Effect of Proprioceptive Training Compared With Other Interventions for Upper Limb Deficits in People With Parkinson Disease: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: This systematic review and meta-analysis aimed to determine the efficacy of proprioceptive training on hand dexterity, upper limb function, and quality of life (QoL) in people with Parkinson disease (PD) compared with no or other active interventions. DATA SOURCES: Medline PubMed, Cochrane Library, CINAHL, PEDro, and Web of Science databases were searched to identify published studies until February 2023. STUDY SELECTION: Peer-reviewed English publications of randomized controlled trials (RCTs) of proprioceptive training conducted among people with PD. DATA EXTRACTION: Study characteristics, exercise program type and dosage, outcome of interest, and between-group comparisons of post-test results of intervention and comparison groups. DATA SYNTHESIS: Eight RCTs were included, involving 344 people with PD. Six RCTs contributed to meta-analyses. There was very low certainty of evidence that proprioceptive training may improve dominant hand (standard mean difference [SMD] 0.34, 95% CI 0.08-0.60, P=.01) and non-dominant hand (SMD 0.36, 95% CI 0.10-0.63, P<.01) fine motor dexterity, and dominant hand gross manual dexterity (SMD 1.73, 95% CI 0.30-3.16, P=.02), following 2-8 weeks of proprioceptive training. There was no evidence of effects on non-dominant hand gross manual dexterity, upper limb function, and QoL after proprioceptive training. CONCLUSIONS: Findings regarding the effect of proprioceptive training on hand dexterity in the short-term are inconclusive. The small sample size likely limited effect detection. Future large RCTs should compare proprioceptive training with no intervention and perform comprehensive biomechanical analysis to gain a clearer idea of its effects. Incorporating longer-duration proprioceptive training programs is also recommended to investigate long-lasting effects.

Fall-related health service use in Stepping On programme participants and matched controls: a non-randomised observational trial within the 45 and Up Study.

BACKGROUND: Falls and fall-related health service use among older adults continue to increase. The New South Wales Health Department, Australia, is delivering the Stepping On fall prevention programme at scale. We compared fall-related health service use in Stepping On participants and matched controls. METHODS: A non-randomised observational trial was undertaken using 45 and Up Study data. 45 and Up Study participants who did and did not participate in Stepping On were extracted in a 1:4 ratio. Rates of fall-related health service use from linked routinely collected data were compared between participants and controls over time using multilevel Poisson regression models with adjustment for the minimally sufficient set of confounders identified from a directed acyclic graph. RESULTS: Data from 1,452 Stepping On participants and 5,799 controls were analysed. Health service use increased over time and was greater in Stepping On participants (rate ratios (RRs) 1.47-1.82) with a spike in use in the 6 months prior to programme participation. Significant interactions indicated differential patterns of health service use in participants and controls: stratified analyses revealed less fall-related health service use in participants post-programme compared to pre-programme (RRs 0.32-0.48), but no change in controls' health service use (RRs 1.00-1.25). Gender was identified to be a significant effect modifier for health service use (P < 0.05 for interaction). DISCUSSION: Stepping On appeared to mitigate participants' rising fall-related health service use. Best practice methods were used to maximise this study's validity, but cautious interpretation of results is required given its non-randomised nature.

Using virtual reality to assess vestibulo-visual interaction in people with Parkinson's disease compared to healthy controls.

People with Parkinson's disease (PD) have increased visual dependency for balance and suspected vestibular dysfunction. Immersive virtual reality (VR) allows graded manipulation of visual sensory inputs during balance tasks, and hence VR coupled with portable force platforms have emerged as feasible, affordable, and validated tools for assessing sensory-motor integration of balance. This study aims to determine (i) how people with PD perform on a VR-based visual perturbation standing balance task compared to healthy controls (HC), and (ii) whether balance performance is influenced by vestibular function, when other known factors are controlled for. This prospective observational study compared the balance performance under varying sensory conditions in 40 people with mild to moderate PD with 40 age-matched HC. Vestibular function was assessed via Head Impulse Test (HIMP), cervical and ocular vestibular evoked myogenic potentials (cVEMPs and oVEMPs) and subjective visual vertical (SVV). Regression analyses were used to determine associations between VR balance performance on firm and foam surfaces with age, group, vestibular function, and lower limb proprioception. PD failed at significantly lower levels of visual perturbation than HC on both surfaces. In PD, greater disease severity was significantly associated with lower fall thresholds on both surfaces. Multiple PD participants failed prior to visual perturbation on foam. On firm, PD had a greater visual dependency. Increasing age, impaired proprioception, impaired SVV, abnormal HIMP and cVEMP scores were associated with worse balance performance. The multivariate model containing these factors explained 29% of the variability in balance performance on both surfaces. Quantitative VR-based balance assessment is safe and feasible in PD. Balance performance on both surfaces was associated with age, HIMP abnormality and proprioception.

