A physiotherapy group exercise and self-management approach to improve physical activity in people with mild-moderate Parkinson's disease: a randomized controlled trial.

BACKGROUND: Physical activity levels are low in people with Parkinson's disease (PD) and have proved difficult to increase with exercise programs alone. Intervention approaches that address both the capacity to engage in physical activity and self-management strategies to change and maintain exercise behaviours are needed to address this intractable issue. METHODS: This will be an assessor-blinded, randomized controlled trial performed in Brisbane, Australia. Ninety-two people with mild-moderate PD will be randomly allocated to two groups: usual care, and a physiotherapy-led group exercise program combined with self-management strategies. In the intervention group, twelve, 80-min sessions will be conducted over 4 weeks in groups of up to 4 participants. The intervention will consist of circuit training including treadmill walking to target aerobic fitness, and activities targeting strength, balance, and gait performance. In addition, each session will also incorporate strategies focusing on self-management and behaviour change, augmented by the provision of a fitness activity tracker. Outcome measures will be collected at baseline (T1), immediately post intervention (T2) and at 6 months follow-up (T3). The primary outcome measure is free-living physical activity (average daily step count over 7 days) at pre (T1) and post (T2) intervention measured using an activPAL™ device. Secondary outcome measures captured at all time points include time spent walking, sedentary and in moderate intensity exercise over 7 days; spatiotemporal gait performance (step length, gait speed, endurance); health-related quality of life; and outcome expectations and self-efficacy for exercise. DISCUSSION: Sustainability of gains in physical activity following exercise interventions is a challenge for most populations. Our incorporation of a chronic disease self-management approach into the exercise program including fitness tracking extends previous trials and has potential to significantly improve free-living physical activity in people with PD. TRIAL REGISTRATION: This study has been prospectively registered in Australian and New Zealand Clinical Trial Registry (ACTRN12617001057370), registered on 19/07/2017. Available from www.anzctr.org.au/ACTRN12617001057370.aspx .

Lifespace metrics of older adults with mild cognitive impairment and dementia recorded via geolocation data.

OBJECTIVE: Lifespace, the physical area in which someone conducts life activities, indicates lived community mobility. This study explored the feasibility of technology-based lifespace measurement for older people with dementia and mild cognitive impairment (MCI), including the generation of a range of lifespace metrics, and investigation of relationships with health and mobility status. METHODS: An exploratory study was conducted within a longitudinal observational study. Eighteen older adults (mean age 86.7 years (SD: 3.2); 8 men; 15 MCI), participated. Lifespace metrics were generated from geolocation data (GPS and Bluetooth beacon) collected through a smartphone application for one week (2015-2016). Cognitive and mobility-related outcomes were compared from study data sets at baseline (2005-2007) and 6-year follow-up (2011-2014). RESULTS: Lifespace data could be collected from all participants, and metrics were generated including percentage of time at home, maximum distance from home, episodes of travel in a week, days in a week participants left home, lifespace area (daily, weekly and total), indoor lifespace (regions in the home/hour), and a developed lifespace score that combined time, frequency of travel, distance and area. Results indicated a large range of lifespace areas (0.1 - 97.88 km2 ; median 6.77 km2 ) with similar patterns across lifespace metrics. Significant relationships were found between lifespace metrics and concurrent driving status and anteceding scores on the sit-to-stand test (at baseline and follow-up). CONCLUSIONS: Further longitudinal exploration of lifespace is required to develop an understanding of the nature of lifespace of older community-dwelling people, and its relationship with health, mobility and well-being outcomes.

What are the barriers and enablers that people with a lower limb amputation experience when walking in the community?

