Glycovaccinology: The design and engineering of carbohydrate-based vaccine components.

Vaccines remain one of the most important pillars in preventative medicine, providing protection against a wide array of diseases by inducing humoral and/or cellular immunity. Of the many possible candidate antigens for subunit vaccine development, carbohydrates are particularly appealing because of their ubiquitous presence on the surface of all living cells, viruses, and parasites as well as their known interactions with both innate and adaptive immune cells. Indeed, several licensed vaccines leverage bacterial cell-surface carbohydrates as antigens for inducing antigen-specific plasma cells secreting protective antibodies and the development of memory T and B cells. Carbohydrates have also garnered attention in other aspects of vaccine development, for example, as adjuvants that enhance the immune response by either activating innate immune responses or targeting specific immune cells. Additionally, carbohydrates can function as immunomodulators that dampen undesired humoral immune responses to entire protein antigens or specific, conserved regions on antigenic proteins. In this review, we highlight how the interplay between carbohydrates and the adaptive and innate arms of the immune response is guiding the development of glycans as vaccine components that act as antigens, adjuvants, and immunomodulators. We also discuss how advances in the field of synthetic glycobiology are enabling the design, engineering, and production of this new generation of carbohydrate-containing vaccine formulations with the potential to prevent infectious diseases, malignancies, and complex immune disorders.

"It's a lot more complicated than it seems": physiotherapists' experiences of using compensation strategies in people with Parkinson's.

Background: Gait disturbances often result in functional limitations in daily activities and negatively impact the quality of life in people with Parkinson's disease. Physiotherapists often employ compensation strategies in an attempt to improve patients' walking. However, little is known about physiotherapists' experiences in this regard. We evaluated how physiotherapists adopt compensation strategies and what they draw on to inform their clinical decision-making. Methods: We carried out semi-structured online interviews with 13 physiotherapists with current or recent experience working with people with Parkinson's disease in the United Kingdom. Interviews were digitally recorded and transcribed verbatim. Thematic analysis was utilized. Results: Two main themes were developed from the data. The first theme, optimizing compensation strategies through personalized care, shows how physiotherapists accounted for the individual needs and characteristics of people with Parkinson's, which resulted in them individually tailoring compensation strategies. The second theme, delivering compensation strategies effectively, considers the available support and perceived challenges with work settings and experience that impact physiotherapists' ability to deliver compensation strategies. Discussion: Although physiotherapists strived to optimize compensation strategies, there was a lack of formal training in this area, and their knowledge was primarily acquired from peers. Furthermore, a lack of specific knowledge on Parkinson's can impact physiotherapists' confidence in maintaining person-centered rehabilitation. However, the question that remains to be answered is what accessible training could address the knowledge-practice gap to contribute to the delivery of better-personalized care for people with Parkinson's.

Participant expectations and experiences of a tailored physiotherapy intervention for people with Parkinson's and a history of falls.

PURPOSE: People with Parkinson's are twice as likely to fall as older people within the general population. This longitudinal qualitative study was part of a larger programme of research including a randomised controlled trial to test the effectiveness of a tailored physiotherapy intervention. Specific qualitative aims focused on a subsample of trial participants in the intervention arm of the trial, and comprised the following:To explore the expectations of participants about the intervention.To investigate participants' experiences of the intervention, and its perceived impacts.To understand the facilitators and barriers to engagement. METHODS: Two semi-structured interviews were completed with a theoretical sample of people with Parkinson's from the intervention arm, initially after randomisation but before the intervention commenced, and then again six months later. RESULTS: Forty-two participants out of a large clinical trial were interviewed initially, with 37 agreeing to a second interview at six months. Prior experience of rehabilitation plus information accessed through the trial consent procedure informed participants' realistic expectations. Most found the level of the intervention acceptable, and perceived a range of benefits. However, views about equipment provided were more equivocal. The biggest barriers to participation were time and motivation, whilst social support facilitated engagement with the intervention. CONCLUSIONS: This study is the first to capture expectations about participation in a programme of exercises and strategies. It highlights that previous challenges to engagement in physical exercises and activities are not a barrier to future participation and provides new insights into the role of equipment and technology in programmes of physical activity for people with Parkinson's. The challenge of ensuring that programmes of exercise and strategies become an embedded feature of everyday life is highlighted, particularly alongside busy social engagements and leisure pursuits.Implications for rehabilitationFor people with Parkinsons, a programme of exercises and strategies has the potential to reduce the risk of falls amongst those with a history of falling.Adherence to such programmes can prove challenging for a variety of reasons, even when participants have realistic expectations about the commitment and effort needed.Clear explanations about the role of equipment and technology within such programmes could enhance adherence.In order to further individualise programmes of exercise for people with Parkinsons, choice regarding social support, reminders and integration into everyday activities should be explored.

