Marion F Walker

PD REHAB: a large pragmatic randomised controlled trial of physiotherapy and occupational therapy versus no therapy in mild to moderate Parkinson's disease

Objective: To explore the association between striatal dopaminergic deficits and cognitive impairment within a large cohort of early, drug-naive Parkinson’s disease patients and to test the hypothesis that executive dysfunction in Parkinson’s disease is caused by striatal dopaminergic depletion. Background: Cognitive impairment in Parkinson’s disease is common and influences patients’ everyday functioning, but the mechanisms of early cognitive decline are not known. Understanding of these mechanisms is important for the development of methods preventing cognitive decline in Parkinson’s disease. Previous studies suggest that the dopaminergic system influences cognition in PD. Methods: Neuropsychological and cerebral dopamine transporter SPECT imaging data of 339 Parkinson’s disease patients and 158 Healthy controls of the Parkinson’s Progression Markers Initiative study were analysed. Neuropsychological evaluation consisted of standardized tests of memory, visuospatial and executive function. SPECT imaging was performed with [123I]FP-CIT and specific binding ratios in left and right putamen and caudate nucleus were calculated. The association between specific binding ratios and cognition was performed using a cognitive composite z-score, domain z-scores and individual test scores. Multivariate general linear model regression analyses were performed including age, gender, education, and laterality as predictors and specific binding ratios as dependent variables. Results: Uncorrected analysis showed no associations between dopamine transporter imaging and memory and visuospatial domains. A small but significant positive association between specific binding ratios and the attention/executive domain was found, which was not significant after adjusting for age. However, in a moderated mediation model, we found that cognitive executive differences between controls and patients with Parkinson’s disease were mediated by an age-moderated dopaminergic deficit in the left caudate nucleus. Conclusions: Our findings support the hypothesis that nigrostriatal dopaminergic deficit contributes to executive impairment, but not to memory or visuospatial impairment in early Parkinson’s disease.Objective: To investigate whether spirography-based objective measures of motor dysfunctions are able to discriminate between Parkinson’s disease (PD) patients with different motor states (Off and ...Objective: This study aims to determine PPN’s electrophysiological activities in rats to help future studies and to investigate the effect of subthalamic nucleus stimulation on PPN. Background: Long-duration medical treatment of Parkinson patients causes complications and morbidity. Risks in destructive surgery are releatively high, new treatment methods such as stereotactic functional surgery has been proposed recently. While sensory and behavioral processes of pedunculopontine nucleus (PPN) are well known as a locomotor center, its role on initiating and sustaining motion function in primates or rats has been also demonstrated. All functions of PPN are not fully known yet, and its DBS has been proposed as an alternative therapeutic target in treating gait problems of Parkinson’s disease recently. Methods: In this study, 14 male wistar type healthy rats with average 292 (284-317) gram weight and with the same age group were used. In the sham group, two probes were inserted, one to the STN bilaterally and the other to the right PPN to record PPN’s electrophysiological activities. In the experiment group, in addition to the same procedures used in the sham group, STN was stimulated bilaterally at 0.5 Hz, 10 Hz, 60 Hz ve 130 Hz and PPN’s electrophysiological activities were recorded before and after bilateral STN stimulations. Results: Analyzing the neural activity after the 60 Hz stimulation, it revealed that STN has a stimulus effect on PPN neurons increasing the firing rate. The PPN neurons demonstrated three different patterns of firing, burst random and regular. The majority of the neurons (68%) exhibited a regular pattern of firing in the sham group. After bilateral STN stimulation with very low (0,5 Hz and 10 Hz) and high (130 Hz) frequencies the PPN neurons maintained their firing patterns. However, after 60 Hz stimulation of STN a significant percentage of neurons (82,1 %) fired with a more regular pattern. Conclusions: The results of this study provides additional information to our understanding on PPN’s electrophysiological activities. 60 Hz STN stimulation can increase the firing rates and changes the behaviour of the PPN neurons.Objective: To analyze the relationship between the electric field and the volume of tissue activated (VTA) during model-based investigations of deep brain stimulation (DBS).Background: An important ...This journal suppl. entitled: Supplement: Abstracts of the Eighteenth International Congress of Parkinsons Disease and Movement Disorders / Poster Presentation

