Exercise therapy for prevention of falls in people with Parkinson's disease: A protocol for a randomised controlled trial and economic evaluation

Background

People with Parkinson's disease are twice as likely to be recurrent fallers compared to other older people. As these falls have devastating consequences, there is an urgent need to identify and test innovative interventions with the potential to reduce falls in people with Parkinson's disease. The main objective of this randomised controlled trial is to determine whether fall rates can be reduced in people with Parkinson's disease using exercise targeting three potentially remediable risk factors for falls (reduced balance, reduced leg muscle strength and freezing of gait). In addition we will establish the cost effectiveness of the exercise program from the health provider's perspective.

Methods/Design

230 community-dwelling participants with idiopathic Parkinson's disease will be recruited. Eligible participants will also have a history of falls or be identified as being at risk of falls on assessment. Participants will be randomly allocated to a usual-care control group or an intervention group which will undertake weight-bearing balance and strengthening exercises and use cueing strategies to address freezing of gait. The intervention group will choose between the home-based or support group-based mode of the program. Participants in both groups will receive standardized falls prevention advice. The primary outcome measure will be fall rates. Participants will record falls and medical interventions in a diary for the duration of the 6-month intervention period. Secondary measures include the Parkinson's Disease Falls Risk Score, maximal leg muscle strength, standing balance, the Short Physical Performance Battery, freezing of gait, health and well being, habitual physical activity and positive and negative affect schedule.

Discussion

No adequately powered studies have investigated exercise interventions aimed at reducing falls in people with Parkinson's disease. This trial will determine the effectiveness of the exercise intervention in reducing falls and its cost effectiveness. This pragmatic program, if found to be effective, has the potential to be implemented within existing community services.

Trial registration

The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12608000303347).     

Changes in Parkinsonian gait kinematics with self-generated and externally-generated cues: a comparison of responders and non-responders

Abstract

Purpose: Rhythmic auditory stimulation such as listening to music can alleviate gait bradykinesia in people with Parkinson disease (PD) by increasing spatiotemporal gait features. However, evidence about what specific kinematic alterations lead to these improvements is limited, and differences in responsiveness to cueing likely affect individual motor strategies. Self-generated cueing techniques, such as singing or mental singing, provide similar benefits but no evidence exists about how these techniques affect lower limb joint movement. In this study, we assessed immediate effects of external and self-generated cueing on lower limb movement trajectories during gait.

Methods: Using 3D motion capture, we assessed sagittal plane joint angles at the hip, knee, and ankle across 35 participants with PD, divided into responders (n?=?23) and non-responders (n?=?12) based on a clinically meaningful change in gait speed. Joint motion was assessed as overall range of motion as well as at two key time points during the gait cycle: initial contact and toe-off.

Results: Responders used both cue types to increase gait speed and induce increases in overall joint ROM at the hip while only self-generated cues also increased ROM at the ankle. Increased joint excursions for responders were also evident at initial contact and toe-off.

Conclusions: Our results indicate that self-generated rhythmic cues can induce similar increases in joint excursions as externally-generated cues and that some people may respond more positively than others. These results provide important insight into how self-generated cueing techniques may be tailored to meet the varied individual needs of people with PD.     

Amplitude Manipulation Evokes Upper Limb Freezing during Handwriting in Patients with Parkinson’s Disease with Freezing of Gait

Background

Recent studies show that besides freezing of gait (FOG), many people with Parkinson’s disease (PD) also suffer from freezing in the upper limbs (FOUL). Up to now, it is unclear which task constraints provoke and explain upper limb freezing.

Objective

To investigate whether upper limb freezing and other kinematic abnormalities during writing are provoked by (i) gradual changes in amplitude or by (ii) sustained amplitude generation in patients with and without freezing of gait.

Methods

Thirty-four patients with PD, including 17 with and 17 without FOG, performed a writing task on a touch-sensitive writing tablet requiring writing at constant small and large size as well as writing at gradually increasing and decreasing size. Patients of both groups were matched for disease severity, tested while ‘on’ medication and compared to healthy age-matched controls.

Results

Fifty upper limb freezing episodes were detected in 10 patients, including 8 with and 2 without FOG. The majority of the episodes occurred when participants had to write at small or gradually decreasing size. The occurrence of FOUL and the number of FOUL episodes per patient significantly correlated with the occurrence and severity of FOG. Patients with FOUL also showed a significantly smaller amplitude in the writing parts outside the freezing episodes.

