Maria Elisa Pimentel Piemonte

Effect of Nintendo Wii™-based motor and cognitive training on activities of daily living in patients with Parkinson's disease: a randomised clinical trial.

OBJECTIVES To investigate the effect of Nintendo Wii™-based motor cognitive training versus balance exercise therapy on activities of daily living in patients with Parkinsons disease. DESIGN Parallel, prospective, single-blind, randomised clinical trial. SETTING Brazilian Parkinson Association. PARTICIPANTS Thirty-two patients with Parkinsons disease (Hoehn and Yahr stages 1 and 2). INTERVENTIONS Fourteen training sessions consisting of 30 minutes of stretching, strengthening and axial mobility exercises, plus 30 minutes of balance training. The control group performed balance exercises without feedback or cognitive stimulation, and the experimental group performed 10 Wii Fit™ games. MAIN OUTCOME MEASURE Section II of the Unified Parkinsons Disease Rating Scale (UPDRS-II). RANDOMISATION Participants were randomised into a control group (n=16) and an experimental group (n=16) through blinded drawing of names. STATISTICAL ANALYSIS Repeated-measures analysis of variance (RM-ANOVA). RESULTS Both groups showed improvement in the UPDRS-II with assessment effect (RM-ANOVA P<0.001, observed power=0.999). There was no difference between the control group and the experimental group before training {8.9 [standard deviation (SD) 2.9] vs 10.1 (SD 3.8)}, after training [7.6 (SD 2.9) vs 8.1 (SD 3.5)] or 60 days after training [8.1 (SD 3.2) vs 8.3 (SD 3.6)]. The mean difference of the whole group between before training and after training was -0.9 (SD 2.3, 95% confidence interval -1.7 to -0.6). CONCLUSION Patients with Parkinsons disease showed improved performance in activities of daily living after 14 sessions of balance training, with no additional advantages associated with the Wii-based motor and cognitive training. Registered on http://www.clinicaltrials.gov (identifier: NCT01580787).

Motor learning, retention and transfer after virtual-reality-based training in Parkinson's disease - effect of motor and cognitive demands of games: a longitudinal, controlled clinical study

OBJECTIVES To evaluate the learning, retention and transfer of performance improvements after Nintendo Wii Fit™ training in patients with Parkinsons disease and healthy elderly people. DESIGN Longitudinal, controlled clinical study. PARTICIPANTS Sixteen patients with early-stage Parkinsons disease and 11 healthy elderly people. INTERVENTIONS Warm-up exercises and Wii Fit training that involved training motor (shifts centre of gravity and step alternation) and cognitive skills. A follow-up evaluative Wii Fit session was held 60 days after the end of training. Participants performed a functional reach test before and after training as a measure of learning transfer. MAIN OUTCOME MEASURES Learning and retention were determined based on the scores of 10 Wii Fit games over eight sessions. Transfer of learning was assessed after training using the functional reach test. RESULTS Patients with Parkinsons disease showed no deficit in learning or retention on seven of the 10 games, despite showing poorer performance on five games compared with the healthy elderly group. Patients with Parkinsons disease showed marked learning deficits on three other games, independent of poorer initial performance. This deficit appears to be associated with cognitive demands of the games which require decision-making, response inhibition, divided attention and working memory. Finally, patients with Parkinsons disease were able to transfer motor ability trained on the games to a similar untrained task. CONCLUSIONS The ability of patients with Parkinsons disease to learn, retain and transfer performance improvements after training on the Nintendo Wii Fit depends largely on the demands, particularly cognitive demands, of the games involved, reiterating the importance of game selection for rehabilitation purposes.

