 wore Fitbit and ActiGraph devices simultaneously during a 2 min walk test (2MWT) and then during waking hours over a 7-day period. A physiotherapist counted the steps taken during the 2MWT. RESULTS: There was excellent agreement between Fitbit and visually counted steps (intraclass correlation coefficient (ICC2,1)=0.88, 95% CI 0.76 to 0.94) from the 2MWT, and good agreement between Fitbit and ActiGraph (ICC2,1=0.66, 95% CI 0.41 to 0.82), and between ActiGraph and visually counted steps (ICC2,1=0.60, 95% CI 0.33 to 0.79). There was excellent agreement between the Fitbit and ActiGraph in average steps/day over 7 days (ICC2,1=0.94, 95% CI 0.88 to 0.97). Percentage agreement was closest for Fitbit steps compared to visual count (mean 0%, SD 4%) and least for Fitbit average steps/day compared to the ActiGraph (mean 13%, SD 25%). CONCLUSIONS: The Fitbit accurately tracked steps during the 2MWT, but the ActiGraph appeared to underestimate steps. There was strong agreement between Fitbit and ActiGraph counted steps. The Fitbit tracker is sufficiently accurate to be used among community-dwelling older adults to monitor and give feedback on step counts.

Circuit class therapy can provide a fitness training stimulus for adults with severe traumatic brain injury: a randomised trial within an observational study.

QUESTIONS: Can circuit class therapy provide sufficient exercise dosage (at least 20 minutes at ≥ 50% heart rate reserve or total caloric expenditure ≥ 300 kilocalories) to induce a cardiorespiratory fitness effect in adults with traumatic brain injury? Can feedback from heart rate monitors influence exercise intensity? DESIGN: Randomised controlled trial within an observational study. PARTICIPANTS: Fifty-three people with severe traumatic brain injury, of whom 40 progressed into the trial. INTERVENTION: All participants undertook circuit class therapy. Participants allocated to the experimental group received exercise intensity feedback from a heart rate monitor and the control group received no feedback. OUTCOME MEASURES: Proportion of participants exercising at ≥ 50% heart rate reserve for at least 20 minutes or expending ≥ 300 kilocalories during circuit class therapy. The primary outcome measure for the trial was the time spent in the heart rate training zone (ie, at ≥ 50% heart rate reserve) during the intervention and re-assessment periods. RESULTS: Circuit class therapy provided sufficient cardiorespiratory exercise dosage for 28% (95% CI 18 to 42) of the cohort according to the heart rate reserve criteria and 62% (95% CI 49 to 74) according to the caloric criteria. Feedback did not increase the time in the training zone during the intervention (mean difference 4.8 minutes, 95% CI -1.4 to 10.9) or re-assessment (1.9 minutes, -4.4 to 8.3) periods. CONCLUSION: The low intensity, long duration structure of circuit class therapy can provide sufficient exercise dosage for a fitness training effect for 62% of people with traumatic brain injury. Feedback from heart rate monitors does not necessarily influence exercise intensity. TRIAL REGISTRATION: ACTRN12607000522415.

Efficacy of a fitness centre-based exercise programme compared with a home-based exercise programme in traumatic brain injury: a randomized controlled trial.

OBJECTIVE: To compare the effects of a supervised fitness centre-based exercise programme with an unsupervised home-based exercise programme on cardiorespiratory fitness and psychosocial functioning in people with traumatic brain injury. DESIGN: Multi-centre, assessor-blinded, parallel group, randomized controlled trial. PARTICIPANTS: Sixty-two participants with severe traumatic brain injuries, who could walk at a speed exceeding 1 m/sec, discharged from 3 brain injury units. INTERVENTIONS: The fitness centre group completed a combined fitness and strength training exercise programme supervised by a personal trainer in a local fitness centre 3 times per week for 12 weeks. The home group completed a similar exercise programme unsupervised at home. MAIN OUTCOME MEASURE: Cardiorespiratory fitness measured using the modified 20-m shuttle test. RESULTS: Both groups improved in fitness: the maximal velocity achieved on the modified 20-m shuttle test increased with intervention and was maintained at follow-up. However, the difference between groups was not significant (mean between-group difference (95% confidence interval) 0 m/sec (-0.6 to 0.6) at the end of intervention). There were also no between-group differences in psychosocial functioning at the end of intervention or at follow-up. CONCLUSION: Both interventions were equally effective at improving cardiorespiratory fitness in adults with traumatic brain injuries.

Serial casting versus positioning for the treatment of elbow contractures in adults with traumatic brain injury: a randomized controlled trial.

OBJECTIVE: To compare the effects of serial casting with positioning for 1 hour per day for the treatment of elbow flexion contracture in adults with traumatic brain injury. DESIGN: Pragmatic randomized controlled trial with concealed allocation and assessor blinding. SETTING: Four brain injury rehabilitation units. SUBJECTS: Twenty-six adults with elbow flexion contracture after traumatic brain injury participating in multidisciplinary inpatient rehabilitation. INTERVENTIONS: Subjects were randomized to receive either serial casting or positioning for two weeks. In the subsequent four weeks subjects could be positioned for up to 1 hour/day. MAIN MEASURES: Torque-controlled passive elbow extension was measured at baseline, post-intervention (two weeks), post-intervention plus one day, and at follow-up (four weeks post-intervention). RESULTS: All 26 subjects completed the study. Post-intervention, serial casting reduced contracture by an average of 22 degrees (95% confidence interval (CI) 13 to 31; P <0.001) compared with the positioning group. One day later this effect had decreased to 11 degrees (95% CI 0 to 21 degrees; P= 0.052). The effect had almost completely disappeared at the four-week follow-up (mean 2 degrees, 95% CI -13 to 17; P= 0.782). CONCLUSIONS: Serial casting induces transient increases in range of motion. These effects are not maintained.