Carolyn Fitton

A randomised controlled trial of a home based exercise programme to reduce the risk of falling among people with Parkinson’s disease

Objective: To evaluate the effectiveness of a personalised home programme of exercises and strategies for repeat fallers with Parkinson’s disease (PD). Method: Patients with a confirmed diagnosis of idiopathic PD, independently mobile, living at home in the community, experiencing more than one fall in the previous 12 months and with intact gross cognitive function were invited to participate in this randomised controlled trial. Usual care was compared with a personalised 6 week, home based exercise and strategy programme. The primary outcomes were rates of falling at 8 weeks and 6 months. Whether participants had repeat fallen, nearly fallen or experienced injurious falls were also examined. Functional Reach, the Berg Balance Test, PD Self-assessment Scale and the Euro Quol were rated by a blinded assessor. Results: Participants were randomised to the exercise (n = 70) and control (n = 72) groups. There was a consistent trend towards lower fall rates in the exercise group at both 8 weeks and 6 months and lower rates of injurious falls needing medical attention at 6 months. Lower rates of repeat near falling were evident for the exercise group at 8 weeks (p = 0.004) and 6 months (p = 0.007). There was a positive effect of exercises at 6 months on Functional Reach (p = 0.009) and quality of life (p = 0.033). No significant differences were found on other secondary outcomes measures. Conclusion: There was a trend towards a reduction in fall events and injurious falls with a positive effect of exercises on near falls and quality of life.

The circumstances of falls among people with Parkinson's disease and the use of Falls Diaries to facilitate reporting

Purpose. Falls are common in Parkinsons disease (PD). Falls Diaries are one way of recording fall frequency and the surrounding circumstances; completing them encourages recall, and their content focuses intervention. We reviewed the diaries completed by people with PD during a randomized controlled trial (RCT) of fall prevention to ascertain the key circumstances surrounding falls. Method. We asked independently mobile, cognitively intact people with a diagnosis of PD to maintain a Falls Diary throughout a six-month RCT. We sent monthly diary sheets on which to answer questions about the ‘Location’, ‘Fall-related activity’, ‘Perceived cause’, ‘Landing’ and ‘Consequences’ of every fall. We coded responses and counted frequencies. Results. Of the 142 RCT participants (mean age 72 years; mean years since diagnosis 8), 135 completed the trial and their diary. We excluded 11 (8%) for missing data and/or unintelligible writing. The 124 remaining diaries recorded 639 falls: 80% happened at home, commonly in bedrooms, living areas, kitchens and gardens. Fallers had been ambulant in 45% of events, standing in 32% and transferring in 21%. Six ‘activity-cause combinations’ accounted for 55% of falls (tripping 13%; freezing, festination and retropulsion 11%; and postural instability when bending or reaching 9%, transferring 8%, walking 7% and washing or dressing 7%). Misjudgement and distraction played a part in 12% of falls described. Conclusions. Of over 600 falls surveyed, most happened at home, provoked by postural instability, tripping and freezing. Environmental adaptation and cognitive training should be trialled in falls prevention in PD, plus or minus traditional movement rehabilitation. Most participants completed Falls Diaries successfully. We advocate diary use, with follow-up interviews, in research and clinically. People with handwriting difficulty may require a typed diary, proxy diarist or interview.

Self reported adherence to a home-based exercise programme among people with Parkinson's disease.

BACKGROUND There is an extensive literature addressing compliance with medication, techniques to measure, and ways to improve it. In comparison the literature concerning adherence to exercise programmes agreed with a physiotherapist is limited. OBJECTIVE We estimate the percentage of exercise repetitions completed of those agreed with a physiotherapist in the context of a six week personalized exercise programme to reduce falling in people with Parkinsons disease, and examine patient characteristics that predict adherence. METHODS Secondary analysis of data collected during a randomized controlled trial. Participants allocated to receive the exercise programme self-reported the number of repetitions of prescribed strengthening, range of movement and balance exercises they had completed in daily dairies. Indoor or outdoor walking was also prescribed but in terms of target distances or lengths of time, and was not included in our analysis. RESULTS On average the 70 participants allocated to the exercise programme reported completing 79% (95% confidence interval 73%-86%) of the prescribed number of repetitions of their exercises. The percentage of exercises completed varied depending on the specific exercise prescribed, and on participant characteristics: those who were older, in poorer health and with anxiety, depression, or mental heath problems reported lower adherence to exercise. CONCLUSION Several of the factors we found to reduce adherence to exercise have been shown by others to reduce compliance with antiparkinsonian medication, but we found adherence decreased with age in contrast to the pattern of better compliance with medication amongst older people with Parkinsons disease reported previously.