Fatigue in amyotrophic lateral sclerosis: Frequency and associated factors

We aimed to quantify fatigue frequency and evolution in amyotrophic lateral sclerosis (ALS), and to correlate fatigue with factors such as age, sex, educational level, disease duration, functionality, quality of life, dyspnoea, depression and sleepiness. Sixty ALS patients (test group: TG) selected by El Escorial criteria and 60 normal individuals (control group: CG) matched according to sex and age, were followed every three months, during 9 months, by means of self‐report scales: Fatigue Assessment Instrument (Fatigue Severity Scale plus three qualitative subscales); ALS Functional Rating Scale; McGill Quality of Life Questionnaire; dyspnoea analogical scale; Beck Depression Inventory and Epworth Sleepiness Scale. Fatigue was reported by 83% of TG (median: 3.6, interquartile range 1.5−5.4), compared with 20% of CG (median: 1, 1−1), and was significantly greater in the TG (p<0.001, Mann‐Whitney test). Fatigue severity increased by the ninth month of the study (p = 0.0008, Friedman, Müller‐Dunn post test). There was no correlation between fatigue and other parameters, except for an inverse correlation with age at disease onset (p = 0.0395, Spearman rank correlation). In conclusion, fatigue was frequent in ALS, greater in the youngest patients and worsened during follow‐up. Possibly, ALS related fatigue is an independent factor, which deserves individualized approach and treatment.

Resistance Training with Instability for Patients with Parkinson’s Disease

PURPOSE This randomized controlled trial compared the effects of resistance training (RT) and RT with instability (RTI) on the timed up and go test (TUG), on-medication Unified Parkinsons Disease Rating Scale part III motor subscale score (UPDRS-III), Montreal Cognitive Assessment (MoCA) score, Parkinsons Disease Questionnaire (PDQ-39) score, and muscle strength in the leg press exercise (one-repetition maximum) of patients with Parkinsons disease (PD). METHODS Thirty-nine patients with moderate to severe PD were randomly assigned to a nonexercising control group (C), RT group, and RTI group. The RT and RTI groups performed progressive RT twice a week for 12 wk. However, only the RTI group used high motor complexity exercises (i.e., progressive RT with unstable devices), for example, half squat exercise on the BOSU® device. The primary outcome was mobility (TUG). The secondary outcomes were on-medication motor signs (UPDRS-III), cognitive impairment (MoCA), quality of life (PDQ-39), and muscle strength (one-repetition maximum). RESULTS There were no differences between RTI and RT groups for any of the outcomes at posttraining (P > 0.05). However, there were differences between RTI and C groups in the TUG, MoCA, and muscle strength values at posttraining (P < 0.05). Only the RTI group improved the TUG (-1.9 s), UPDRS-III score (-4.5 score), MoCA score (6.0 score), and PDQ-39 score (-5.2 score) from pre- to posttraining (P < 0.001). Muscle strength improved for both training groups (P < 0.001). No adverse events were reported during the trial. CONCLUSIONS Both training protocols improved muscle strength, but only RTI improved the mobility, motor signs, cognitive impairment, and quality of life, likely because of the usage of high motor complexity exercises. Thus, RTI may be recommended as an innovative adjunct therapeutic intervention for patients with PD.

Interferência mútua entre atividade visual e atividade motora em jovens e idosos

Como o envelhecimento provoca dificuldade na capacidade de dividir a atencao, este estudo visou verificar, em jovens e idosos: (1) a eventual interferencia entre uma tarefa visual e uma motora; (2) se essa interferencia (caso exista) ocorre de forma diferente no desempenho de jovens e idosos; (3) se as tarefas propostas tem correlacao com testes validados, de sequencia alfanumerica (TMT) e de levantar e caminhar cronometrado (TLCC). A tarefa visual consistiu na verbalizacao do reconhecimento de duas figuras iguais ou diferentes apresentadas rapidamente. A tarefa motora consistiu na alternância de passos do chao a uma plataforma fixa de 10 cm de altura. As tarefas foram avaliadas isoladas (tarefa-simples) e associadas (tarefa-dupla) em dois grupos: 10 jovens (23±2,8 anos) e 10 idosos (68,8±8,6 anos). Na tarefa visual, os jovens fizeram menos erros que os idosos (p<0,001); nos dois grupos nao houve maior numero de erros na tarefa-simples quando comparada a tarefa-dupla. Na tarefa motora, os idosos tiveram pior desempenho na tarefa-dupla em relacao a tarefa-simples (p=0,009). Houve correlacao positiva entre o TMT e o numero de alternâncias de passos (p<0,05) e correlacao negativa entre o numero de alternâncias de passos e o TLCC (p<0,05). A tarefa motora nao interferiu na tarefa visual em jovens nem em idosos, mas a tarefa visual diminuiu a velocidade da tarefa motora dos idosos. A proposicao das tarefas sem atribuir primariedade a uma ou outra permitiu detectar essas interferencias.

