Clinical and neuroimaging correlates in a pilot randomized trial of aerobic exercise for major depression.

BACKGROUND: Aerobic exercise (AE) combined with pharmacotherapy is known to reduce depressive symptoms; however, studies have not focused on long-term AE for volumetric changes of brain regions (amygdala, thalamus, and nucleus accumbens [NAcc]) linked to the control of affective responses and hopelessness in individuals with major depression (MD). In addition, AE with motor complexity (AEMC) would be more effective than AE in causing brain plasticity. We compared the effects of 24 weeks of AE and AEMC combined with pharmacotherapy on clinical and volumetric outcomes in individuals with MD. METHODS: Forty medicated individuals with MD were randomly assigned to nonexercising control (C), AE, and AEMC groups. The training groups exercised for 60 min, twice a week for 24 weeks. Clinical and volumetric outcomes were assessed before and after the 24 weeks. Effect size (ES) and confidence interval (CI) were calculated for within-group and between-groups changes. RESULTS: AE and AEMC reduced hopelessness (ES = -0.73 and ES = -0.62, respectively) and increased affective responses (ES = 1.24 and ES = 1.56, respectively). Only AE increased amygdala (ES = 0.27 left and ES = 0.34 right), thalamus (ES = 0.33 left and ES = 0.26 right) and left NAcc (ES = 0.54) volumes. AE was more effective than the C group in reducing hopelessness and causing brain plasticity. The changes in the right amygdala volume showed a strong trend in explaining 72 % of the changes in affective responses following AE (p = 0.06). LIMITATION: Lack of posttraining follow-up and small sample size. CONCLUSION: These preliminary data indicate that AE combined with pharmacotherapy can cause clinical improvement and brain plasticity in individuals with MD.

Telerehabilitation during social distancing for people with Parkinson's disease: a retrospective study.

INTRODUCTION/AIM: Clinical worsening has been common in people with Parkinson's disease (PD) during the social distancing due to pandemic. It is unclear if telerehabilitation applied during social distancing preserves clinical aspects of people with PD who are frequent exercisers before the pandemic. Thus, we compared the effects of 10 months of supervised, home-based, real-time videoconferencing telerehabilitation (SRTT) and nonexercising control on clinical aspects in people with PD who are frequent exercisers before the pandemic. METHODS: Fifty-seven (SRTT group) and 29 (nonexercising control group) people with PD were retrospectively assessed (Clinical Trials Registry: RBR-54sttfk). Only the SRTT group performed a 60-min online training sessions, 2-3 days per week, for 10 months (April 2020 to January 2021) during social distancing. Quality of life (PD Questionnaire [PDQ-39]), walking (item 28 from the Unified Parkinson's Disease Rating Scale part III [UPDRS-III]), posture (item 29 from the UPDRS-III), and freezing of gait (New-FOG questionnaire [NFOGQ]) were retrospectively assessed before (February-March 2020) and during social distancing (February-March 2021). The assessments were performed in-person and remotely before and during social distancing, respectively. RESULTS: There were no between-group differences at baseline (p > 0.05). SRTT preserves PDQ-39 and walking scores but not posture and NFOGQ scores, while nonexercising control worsens scores in all variables. In addition, SRTT is more effective than nonexercising control in preserving PDQ-39 and walking scores. CONCLUSION: During social distancing, long-term SRTT preserves the subjective quality of life and walking, but not subjective posture and FOG in people with PD who are frequent exercisers before the pandemic.

Cognitive and emotional factors influence specific domains of postural control in individuals with moderate-to-severe Parkinson's disease.

INTRODUCTION: Cognition and emotional state are domains that highly interfere with postural control in individuals with Parkinson's disease (PD). This study aims to find associations between executive function, anxiety, depression, and reactive and anticipatory postural control domains in individuals with moderate-to-severe Parkinson's disease. METHODS: In this study, 34 individuals with PD while on medication were thoroughly assessed for postural control in perturbed, quiet standing and stepping. We performed multiple linear stepwise regressions using postural variables as dependent and cognitive/emotional as independent variables. RESULTS: The results showed that cognitive flexibility explained 23 % of anticipatory postural adjustments (APA) duration, inhibitory control explained 42 % of instability on a malleable surface, anxiety explained 21 % of APA amplitude, and 38 % of reactive postural response amplitude. CONCLUSION: Our results highlight the impact of emotional and cognitive states on particular domains of postural control in individuals with PD while on medication. These results may have significant implications for future treatments, mainly considering the predictors for postural control domains, which were consistent with the assumption that impairments in affective and executive domains underlie posture. As we have shown that cognitive and emotional states influence postural control domains in individuals with PD, this should be taken into account in rehabilitation protocols.