Shotgun scanning glycomutagenesis: A simple and efficient strategy for constructing and characterizing neoglycoproteins.

As a common protein modification, asparagine-linked (N-linked) glycosylation has the capacity to greatly influence the biological and biophysical properties of proteins. However, the routine use of glycosylation as a strategy for engineering proteins with advantageous properties is limited by our inability to construct and screen large collections of glycoproteins for cataloguing the consequences of glycan installation. To address this challenge, we describe a combinatorial strategy termed shotgun scanning glycomutagenesis in which DNA libraries encoding all possible glycosylation site variants of a given protein are constructed and subsequently expressed in glycosylation-competent bacteria, thereby enabling rapid determination of glycosylatable sites in the protein. The resulting neoglycoproteins can be readily subjected to available high-throughput assays, making it possible to systematically investigate the structural and functional consequences of glycan conjugation along a protein backbone. The utility of this approach was demonstrated with three different acceptor proteins, namely bacterial immunity protein Im7, bovine pancreatic ribonuclease A, and human anti-HER2 single-chain Fv antibody, all of which were found to tolerate N-glycan attachment at a large number of positions and with relatively high efficiency. The stability and activity of many glycovariants was measurably altered by N-linked glycans in a manner that critically depended on the precise location of the modification. Structural models suggested that affinity was improved by creating novel interfacial contacts with a glycan at the periphery of a protein-protein interface. Importantly, we anticipate that our glycomutagenesis workflow should provide access to unexplored regions of glycoprotein structural space and to custom-made neoglycoproteins with desirable properties.

'Digital Dancing' - "Can you see, what I feel" - An exploration of the physical 'experience' of dance for Parkinson's through 3-dimensional motion analysis.

BACKGROUND: Parkinson's is a common, progressive, neurodegenerative movement disorder of the central nervous system. Research has consistently shown that dancing can have a positive impact on the lives of people living with Parkinson's (PwP). PwP who dance report that current measurement of the effects fails to appreciate the multifactorial presentation of the condition as well as the biopsychosocial potential of dance holistically. AIM: To explore the feasibility of combining measurements of whole-body movement using 3-dimensional motion analysis with the lived experience of dance for PwP, to see if it is possible to 'see (measure)' what PwP say they 'feel (experience)' when dancing, in a 'mind/body approach' METHOD: : Thirteen PwP and ten Carers took part in three community delivered 'Parkinson's Dance Science' classes followed by focus group reflection. Three PwP wore a 3-dimensional, motion capture suit that recorded whole-body movement throughout the class and were interviewed about their experiences. Data were analysed using a 'Convergent Parallel' mixed methods design, mapping participant's experiences and reflections over six biomechanical movement variables. RESULTS: Quantitative results indicate that it is possible to use 3-dimensional motion capture to measure biomechanical change during and following dance in PwP but the amount and direction of change was different for each participant. Qualitative results showed PwP felt the methods were feasible and reported a positive immediate and long-term effect of dance in a complete 'mind/body experience'. The sample size did not permit further analysis, but areas of development suggest it may not be the change in physical ability that is important, but more the perception of change following dance that is unique to each individual. Thus single measures of the effects of dance for PwP are likely to be insufficient when trying to understand the effect holistically. CONCLUSION: A 'Convergent Parallel' mixed methods research design, mapping the experience of dance for PwP ('what I feel') and their peers against biomechanical change ('what you see') following dance is feasible. Further research is required to develop the method with a larger sample to truly begin to understand the potential and effects of dance for PwP.