Purpose: To explore barriers and enablers to community walking perceived by people with lower limb amputation.Materials and methods: Three focus groups (n = 14 participants), using purposive sampling, were conducted with people with lower limb amputation who used a prosthesis to walk in the community. Three investigators analyzed transcripts using thematic content analysis.Results: Themes aligned with the International Classification of Functioning, Disability and Health domains. Barriers related to body function and structure included prosthetic function, residual limb integrity, phantom limb pain and other medical issues, with optimal prosthetic function and adequate fitness identified as enablers. Personal barriers included challenges adjusting to change, whereas personal enablers included being able to adjust to change, having a positive attitude, goal setting and a purpose for community walking. Environmental barriers included physical (e.g., terrain, crowds, climate) and social (e.g., unwanted attention and finances). Environmental enablers included aids, transport, preparation, social support and finances. Community walking was essential to participation in work, leisure, social activities and family roles.Conclusion: Walking in the community for people with a lower limb amputation presents many barriers, but enablers have also been identified. Targeted assessments and interventions, and appropriate environmental planning may assist in minimizing barriers to community walking.Implications for rehabilitationAlthough rehabilitation for people with lower limb amputation should continue to optimise body function and structure (such as strength, fitness, pain and prosthetic function) to help prepare individuals for walking in the community, personal and environmental factors should also be addressed.Optimising an individual's personal enablers may facilitate community walking; this may include strategies to assist with adjusting to change, setting goals, instilling a positive attitude towards walking, and seeing a purpose for walking in the community.Enhancing environmental (physical and social) enablers and minimising environmental barriers to walking in the community may be possible through environmental planning (e.g. infrastructure such as lifts), social awareness and education.

Accuracy of wearable physical activity trackers in people with Parkinson's disease.

INTRODUCTION: The purpose of this study was to determine the accuracy of the Fitbit Charge HR™ and Garmin vívosmart® HR in measuring steps and reflecting intensity of activity in people with Parkinson's disease (PD). METHODS: Thirty-three people with mild-moderate PD performed six, two-minute indoor walks at their self-selected walking pace, and at target cadences of 60, 80, 100, 120 and 140 beats/min. A 500 m outdoor walk with terrain challenges was also performed. Step count was recorded by the two wrist-worn activity trackers (Fitbit Charge HR™ and Garmin vívosmart® HR) and compared to an accelerometer (ActivPAL3™). Intensity was recorded by a portable breath-by-breath gas analyser (VO2), heart rate and Borg scale. RESULTS: Both commercial activity trackers had low error (<3%) and moderate to high consistency at self-selected pace both indoors and outdoors (ICC 0.88-0.97; p < 0.05) compared to the ActivPAL3™. The Garmin recorded low error (<5%) and high agreement (ICCs > 0.68; p < 0.001) for all target cadences ≥80steps/min. The Fitbit had higher error was less consistent for all target cadences ≥80steps/min. Cadence measured by the Fitbit and Garmin weakly reflected increases in heart rate (ICCs 0.27-0.28; p < 0.05), and did not reflect VO2 or Borg (ICCs 0.08-0.15, p > 0.05). CONCLUSION: The Garmin device was more accurate at reflecting step count across a broader range of walking cadences than the Fitbit, but neither strongly reflected intensity of activity. While not intended to replace research grade devices, these wrist-worn devices may be a clinically useful adjunct to exercise therapy to increase physical activity in people with PD.

Falls in people with Parkinson's disease: A prospective comparison of community and home-based falls.

BACKGROUND: Falls are common and debilitating in people with Parkinson's disease (PD) and restrict participation in daily activities. Understanding circumstances of falls in the community and at home may assist clinicians to target therapy more effectively. OBJECTIVE: To compare the characteristics of community and home fallers and the circumstances that contribute to falls in people living with PD. METHODS: People with mild-moderately severe PD (n=196) used a daily falls diary and telephone hotline to report prospectively the occurrence, location and circumstances of falls over 14 months. RESULTS: 62% of people with PD fell, with most falling at least once in the community. Compared to people who fell at home, the community-only fallers had shorter durations of PD (p=0.012), less severe disease (p=0.008) and reported fewer falls in the year prior to the study (p=0.003). Most falls occurred while people were ambulant, during postural transitions and when medication was working well. Community-based falls were frequently attributed to environmental factors such as challenging terrains (p<0.001), high attention demands (p=0.029), busy or cluttered areas (p<0.001) and tasks requiring speed (p=0.020). Physical loads were more often present in home than community-based falls (p=0.027). CONCLUSION: Falls that occur in the community typically affect people with earlier PD and less severe disease than home-based falls. Individuals experiencing community-based falls may benefit from physiotherapy to manage challenging environments and high attention demands.