Suppression head impulse test paradigm (SHIMP) characteristics in people with Parkinson's disease compared to healthy controls.

The suppression head impulse test paradigm (SHIMP) is a newly described indicator of vestibular function which yields two measures: vestibulo-ocular reflex (VOR) gain and a saccadic response. It is an alternative and complementary test to the head impulse test paradigm (HIMP). Parkinson's disease (PD) has known saccadic and central vestibular pathway dysfunction. This paper is the first description of SHIMP VOR gain and saccade characteristic in this population. This prospective observational study measured the SHIMP VOR gain and saccade characteristics in 39 participants with idiopathic PD and compared this to 40 healthy controls (HC). The effect of group, demographic variables and SHIMP characteristics were evaluated. SHIMP VOR gains were not significantly different between groups (p = 0.10). Compared to HC, the PD group mean SHIMP peak saccade velocity was significantly reduced by an average of 77.07°/sec (p < 0.001), and SHIMP saccade response latency was longer, with an average delay of 23.5 ms (p = 0.003). SHIMP saccade peak velocity was also associated with both head impulse velocity (p = 0.002) and SHIMP VOR gain (p = 0.004) variables, but there was no significant influence of these variables when SHIMP saccade peak velocity was considered as a predictor of PD (p = 0.52-0.91). VOR gains were unaffected by PD. PD-specific saccadic dysfunction, namely reduced peak saccade velocities and prolonged response latencies, were observed in the SHIMP-induced saccade responses. VOR gain using slow phase eye velocity is preferred as the indicator of vestibular function in the SHIMPs paradigm as non-vestibular factors affected saccade peak velocity.

Control of Linear Head and Trunk Acceleration During Gait After Unilateral Vestibular Deficits.

OBJECTIVE: To use clinically available inertial measurement units to quantify the control of linear accelerations at the head and trunk during gait in different sensory conditions in individuals with unilateral vestibular loss. DESIGN: Observational study. SETTING: Outpatient research laboratory. PARTICIPANTS: Individuals (n=13; mean age, 47.6±13.7y; 69% women) 6 weeks after vestibular schwannoma resection surgery and vestibular healthy participants (n=16; mean age, 29.7±5.9y; 56% women). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Walking speed normalized, root mean square values of cranial-caudal, medial-lateral, and anterior-posterior directed linear accelerations at the head and the trunk while walking in 2 visual sensory conditions (eyes open and eyes closed). RESULTS: Linear mixed models for each root mean square value were fit on the effects of group, condition, and group by condition. The group by condition effect was used to examine the primary hypothesis that individuals with vestibular loss would experience greater change in triplanar root mean square values at the head and trunk from the eyes open to eyes closed condition compared with the vestibular healthy group. The group by condition effect was found to be significant at the head in the cranial-caudal (ß=0.39; P=.002), medial-lateral (ß=0.41; P<.001), and anterior-posterior (ß=0.43; P<.001) directions. The group by condition effect was also significant in the cranial-caudal (ß=0.39; P=.002), medial-lateral (ß=0.39; P<.001), and anterior-posterior (ß=0.23; P=.002) directions at the trunk. CONCLUSIONS: Participants who underwent vestibular schwannoma resection were more impaired in their ability to control accelerations at the head and trunk without visual sensory information than vestibular healthy participants. These impairments were detectable using clinically available inertial measurement units.

Static and dynamic otolith reflex function in people with Parkinson's disease.