Impact of stroke-associated infection on long-term survival: a cohort study

Background and objective The effects of stroke-associated infection (SAI) on long-term survival are unclear. We performed a prospective evaluation to explore risk factors of SAI, and compared survival status over the 3 years following stroke onset between those who experienced SAI and those who did not. Methods Consecutive patients with acute stroke admitted to a stroke unit between April 2005 and December 2006 were invited to participate. We prospectively collected data on demographics, pathological and clinical stroke subtype, stroke severity, and neurological and functional consequences, and abstracted additional data on occurrence and timing of SAI in hospital from medical notes. Survival status 3 years after stroke onset was obtained. Results We recruited 413 acute stroke patients, 161 (39%) experienced SAI. After excluding patients with infection at onset, patients with intracerebral haemorrhage (p=0.014), dysphagia (p=0.003) and urinary incontinence/catheterisation (p=0.000) were at higher risk of infection after controlling for case mix. The risk of death in hospital was greater following an SAI (HR 3.56; 95% CI 1.94 to 6.53; p=0.000), as was risk of death calculated over the whole 3-year follow-up period among those acquiring SAI within 2 weeks of onset (HR 1.66; 95% CI 1.14 to 2.40; p=0.031). Conclusions SAIs have long-lasting effects on patient survival. This serves to emphasise the importance of immediate access to organised stroke unit care for people with acute stroke, with active physiological monitoring and protocols for early detection and treatment of SAIs.

Physical inactivity post-stroke: a 3-year longitudinal study

Abstract Purpose: To explore change in activity levels post-stroke. Methods: We measured activity levels using the activPAL™ in hospital and at 1, 2 and 3 years’ post-stroke onset. Results: Of the 74 participants (mean age 76 (SD 11), 39 men), 61 were assessed in hospital: 94% of time was spent in sitting/lying, 4% standing and 2% walking. Activity levels improved over time (complete cases n = 15); time spent sitting/lying decreased (p = 0.001); time spent standing, walking and number of steps increased (p = 0.001, p = 0.028 and p = 0.03, respectively). At year 3, 18% of time was spent in standing and 9% walking. Time spent upright correlated significantly with Barthel (r = 0.69 on admission, r = 0.68 on discharge, both p < 0.01) and functional ambulation category scores (r = 0.55 on admission, 0.63 on discharge, both p < 0.05); correlations remained significant at all assessment points. Depression (in hospital), left hemisphere infarction (Years 1–2), visual neglect (Year 2), poor mobility and balance (Years 1–3) correlated with poorer activity levels. Conclusion: People with stroke were inactive for the majority of time. Time spent upright improved significantly by 1 year post-stroke; improvements slowed down thereafter. Poor activity levels correlated with physical and psychological measures. Larger studies are indicated to identify predictors of activity levels. Implications for Rehabilitation Activity levels (measured using activPAL™ activity monitor), increased significantly by 1 year post-stroke but improvements slowed down at 2 and 3 years. People with stroke were inactive for the majority of their day in hospital and in the community. Poor activity levels correlated with physical and psychological measures. Larger studies are indicated to identify the most important predictors of activity levels.

A Design to Investigate the Feasibility and Effects of Partnered Ballroom Dancing on People With Parkinson Disease: Randomized Controlled Trial Protocol

