Feasibility of a novel eHealth intervention for Parkinson's disease targeting motor-cognitive function in the home.

BACKGROUND: Parkinson's disease (PD) drastically affects motor and cognitive function, but evidence shows that motor-cognitive training improves disease symptoms. Motor-cognitive training in the home is scarcely investigated and eHealth methods can provide continual support for PD self-management. Feasibility testing is however required. OBJECTIVE: To assess the feasibility (i) Recruitment capability (ii) Acceptability and Suitability (iii) Demand and Safety of a home-based motor-cognitive eHealth exercise intervention in PD. METHODS: The 10-week intervention was delivered using the ExorLive® application and exercises were individually adapted and systematically progressed and targeted functional strength, cardiovascular fitness, flexibility, and motor-cognitive function. People with mild-to moderate PD were assessed before and after the intervention regarding; gait performance in single and dual-task conditions; functional mobility; dual-task performance; balance performance; physical activity level; health related quality of life and perceived balance confidence and walking ability; global cognition and executive function. Feasibility outcomes were continuously measured using a home-exercise diary and contact with a physiotherapist. Changes from pre- and post-intervention are reported descriptively. RESULTS: Fifteen participants (mean age 68.5 years) commenced and 14 completed the 10-week intervention. In relation to intervention Acceptability, 64% of the motor sessions and 52% of motor-cognitive sessions were rated as "enjoyable". Concerning Suitability, the average level of exertion (Borg RPE scale) was light (11-12). Adherence was high, with 86% of all (420) sessions reported as completed. No falls or other adverse events occurred in conjunction with the intervention. CONCLUSIONS: This motor-cognitive eHealth home exercise intervention for PD was safe and feasible in terms of Recruitment capability, Acceptability, Safety and Demand. The intensity of physical challenge needs to be increased before testing in an efficacy trial. TRIAL REGISTRATION: This trial is registered at Clinicaltrials.gov (NCT05027620).

Design of the STEPS trial: a phase II randomized controlled trial evaluating eHealth-supported motor-cognitive home training for Parkinson's disease.

BACKGROUND: Electronic health (eHealth) technology offers the potential to support and motivate physical activity for symptom management in Parkinson's disease (PD). It is also recommended that motor exercise in PD be complemented with cognitive training aimed at attentional or executive functions. This paper describes the protocol for a double-blind randomized controlled trial to evaluate the effects of motor-cognitive training in the home environment, supported by eHealth. METHODS/DESIGN: The Support for home Training using Ehealth in Parkinsons diseaSe (STEPS) is a double-blind single center randomized controlled trial. Two parallel groups will include in total 120 participants with mild to moderate PD who will receive either (i) the intervention (a progressive 10-week individualized motor-cognitive eHealth training with cognitive behavioral elements to increase physical activity levels) or (ii) an active control group (an individualized 10-week paper-based home exercise program). The active control group will not receive motor-cognitive exercises or cognitive behavioral approaches to increase physical activity level. The primary outcome is walking capacity assessed by the six-minute walk test (6MWT). Secondary outcomes will include gait performance during single and dual task conditions, gait speed, functional mobility and lower limb strength, balance, physical activity behavior and a range of patient reported outcome measures relevant in PD. DISCUSSION: The STEPS trial will answer the question whether 10 weeks of eHealth supported motor-cognitive exercise in the home environment can improve walking capacity in PD when compared to a standard paper exercise program. Findings from this study will also strengthen the evidence concerning the efficacy of PD-specific eHealth interventions with a view meeting future health care demands by addressing issues of inaccessibility to specialized neurological rehabilitation in PD. TRIAL REGISTRATION: ClinicalTrials.gov August 2022, NCT05510739.

Predictors of Sustained Physical Activity During the COVID-19 Pandemic in People With Parkinson Disease in Sweden.