PURPOSE: Parkinson's disease (PD) is a neurodegenerative disorder with possible vestibular system dysfunction. This study reports the transient and sustained functions of the otoliths and their reflex pathways in PD compared to healthy controls (HC) and determines if otolith function relates to previous fall history. METHODS: Forty participants with PD and 40 HC had their otolith function assessed. Transient saccular and utricular-mediated reflexes were assessed by cervical and ocular vestibular evoked myogenic potentials (cVEMPs and oVEMPs, respectively) elicited by air-conducted stimulus (clicks) and bone-conducted vibration (light tendon hammer taps). Static otolith function was assessed by the Curator Subjective Visual Vertical (SVV) test. RESULTS: Compared to HC, the PD group had significantly more absent cVEMP responses to both clicks (47.5% vs. 30%, respectively, p = 0.03) and taps (21.8% vs. 5%, respectively, p = 0.002). Only the PD group had bilaterally absent tap cVEMPs, this was related to previous falls history (p < 0. 001). In both groups, click oVEMPs were predominantly absent, and tap oVEMPs were predominantly present. The PD group had smaller tap oVEMP amplitudes (p = 0.03) and recorded more abnormal SVV responses (p = 0.01) and greater error on SVV compared to HC, p < 0.001. SVV had no relationship with VEMP responses (p = 0.14). CONCLUSIONS: PD impacts on cVEMP reflex pathways but not tap oVEMP reflex pathways. Bone-conducted otolith stimuli (taps) are more robust than air-conducted sound stimuli (clicks) for both o and cVEMPs. A lack of association between SVV and VEMP responses suggest that static and dynamic otolith functions are differentially affected in PD.

Scale-up of the Stepping On fall prevention program amongst older adults in NSW: Program reach and fall-related health service use.

ISSUE ADDRESSED: We describe the reach of the scale-up of Stepping On, a fall prevention program targeting community-dwellers aged ≥65 years in NSW, along with fall-related ambulance service use and fall-related hospitalisations after scale-up. METHODS: Data on program provision were received from Local Health Districts. Routinely collected fall-related ambulance usage and hospital admissions in NSW residents aged ≥65 years between 2009 and 2015 were compared within Statistical Local Areas prior to and following the implementation of Stepping On using multilevel models. RESULTS: Between 2009 and 2014 the program was delivered in 1077 sites to 10 096 older adults. Rates of fall-related ambulance use and hospital admissions per 100-person-years were 1-2 in people aged 66-74, 4-5 in people aged 75-84 and 12-13 in people aged ≥85. These rates increased over time (P < .001). The interaction between time and program delivery was not significant for fall-related ambulance use or hospital admissions. The time-related increase in fall-related ambulance usage in people aged 75-84 years may have been moderated by the Stepping On program (rate ratio 0.97, 95% CI 0.93-1.00, P = .045). CONCLUSIONS: There was no indication of a reduced rate of fall-related ambulance use or hospital admissions across the entire sample. Ambulance call-outs for falls in people aged 75-84 years may have reduced following program participation. SO WHAT?: Program scale-ups need to reach a large proportion of the target population with a focus on those groups contributing most to fall-related health service utilisation. Linking individual participants' health data as part of large-scale evaluations may provide better insights into program outcomes.

Predicting falls in people with Parkinson's disease: impact of methodological approaches on predictors identified.

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.

A roadmap for implementation of patient-centered digital outcome measures in Parkinson's disease obtained using mobile health technologies.