Freezing of gait, gait initiation, and gait automaticity share a similar neural substrate in Parkinson's disease.

Individuals with Parkinson's disease (PD) and freezing of gait (FOG) have difficulty initiating and maintaining a healthy gait pattern; however, the relationship among FOG severity, gait initiation, and gait automaticity, in addition to the neural substrate of this relationship has not been investigated. This study investigated the association among FOG severity during turning (FOG-ratio), gait initiation (anticipatory postural adjustment [APA]), and gait automaticity (dual-task cost [DTC]), and the neural substrates of these associations. Thirty-four individuals with FOG of PD were assessed in the ON-medication state. FOG-ratio during a turning test, gait automaticity using DTC on stride length and gait speed, and APA during an event-related functional magnetic resonance imaging protocol to assess brain activity from the regions of interest (e.g., dorsolateral prefrontal cortex [DLPFC] and mesencephalic locomotor region [MLR]) were assessed in separated days. Results showed that FOG-ratio, APA amplitude, and DTC on stride length are negatively associated among them (P < 0.05). APA amplitude and DTC on stride length explained 59% of the FOG-ratio variance (P < 0.05). Although the activity of the right DLPFC and right MLR explained 55% of the FOG-ratio variance (P < 0.05) and 30% of the DTC on stride length variance (P ≤ 0.05), only the activity of the right MLR explained 23% of the APA amplitude (P < 0.05). FOG severity during turning, APA amplitude, and stride length automaticity are associated among them and share a similar locomotor substrate, as the MLR activity was a common brain region in explaining the variance of these variables.

Can remotely supervised exercise positively affect self-reported depressive symptoms and physical activity levels during social distancing?

The main objective of this cross-sectional study was to compare the self-reported depressive symptoms and physical activity (PA) levels among participants who performed self- nonexercising (NE), guided exercise (SGE), remotely supervised exercise (RSE), and face-to-face supervised exercise (FFE) during social distancing. Three hundred and forty-four individuals (≥18 years and 67% women) answered a self-reported online survey that included questions related to the physical exercise practice (e.g., supervised and remote) during social distancing and questions about perceptions of depressive symptoms (Montgomery-Åsberg Depression Rating Scale-Self Rated [MADRS-S] scores) and metabolic equivalent task minutes per week (METs min•wk-1) of moderate- and vigorous-intensity PA, and total PA scores (International Physical Activity Questionnaire-Short Form) before and during social distancing. The RSE group (n=45) showed higher METs of vigorous-intensity PA than the SGE (n=146) and NE (n=109) groups. The RSE and FFE (n=44) groups showed higher METs of the total PA scores than the SGE and NE groups. The NE group showed higher MADRS-S scores than the other groups. Lower MADRS-S scores depend on the exercise practice and higher METs of vigorous-intensity PA depend on the supervised exercise practice. Thus, telehealth interventions can be implemented during the pandemic to enhance vigorous PA.

Poor sleep quality is associated with cognitive, mobility, and anxiety disability that underlie freezing of gait in Parkinson's disease.

BACKGROUND: Individuals with Parkinson's disease (PD) who report freezing of gait (FOG) have poorer sleep quality than those without FOG. Cognitive, anxiety, and mobility disability are components of the FOG phenotype, however, no study has investigated if poor sleep quality is associated with all three components that underlie FOG in PD. RESEARCH QUESTION: Are there associations among sleep quality and all three components of the FOG phenotype? METHODS: Forty and 39 individuals with and without FOG (PD + FOG and PD-FOG), respectively, and 31 age-matched healthy controls (HC) participated in this study. Self-reported FOG (new-FOG questionnaire-NFOGQ), sleep quality (Pittsburgh Sleep Quality Index-PSQI), cognitive function (Montreal Cognitive Assessment-MoCA), anxiety (subscale from Hospital Anxiety and Depression Scale-HADS-A), and mobility (timed-up-and-go test-TUG) were assessed. RESULTS AND SIGNIFICANCE: PSQI scores were correlated with the scores of NFOGQ, MoCA, HADS-A, and TUG time in PD + FOG (P ≤ 0.0038). The multiple regression analysis identified the PSQI scores as the only predictor of the variance of the NFOGQ scores (R2 = 0.46, P < .0001). The variance in the PSQI scores were explained (69 %) by MoCA scores, NFOGQ scores, TUG time, and HADS-A scores (P ≤ 0.05). Although PD + FOG had a higher disease severity compared to PD-FOG (P < 0.001), disease severity did not enter in the regression model to explain PSQI scores and NFOGQ scores. We also observed associations of PSQI scores with the MoCA scores and TUG time for HC (P ≤ 0.0038), whereas there was no association between PSQI scores and any variable in PD-FOG (P > 0.05). Finally, PD + FOG presented worse scores of PSQI, MoCA, HADS-A, and TUG time than PD-FOG and HC (P < 0.05). Thus, poor sleep quality is associated with FOG and all three components that underlie FOG, regardless of the disease severity. Therefore, treatments useful to decrease FOG should be targeted to ameliorate sleep quality, cognition, anxiety, and mobility.