Cost-effectiveness of the PDSAFE personalised physiotherapy intervention for fall prevention in Parkinson's: an economic evaluation alongside a randomised controlled trial.

BACKGROUND: PDSAFE is an individually-tailored, physiotherapist-delivered, balance, strength and strategy training programme aimed at preventing falls among people with Parkinson's. We evaluated the cost-effectiveness of PDSAFE compared with usual care for people with Parkinson's at higher risk of falling, from a UK National Health Service and Personal Social Service perspective. METHODS: Resource use and quality of life data (EQ-5D-3L) were collected from 238 participants randomised to the PDSAFE intervention and 236 participants randomised to control, at baseline, 3 months, 6 months (primary outcome), and 12 months. Adjusted cost and quality-adjusted life-years (QALYs) were estimated using generalised linear models and uncertainty estimated using a non-parametric bootstrap. RESULTS: Over 6 months, the PDSAFE intervention was associated with an incremental cost of £925 (95% CI £428 to £1422) and a very small and statistically insignificant QALY gain of 0.008 (95% CI - 0.006 to 0.021). The resulting incremental cost-effectiveness ratio (ICER) was £120,659 per QALY and the probability of the intervention being cost-effective at a UK threshold of £30,000/QALY was less than 1%. The ICER varied substantially across subgroups although no subgroup had an ICER lower than the £30,000 threshold. The result was sensitive to the time horizon with the ICER reducing to £55,176 per QALY when adopting a 12-month time horizon and assuming a sustained treatment effect on QoL, nevertheless, the intervention was still not cost-effective according to the current UK threshold. CONCLUSIONS: Evidence from this trial suggests that the PDSAFE intervention is unlikely to be cost-effective at 6 months. The 12-month analysis suggested that the intervention became closer to being cost-effective if quality of life effects were sustained beyond the intervention period, however this would require confirmation. Further research, including qualitative studies, should be conducted to better understand the treatment effect of physiotherapy and its impact on quality of life in people with Parkinson's given existing mixed evidence on this topic. TRIAL REGISTRATION: ISRCTN48152791. Registered 17 April 2014. http://www.isrctn.com/ISRCTN48152791.

'Mind the gap' - a scoping review of long term, physical, self-management in Parkinson's.

BACKGROUND: Parkinson's is a common progressive neurological condition characterised by impairments of movement and balance; and non-motor deficits. It is now accepted that physical activity is a fundamental for people with Parkinson's (PwP), despite this PwP remain inactive. There is a social and financial drive to increase physical activity for PwP through physical self-management, however little is known about this concept. OBJECTIVE: This scoping review provides an overview of the literature concerning physical self-management for PwP and its provision, participation and uptake by PwP. DESIGN AND SOURCES OF EVIDENCE: Systematic search of the databases; Medline, EMBASE, HMIC, CDSR, Cochrane Methods Studies, DARE, CINAHL, PEDro, PsycINFO and Cochrane Library using the search terms 'Parkinson*' and 'self-manag*' was undertaken alongside citation and grey literature searching and a consultation exercise. CHARTING METHODS: A narrative summary was undertaken to describe the current state of the literature. RESULTS: 1959 studies were identified with nineteen papers from seventeen studies meeting the inclusion criteria - Three reviews, four experimental studies, three pre-post-test designs, six cross-sectional designs, one qualitative interview design and two mixed method designs. CONCLUSION: The findings of this scoping review suggest a need for clarity on what 'physical self-management' means and involves, with a gap between what the evidence promotes and what is being achieved by PwP. Further research should focus on the amount, type, intensity and duration of physical self-management models including behavioural change approaches and how, where and by whom this should be implemented.

Exercise- and strategy-based physiotherapy-delivered intervention for preventing repeat falls in people with Parkinson's: the PDSAFE RCT.