Effects of Progressive Resistance Training on Cardiovascular Autonomic Regulation in Patients With Parkinson Disease: A Randomized Controlled Trial

OBJECTIVE To evaluate the effects of a progressive resistance training (RT) on cardiac autonomic modulation and on cardiovascular responses to autonomic stress tests in patients with Parkinson disease (PD). DESIGN Randomized clinical trial. SETTING The Brazil Parkinson Association. PARTICIPANTS Patients (N=30) with PD (modified Hoehn & Yahr stages 2-3) were randomly divided into 2 groups: a progressive RT group (PD training [PDT] group) and a control group (PD control [PDC] group). In addition, a group of paired healthy control (HC) subjects without PD was evaluated. INTERVENTIONS The PDT group performed 5 resistance exercises, 2 to 4 sets, 12 to 6 repetitions maximum per set. Individuals in the PDC group maintained their usual lifestyle. MAIN OUTCOME MEASURES The PDT and PDC groups were evaluated before and after 12 weeks. The HC group was evaluated once. Autonomic function was assessed by spectral analysis of heart rate variability and cardiovascular responses to autonomic stress tests (deep breathing, Valsalva maneuver, orthostatic stress). RESULTS Compared with baseline, the normalized low-frequency component of heart rate variability decreased significantly after 12 weeks in the PDT group only (PDT: 61±17 normalized units [nu] vs 47±20nu; PDC: 60±14nu vs 63±10nu; interaction P<.05). A similar result was observed for systolic blood pressure fall during orthostatic stress that also was reduced only in the PDT group (PDT: -14±11mmHg vs -6±10mmHg; PDC: -12±10mmHg vs -11±10mmHg; interaction P<.05). In addition, after 12 weeks, these parameters in the PDT group achieved values similar to those in the HC group. CONCLUSIONS In patients with PD, progressive RT improved cardiovascular autonomic dysfunction.

Case Report: Physical therapy management of axial dystonia

Abstract Few studies have described physical therapy approaches to provide functional independence and reduce pain in individuals with dystonia. This report describes the physical therapy treatment of a 46-year-old woman diagnosed with idiopathic segmental axial dystonia. For two years, the patient was treated with kinesiotherapy (active and resisted movements and stretching of neck and trunk muscles), abdominal taping (kinesiotaping techniques), functional training, and sensory tricks. She was assessed with parts I, II and III of Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS-I, TWSTRS-II and TWSTRS-III), Berg Balance Scale (BBS), Six-Minute Walk Test (6-MWT), and the motor domain of Functional Independence Measure (FIM-motor) before and after the two-year treatment and after the one year follow-up. Postural control and symmetry improved (TWSTRS-I: from 30 to 18), functional independence increased (TWSTRS-II: from 27 to 15; BBS: from 36 to 46; 6-MWT: from 0 to 480 meters (m); FIM-motor: from 59 to 81), and the pain diminished (TWSTRS-III: from 12 to 5). The functional improvement was retained after one year (TWSTRS-I: 14/35; TWRTRS-II: 12/30; TWRTRS-III: 5/20; BBS: 48/56; 6-MWT: 450 m; FIM-motor: 81/91). This program showed efficacy on providing a better control of the dystonic muscles and thus the doses of botulinum toxin needed to treat them could be reduced. Outcomes support the therapeutic strategies used to deal with this type of dystonia.