Conclusions

Corroborating findings of gait research, the current study supports a core problem in amplitude control underlying FOUL, both in maintaining as well as in flexibly adapting the cycle size.     

A Validated Smartphone-Based Assessment of Gait and Gait Variability in Parkinson’s Disease

Background

A well-established connection exists between increased gait variability and greater fall likelihood in Parkinson’s disease (PD); however, a portable, validated means of quantifying gait variability (and testing the efficacy of any intervention) remains lacking. Furthermore, although rhythmic auditory cueing continues to receive attention as a promising gait therapy for PD, its widespread delivery remains bottlenecked. The present paper describes a smartphone-based mobile application (“SmartMOVE”) to address both needs.

Methods

The accuracy of smartphone-based gait analysis (utilizing the smartphone’s built-in tri-axial accelerometer and gyroscope to calculate successive step times and step lengths) was validated against two heel contact–based measurement devices: heel-mounted footswitch sensors (to capture step times) and an instrumented pressure sensor mat (to capture step lengths). 12 PD patients and 12 age-matched healthy controls walked along a 26-m path during self-paced and metronome-cued conditions, with all three devices recording simultaneously.

Results

Four outcome measures of gait and gait variability were calculated. Mixed-factorial analysis of variance revealed several instances in which between-group differences (e.g., increased gait variability in PD patients relative to healthy controls) yielded medium-to-large effect sizes (eta-squared values), and cueing-mediated changes (e.g., decreased gait variability when PD patients walked with auditory cues) yielded small-to-medium effect sizes—while at the same time, device-related measurement error yielded small-to-negligible effect sizes.

Conclusion

These findings highlight specific opportunities for smartphone-based gait analysis to serve as an alternative to conventional gait analysis methods (e.g., footswitch systems or sensor-embedded walkways), particularly when those methods are cost-prohibitive, cumbersome, or inconvenient.     

Variability of Stepping during a Virtual Reality Paradigm in Parkinson’s Disease Patients with and without Freezing of Gait

Background

Freezing of gait is a common and debilitating symptom affecting many patients with advanced Parkinson’s disease. Although the pathophysiology of freezing of gait is not fully understood, a number of observations regarding the pattern of gait in patients with this symptom have been made. Increased ‘Stride Time Variability’ has been one of the most robust of these features. In this study we sought to identify whether patients with freezing of gait demonstrated similar fluctuations in their stepping rhythm whilst performing a seated virtual reality gait task that has recently been used to demonstrate the neural correlate of the freezing phenomenon.

Methods

Seventeen patients with freezing and eleven non-freezers performed the virtual reality task twice, once whilst ‘On’ their regular Parkinsonian medication and once in their practically defined ‘Off’ state.

Results

All patients displayed greater step time variability during their ‘Off’ state assessment compared to when medicated. Additionally, in the ‘Off’ state, patients with freezing of gait had greater step time variability compared to non-freezers. The five steps leading up to a freezing episode in the virtual reality environment showed a significant increase in step time variability although the final three steps preceding the freeze were not characterized by a progressive shortening of latency.

Conclusions

The results of this study suggest that characteristic features of gait disturbance observed in patients with freezing of gait can also be demonstrated with a virtual reality paradigm. These findings suggest that virtual reality may offer the potential to further explore the freezing phenomenon in Parkinson’s disease.     

A cross-sectional study of the nutritional status of community-dwelling people with idiopathic Parkinson's disease

Background  

Parkinson's disease (PD) patients have an increased risk of under-nutrition, but we are unaware of any population based prevalence studies of under-nutrition in PD. The main objective of this study was to identify the prevalence, and nature, of under-nutrition in a representative population of people with PD.     

Comparing auditory,visual and vibrotactile cues in individuals with Parkinson’s disease for reducing risk of falling over different types of soil

Introduction: Several researchers have demonstrated the positive benefits of auditory and visual cueing in the gait improvements among individuals with Parkinson’s disease (PD). However, few studies have evaluated the role of vibrotactile cueing when compared to auditory and visual cueing. This paper compares how these stimuli affect the risk of falling while walking on six types of soil (concrete, sand, parquet, broken stone, two types of carpet).