BACKGROUND: People with Parkinson's disease are twice as likely to experience a fall as a healthy older person, often leading to debilitating effects on confidence, activity levels and quality of life. OBJECTIVE: To estimate the effect of a physiotherapy programme for fall prevention among people with Parkinson's disease. DESIGN: A multicentre, pragmatic, investigator-masked, individually randomised controlled trial (RCT) with prespecified subgroup analyses. SETTING: Recruitment from NHS hospitals and clinics and community and social services in eight English regions with home-based interventions. PARTICIPANTS: A total of 474 people with Parkinson's disease (i.e. Hoehn and Yahr scale stages 1-4) were recruited: 238 were assigned to a physiotherapy programme and 236 were assigned to usual care. Random allocation was 50 : 50. INTERVENTIONS: All participants received routine care; the usual-care group received an information digital versatile disc (DVD) and a single advice session at trial completion. The intervention group had an individually tailored, progressive, home-based fall avoidance strategy training programme with balance and strengthening exercises: PDSAFE. MAIN OUTCOME MEASURES: The primary outcome was the risk of repeat falling, collected by self-report monthly diaries between 0 and 6 months after randomisation. Secondary outcomes included near-falls, falls efficacy, freezing of gait (FoG), health-related quality of life, and measurements taken using the Mini-Balance Evaluation Systems Test (Mini-BESTest), the Chair Stand Test (CST), the Geriatric Depression Scale, the Physical Activity Scale for the Elderly and the Parkinson's Disease Questionnaire. RESULTS: PDSAFE is the largest RCT of falls management among people with Parkinson's disease: 541 patients were screened for eligibility. The average age was 72 years, and 266 out of 474 (56%) participants were men. Of the 474 randomised participants, 238 were randomised to the intervention group and 236 were randomised to the control group. No difference in repeat falling within 6 months of randomisation was found [PDSAFE group to control group odds ratio (OR) 1.21, 95% confidence interval (CI) 0.74 to 1.98; p = 0.447]. An analysis of secondary outcomes demonstrated better balance (Mini-BESTest: mean difference 0.95, 95% CI 0.24 to 1.67; p = 0.009), functional strength (CST: p = 0.041) and falls efficacy (Falls Efficacy Scale - International: mean difference 1.6, 95% CI -3.0 to -0.19; p = 0.026) with near-falling significantly reduced with PDSAFE (OR 0.67, 95% CI 0.53 to 0.86; p = 0.001) at 6 months. Prespecified subgroup analysis (i.e. disease severity and FoG) revealed a PDSAFE differing effect; the intervention may be of benefit for people with moderate disease but may increase falling for those in the more severe category, especially those with FoG. LIMITATIONS: All participants were assessed at primary outcome; only 73% were assessed at 12 months owing to restricted funding. CONCLUSIONS: PDSAFE was not effective in reducing repeat falling across the range of people with Parkinson's disease in the trial. Secondary analysis demonstrated that other functional tasks and self-efficacy improved and demonstrated differential patterns of intervention impact in accordance with disease severity and FoG, which supports previous secondary research findings and merits further primary evaluation. FUTURE WORK: Further trials of falls prevention on targeted groups of people with Parkinson's disease are recommended. TRIAL REGISTRATION: Current Controlled Trials ISRCTN48152791. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 36. See the NIHR Journals Library website for further project information. Sarah E Lamb is funded by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) at Oxford Health NHS Foundation Trust, the NIHR Oxford Biomedical Research Centre at the Oxford University Hospitals NHS Foundation Trust and CLAHRC Oxford. Victoria A Goodwin is supported by the NIHR Collaborations for Leadership in Applied Health Research and Care in the South West Peninsula (PenCLAHRC). Lynn Rochester is supported by the NIHR Newcastle Biomedical Research Centre based at Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University. The research was also supported by the NIHR Newcastle Clinical Research Facility Infrastructure funding. Helen C Roberts is supported by CLAHRC Wessex and the NIHR Southampton Biomedical Research Centre.