Assessment of gait deviation on the Babinski-Weill test in healthy Brazilians

OBJECTIVE The aim of this study was to validate a simple and reproducible method for assessing gait deviation on the Babinski-Weill test in a representative sample of healthy Brazilians. METHODS Gait deviations were measured in 75 individuals (median=30 years, 41 women) for forward, backwards, and Babinski-Weill steps. The test entailed blindfolded individuals walking 10 paces at a frequency of 1 Hz with deviations subsequently measured by a protractor. RESULTS Mean gait deviation forward was 0.53° with standard deviation (SD)=4.22 and backwards was 2.14° with SD=4.29. No significant difference in deviation was detected between genders (t test p=0.40 forward and p=0.77 backwards) or for age (ANOVA, p=0.33 forward and p=0.63 backwards). On the Babinski-Weill test, mean gait deviation was 5.26°; SD=16.32 in women and -3.11°; SD=12.41 in men, with no significant difference between genders (t test, p=0.056). DISCUSSION Defining normative gait patterns helps distinguish pathological states.

Resistance training with instability is more effective than resistance training in improving spinal inhibitory mechanisms in Parkinson's disease

This study assessed 1) the effects of 12 wk of resistance training (RT) and resistance training with instability (RTI) on presynaptic inhibition (PSI) and disynaptic reciprocal inhibition (DRI) of patients with Parkinsons disease (PD); 2) the effectiveness of RT and RTI in moving PSI and DRI values of patients toward values of age-matched healthy controls (HC; Z-score analysis); and 3) associations between PSI and DRI changes and clinical outcomes changes previously published. Thirteen patients in RT group, 13 in RTI group, and 11 in a nonexercising control group completed the trial. While RT and RTI groups performed resistance exercises twice a week for 12 wk, only the RTI group used unstable devices. The soleus H reflex was used to evaluate resting PSI and DRI before and after the experimental protocol. The HC (n = 31) was assessed at pretest only. There were significant group × time interactions for PSI (P < 0.0001) and DRI (P < 0.0001). RTI was more effective than RT in increasing the levels of PSI (P = 0.0154) and DRI (P < 0.0001) at posttraining and in moving PSI [confidence interval (CI) 0.1-0.5] and DRI (CI 0.6-1.1) levels to those observed in HC. There was association between DRI and quality of life changes (r = -0.69, P = 0.008) and a strong trend toward association between PSI and postural instability changes (r = 0.60, P = 0.051) after RTI. RTI increased PSI and DRI levels more than RT, reaching the average values of the HC. Thus RTI may cause plastic changes in PSI and DRI pathways that are associated with some PD clinical outcomes. NEW & NOTEWORTHY Patients with Parkinsons disease (PD) have motor dysfunction. Spinal inhibitory mechanisms are important for modulating both supraspinal motor commands and sensory feedback at the spinal level. Resistance training with instability was more effective than resistance training in increasing the levels of presynaptic inhibition and disynaptic reciprocal inhibition of lower limb at rest of the patients with PD, reaching the average values of the healthy controls.

Immediate effects of adding mental practice to physical practice on the gait of individuals with Parkinson’s disease: Randomized clinical trial

BACKGROUND Mental practice has shown benefits in the rehabilitation of neurological patients, however, there is no evidence of immediate effects on gait of individuals with Parkinsons disease. OBJECTIVE Determine the effects of mental practice activity added to physical practice on the gait of individuals with Idiopathic Parkinsons Disease (IPD). METHODS 20 patients classified with stage 2 and 3, according to the Hoehn and Yahr scale were randomized into 2 groups. The experimental group (N = 10) was submitted to a single session of mental practice and physical practice gait protocol and the control group (N = 10) only to physical practice. The primary outcomes were stride length and total stance and swing time. Secondary outcomes were hip range of motion, velocity and mobility. Subjects were reassessed 10 minutes, 1 day and 7 days after the end of the session. RESULTS There was no statistically significant difference between the groups. An intragroup difference was observed in velocity, stride length, hip range of motion, and mobility, as well as total stance and swing time. These results were also observed on follow-ups. CONCLUSIONS Mental practice did not have a greater effect on the gait of individuals with IPD than physical practice, after a single session.