BACKGROUND AND PURPOSE: During the first wave of the COVID-19 pandemic, people with Parkinson disease (PwPD) reported deterioration in health and physical activity. The aim of this study was to describe 1-year changes in physical activity and perceived health in PwPD during the COVID-19 pandemic and to identify predictors of sustained physical activity. METHODS: This study compared perceived health and sensor-derived physical activity (Actigraph GT3x) in PwPD between the first (June to July 2020) and third waves (June to July 2021) of the pandemic. Multiple logistic regression analyses were used to predict sustained physical activity across the study period using personal factors, disease severity, and functioning as independent variables. RESULTS: Sixty-three PwPD (mean age 71.0 years, 41% females) completed both baseline and 1-year follow-up (26 lost to follow-up). PwPD showed a decrease in average number of steps per day (Δ415 steps, P = 0.048), moderate-to-vigorous-physical activity (Δ7 minutes, P = 0.007) and increase in sedentary time (Δ36 minutes, P <.001) between baseline and 1-year follow-up. While self-perceived walking impairments and depressive symptoms increased significantly, balance confidence decreased between baseline and 1-year follow-up, no significant changes occurred for self-rated health, quality of life, or anxiety. Significant predictors of sustained physical activity levels were 15 years or more of education (odds ratio [OR] = 7.38, P = 0.013) and higher perceived walking ability (OR = 0.18, P = 0.041). DISCUSSION AND CONCLUSION: Among PwPD with mild to moderate disease severity living in Sweden, factors associated with reduced physical activity levels during the COVID-19 pandemic included older age, lower education levels, and greater perceived walking difficulties.Video Abstract available for more insights from the authors (see the Video, the Supplemental Digital Content, available at: http://links.lww.com/JNPT/A451).

The Swedish King's Parkinson's disease Pain Scale: Validation and pain prevalence in persons with mild-moderate severity Parkinson's disease.

OBJECTIVES: To examine convergent and divergent validity of the King's Parkinson's disease Pain Scale - Swedish translated version, and to determine the prevalence of pain according to scale domains in persons with Parkinson's disease. DESIGN: Cross-sectional, validation study. PATIENTS: Ninety-seven persons with Parkinson's disease. METHODS: The pain scale was translated into Swedish by an accredited company, and permission was granted to use the resultant version. Participants completed the rater-administered The King's Parkinson's disease Pain Scale - Swedish version, the visual analogue scale (pain), Parkinson's Disease Questionnaire (bodily discomfort subscale), MiniBESTest and Walk-12G. Spearman's rank correlation coefficient was used to assess the strength of associations. RESULTS: The mean (standard deviation) age of participants was 71 (6.1) years, 63% were male, and 76% presented with mild disease severity. The mean (standard deviation) The King's Parkinson's disease Pain Scale - Swedish version score was 7.84 (12.8). A strong (r = 0.65) and moderate (r = 0.45) association was found between the newly-translated version and visual analogue scale (pain) and Parkinson's Disease Questionnaire - bodily discomfort subscale, respectively. Weak associations were found between the newly translated version and divergent measures. Overall pain prevalence was 57%, with musculoskeletal pain being the most common, followed by chronic and radicular pain. CONCLUSION: This study affirms aspects of validity of the Swedish King's Parkinson's disease Pain Scale. Most participants presented with 1 or more types of pain, highlighting the need for targeted interventions.

Everyday technology use among people with Parkinson's disease.

OBJECTIVES: To explore the relevance of and ability to use everyday technology (ET) among people with Parkinson's Disease (PD) and to explore associations between ET use and global cognition and motor ability. MATERIALS AND METHODS: Cross-sectional data was collected from 34 people with PD using the Short Everyday Technology Use Questionnaire+ (S-ETUQ+), the Movement Disorder Society-Unified Parkinson's Disease Rating Scale and the Montreal Cognitive Assessment (MoCA). RESULTS: Out of 41 ETs in the S-ETUQ+, the mean number perceived as relevant was 27.5 (min-max 19-35, SD 3.6). A good ability to use ET was reported where many ETs had a challenge measure below participants' ability to use them. A strong positive correlation between the ability to use ET and global cognition (MoCA) (r = .676, p = <0.01) was shown. CONCLUSIONS: ET use has become integrated into everyday life and is important for participation. This study showed a high relevance of and good ability to use ET and a correlation between ET use and global cognition among people with mild-moderate PD. Evaluation and support to use ET in PD are important for maintaining independence and participation, especially among those with cognitive decline.