People with Parkinson's disease fall often. Falls are scary and make moving about harder. The PDSAFE trial tested a new 'home physiotherapy' programme for reducing falls. People with Parkinson's disease were allocated to one of two groups by chance: they either received the PDSAFE exercises or just normal care. The costs were looked at and people were asked for their views of the PDSAFE exercises. To take part, people had to have Parkinson's disease, live in their own home, be able to walk, have had at least one fall in the previous year and pass a memory test. PDSAFE was taught by physiotherapists and included exercises and fall avoidance strategies. Everyone had to record falls on a monthly calendar, and balance, strength and walking were tested. To our knowledge, this was the largest falls trial looking at people with Parkinson's disease in the world: 541 people took part. The number of falls an individual reported differed a lot between people. When all people with Parkinson's disease in the trial were considered, the physiotherapy programme did not reduce falls in the first 6 months. However, it was found that some people had fewer falls after taking part in the exercises, whereas others did not. Those with more severe Parkinson's disease (i.e. problems with movement, memory and freezing of gait) fell more often after the PDSAFE intervention, even though their balance and confidence improved. Those with good memory, moderate disease and two or three falls in the previous year reacted well to PDSAFE and had fewer falls. It was found that PDSAFE reduced near-falls (about to fall but managed to save themselves) and improved balance and confidence. The physiotherapists and those who took part liked the programme and felt that it helped, but it was expensive to run. In conclusion, a falls prevention programme should be based on each person's needs and a different treatment should be used for those with more severe Parkinson's disease.

Multicentre, randomised controlled trial of PDSAFE, a physiotherapist-delivered fall prevention programme for people with Parkinson's.

OBJECTIVE: To estimate the effect of a physiotherapist-delivered fall prevention programme for people with Parkinson's (PwP). METHODS: People at risk of falls with confirmed Parkinson's were recruited to this multicentre, pragmatic, investigator blind, individually randomised controlled trial with prespecified subgroup analyses. 474 PwP (Hoehn and Yahr 1-4) were randomised: 238 allocated to a physiotherapy programme and 236 to control. All participants had routine care; the control group received a DVD about Parkinson's and single advice session at trial completion. The intervention group (PDSAFE) had an individually tailored, progressive home-based fall avoidance strategy training programme with balance and strengthening exercises. The primary outcome was risk of repeat falling, collected by self-report monthly diaries, 0-6 months after randomisation. Secondary outcomes included Mini-BESTest for balance, chair stand test, falls efficacy, freezing of gait, health-related quality of life (EuroQol EQ-5D), Geriatric Depression Scale, Physical Activity Scale for the Elderly and Parkinson's Disease Questionnaire, fractures and rate of near falling. RESULTS: Average age is 72 years and 266 (56%) were men. By 6 months, 116 (55%) of the control group and 125 (61.5%) of the intervention group reported repeat falls (controlled OR 1.21, 95% CI 0.74 to 1.98, p=0.447). Secondary subgroup analyses suggested a different response to the intervention between moderate and severe disease severity groups. Balance, falls efficacy and chair stand time improved with near falls reduced in the intervention arm. CONCLUSION: PDSAFE did not reduce falling in this pragmatic trial of PwP. Other functional tasks improved and reduced fall rates were apparent among those with moderate disease. TRIAL REGISTRATION NUMBER: ISRCTN48152791.

"Staying safe" - a narrative review of falls prevention in people with Parkinson's - "PDSAFE".

Background: Parkinson's disease demonstrates a spectrum of motor and non-motor symptoms. Falling is common and disabling. Current medical management shows minimal impact to reduce falls or fall-related risk factors, such as deficits in gait, strength, and postural instability. Despite evidence supporting rehabilitation in reducing fall risk factors, the most appropriate intervention to reduce overall fall rate remains inconclusive. This article aims to 1) synthesise current evidence and conceptual models of falls rehabilitation in Parkinson's in a narrative review; and based on this evidence, 2) introduce the treatment protocol used in the falls prevention and multi-centre clinical trial "PDSAFE". Method: Search of four bibliographic databases using the terms "Parkinson*" and "Fall*" combined with each of the following; "Rehab*, Balanc*, Strength*, Strateg*and Exercis*" and a framework for narrative review was followed. A total of 3557 papers were identified, 416 were selected for review. The majority report the impact of rehabilitation on isolated fall risk factors. Twelve directly measure the impact on overall fall rate. Discussion: Results were used to construct a narrative review with conceptual discussion based on the "International Classification of Functioning", leading to presentation of the "PDSAFE" intervention protocol. Conclusions: Evidence suggests training single, fall risk factors may not affect overall fall rate. Combining with behavioural and strategy training in a functional, personalised multi-dimensional model, addressing all components of the "International Classification of Functioning" is likely to provide a greater influence on falls reduction. "PDSAFE" is a multi-dimensional, physiotherapist delivered, individually tailored, progressive, home-based programme. It is designed with a strong evidence-based approach and illustrates a model for the clinical delivery of the conceptual theory discussed. Implications for Rehabilitation Parkinson's disease demonstrates a spectrum of motor and non-motor symptoms, where falling is common and disabling. Current medical and surgical management have minimal impact on falls, rehabilitation of falls risk factors has strong evidence but the most appropriate intervention to reduce overall fall rate remains inconclusive. Addressing all components of the International Classification of Function in a multifactorial model when designing falls rehabilitation interventions may be more effective at reducing fall rates in people with Parkinson's than treating isolated risk factors. The clinical model for falls rehabilitation in people with Parkinson's should be multi-dimensional.

