Breiffni Leavy

“Pushing the Limits”: Rethinking Motor and Cognitive Resources After a Highly Challenging Balance Training Program for Parkinson Disease

Background There is growing evidence for the positive effects of exercise training programs on balance control in Parkinson disease (PD). To be effective, balance training needs to be specific, progressive, and highly challenging. Little evidence exists, however, for how people with PD‐related balance impairments perceive highly challenging and progressive balance training programs with dual‐task components. Objective The purpose of this study was to explore and describe perceptions of a highly challenging balance training program among people with mild to moderate PD. Design This study was qualitative in nature. In‐depth interviews were conducted with 13 individuals with mild to moderate PD who had participated in a highly challenging balance training program. Interview transcripts were analyzed using qualitative content analysis, with an inductive approach. Results The analysis revealed 3 subthemes concerning participants’ perceptions of highly challenging and progressive balance training: (1) movement to counter the disease, (2) dual‐task training in contrast to everyday strategies, and (3) the struggle to maintain positive effects. The first subtheme reflects how physical activity was used as a short‐term and long‐term strategy for counteracting PD symptoms and their progression. The second subtheme incorporates the described experiences of being maximally challenged in a secure and supportive group environment, circumstances that stood in contrast to participants’ everyday lives. The third subtheme describes participants’ long‐term struggle to maintain program effects on cognitive and physical function in the face of disease progression. Interpretation of the underlying patterns of these subthemes resulted in one overarching theme: training at the limits of balance capacity causes a rethinking motor and cognitive resources. Limitations The findings of this study cannot be considered to reflect the beliefs of those with weaker or negative beliefs concerning physical activity or be transferred to those at more severe stages of the disease. Conclusions Findings from this study suggest that being pushed to the limits of balance capacity provoked people with mild to moderate PD to rethink their individual motor and cognitive resources, a process that was further enabled by the PD‐specific group setting.

Physiotherapy for Parkinson's disease in Sweden: Provision, expertise and multi‐professional collaborations

Evidence for the positive effects of physiotherapy for persons with Parkinsons disease (PwPD) is rapidly increasing. However, little is known about the provision of physiotherapy for PwPD in everyday practice. The objective of this study was to gain insight into the nature of physiotherapeutic care for PwPD in hospitals, primary care units, and community services in Sweden.

Evaluation and implementation of highly challenging balance training in clinical practice for people with Parkinson’s disease: protocol for the HiBalance effectiveness-implementation trial

BackgroundIf people with progressive neurological diseases are to avail of evidence-based rehabilitation, programs found effective in randomized controlled trials (RCT’s) must firstly be adapted and tested in clinical effectiveness studies as a means of strengthening their evidence base. This paper describes the protocol for an effectiveness-implementation trial that will assess the clinical effectiveness of a highly challenging balance training program (the HiBalance program) for people with mild-moderate Parkinson’s disease (PD) while simultaneously collecting data concerning the way in which the program is implemented. The HiBalance program is systemically designed to target balance impairments in PD and has been shown effective at improving balance control and gait in a previous RCT. Study aims are to i) determine the effectiveness of the adapted HiBalance program on performance and self-rated outcomes such as balance control, gait and physical activity level ii) conduct a process evaluation of program implementation at the various clinics iii) determine barriers and facilitators to program implementation in these settings.MethodsThis effectiveness-implementation type 1 hybrid study will use a non-randomized controlled design with consecutive inclusion of people with PD at multiple clinical sites. A mixed method approach will be used to collect clinical effectiveness data and process evaluation data which is both quantitative and qualitative in nature. The consolidated framework for implementation research (CFIR) will be used to guide the planning and collection of data concerning implementation barriers and facilitators. The HiBalance program will be provided by physical therapists as a part of standard rehabilitation care at the clinical sites, while the evaluation of the implementation process will be performed by the research group and funded by research grants.DiscussionAn effectiveness-implementation study design benefits patients by speeding up the process of translating findings from research settings to routine health care. Findings from this study will also be highly relevant for those working with neurological rehabilitation when faced with decisions concerning the translation of training programs from efficacy studies to everyday clinical practice.Trial registrationClinicalTrials.gov march 2016, NCT02727478.

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.

Implementation of the HiBalance training program for Parkinson’s disease in clinical settings: A feasibility study

Translating evidence into practice requires adaptation to facilitate the implementation of efficacious interventions. A novel highly challenging balance training program (HiBalance) was found to improve gait, balance, and physical activity in persons with Parkinson’s disease (PD) in an earlier randomized controlled trial. This study aimed to describe the adaptation process and feasibility of implementing the HiBalance program for PD within primary healthcare settings.

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

Knowledge of the relationships between patient‐reported and performance‐based walking measures in Parkinsons 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.

Perceptions of balance and falls following a supervised training intervention – a qualitative study of people with Parkinson’s disease

Abstract 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.