Obtaining reliable longitudinal information about everyday functioning from individuals with Parkinson's disease (PD) in natural environments is critical for clinical care and research. Despite advances in mobile health technologies, the implementation of digital outcome measures is hindered by a lack of consensus on the type and scope of measures, the most appropriate approach for data capture (eg, in clinic or at home), and the extraction of timely information that meets the needs of patients, clinicians, caregivers, and health care regulators. The Movement Disorder Society Task Force on Technology proposes the following objectives to facilitate the adoption of mobile health technologies: (1) identification of patient-centered and clinically relevant digital outcomes; (2) selection criteria for device combinations that offer an acceptable benefit-to-burden ratio to patients and that deliver reliable, clinically relevant insights; (3) development of an accessible, scalable, and secure platform for data integration and data analytics; and (4) agreement on a pathway for approval by regulators, adoption into e-health systems and implementation by health care organizations. We have developed a tentative roadmap that addresses these needs by providing the following deliverables: (1) results and interpretation of an online survey to define patient-relevant endpoints, (2) agreement on the selection criteria for use of device combinations, (3) an example of an open-source platform for integrating mobile health technology output, and (4) recommendations for assessing readiness for deployment of promising devices and algorithms suitable for regulatory approval. This concrete implementation guidance, harmonizing the collaborative endeavor among stakeholders, can improve assessments of individuals with PD, tailor symptomatic therapy, and enhance health care outcomes. © 2019 International Parkinson and Movement Disorder Society.

Predicting Motor Sequence Learning in People With Parkinson Disease.

BACKGROUND AND PURPOSE: Skill acquisition (ie, performance changes during practice) occurs in a nonlinear fashion. Despite this, motor learning is typically measured by comparing discrete timepoints. Thus, typical measures of motor learning do not detect skill acquisition characteristics that may be clinically meaningful. Reliable prediction of motor skill learning in people with Parkinson disease (PD) would allow therapists to more effectively individualize practice doses to fit specific patients' needs. The purposes of this study were to (a) characterize postural skill acquisition in people with PD, and identify factors (such as acquisition rate and practice dose to plateau) that predict learning, and (b) investigate whether levodopa medication (L-dopa) status during practice impacted learning. METHODS: Twenty-seven adults with PD practiced a postural motor task over 3 days, followed by 2 retention tests. Participants were randomized to practice either ON or OFF L-dopa. Data for repeating and random sequences were each analyzed using nonlinear curve-fitting and mixed-effects regressions. Learning was defined as pretest minus retention test performance. RESULTS: Participants with less physical impairment demonstrated less learning on the repeating and random sequence tasks compared with participants with more impairment. Participants who improved faster during practice demonstrated less learning on the repeating sequence task compared with participants who improved more slowly. Reaching plateau during practice was not related to learning. L-dopa did not impair learning. DISCUSSION AND CONCLUSIONS: Participants' skill acquisition characteristics were related to learning a postural motor task. Patient-specific factors, such as the rate of skill acquisition, level of physical function, and medication status, may influence how postural motor practice is delivered during balance rehabilitation.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A250).

Home-based step training using videogame technology in people with Parkinson's disease: a single-blinded randomised controlled trial.

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.

Flexed Truncal Posture in Parkinson Disease: Measurement Reliability and Relationship With Physical and Cognitive Impairments, Mobility, and Balance.

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).

Exercise to prevent falls in older adults: an updated systematic review and meta-analysis.

OBJECTIVE: Previous meta-analyses have found that exercise prevents falls in older people. This study aimed to test whether this effect is still present when new trials are added, and it explores whether characteristics of the trial design, sample or intervention are associated with greater fall prevention effects. DESIGN: Update of a systematic review with random effects meta-analysis and meta-regression. DATA SOURCES: Cochrane Library, CINAHL, MEDLINE, EMBASE, PubMed, PEDro and SafetyLit were searched from January 2010 to January 2016. STUDY ELIGIBILITY CRITERIA: We included randomised controlled trials that compared fall rates in older people randomised to receive exercise as a single intervention with fall rates in those randomised to a control group. RESULTS: 99 comparisons from 88 trials with 19 478 participants were available for meta-analysis. Overall, exercise reduced the rate of falls in community-dwelling older people by 21% (pooled rate ratio 0.79, 95% CI 0.73 to 0.85, p<0.001, I2 47%, 69 comparisons) with greater effects seen from exercise programmes that challenged balance and involved more than 3 hours/week of exercise. These variables explained 76% of the between-trial heterogeneity and in combination led to a 39% reduction in falls (incident rate ratio 0.61, 95% CI 0.53 to 0.72, p<0.001). Exercise also had a fall prevention effect in community-dwelling people with Parkinson's disease (pooled rate ratio 0.47, 95% CI 0.30 to 0.73, p=0.001, I2 65%, 6 comparisons) or cognitive impairment (pooled rate ratio 0.55, 95% CI 0.37 to 0.83, p=0.004, I2 21%, 3 comparisons). There was no evidence of a fall prevention effect of exercise in residential care settings or among stroke survivors or people recently discharged from hospital. SUMMARY/CONCLUSIONS: Exercise as a single intervention can prevent falls in community-dwelling older people. Exercise programmes that challenge balance and are of a higher dose have larger effects. The impact of exercise as a single intervention in clinical groups and aged care facility residents requires further investigation, but promising results are evident for people with Parkinson's disease and cognitive impairment.