It takes two: the influence of dance partners on the perceived enjoyment and benefits during participation in partnered ballroom dance classes for people with Parkinson's.

PURPOSE: To explore the views of people with Parkinson's and their dance partners on the influence and issues surrounding dancing with an able-bodied dance partner during partnered ball room dance classes. METHODS: In depth, semi-structured interviews explored purposively selected participants' experiences and views about dance classes. Fourteen people with Parkinson's and their dance partners (six spouses, two friends/relatives, five volunteers) were interviewed within a month of completing the 10-week dance class program. Data were analyzed thematically. RESULTS: Generally, those partnered with a spouse or an experienced dancer, or when dance couples were able to develop good rapport, gained greater enjoyment and sense of achievement from dance classes in comparison to couples who did not enjoy dancing together or had clashing approaches to dance. Managing and negotiating who would "lead" in a dance was challenging for dance couples particularly among male people with Parkinson's. CONCLUSIONS: People with Parkinson's experience of the dance classes were influenced by the relationship and compatibility with their dance partner. Dance partnerships may impact on recruitment, enjoyment, outcome and continued participation in dance classes. Potential effects of partnerships should be analyzed and reported in studies evaluating the outcomes of dance classes. Implications for rehabilitation We recommend that health professionals consider involving spouses in Parkinson's dance classes as this may improve recruitment, adherence, enjoyment and overall outcome of the dance classes. If volunteers are needed, aim to recruit those who already have good dancing ability, convey a love of dancing and have the sensitivity and social skills to interact positively with the person with Parkinson's. Consider dance partnership issues when advertising and promoting dance classes. Address partnership issues through open communication and by changing partners if the dance partnership is not working well.

Dance for Parkinson's-The effects on whole body co-ordination during turning around.

OBJECTIVE: To investigate the effects of ballroom and Latin American dancing classes on turning in people with Parkinson's. DESIGN: This study employed a randomised, controlled, experimental design. SETTING: Dance classes were performed in a community dance centre in Southern England and all assessments took place a gait laboratory. PARTICIPANTS: Twenty-seven people with mild-moderate Parkinson's participated. INTERVENTION: Participants were randomly allocated to receive either 20, 1-h dancing classes over 10 weeks (n=15), or a 'usual care' control group (n=12). MAIN OUTCOME MEASURE: Twelve, 180° on-the-spot turns to the predicted/un-predicted and preferred/un-preferred direction were analysed for each participant, using 3-dimensional motion analysis before and after the intervention period, alongside clinical measures. RESULTS: Movement of the head, pelvis, and feet during turning in people with Parkinson's are affected by dancing with tighter coupling of body segments. Significant 4-way interactions between the groups, over time and turn style, with longer latency of the head (p=0.008) and greater rotation in the pelvis (p=0.036), alongside a trend of slower movement of the first (p=0.063) and second (p=0.081) foot in controls were shown, with minimal change in dancers. All interactions were affected by the type of turn. No significant differences were found in the centre of mass displacement, turn time or clinical measures. CONCLUSION: Those who danced were better able to coordinate their axial and perpendicular segments and surprisingly became more 'en bloc' in their turning behaviour, suggesting this may be a beneficial adaptation, rather than a maladaptive result of Parkinson's, as previously suggested.