Effects of motor-cognitive training on dual-task performance in people with Parkinson's disease: a systematic review and meta-analysis.

Motor-cognitive training in Parkinson's disease (PD) can positively affect gait and balance, but whether motor-cognitive (dual-task) performance improves is unknown. This meta-analysis, therefore, aimed to establish the current evidence on the effects of motor-cognitive training on dual-task performance in PD. Systematic searches were conducted in five databases and 11 studies with a total of 597 people (mean age: 68.9 years; mean PD duration: 6.8 years) were included. We found a mean difference in dual-task gait speed (0.12 m/s (95% CI 0.08, 0.17)), dual-task cadence (2.91 steps/min (95% CI 0.08, 5.73)), dual-task stride length (10.12 cm (95% CI 4.86, 15.38)) and dual-task cost on gait speed (- 8.75% (95% CI - 14.57, - 2.92)) in favor of motor-cognitive training compared to controls. The GRADE analysis revealed that the findings were based on high certainty evidence. Thus, we can for the first time systematically show that people with PD can improve their dual-task ability through motor-cognitive training.

Behavioural and neuroplastic effects of a double-blind randomised controlled balance exercise trial in people with Parkinson's disease.

Balance dysfunction is a disabling symptom in people with Parkinson's disease (PD). Evidence suggests that exercise can improve balance performance and induce neuroplastic effects. We hypothesised that a 10-week balance intervention (HiBalance) would improve balance, other motor and cognitive symptoms, and alter task-evoked brain activity in people with PD. We performed a double-blind randomised controlled trial (RCT) where 95 participants with PD were randomised to either HiBalance (n = 48) or a control group (n = 47). We found no significant group by time effect on balance performance (b = 0.4 95% CI [-1, 1.9], p = 0.57) or on our secondary outcomes, including the measures of task-evoked brain activity. The findings of this well-powered, double-blind RCT contrast previous studies of the HiBalance programme but are congruent with other double-blind RCTs of physical exercise in PD. The divergent results raise important questions on how to optimise physical exercise interventions for people with PD.Preregistration clinicaltrials.gov: NCT03213873.

Physical Activity and Perceived Health in People With Parkinson Disease During the First Wave of Covid-19 Pandemic: A Cross-sectional Study From Sweden.

BACKGROUND: People with Parkinson disease (PD) are known to be at risk of physical inactivity and may therefore be especially vulnerable to negative health outcomes during the COVID-19 pandemic due to social distancing recommendations. PURPOSE: To investigate sensor-derived physical activity and perceived health of people with PD during the first wave of the COVID-19 pandemic, as well as the factors associated with these outcomes. METHODS: Physical activity was measured over 7 days using the Actigraph GT3x accelerometer. Data were collected regarding perceived health status and physical activity habits, as well as rehabilitation attendance during the pandemic. Multiple linear and logistic regression analyses were used to identify factors associated with physical activity and perceived changes in health. RESULTS: Of 89 participants, a majority (67%) reported a pandemic-related reduction in exercise habits. Women more commonly reported a reduction in scheduled exercise and cancelled rehabilitation than men. Study participants took on average 5876 ± 3180 steps per day. In the multivariate analysis, female gender, being 70 years of age and older, and greater reported mobility problems were associated with being less physically active. A pandemic-induced deterioration in health was reported by 42% and women were 5 times more likely than men to do so (odds ratio: 5.12, 95% confidence interval, 1.87-15.03; P = 0.002). DISCUSSION AND CONCLUSIONS: Despite a pandemic-related reduction in reported exercise habits and rehabilitation, the participants in this Swedish sample were relatively physically active. However, women were less active at moderate-vigorous levels and were at greater risk of deterioration in perceived health during this time.Video Abstract available for more insight from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A359).

Insights Into the Mini-BESTest Scoring System: Comparison of 6 Different Structural Models.