Minimal Detectable Change for Balance Using the Biodex Balance System in Patients with Parkinson Disease.

BACKGROUND: Minimal detectable change (MDC) when assessing balance using the Biodex Balance System (BBS) in patients with Parkinson disease (PD) is currently unknown, limiting the interpretability of the scores. OBJECTIVE: To determine the MDC on the Anterior/Posterior Stability Index (APSI), Medial/Lateral Stability Index (MLSI), and Overall Stability Index (OSI) from postural stability and fall risk protocols of the BBS in patients with PD. DESIGN: This was a repeated-measures design (at a 1-week interval). SETTING: Strength training laboratory of a public university. PATIENTS: 46 patients with PD (men and women) at stages 2 and 3 (67.9 ± 7.4 years old) were assessed in the "on" state (fully medicated). METHODS: Patients performed three trials of 20 s for each protocol. MAIN OUTCOME MEASUREMENTS: Absolute and relative MDC (MDC%) calculated for APSI, MLSI, and OSI from the postural stability (stable condition) and fall risk protocols (unstable condition). RESULTS: For the postural stability, the MDC and MDC% were 0.26° and 17% for APSI, 0.41° and 21% for MLSI, and 0.22° and 12% for OSI, respectively. For the fall risk, the MDC and MDC% were 0.51° and 18% for APSI, 0.21° and 15% for MLSI, and 0.41° and 20% for OSI, respectively. These results were considered acceptable, despite indices with high MDC for MLSI (postural stability) and APSI (fall risk). CONCLUSIONS: Patients with PD have more mediolateral and anteroposterior changes in the stable and unstable conditions, respectively. These abnormal balance strategies can occur principally due to postural instability of PD. However, our results demonstrated acceptable MDCs in both conditions in all of the assessed axes. Thus, BBS should be incorporated into the clinical evaluation to help therapists to determine if intervention-induced changes in balance are clinically significant or due to measurement error. LEVEL OF EVIDENCE: II.

Aerobic exercise program with or without motor complexity as an add-on to the pharmacological treatment of depression - study protocol for a randomized controlled trial.

BACKGROUND: Patients with major depression disorder presents increased rates of cognitive decline, reduced hippocampal volume, poor sleep quality, hypertension, obesity, suicidal ideation and behavior, and decreased functionality. Although continuous aerobic exercise (CAE) improves some of the aforementioned symptoms, comorbidities, and conditions, recent studies have suggested that performing aerobic exercise with motor complexity (AEMC) may be more beneficial for cognitive decline, hippocampal volume, and functionality. Therefore, this randomized controlled trial will compare the effects of CAE and AEMC on depression score, cognitive function, hippocampal volume, brain-derived neurotrophic factor expression, sleep parameters, cardiovascular risk parameters, suicidal behavior, functionality, and treatment costs in patients with depression. METHODS/DESIGN: Seventy-five medicated patients with depression will be recruited from a Basic Healthcare Unit to participate in this prospective, parallel group, single blinded, superiority, randomized controlled trial. Patients with depression according to DSM-V criteria will be balanced and randomly assigned (based on depression scores and number of depressive episodes) to a non-exercising control (C), CAE, and AEMC groups. The CAE and AEMC groups will exercise for 60 min, twice a week for 24 weeks (on non-consecutive days). Exercise intensity will be maintained between 12 and 14 points of the rating of perceived exertion scale (~ 70-80% of the maximum heart rate). The CAE group will perform a continuous aerobic exercise while the AEMC group will perform exercises with progressively increased motor complexity. Blinded raters will assess patients before and after the intervention period. The primary outcome measure will be the change in depression score measured by the Montgomery-Asberg Depression Rating Scale. Secondary outcomes will include measures of cognitive function, hippocampal volume, brain-derived neurotrophic factor expression, sleep parameters, cardiovascular risk parameters, suicidal behavior, functionality, and treatment costs. DISCUSSION: This study was selected in the call of public policy programs for the Brazilian Unified National Health System - "PPSUS 2015". To our knowledge, this is the first pragmatic trial to test the effect of adding AEMC to the pharmacological treatment of patients with depression and to evaluate the possible reductions in depression symptoms and healthcare costs. TRIAL REGISTRATION: Brazilian Clinical Trials Registry (ReBec) - RBR-9zgxzd - Registered on 4 Jan. 2017.