Classification of Movement of People with Parkinsons Disease Using Wearable Inertial Movement Units and Machine Learning.

In this work, inertial movement units were placed on people with Parkinsons disease (PwPD) who subsequently performed a standard test of walking endurance (six-minute walk test - 6MWT). Five devices were placed on each the limbs and small of the back. These devices captured the acceleration and rotational motion while the person walked as far as they can in six minutes. The wearable devices can objectively indicate the pattern and rhythmicity of limb and body movements. It is possible that this data, when subject to machine learning could provide additional objective measures that may support clinical observations related to the quality of movement. The aim of this work is two fold. First, to identify the most useful features of the captured signals; second, to identify the accuracy of using these features to predict the severity of PD as measured by standard clinical assessment.

Transcranial Direct Current Stimulation to Enhance Dual-Task Gait Training in Parkinson's Disease: A Pilot RCT.

OBJECTIVE: To investigate the feasibility and safety of a combined anodal transcranial direct current stimulation (tDCS) and dual task gait training intervention in people with Parkinson's Disease (PD) and to provide data to support a sample size calculation for a fully powered trial should trends of effectiveness be present. DESIGN: A pilot, randomized, double-blind, sham-controlled parallel group trial with 12 week follow-up. SETTING: A university physiotherapy department. INTERVENTIONS: Sixteen participants diagnosed with PD received nine dual task gait training sessions over 3 weeks. Participants were randomized to receive either active or sham tDCS applied for the first 20 minutes of each session. MAIN MEASURES: The primary outcome was gait speed while undertaking concurrent cognitive tasks (word lists, counting, conversation). Secondary measures included step length, cadence, Timed Up and Go, bradykinesia and motor speed. RESULTS: Gait speed, step length and cadence improved in both groups, under all dual task conditions. This effect was maintained at follow-up. There was no difference between the active and sham tDCS groups. Time taken to perform the TUGwords also improved, with no difference between groups. The active tDCS group did however increase their correct cognitive response rate during the TUGwords and TUGcount. Bradykinesia improved after training in both groups. CONCLUSION: Three weeks of dual task gait training resulted in improved gait under dual task conditions, and bradykinesia, immediately following training and at 12 weeks follow-up. The only parameter enhanced by tDCS was the number of correct responses while performing the dual task TUG. tDCS applied to M1 may not be an effective adjunct to dual task gait training in PD. TRIAL REGISTRATION: Australia-New Zealand Clinical Trials Registry ACTRN12613001093774.

Could everyday technology improve access to assessments? A pilot study on the feasibility of screening cognition in people with Parkinson's disease using the Montreal Cognitive Assessment via Internet videoconferencing.

BACKGROUND: The distances and distribution of people, and pressures on the health system in Australia mean that access to services for people living with a neurodegenerative condition may be inadequate. Telehealth may offer ways to provide timely and efficient monitoring and support. People with Parkinson's disease require regular screening of their symptoms and needs, but may have limited access to health professionals. Cognitive changes can impact on occupational performance, thus timely monitoring of cognition is important for informing occupational therapy interventions. AIM: To evaluate the feasibility of screening cognition in people with Parkinson's disease using available technology in their homes. METHOD: Eleven participants with Parkinson's disease completed the Montreal Cognitive Assessment face-to-face and then via videoconferencing one week later using the technology available at their home. Participants and assessors provided feedback on their experience. RESULTS: All Montreal Cognitive Assessment items could be completed over videoconference (e.g. Skype), with a median difference of 2 (IQR: 1-2.5) between face-to-face and videoconference scores. Higher scores were not favoured by either mode of assessment. Three participants received inconsistent cognitive classifications between the two assessment methods. Participant and assessor feedback indicated reported benefits including convenience as well as technological limitations. CONCLUSIONS: Given the pressures on the health system and the apparent acceptability to consumers, occupational therapists may explore the utility of readily accessible technology to enable timely monitoring of cognition for people with Parkinson's disease. Further research is needed to develop and demonstrate the reliability and validity of this approach.