Two-Year Trajectory of Fall Risk in People With Parkinson Disease: A Latent Class Analysis.

OBJECTIVE: To examine fall risk trajectories occurring naturally in a sample of individuals with early to middle stage Parkinson disease (PD). DESIGN: Latent class analysis, specifically growth mixture modeling (GMM), of longitudinal fall risk trajectories. SETTING: Assessments were conducted at 1 of 4 universities. PARTICIPANTS: Community-dwelling participants with PD of a longitudinal cohort study who attended at least 2 of 5 assessments over a 2-year follow-up period (N=230). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Fall risk trajectory (low, medium, or high risk) and stability of fall risk trajectory (stable or fluctuating). Fall risk was determined at 6 monthly intervals using a simple clinical tool based on fall history, freezing of gait, and gait speed. RESULTS: The GMM optimally grouped participants into 3 fall risk trajectories that closely mirrored baseline fall risk status (P=.001). The high fall risk trajectory was most common (42.6%) and included participants with longer and more severe disease and with higher postural instability and gait disability (PIGD) scores than the low and medium fall risk trajectories (P<.001). Fluctuating fall risk (posterior probability <0.8 of belonging to any trajectory) was found in only 22.6% of the sample, most commonly among individuals who were transitioning to PIGD predominance. CONCLUSIONS: Regardless of their baseline characteristics, most participants had clear and stable fall risk trajectories over 2 years. Further investigation is required to determine whether interventions to improve gait and balance may improve fall risk trajectories in people with PD.

What is the effect of a combined physical activity and fall prevention intervention enhanced with health coaching and pedometers on older adults' physical activity levels and mobility-related goals? Study protocol for a randomised controlled trial.

BACKGROUND: Physical inactivity and falls in older people are important public health problems. Health conditions that could be ameliorated with physical activity are particularly common in older people. One in three people aged 65 years and over fall at least once annually, often resulting in significant injuries and ongoing disability. These problems need to be urgently addressed as the population proportion of older people is rapidly rising. This trial aims to establish the impact of a combined physical activity and fall prevention intervention compared to an advice brochure on objectively measured physical activity participation and mobility-related goal attainment among people aged 60+. METHODS/DESIGN: A randomised controlled trial involving 130 consenting community-dwelling older people will be conducted. Participants will be individually randomised to a control group (n = 65) and receive a fall prevention brochure, or to an intervention group (n = 65) and receive the brochure plus physical activity promotion and fall prevention intervention enhanced with health coaching and a pedometer. Primary outcomes will be objectively measured physical activity and mobility-related goal attainment, measured at both six and 12 months post randomisation. Secondary outcomes will include: falls, the proportion of people meeting the physical activity guidelines, quality of life, fear of falling, mood, and mobility limitation. Barriers and enablers to physical activity participation will be measured 6 months after randomisation. General linear models will be used to assess the effect of group allocation on the continuously-scored primary and secondary outcome measures, after adjusting for baseline scores. Between-group differences in goal attainment (primary outcome) will be analysed with ordinal regression. The number of falls per person-year will be analysed using negative binomial regression models to estimate the between-group difference in fall rates after one year (secondary outcome). Modified Poisson regression models will compare groups on dichotomous outcome measures. Analyses will be pre-planned, conducted while masked to group allocation and will use an intention-to-treat approach. DISCUSSION: This trial will address a key gap in evidence regarding physical activity and fall prevention for older people and will evaluate a program that could be directly implemented within Australian health services. TRIAL REGISTRATION: ACTRN12614000016639, 7/01/2014.

Leg muscle power is enhanced by training in people with Parkinson's disease: a randomized controlled trial.