Background Self-help and physical leisure activities has become increasingly important in the maintenance of safe and functional mobility among an increasingly elderly population. Preventing the cycle of deterioration, falling, inactivity, dependency, and secondary complications in people with Parkinson disease (PD) is a priority. Research has shown that people with PD are interested in dance and although the few existing trials are small, initial proof of principle trials from the United States have demonstrated beneficial effects on balance control, gait, and activity levels. To our knowledge, there has been no research into long-term effects, cost effectiveness, the influence on spinal posture and turning, or the personal insights of dance participants. Objective The purpose of this study was to determine the methodological feasibility of conducting a definitive phase III trial to evaluate the benefits of dance in people with PD. We will build on the proof of principle trials by addressing gaps in knowledge, focusing on areas of greatest methodological uncertainty; the choice of dances and intensity of the program; for the main trial, the availability of partners, the suitability of the currently envisaged primary outcomes, balance and spinal posture; and the key costs of delivering and participating in a dance program to inform economic evaluation. Methods Fifty participants (mild-to-moderate condition) will be randomized to the control (usual care) or experimental (dance plus usual care) groups at a ratio of 15:35. Dance will be taught by professional teachers in a dance center in the South of England. Each participant in the experimental group will dance with his or her spouse, a friend, or a partner from a bank of volunteers. A blinded assessor will complete clinical measures and self-reported ability at baseline, and at 3 and 6 months after randomization. A qualitative study of a subgroup of participants and partners will examine user’s views about the appropriateness and acceptability of the intervention, assessment protocol, and general trial procedures. Procedures for an economic evaluation of dance for health care will be developed for the main trial. Results Recruitment began in January 2013 and the last participant is expected to complete the trial follow-up in June 2014. Conclusions Findings from our study may provide novel insights into the way people with PD become involved in dance, their views and opinions, and the suitability of our primary and secondary outcomes. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 63088686; http://www.controlled-trials.com/ISRCTN63088686/63088686 (Archived by WebCite at http://www.webcitation.org/6QYyjehP7).

It takes two: the influence of dance partners on the perceived enjoyment and benefits during participation in partnered ballroom dance classes for people with Parkinson’s

Abstract Purpose: To explore the views of people with Parkinson’s and their dance partners on the influence and issues surrounding dancing with an able-bodied dance partner during partnered ball room dance classes. Methods: In depth, semi-structured interviews explored purposively selected participants’ experiences and views about dance classes. Fourteen people with Parkinson’s and their dance partners (six spouses, two friends/relatives, five volunteers) were interviewed within a month of completing the 10-week dance class program. Data were analyzed thematically. Results: Generally, those partnered with a spouse or an experienced dancer, or when dance couples were able to develop good rapport, gained greater enjoyment and sense of achievement from dance classes in comparison to couples who did not enjoy dancing together or had clashing approaches to dance. Managing and negotiating who would “lead” in a dance was challenging for dance couples particularly among male people with Parkinson’s. Conclusions: People with Parkinson’s experience of the dance classes were influenced by the relationship and compatibility with their dance partner. Dance partnerships may impact on recruitment, enjoyment, outcome and continued participation in dance classes. Potential effects of partnerships should be analyzed and reported in studies evaluating the outcomes of dance classes. Implications for rehabilitation We recommend that health professionals consider involving spouses in Parkinson’s dance classes as this may improve recruitment, adherence, enjoyment and overall outcome of the dance classes. If volunteers are needed, aim to recruit those who already have good dancing ability, convey a love of dancing and have the sensitivity and social skills to interact positively with the person with Parkinson’s. Consider dance partnership issues when advertising and promoting dance classes. Address partnership issues through open communication and by changing partners if the dance partnership is not working well.

“Staying safe” – a narrative review of falls prevention in people with Parkinson’s – “PDSAFE”