Methods: An instrumented Timed Up and Go (iTUG) test served to evaluate how audio, visual and vibrotactile cueing can affect the risk of falling of elderly. This pilot study proposes 12 participants with PD (67.7?±?10.07?years) and nine age-matched controls (66.8?±?8.0?years). Both groups performed the iTUG test with and without cueing. The cueing frequency was set at 10% above the cadence computed at the lower risk level of falling (walking over the concrete). A computed risk of falling (ROFA) index has been compared to the TUG time (total TUG duration).

Results: The index for evaluating the risk of falling appears to have a good reliability (ICC >?0.88) in this pilot study. In addition, the minimal detectable change (MDC) suggests that the proposed index could be more sensitive to the risk of falling variation compared to the TUG time. Moreover, while using the cueing, observed results suggest a significant decrease in the computed risk of falling compared to ‘without cueing’ for most of types of soil, especially for deformable soils, which can lead to falls.

Conclusion: When compared to other cueing, it seems that audio could be a better neurofeedback for reducing the risk of falling over different walking surfaces, which represent important risk factors for persons with gait disorder or lost functional autonomy.     

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.     

StartReact Effects Support Different Pathophysiological Mechanisms Underlying Freezing of Gait and Postural Instability in Parkinson’s Disease

Introduction

The pathophysiology underlying postural instability in Parkinson’s disease is poorly understood. The frequent co-existence with freezing of gait raises the possibility of shared pathophysiology. There is evidence that dysfunction of brainstem structures contribute to freezing of gait. Here, we evaluated whether dysfunction of these structures contributes to postural instability as well. Brainstem function was assessed by studying the StartReact effect (acceleration of latencies by a startling acoustic stimulus (SAS)).

Methods

We included 25 patients, divided in two different ways: 1) those with postural instability (HY = 3, n = 11) versus those without (HY<3, n = 14); and 2) those with freezing (n = 11) versus those without freezing (n = 14). We also tested 15 matched healthy controls. We tested postural responses by translating a balance platform in the forward direction, resulting in backward balance perturbations. In 25% of trials, the start of the balance perturbation was accompanied by a SAS.

Results

The amplitude of automatic postural responses and length of the first balance correcting step were smaller in patients with postural instability compared to patients without postural instability, but did not differ between freezers and non-freezers. In contrast, the StartReact effect was intact in patients with postural instability but was attenuated in freezers.

Discussion

We suggest that the mechanisms underlying freezing of gait and postural instability in Parkinson’s disease are at least partly different. Underscaling of automatic postural responses and balance-correcting steps both contribute to postural instability. The attenuated StartReact effect was seen only in freezers and likely reflects inadequate representation of motor programs at upper brainstem level.     

A linkage study of candidate loci in familial Parkinson's Disease

Background  

Parkinson's disease is the second most common neurodegenerative disorder after Alzheimer's disease. Most cases are sporadic, however familial cases do exist. We examined 12 families with familial Parkinson's disease ascertained at the Movement Disorder clinic at the Oregon Health Sciences University for genetic linkage to a number of candidate loci. These loci have been implicated in familial Parkinson's disease or in syndromes with a clinical presentation that overlaps with parkinsonism, as well as potentially in the pathogenesis of the disease.     

Development and testing of a self administered version of the Freezing of Gait Questionnaire

Background  

The Freezing of Gait Questionnaire (FOGQ) was developed in response to the difficulties of observing and quantifying freezing of gait (FOG) clinically as well as in laboratory settings. However, as the FOGQ is a clinician-administered patient-reported rating scale it cannot be used in postal surveys. Here we report the development and measurement properties of a self-administered version of the FOGQ (FOGQsa).     

Effect of educational intervention on medication timing in Parkinson's disease: a randomized controlled trial

Background  

Medicine usage in Parkinson's disease patients is often imperfect, in particular irregular timing of medication. The effect of informing Parkinson's disease patients about the continuous dopaminergic hypothesis (to encourage regular medicine intake) on medication adherence and motor control was tested.     