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.

Three simple clinical tests to accurately predict falls in people with Parkinson's disease.

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.

Transition to a virtual model of physiotherapy and exercise physiology in response to COVID-19 for people in a rural Australia: Is it a viable solution to increase access to allied health for rural populations?

Virtual healthcare has the potential to increase access to allied health for people living in rural areas, but challenges in delivery of such models have been reported. The COVID-19 pandemic provided an opportunity for a rural practice of physiotherapists and exercise physiologists to transition service delivery to a virtual model of care which utilised a combination of phone, video, an exercise app and/or paper handouts. This study aimed to evaluate the uptake and outcomes from virtual delivery of allied health services, and to describe patient and clinician experiences of the virtual model of care. A parallel convergent mixed methods study was conducted. De-identified data from patients who were offered the virtual service between 15 March 2020 and 30 September 2020 were extracted from the database of the rural practice, as were data from patients attending the practice in-person during the same time in 2019 to serve as a historical comparison. De-identified data from a monthly survey tracking clinician experiences of delivering care virtually was also obtained from the practice. Quantitative data were presented descriptively. Between-group differences were compared using independent samples t-tests, and within-group longitudinal changes compared using paired t-tests. Semi-structured interviews were conducted among a purposive sample of patients using the virtual service, and focus groups conducted among clinicians providing this model of care. Qualitative data were recorded and transcribed verbatim, then thematic analysis conducted. During the study period, the practice delivered 4% (n = 242) consultations virtually. Thirty-seven of the 60 patients (62%) using the virtual service were new referrals. Patients attended fewer sessional appointments virtually and a smaller proportion of patients reported high satisfaction with virtual care, compared to those who received in-person care the previous year (p < .05). Clinician confidence in delivering virtual care did not change significantly over time (p>.05), though clinicians not providing virtual care in a given month perceived their lower confidence than those who did provide virtual care (p < .05). Five themes influencing the success of virtual allied health provision emerged from patient interviews and clinician focus groups: adaptation of program elements for virtual delivery, conduct of virtual treatment, clinician flexibility, patient complexity and communication. The theme of communication influenced all the other themes. Virtual healthcare is a potential solution to address lack of access to allied health practitioners in rural areas, but may not suit all patients. Establishing a therapeutic relationship and ensuring people have access to adequate resources prior to virtual care delivery will optimise successful adoption of virtual care models. A hybrid model incorporating limited in-person consultations with virtual consultations appears a more viable option.

Does Exercise Attenuate Disease Progression in People With Parkinson's Disease? A Systematic Review With Meta-Analyses.

INTRODUCTION: Exercise has many benefits for people with Parkinson's disease (PD) and has been suggested to modify PD progression, but robust evidence supporting this is lacking. OBJECTIVE: This systematic review (PROSPERO registration: CRD42020169999) investigated whether exercise may have neuroplastic effects indicative of attenuating PD progression. METHODS: Six databases were searched for randomized controlled trials (RCTs) that compared the effect of exercise to control (no or sham exercise) or to another form of exercise, on indicators of PD progression (eg, brain-derived neurotrophic factor [BDNF], brain activation, "off" Unified Parkinson's Disease Rating Scale [UPDRS] scores). Trial quality was assessed using the Physiotherapy Evidence Database Scale. Random-effects meta-analyses were performed where at least 3 comparable trials reported the same outcome; remaining results were synthesized narratively. RESULTS: Forty-nine exercise trials involving 2104 PD participants were included. Compared to control, exercise improved "off" UPDRS motor scores (Hedge's g -0.39, 95% CI: -0.65 to -0.13, P = .003) and BDNF concentration (Hedge's g 0.54, 95% CI: 0.10-0.98, P = .02), with low to very low certainty of evidence, respectively. Narrative synthesis for the remaining outcomes suggested that compared to control, exercise may have neuroplastic effects. The exercise versus exercise comparisons were too heterogenous to enable pooling of results. DISCUSSION: This review provides limited evidence that exercise may have an attenuating effect on potential markers of PD progression. Further large RCTs are warranted to explore differential effects by exercise type, dose and PD stage, and should report on a core set of outcomes indicative of PD progression.