A narrative review of turning deficits in people with Parkinson's disease.

PURPOSE: Clinically, people with Parkinson's disease (PD) demonstrate a loss of axial rotation of the spine often described as moving "enbloc", with little dissociation between the head, trunk and lower limbs whilst turning. The purpose of this narrative review is to explore the behaviour and relationship of the reported deficits during whole body turning in people with PD, compared to controls. Better understanding of the relationship and impact of the deficits will permit the development of tailored and novel intervention strategies to improve functional performance in turning for people with PD. METHODS: Four electronic databases with the search terms: Parkinson* and turn* were used. RESULTS: Seventy-seven papers were reviewed. Turning deficits in people with PD were identified as originating from two hypothetical body segments - perpendicular (i.e. legs) or axial (i.e. head, trunk and pelvis) segments and the relationship between them discussed. CONCLUSION: Specific movement deficits in turning in people with PD can be categorised into axial and perpendicular deficits. Synthesis of the literature suggests the possibility of axial deficits driving secondary responses in the perpendicular segments. This should be explored when designing rehabilitation aimed at improving turning performance, as current therapy guidelines focus on exercises emphasising perpendicular aspects. Implications for Rehabilitation Turning performance is compromised in people with PD, which can lead to significant disability, falls and loss of function. Specific movement deficits can be categorised into perpendicular deficits (taking more steps and shorter steps and an altered turn strategy) and axial deficits (segment rigidity, altered segment co-ordination and timing, reduced segment rotation and the effects of altered posture). Axial deficits may drive secondary responses in the perpendicular segments during turning in people with PD. Therefore, specific focus should be made to the rehabilitation of the axial deficits alongside those of the perpendicular body segments in the design of multi-modal treatment strategies to improve turning performance.

A design to investigate the feasibility and effects of partnered ballroom dancing on people with Parkinson disease: randomized controlled trial protocol.

BACKGROUND: Self-help and physical leisure activities has become increasingly important in the maintenance of safe and functional mobility among an increasingly elderly population. Preventing the cycle of deterioration, falling, inactivity, dependency, and secondary complications in people with Parkinson disease (PD) is a priority. Research has shown that people with PD are interested in dance and although the few existing trials are small, initial proof of principle trials from the United States have demonstrated beneficial effects on balance control, gait, and activity levels. To our knowledge, there has been no research into long-term effects, cost effectiveness, the influence on spinal posture and turning, or the personal insights of dance participants. OBJECTIVE: The purpose of this study was to determine the methodological feasibility of conducting a definitive phase III trial to evaluate the benefits of dance in people with PD. We will build on the proof of principle trials by addressing gaps in knowledge, focusing on areas of greatest methodological uncertainty; the choice of dances and intensity of the program; for the main trial, the availability of partners, the suitability of the currently envisaged primary outcomes, balance and spinal posture; and the key costs of delivering and participating in a dance program to inform economic evaluation. METHODS: Fifty participants (mild-to-moderate condition) will be randomized to the control (usual care) or experimental (dance plus usual care) groups at a ratio of 15:35. Dance will be taught by professional teachers in a dance center in the South of England. Each participant in the experimental group will dance with his or her spouse, a friend, or a partner from a bank of volunteers. A blinded assessor will complete clinical measures and self-reported ability at baseline, and at 3 and 6 months after randomization. A qualitative study of a subgroup of participants and partners will examine user's views about the appropriateness and acceptability of the intervention, assessment protocol, and general trial procedures. Procedures for an economic evaluation of dance for health care will be developed for the main trial. RESULTS: Recruitment began in January 2013 and the last participant is expected to complete the trial follow-up in June 2014. CONCLUSIONS: Findings from our study may provide novel insights into the way people with PD become involved in dance, their views and opinions, and the suitability of our primary and secondary outcomes. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 63088686; http://www.controlled-trials.com/ISRCTN63088686/63088686 (Archived by WebCite at http://www.webcitation.org/6QYyjehP7).