OBJECTIVE: The Mini-Balance Evaluation Systems Test (Mini-BESTest) is a balance scale common to clinical practice, but different scoring has been proposed, that is, total score and/or subsections. This study aimed to investigate Mini-BESTest validity by comparing 6 structural models and to establish the best model for discriminating fallers from nonfallers, that is, those who did or did not report at least 2 falls in the 6 months before evaluation. METHODS: In this cross-sectional validation study, data from 709 individuals with idiopathic Parkinson disease (Hoehn and Yahr stages 1-3) were analyzed. Individuals were evaluated with the Mini-BESTest, and fall history was recorded. Construct, convergent, and discriminant validity and reliability of the 6 models were analyzed. The ability of the models to adequately identify individuals with or without a history of falls was tested with receiving operating characteristic curves. RESULTS: Confirmatory factor analysis showed that the unidimensional models and the 4-factor solutions showed the best fit indexes. Conversely, second-order models, which allowed reporting of both total and subsections, did not converge. Most models and factors showed a low convergent validity (average variance extracted values <0.5). Correlations among the anticipatory postural adjustments factor with both the sensory orientation and the dynamic gait factors of multidimensional models were high (r ≥ 0.85). Unidimensional model reliability was good, whereas low values were found in one-half of the subsections. Finally, both unidimensional models showed a large area under the receiving operating characteristic curve (0.81). CONCLUSION: The original unidimensional Mini-BESTest model-with a total score of 28-showed the highest validity and reliability and was best at discriminating fallers from nonfallers. Conversely, its 4 subsections should not be reported separately, because they were highly correlated and had low reliability; therefore, they are not actually capable of measuring different aspects of balance. IMPACT: This study shows that the Mini-BESTest should be used only with the original unidimensional scoring system in people with Parkinson disease.

Dual-Task Effects During a Motor-Cognitive Task in Parkinson's Disease: Patterns of Prioritization and the Influence of Cognitive Status.

People with Parkinson's disease (PD) experience greater difficulties during dual task (DT) walking compared to healthy controls, but factors explaining the variance in DT costs remain largely unknown. Additionally, as cognitive impairments are common in PD it is important to understand whether cognitive status influences the strategies used during DT paradigms. The study aimed to (1) explore DT costs on gait and cognition during DT walking, (2) investigate factors associated with DT costs, and (3) to investigate to what extent patterns of DT costs and prioritization differed according to cognitive status. A total of 93 people with Parkinson's disease were examined when walking in single and DT conditions. Information regarding demographics, PD severity, mobility, and cognitive and affective symptoms was collected, and an extensive neuropsychological test battery was used to classify whether participants had mild cognitive impairment (PD MCI) or not (PD non-MCI). Dual task costs were observed across all gait domains except asymmetry. Cognitive status was associated with DT costs on both gait and cognition. Nonmotor experiences of daily living were further associated with DT cost on cognition, and TUG-cog associated with DT cost on gait. People with PD MCI had larger DT costs on gait than PD non-MCI. Strategies differed according to cognitive status, whereby PD MCI used a posture-second strategy, and PD non-MCI used a posture-first strategy. Once verified in future studies, these results can inform clinicians and researchers when tailoring DT training paradigms to the specific characteristics of people with PD.

Implementation of highly challenging balance training for Parkinson's disease in clinical practice: a process evaluation.

BACKGROUND: Process evaluations provide contextual insight into the way in which interventions are delivered. This information is essential when designing strategies to implement programs into wider clinical practice. We performed a process evaluation of the HiBalance effectiveness trial investigating the effects of a 10-week of highly challenging and progressive balance training for mild-moderate Parkinson's disease (PD). Study aims were to investigate i) the quality and quantity of intervention delivery and ii) barriers and facilitators for implementation. METHODS: Process outcomes included; Fidelity; Dose (delivered and received) Recruitment and Reach. Investigation of barriers and facilitators was guided by the Consolidated Framework for Implementation Research. Program delivery was assessed across four neurological rehabilitation sites during a two-year period. Data collection was mixed-methods in nature and quantitative and qualitative data were merged during the analysis phase. RESULTS: Thirteen program trainers delivered the intervention to 12 separate groups during 119 training sessions. Trainer fidelity to program core components was very high in 104 (87%) of the sessions. Participant responsiveness to the core components was generally high, although adherence to the home exercise program was low (50%). No significant context-specific differences were observed across sites in terms of fidelity, dose delivered/ received or participant characteristics, despite varying recruitment methods. Facilitators to program delivery were; PD-specificity, high training frequency and professional autonomy. Perceived barriers included; cognitive impairment, absent reactional balance among participants, as well a heterogeneous group in relation to balance capacity. CONCLUSION: These findings provide corroborating evidence for outcome evaluation results and valuable information for the further adaptation and implementation of this program. Important lessons can also be learned for researchers and clinicians planning to implement challenging exercise training programs for people with mild-moderate PD. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02727478 , registered 30 march, 2016 - Retrospectively registered.

