Physical therapy in Parkinson's disease: Evolution and future challenges

Even with optimal medical management using drugs or neurosurgery, patients with Parkinson's disease (PD) are faced with progressively increasing mobility problems. For this reason, many patients require additional physical therapy. Here, we review the professional evolution and scientific validation of physical therapy in PD, and highlight several future challenges. To gain insight in ongoing, recently completed or published trials and systematic reviews, we performed a structured literature review and contacted experts in the field of physical therapy in PD. Following publication of the first controlled clinical trial in 1981, the quantity and quality of clinical trials evaluating the efficacy of physical therapy in PD has evolved rapidly. In 2004 the first guideline on physical therapy in PD was published, providing recommendations for evidence‐based interventions. Current research is aiming to gather additional evidence to support specific intervention strategies such as the prevention of falls, and to evaluate the implementation of evidence into clinical practice. Although research focused on physical therapy for PD is a relatively young field, high‐quality supportive evidence is emerging for specific therapeutic strategies. We provide some recommendations for future research, and discuss innovative strategies to improve the organization of allied health care in PD, making evidence‐based care available to all PD patients. © 2008 Movement Disorder Society     

Walking stability using harmonic ratios in Parkinson's disease

Kinematic changes in Parkinson's disease (PD) gait are well documented; however, upper body dynamics are less understood. Harmonic ratios (HRs) measure the rhythm of trunk accelerations and can be examined in the vertical, anterior‐posterior, and mediolateral planes, providing an indication of global walking stability (lower HR indicates poorer stability). We examined differences in HRs between persons with PD and healthy older adults and relationships between HRs and stride parameters. Eleven people with PD and 11 older adults walked over ground at their preferred pace. A triaxial accelerometer measured trunk accelerations. HRs and spatiotemporal parameters were calculated and standardized to remove the influence of gait velocity. The PD group exhibited lower HRs in all three planes, with the most pronounced differences in the mediolateral and anterior‐posterior planes. Greater stride time variability was most closely associated with a lower anterior‐posterior HR in PD and the presence of disease with the mediolateral HR. By demonstrating decreased walking stability in medial‐lateral and anterior‐posterior planes, we conclude that HRs offer unique information beyond that of typical stride parameters, and stride time variability is most closely associated with these direct measures of global walking stability. © 2008 Movement Disorder Society     

Gait and balance in essential tremor: Variable effects of bilateral thalamic stimulation

Essential tremor (ET) is a multi‐faceted condition best known for postural and action tremor but also may include disordered gait and postural instability. Deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) of the thalamus provides substantial tremor reduction yet some patients with bilateral VIM DBS have gait and balance impairment. This study examines gait and balance performance in 13 participants with ET who have bilateral VIM DBS compared with a matched control group. Participants with ET were tested with their stimulators off (DBS OFF) and on (DBS ON). For both standard and tandem walking, participants with ET walked significantly more slowly than controls, with significantly lower cadence, spending a lower percentage of the gait cycle in single limb support and a higher percentage in double support compared with controls. Participants with ET also had significantly lower tandem and one leg stance times, Berg balance scores, balance confidence, and required significantly greater time to perform the Timed Up‐and‐Go relative to controls. There were no significant differences in any gait or balance measures in the DBS OFF versus DBS ON conditions, but the effects of DBS on gait and balance were highly variable among individuals. Future studies are needed to determine why some individuals experience gait and balance difficulties after bilateral thalamic DBS and others do not. A better understanding of the mechanisms underlying gait and balance impairments in those with bilateral DBS is critical to reduce falls and fractures in this group. © 2008 Movement Disorder Society     

Norepinephrine and cardiovascular responses to maximal exercise in Parkinson's disease on and off medication