Falls and mobility in Parkinson's disease: protocol for a randomised controlled clinical trial

Background  

Although physical therapy and falls prevention education are argued to reduce falls and disability in people with idiopathic Parkinson's disease, this has not yet been confirmed with a large scale randomised controlled clinical trial. The study will investigate the effects on falls, mobility and quality of life of (i) movement strategy training combined with falls prevention education, (ii) progressive resistance strength training combined with falls prevention education, (iii) a generic life-skills social program (control group).     

Parkinson's disease candidate gene prioritization based on expression profile of midbrain dopaminergic neurons

Background  

Parkinson's disease is the second most common neurodegenerative disorder. The pathological hallmark of the disease is degeneration of midbrain dopaminergic neurons. Genetic association studies have linked 13 human chromosomal loci to Parkinson's disease. Identification of gene(s), as part of the etiology of Parkinson's disease, within the large number of genes residing in these loci can be achieved through several approaches, including screening methods, and considering appropriate criteria. Since several of the indentified Parkinson's disease genes are expressed in substantia nigra pars compact of the midbrain, expression within the neurons of this area could be a suitable criterion to limit the number of candidates and identify PD genes.     

Clinical profile of parkinsonism and Parkinson's disease in Lagos, Southwestern Nigeria

Background  

Current data on the pattern of parkinsonism and Parkinson's disease in Nigerians are sparse.     

Body electrical loss analysis (BELA) in the assessment of visceral fat: a demonstration

Background

Parkinson's disease (PD) is a neurodegenerative disorder resulting in motor disturbances that can impact normal gait. Although PD initially responds well to pharmacological treatment, as the disease progresses efficacy often fluctuates over the course of the day, and clinical management would benefit from long-term objective measures of gait. We have previously described a small device worn on the shank that uses acceleration and angular velocity sensors to calculate stride length and identify freezing of gait in PD patients. In this study we extend validation of the gait monitor to 24-h using simultaneous video observation of PD patients.

Methods

A sleep laboratory was adapted to perform 24-hr video monitoring of patients while wearing the device. Continuous video monitoring of a sleep lab, hallway, kitchen and conference room was performed using a 4-camera security system and recorded to hard disk. Subjects (3) wore the gait monitor on the left shank (just above the ankle) for a 24-h period beginning around 5 pm in the evening. Accuracy of stride length measures were assessed at the beginning and end of the 24-h epoch. Two independent observers rated the video logs to identify when subjects were walking or lying down.

Results

The mean error in stride length at the start of recording was 0.05 m (SD 0) and at the conclusion of the 24 h epoch was 0.06 m (SD 0.026). There was full agreement between observer coding of the video logs and the output from the gait monitor software; that is, for every video observation of the subject walking there was a corresponding pulse in the monitor data that indicated gait.

Conclusions

The accuracy of ambulatory stride length measurement was maintained over the 24-h period, and there was 100% agreement between the autonomous detection of locomotion by the gait monitor and video observation.     

Dopamine Agonists and their risk to induce psychotic episodes in Parkinson's disease: a case-control study

Background  

Psychosis is rare in untreated patients with Parkinson's disease (PD) but the prevalence rises to 40% during dopaminergic treatment. So far, no systematic comparison of the psychogenic potential of different dopaminergic drugs had been performed.     

Efficacy of a hybrid assistive limb in post-stroke hemiplegic patients: a preliminary report

Background  

Robotic devices are expected to be widely used in various applications including support for the independent mobility of the elderly with muscle weakness and people with impaired motor function as well as support for nursing care that involves heavy laborious work. We evaluated the effects of a hybrid assistive limb robot suit on the gait of stroke patients undergoing rehabilitation.     

The predictive value of transcranial duplex sonography for the clinical diagnosis in undiagnosed parkinsonian syndromes: comparison with SPECT scans

Background  

Transcranial duplex sonography (TCD) of the substantia nigra has emerged as a promising, non-invasive tool to diagnose idiopathic Parkinson's disease (IPD). However, its diagnostic accuracy in patients with undefined parkinsonism remains to be determined.     

Abnormal susceptibility to distracters hinders perception in early stage Parkinson's disease: a controlled study

Background  

One of the perceptual abnormalities observed in Parkinson's disease (PD) is a deficit in the suppression of reflexive saccades that are automatically triggered by the onset of a peripheral target. Impairment of substantia nigra function is thought to lead to this reduced ability to suppress reflexive saccades.