Physical activity profiles in Parkinson's disease.

BACKGROUND: Identifying physical activity (PA) profiles of people with Parkinson's Disease (PD) could provide clinically meaningful knowledge concerning how to tailor PA interventions. Our objectives were therefore to i) identify distinct PA profiles in people with PD based on accelerometer data, ii) explore differences between the profiles regarding personal characteristics and physical function. METHODS: Accelerometer data from 301 participants (43% women, mean age: 71 years) was analysed using latent profile analyses of 15 derived PA variables. Physical function measurements included balance performance, comfortable gait speed and single and dual-task functional mobility. RESULTS: Three distinct profiles were identified; "Sedentary" (N = 68), "Light Movers" (N = 115), "Steady Movers" (N = 118). "Sedentary" included people with PD with high absolute and relative time spent in Sedentary behaviour (SB), little time light intensity physical activity (LIPA) and negligible moderate-to-vigorous physical activity (MVPA). "Light Movers" were people with PD with values close to the mean for all activity variables. "Steady Movers" spent less time in SB during midday, and more time in LIPA and MVPA throughout the day, compared to the other profiles. "Sedentary" people had poorer balance (P = 0.006), poorer functional mobility (P = 0.027) and were more likely to have fallen previously (P = 0.027), compared to "Light Movers. The Timed Up and Go test, an easily performed clinical test of functional mobility, was the only test that could distinguish between all three profiles. CONCLUSION: Distinct PA profiles, with clear differences in how the time awake is spent exist among people with mild-moderate PD.

Predictors of improved balance performance in persons with Parkinson's disease following a training intervention: analysis of data from an effectiveness-implementation trial.

OBJECTIVE: (1) To determine associated factors of improved balance performance after a 10-week HiBalance intervention period, and (2) to determine effects of the programme on modifiable factors found above, considering both groups. DESIGN: Pre-posttest substudy founded on the outcomes evaluation of an effectiveness-implementation trial. PARTICIPANTS: Sixty-one participants were allocated the HiBalance training, while 56 were controls. INTERVENTION: Participants received a 10-week, two times weekly, progressive balance training, that is, HiBalance intervention, led by physical therapists. The intervention was group based and gradually incorporated dual-tasking over the training period. Participants also performed, unsupervised, a 1×/week home exercise programme. MAIN OUTCOME: The Mini-Balance Evaluation Systems Test (Mini-BESTest) assessed balance performance, and those having improved by ⩾2 points were classified as positive responders. Balance confidence was the secondary outcome. RESULTS: Fifty-three (87%) participants completed the intervention and 32 (60%) improved their balance scores by ⩾2 points in the intervention group, with 11 (24%) in the control group. The multivariable logistic regression analysis revealed two independently associated factors of improved balance, which included balance confidence (odds ratio (OR) = 0.95; 95% confidence interval (CI) = 0.90-0.99) and attendance of ⩾80% of training sessions (OR = 10.10; 95% CI = 1.71-59.60). The final model demonstrated good fit and acceptable discrimination (area under the curve = 0.84). Secondary analysis revealed a fair relationship (Rho = 0.30; P = 0.044) between improvements in balance confidence and balance performance in the intervention but not control group. CONCLUSION: Two personal factors were significantly associated with a higher likelihood of improvement in clinically measured balance performance. The HiBalance intervention appears to benefit those with lower balance confidence.