The aim of this experiment is to understand how Parkinson's disease (PD) medication affects the autonomic responses of individuals during an acute exercise stress test. Fourteen people with PD and fifteen healthy individuals age‐matched between 50 and 80 years performed a modified Bruce protocol. Subjects with PD performed the test once off medication (PD‐off) and then 1 week later on medication (PD‐on). Heart rate (HR), blood pressure (BP), VO₂, and norepinephrine (NE) levels were taken at rest and at peak exercise. At peak exercise HR, BP, and NE values for the PD‐on and PD‐off group were all significantly lower than healthy controls, regardless of whether subjects were on their medication. Autonomic abnormalities during exercise in this population appear to be disease manifested and not impactedby medications used to treat PD. We can assume, both on and off medication, this population will show markedly lower BP, HR, and NE responses. © 2009 Movement Disorder Society     

Comfortably numb? Exploring satisfaction with chronic back pain visits

Background contextChronic back pain is a condition characterized by high rates of disability, health-care service use, and costs.PurposeThe purpose of this study was to identify factors associated with patients' satisfaction with their last health-care provider visit for chronic low back pain (LBP).Study design/settingA cross-sectional, state-level, telephone survey was administered to patients with chronic LBP.Patient sampleThe sample consisted of 624 individuals with chronic LBP who reported seeing a health-care provider in the previous year.Outcome measuresDependent variables included satisfaction with last visit for LBP and intent to seek care from additional providers. Independent variables included the Roland-Morris Disability Questionnaire, 3-month pain ratings using a 0 to 10 Likert scale, the Medical Outcomes Survey Short Form 12, and self-reported health service utilization (provider type, number of visits to health-care providers, medication use during the previous month, and treatments and diagnostic tests during the previous year).MethodsBivariate and multivariate analyses were used to explore how demographic, insurance-related, and health-related characteristics were associated with patient satisfaction.ResultsParticipants who were not satisfied with one or more aspects of their last clinic visit were younger (51.0 vs. 54.21 years), reported higher 3-month pain ratings (7.23 vs. 6.53), and were more commonly Hispanic (53.2% vs. 46.8% for other ethnicities) and uninsured (43.1% vs. 29.3% for other insurance groups). Those who intended to seek care from additional providers were younger (50.05 vs. 55.49 years), had higher 3-month pain ratings (7.20 vs. 6.46), had lower Short Form 12 mental health component scores (44.75 vs. 49.55) and physical component scores (30.07 vs. 31.55), and were more commonly black (54.6% vs. 45.4% for other racial groups) and uninsured (56.9% vs. 43.1% for other insurance groups). Narcotic use was associated with satisfaction (odds ratio=2.12, p=.01), whereas lack of insurance was associated with respondents' intent to seek care from additional providers (odds ratio=2.97, p<.01).ConclusionsFactors other than disability were associated with satisfaction with chronic LBP visits. Understanding the role of medication in satisfaction and its implications for the health behaviors of this highly disabled population may be particularly important.     

Streptococcus pneumoniae Capsular Serotype 19F Is More Resistant to C3 Deposition and Less Sensitive to Opsonophagocytosis than Serotype 6B

The polysaccharide capsule is a major virulence mechanism of Streptococcus pneumoniae, shielding the bacterium from phagocytes. Capsule types may differ in their abilities to resist immune defense. Antibody-mediated complement activation and opsonophagocytosis are crucial in protection against pneumococcus. Conjugate vaccine trials suggest imperfect protection against 19F. We have previously shown that significantly more anti-19F than anti-6B antibody is needed for killing in the opsonophagocytic assay (OPA). In this study, we explored whether the amount of C3 deposited on serotype 6B and 19F pneumococcal strains reflects their sensitivity to opsonophagocytosis. We compared clinical 6B and 19F nasopharyngeal, middle ear, and blood isolates as well as reference OPA strains (n = 16) for their sensitivity to opsonophagocytosis and C3 deposition. Sixfold anticapsular antibody concentrations were required for 50% opsonophagocytic killing of 19F compared to that of 6B strains. Serotype 19F was more resistant to C3 deposition than 6B. Complement deposition and opsonophagocytosis were dependent on the concentration of anticapsular antibodies. Differences between pneumococcal serotypes in antibody-mediated protection may partly be explained by the abilities of the capsules to resist complement deposition. These findings support previous studies suggesting that higher antibody concentrations to the capsular polysaccharide are needed for protection against disease caused by serotype 19F than that caused by 6B.     