Remotely Assessing Symptoms of Parkinson's Disease Using Videoconferencing: A Feasibility Study.

Purpose. To evaluate the feasibility of assessing a person's symptoms of Parkinson's disease (PD) in their home using the videoconferencing technology they already possess, without a home visit. Method. Eleven participants with PD completed the Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) face-to-face and then via videoconferencing within a two-week period. Participants used free software and the computers and webcams available at their home to complete the videoconference assessment with a clinical rater scoring remotely. Clinical raters and participants provided feedback on the experience. Results. Excluding rigidity and postural stability, between zero and seven items could not be completed in the assessment of each participant (median 2.0, IQR 1.0-4.0). Between face-to-face and videoconference assessments, the median difference in scores was 3.0 (IQR 1.5-9.0). Content analysis of feedback identified the clinical raters' reasons why some scoring could not be completed and the participants' hope for future clinical application. Conclusions. In using free everyday technology available in participants' homes, MDS-UPDRS ratings could be obtained without an initial home visit; however some items were unable to be scored for some participants. Use of a protocol or technological advances are likely to reduce missing items.

Community walking in people with Parkinson's disease.

People with Parkinson's disease often have walking difficulty, and this is likely to be exacerbated while walking in places in the community, where people are likely to face greater and more varied challenges. This study aims to understand the facilitators and the barriers to walking in the community perceived by people with Parkinson's disease. This qualitative study involved 5 focus groups (n = 34) of people with Parkinson's disease and their partners residing in metropolitan and rural regions in Queensland, Australia. Results found that people with PD reported to use internal personal strategies as facilitators to community walking, but identified primarily external factors, particularly the environmental factors as barriers. The adoption of strategies or the use of facilitators allows people with Parkinson's disease to cope so that participants often did not report disability.

Single and dual task gait training in people with Parkinson's disease: a protocol for a randomised controlled trial.

BACKGROUND: Difficulty performing more than one task at a time (dual tasking) is a common and disabling problem experienced by people with Parkinson disease (PD). If asked to perform another task when walking, people with PD often take shorter steps or walk more slowly. Currently there is uncertainty about whether clinicians should teach people with PD to avoid dual tasking or whether they should encourage them to practice dual tasking with the hope that practice will lead to enhanced performance. This study will address this issue by comparing single to dual task gait training. METHODS AND DESIGN: A prospective randomised clinical trial is being conducted. Sixty participants with idiopathic PD will be recruited, provided they score I-IV on the modified Hoehn and Yahr (1967) scale, and fulfil other inclusion criteria. Participants will be randomly allocated to either a single or dual task gait training group. Both groups will receive 12 hours of walking training over 4 weeks. The single task group will undertake gait training with cueing strategies to increase step length. The dual task group will train to improve step length when walking and performing a variety of added tasks. Both groups will receive a tailored home program for 6 months. Blinded assessors will conduct four assessments: two baseline assessments, one post intervention and one at 6 months follow-up. The primary outcome measure will be step length when dual tasking over 8 m. Secondary outcome measures include: spatiotemporal gait parameters when walking under single and dual task conditions, measures of executive function, the timed up and go test, measures of community mobility, and quality of life. All analyses will be based on intention to treat principle. DISCUSSION: This trial will examine the immediate and longer term effect of dual task walking training as compared to single task training in people with idiopathic PD, at the impairment, activity, and participation levels. It has the potential to identify a new intervention that may improve and maintain walking beyond the laboratory. The results of this trial will provide guidance for clinicians in the development of walking training programs for people with PD. TRIAL REGISTRATION: ACTRN12609000791235.