Feasibility Aspects of Exploring Exercise-Induced Neuroplasticity in Parkinson's Disease: A Pilot Randomized Controlled Trial.

BACKGROUND: Recent studies indicate that exercise can induce neuroplastic changes in people with Parkinson's disease (PwPD). Reports of feasibility outcomes from existing pilot trials however are, of date, insufficient to enable replication by others in larger definitive trials. OBJECTIVE: To evaluate trial design for a definitive trial by exploring process and scientific feasibility. METHODS: The trial design was a parallel-group RCT pilot with a 1 : 1 allocation ratio to either HiBalance or an active control group (HiCommunication). Both groups received one-hour sessions twice weekly, plus home exercises weekly, for 10 weeks. Participants with mild-to-moderate Parkinson's disease (PD) were recruited via advertisement. Assessment included physical performance, structural and functional MRI, blood sampling, neuropsychological assessment, and speech/voice assessment. Process and scientific feasibility were monitored throughout the study. Process feasibility involved recruitment, participant acceptability of assessments and interventions, assessment procedures (focus on imaging, blood sampling, and dual-task gait analysis), and blinding procedures. Scientific feasibility involved trends in outcome response and safety during group training and home exercises. Data are presented in median, minimum, and maximum values. Changes from pre- to postintervention are reported descriptively. RESULTS: Thirteen participants were included (4 women, mean age 69.7 years), with a recruitment rate of 31%. Attendance rates and follow-up questionnaires indicated that both groups were acceptable to participate. Image quality was acceptable; however, diplopia and/or sleepiness were observed in several participants during MRI. With regard to dual-task gait performance, there appeared to be a ceiling effect of the cognitive tasks with seven participants scoring all correct answers at pretest. Blinding of group allocation was successful for one assessor but was broken for half of participants for the other. CONCLUSIONS: The overall trial design proved feasible to perform, but further strengthening ahead of the definitive RCT is recommended, specifically with respect to MRI setup, cognitive dual-tasks during gait, and blinding procedures. This trial is registered with NCT03213873.

Outcome Evaluation of Highly Challenging Balance Training for People With Parkinson Disease: A Multicenter Effectiveness-Implementation Study.

BACKGROUND AND PURPOSE: In order for people with Parkinson disease (PwPD) to benefit from neurorehabilitation research, interventions tested in research settings require assessment in real-world clinical practice. There is little evidence for whether efficacious exercise interventions for PwPD remain effective when transferred to standard clinical settings. The aim of this study was to assess the clinical effectiveness of the adapted HiBalance program on balance control and gait among PwPD. METHODS: Participants (n = 117) with mild-moderate Parkinson disease were consecutively included into either the 10-week HiBalance group training (n = 61) or the control (n = 56) group. The main outcome was balance performance (Mini-BESTest). Secondary outcomes were comfortable gait speed (10-m Walk Test); functional mobility (Timed Up and Go [TUG] test) and dual-task interference (cognitive TUG test); physical activity level (steps per day); perceived balance confidence (Activities-specific Balance Confidence scale) and perceived walking difficulty (Walk-12G) and self-rated health (EQ-5D visual analog scale). RESULTS: In total, 98 people completed the trial. Compared with controls, the training group showed significant improvement in balance performance (P < 0.001), gait speed (P = 0.001), and dual-task interference (P = 0.04) following the intervention. No group differences were observed for physical activity level or any patient-reported measures. DISCUSSION AND CONCLUSIONS: Highly challenging balance training is effective at improving balance, gait, and dual-task performance when delivered at a clinically feasible dose, in a range of rehabilitation settings, without direct involvement of the research group.Video Abstract available for more insights from the authors (see the Video, Supplementary Digital Content 1, available at: http://links.lww.com/JNPT/A299).

Controlling the Uncontrollable: Perceptions of Balance in People With Parkinson Disease.