Abstract Background: Parkinson’s disease demonstrates a spectrum of motor and non-motor symptoms. Falling is common and disabling. Current medical management shows minimal impact to reduce falls or fall-related risk factors, such as deficits in gait, strength, and postural instability. Despite evidence supporting rehabilitation in reducing fall risk factors, the most appropriate intervention to reduce overall fall rate remains inconclusive. This article aims to 1) synthesise current evidence and conceptual models of falls rehabilitation in Parkinson’s in a narrative review; and based on this evidence, 2) introduce the treatment protocol used in the falls prevention and multi-centre clinical trial “PDSAFE”. Method: Search of four bibliographic databases using the terms “Parkinson*” and “Fall*” combined with each of the following; “Rehab*, Balanc*, Strength*, Strateg*and Exercis*” and a framework for narrative review was followed. A total of 3557 papers were identified, 416 were selected for review. The majority report the impact of rehabilitation on isolated fall risk factors. Twelve directly measure the impact on overall fall rate. Discussion: Results were used to construct a narrative review with conceptual discussion based on the “International Classification of Functioning”, leading to presentation of the “PDSAFE” intervention protocol. Conclusions: Evidence suggests training single, fall risk factors may not affect overall fall rate. Combining with behavioural and strategy training in a functional, personalised multi-dimensional model, addressing all components of the “International Classification of Functioning” is likely to provide a greater influence on falls reduction. “PDSAFE” is a multi-dimensional, physiotherapist delivered, individually tailored, progressive, home-based programme. It is designed with a strong evidence-based approach and illustrates a model for the clinical delivery of the conceptual theory discussed. Implications for Rehabilitation Parkinson’s disease demonstrates a spectrum of motor and non-motor symptoms, where falling is common and disabling. Current medical and surgical management have minimal impact on falls, rehabilitation of falls risk factors has strong evidence but the most appropriate intervention to reduce overall fall rate remains inconclusive. Addressing all components of the International Classification of Function in a multifactorial model when designing falls rehabilitation interventions may be more effective at reducing fall rates in people with Parkinson’s than treating isolated risk factors. The clinical model for falls rehabilitation in people with Parkinson’s should be multi-dimensional.

A randomized controlled feasibility trial exploring partnered ballroom dancing for people with Parkinson’s disease:

Objective: To determine the feasibility of a Dance Centre delivering a programme of mixed dances to people with Parkinson’s and identify suitable outcomes for a future definitive trial. Design: A two-group randomized controlled feasibility trial. Methods: People with Parkinson’s were randomized to a control or experimental group (ratio 15:35), alongside usual care. In addition, participants in the experimental group danced with a partner for one hour, twice-a-week for 10 weeks; professional dance teachers led the classes and field-notes were kept. Control-group participants were given dance class vouchers at the end of the study. Blinded assessments of balance, mobility and function were completed in the home. Qualitative interviews were conducted with a subsample to explore the acceptability of dance. Results: A total of 51 people with Parkinson’s (25 male) with Hoehn and Yahr scores of 1–3 and mean age of 71 years (range 49–85 years), were recruited to the study. Dance partners were of similar age (mean 68, range 56–91 years). Feasibility findings focused on recruitment (target achieved); retention (five people dropped out of dancing); outcome measures (three measures were considered feasible, changes were recommended). Proposed sample size for a Phase III trial, based on the 6-minute walk test at six months was 220. Participants described dance as extremely enjoyable and the instructors were skilled in instilling confidence and motivation. The main organizational challenges for a future trial were transport and identifying suitable dance partners. Conclusion: We have demonstrated the feasibility of conducting the study through a Dance Centre and recommend a Phase III trial.

Mobility and falls in people with Parkinson’s Disease (PD) with and without cognitive impairment

Objective: The socio-demographic, epidemiologic, clinical features and genetic causes of Parkinson’s disease patients attending the Neurology out-patients clinic of the Korle Bu Teaching and Comboni hospitals are reviewed. Background: Parkinson’s disease (PD) is a chronic and progressive neurodegenerative disease thought to be rare in Africa. A colloborative project with the Parkinson’s Institute in Milan, Italy is ongoing in Ghana. Methods: Consecutive patients clinically diagnosed with Parkinson’s disease over the last year who were enrolled in the ‘‘Parkinson’s disease in Africa collaboration project’’ were recruited. A detailed personal, family and social history was taken followed by a neurological examination, complete Unified Parkinson’s Disease Rating Scale (UPDRS) assessment (part I to part IV), Hoehn and Yahr staging and initiation of treatment with Levodopa. Patients are reviewed at 3, 6 and 12 months. Brain imaging with a head CT scan is done were feasible. A saliva sample was collected after informed consent for analysis of the LRRK2-G2019S mutation amongst others. Results: 35 subjects with parkinsonism have been identified so far: Mean age at onset 65.7610.5 years; disease duration 7.4563.1 years; Hoehn and Yahr stage 2. Mean daily levodopa dosage 5201187mg. The LRRK2 exon 41 screening did not reveal the presence of any G2019S mutation in the Parkinson’s disease patients studied so far. Recruitment of more patients, follow up at 6 months and 12 months as well as completion of UPDRS data are the main thrust of the study now Conclusions: A good response to Levedopa is seen and further genetic analysis is required