Development of a parent-report computer-adaptive test to assess physical functioning in children with cerebral palsy I: lower-extremity and mobility skills

The objective of this project was to develop computer-adaptive tests (CATs) using parent reports of physical function in children and adolescents with cerebral palsy (CP). The specific aims of this study were to (1) examine the psychometric properties of an item bank of lower-extremity and mobility skills for children with CP; (2) evaluate a CAT using this item bank; (3) examine the concurrent validity of the CAT with the Pediatric Outcomes Data Collection Instrument (PODCI) and the Functional Assessment Questionnaire (FAQ); and (4) establish the discriminant validity of simulated CATs with Gross Motor Function Classification System (GMFCS) levels and CP type (diplegia, hemiplegia, or quadriplegia). Parents ( n =190) of children and adolescents with spastic diplegic (48%), hemiplegic (22%), or quadriplegic (30%) CP consisting of 108 males and 82 females with a mean age of 10 years 7 months (SD 4y 1mo, range 2–21y) and in GMFCS levels I to V participated in item pool calibration and completed the PODCI and FAQ. Confirmatory factor analyses supported a unidimensional model for the 45 basic lower-extremity and mobility items. Simulated CATs of 5, 10, and 15 items demonstrated excellent accuracy (intraclass correlation coefficients [ICCs] >0.91) with the full item bank and had high correlations with PODCI transfers and mobility (ICC = 0.86) and FAQ scores (ICC = 0.77). All CATs discriminated among GMFCS levels and CP type. The lower-extremity and mobility skills item bank and simulated CATs demonstrated excellent performance over a wide span of ages and severity levels.     

Social participation and incident disability and mortality among frail older adults: A JAGES longitudinal study

Background

Frailty is the highest risk factor for incident disability and mortality. Social participation is a modifiable factor for reducing adverse outcomes among independent older adults. However, the association between social participation and incident disability and mortality among frail older adults remains unclear. Therefore, we examined the association between various social activities and incident disability and mortality.

Methods

This nationwide prospective cohort study (The Japan Gerontological Evaluation Study) recruited older adults with frailty, aged 65 years and older (N = 9090) who were followed up for 6 years (2010–2016). We examined incident disability and all-cause mortality at the end of the follow-up period. Frailty was assessed using the Kihon Checklist. The independent variable was social participation in 2010, grouped into the following seven categories: hobby groups, sports groups or clubs, volunteer groups, senior citizens' clubs, industries, neighborhood communities, and paid work.

Results

The incidence of disability among participants was 19.5% (1770) and that of mortality was 19.2% (1753). Belonging to sports groups or clubs (Hazard Ratios [HR] = 0.74; 95% Confidence Interval [CI] = 0.57, 0.98) or hobby groups (HR = 0.77; 95% CI = 0.60, 0.98) was significantly associated with a lower risk of incident disability. Meanwhile, hobby groups (HR = 0.68; 95% CI = 0.56, 0.83), sports groups or clubs (HR = 0.71; 95% CI = 0.57, 0.88), volunteer groups (HR = 0.69; 95% CI = 0.54, 0.88), and senior citizens' club (HR = 0.75; 95% CI = 0.61, 0.90) were associated with lower risk of incident mortality.

Conclusions

Social participation was associated with a lower risk of incident disability and mortality, not only in healthy older adults but also in frail older adults who are at higher risk of incident disability and mortality. This suggests that frail older adults should be encouraged to participate in all the seven types of social participation examined in this study, as this may lower the risk of subsequent disability and mortality.