BACKGROUND: Exercise improves balance in Parkinson disease (PD), yet the majority of people with the diagnosis are physically inactive. Insights gained from understanding how people with PD (PwPD) make sense of their symptoms and their ability to control them may inform the communication strategies and motivational approaches adopted by physical therapists. To our knowledge, no previous study has qualitatively explored how PwPD perceive the concept of balance and the beliefs they hold concerning their ability to affect balance. OBJECTIVE: This study aimed to explore the meaning of balance for PwPD and the beliefs they hold regarding their ability to influence their balance in everyday life. DESIGN: The design was a qualitative study with an inductive approach. METHODS: In-depth interviews were conducted with 18 participants with PD (age range 46-83 years, Hoehn and Yahr range 1-4), and transcripts were analyzed using qualitative content analysis. RESULTS: Five main themes emerged from the analysis: remaining in control over the body, adapting behavior to deal with uncertainty, directing focus to stay 1 step ahead, resilience as a defense, and exercise beliefs and reservations. Interpretation of the underlying patterns in the main themes yielded the overarching theme of focus and determination to regain control over shifting balance. CONCLUSIONS: The concept of balance was perceived as both bodily equilibrium and mind-body interplay and was described in the context of remaining in control over one's body and everyday life. Cognitive resources were utilized to direct focus and attention during balance-challenging situations in a process involving internal dialogue. Even participants who did not express beliefs in their ability to affect balance through exercise used psychological resilience to counter the challenges of impaired balance.

Cost-effectiveness of the HiBalance training program for elderly with Parkinson's disease: analysis of data from a randomized controlled trial.

OBJECTIVE:: To determine the cost-effectiveness of the HiBalance training program for managing Parkinson's disease (PD)-related balance and gait disorders. DESIGN:: Cost comparison design following the randomized controlled trial comparing a novel balance training intervention with care as usual. SUBJECTS:: A total of 100 participants with mild-moderate PD were randomized to either the intervention ( n = 51) or the control group ( n = 49). INTERVENTION:: A 10-week (three times per week), group-based, progressive balance training program, led by two physical therapists. MAIN OUTCOMES:: All program costs were collected for both groups. Cost-utility was evaluated using quality-adjusted life years (QALYs) and cost-effectiveness measures were the Mini Balance Evaluation Systems Test (Mini-BESTest; assessing balance performance) and gait velocity. Incremental cost-effectiveness ratios were calculated and a probabilistic sensitivity analysis was conducted. RESULTS:: The between-group difference in QALYs was 0.043 (95% confidence interval (CI): 0.011-0.075), favoring the intervention group. Between-group differences in balance performance and gait velocity were 2.16 points (95% CI: 1.19-3.13) and 8.2 cm/second (95% CI: 2.9-13.6), respectively, favoring the intervention group. The mean cost per participant in the intervention group was 16,222 SEK (€1649) compared to 2696 SEK (€274) for controls. The estimated incremental cost-effectiveness ratios were 314,558 SEK (€31,969) for an additional QALY, 6262 SEK (€631) for one point improvement in balance performance, and 1650 SEK (€166) for 1 cm/second increase in gait velocity. Sensitivity analyses indicated a high probability (85%) of program success. CONCLUSION:: In terms of QALYs, the HiBalance program demonstrated a high probability of cost-effectiveness in the short-term perspective when considering the willingness-to-pay thresholds used in Europe.

Factors Associated With Responsiveness to Gait and Balance Training in People With Parkinson Disease.

BACKGROUND AND PURPOSE: Although increasing evidence supports the benefit- of exercise among people with Parkinson disease (PwPD), it is unclear whether a given exercise modality suits all PwPD, given the heterogeneity of the disease. The purpose of this study was to explore factors associated with responsiveness to a highly challenging training intervention that incorporated dual-task exercises. METHODS: Forty-seven PwPD (mean age: 73 years; 19 females, Hoehn and Yahr stages 2-3) who had participated in 10 weeks of highly challenging gait and balance training were included. Baseline demographics, disease-related factors, physical and cognitive ability, and perceived health were used for the prediction of percent change in balance performance (the Mini-BESTest) and comfortable gait speed between the pre- and postassessments, using multiple linear regression analyses. RESULTS: Thirty-five percent of the variance of change in balance performance was explained by General Health Perceptions (ß = -0.36), the Timed Up and Go test (ß = -0.33), and the single-task performance of a cognitive task (ß = -0.24). Forty-nine percent of change in gait speed was explained by gait speed while performing a dual task (ß = -0.46), dual-task interference while walking (ß = 0.43), time to complete the Timed Up and Go test (ß = -0.29), and percent error on a cognitive task (ß = -0.25). DISCUSSION AND CONCLUSIONS: The results may suggest that the PwPD with overall lower perceived health, functional mobility, and cognitive functions are the ones most likely to benefit from highly challenging and attention-demanding gait and balance training.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A240).

Perceptions of balance and falls following a supervised training intervention - a qualitative study of people with Parkinson's disease.

PURPOSE: To explore perceptions of balance and falls among people with mild to moderate Parkinson's disease 3 - 12 months following participation in supervised balance training. MATERIALS AND METHODS: This qualitative study used in-depth individual interviews for data collection among 13 people with Parkinson's disease. Interviews were systematically analyzed using qualitative content analysis with an inductive approach. RESULTS: Three main themes arose: Falls - avoided and intended highlights the wide spectrum of fall perceptions, ranging from worse-case scenario to undramatized events; Balance identity incorporates how gradual deterioration in balance served as a reminder of disease progression and how identifying themselves as "aware not afraid" helped certain participants to maintain balance confidence despite everyday activity restriction; Training as treatment recounts how participants used exercise as disease self-management with the aim to maintain independence in daily life. Interpretation of the underlying patterns of these main themes resulted in the overarching theme Training as treatment when battling problems with balance and falls. CONCLUSIONS: Whereas certain participants expressed a fear of falling which they managed by activity restriction, others described being confident in their balance despite avoidance of balance-challenging activities. Training was used as treatment to self-manage disease-related balance impairments in order to maintain independence in daily life. Implication for Rehabilitation People with Parkinson's disease require early advice about the positive effects of physical activity as well as strategies for self-management in order to ease the psychological and physical burden of progressive balance impairment. Fear of falling should be investigated alongside activity avoidance in this group in order to provide a more accurate insight into the scope of psychological concerns regarding balance and falls in everyday life. Certain people with Parkinson's disease define their balance according to activities they continue to participate in, while others who express fear-related activity avoidance require help to adapt balance-challenging activities in order to maintain balance confidence and avoid physical inactivity.

Patient-reported and performance-based measures of walking in mild-moderate Parkinson's disease.

BACKGROUND: Knowledge of the relationships between patient-reported and performance-based walking measures in Parkinson's disease (PD) should inform clinical decision-making. The Walk-12G reliably captures perceived walking difficulties but has not been compared to performance-based walking in laboratory or free-living settings or across different groups. OBJECTIVES: To investigate the relationship between patient-reported walking difficulties (Walk-12G) and performance-based walking in laboratory and free-living conditions and to determine whether the Walk-12G can distinguish between the subgroups, (i) people with/without PD and (ii) mild/moderate disease stages. METHODS: Forty-seven people without and 49 people with PD (Hoehn and Yahr stage II and III) were assessed in relation to patient-reported walking difficulties (Walk-12G scale); spatiotemporal gait characteristics (Pace; Rhythm; Asymmetry; Variability; and Postural control) using a laboratory-based electronic walkway; and walking behavior (mean steps/day and minutes of brisk walking/day) using accelerometers in free-living conditions. RESULTS: The Walk-12G correlated moderately with the spatiotemporal domain step velocity (r = -0.46) and walking behavior, measured as mean steps/day (r = -0.46). Weaker correlations were observed for step length and minutes spent in brisk walking (r = -0.36 and r = -0.35, respectively). Poor correlations were observed for all other spatiotemporal domains. The Walk-12G could distinguish between people with and without PD (Effect size, r = 0.82) and between those at mild/moderate disease stages (r = 0.34). CONCLUSIONS: Perceived walking difficulties showed weak to moderate associations with performance-based measures of walking in mild-moderate PD. As the strongest associations were observed for step velocity and walking behavior, targeting these specific gait aspects could improve perceived walking difficulties in daily life.