Can stroke specific vocational rehabilitation (SSVR) be delivered and measured?: feasibility RCT and economic analysis

Background: The stroke survivor’s voice has been identified as a key priority when evaluating rehabilitation interventions. Employer involvement in vocational rehabilitation (VR) studies has been largely absent yet their influence considered important. This study aimed to explore stroke survivors’ (SS) and employers’ views of the VR intervention received in a feasibility randomised controlled trial. Method: Semi-structured interviews with thirteen mild/moderate SS (8 men aged 45-79 mean 61 SD 11.63), 10 in F/T paid employment, 3 P/T volunteers) and six employers postintervention completion, explored acceptability, usefulness and VR implementation issues. Thematic analysis by three independent researchers followed recording and verbatim transcription. Results/Findings: The most valued aspects of intervention content were emotional support, provision of stroke specific information and feedback and the planning, implementing and reviewing of a phased return to work. Liaison with the workplace was particularly valued by employers. Continuity, accessibility and knowledge of therapist, individualised intervention and liaison with other services were aspects of intervention delivery commended by SS and employers. However, for some, the timing and duration of the intervention were not appropriate to their needs and this appeared to be linked with stroke severity. Discussion: Intervention appeared to influence the timing and success of work return. Opinions were divided on whether the NHS should or could fund this type of intervention and whether employers would be willing to contribute to the costs. Conclusion: Trial participants and employers found stroke specific VR useful, acceptable and influential in terms of return to work outcomes. Funding, targeting and implementation require further debate.Background: A quarter of UK strokes occur in working age people. Fewer than half resume work. Rehabilitation frequently fails to address work needs and evidence for post-stroke vocational rehabilitation is lacking. This pilot trial tested the feasibility of delivering SSVR and measuring its effects and costs compared to usual care (UC). Method: Previously employed stroke survivors (SS) aged ≥16 recruited from a stroke unit were randomised to receive SSVR or UC. Exclusion criteria: refusing consent; not intending to work, medical preclusion. Primary outcomes: occupational and benefit status. Mood, function, participation, quality of life and resource use were measured using standardized and bespoke postal questionnaires at 3, 6 and 12 months. Service use was cross-referenced in 10% of participants and costs calculated. Results: 46/126 patients screened (36 men, mean 56 (SD 12.7, 18-78 years) were recruited in 15 months; 40 declined. Most (29) had NIHSS scores ≤ 15, were in professional roles (65%), self-employed (21.7%) at onset. 32 available at 12-month follow-up, with poorer response (61%) among UC. Intervention successfully deployed in 22/23 cases. 39% returned to work at 12 months - twice as many in SSVR. More depression and productivity loss in UC, especially at 6 mths. Cross-referencing for 5 participants involved 51 phone calls, 23 letters/emails. Self-reported and actual service use data were discrepant. SS underestimated GP& consultant and overestimated therapy input. Discussion: SSVR can be delivered and its effects and costs measured. More reliable methods of capturing service use, income and benefit data and clearer definitions of work are needed. Conclusion: Findings inform the definitive trial.Background: Return to work (RTW) is an outcome in determining the effectiveness of rehabilitation post-stroke. However, stroke survivors (SS) may return to different roles with altered work status. Income, hours, responsibilities and job-satisfaction may be reduced. SS may be dissatisfied if unable to resume apriori work status; alternatively adjusted work status may be viewed positively if perceived as a way of reducing the risk of another stroke. The purpose of this study was to explore what is meant by RTW. Method: Information about the nature of RTW (job type, hours, roles, responsibilities) was extracted from 3, 6 and 12 month follow-up postal questionnaires in 46 SS participants in a feasibility randomised controlled trial investigating effectiveness of a vocational rehabilitation intervention. Results/Findings: Participants took a mean 90 (SD:70, range 7-227) days to RTW. 19/46 reported working at 12 months. In 17 who supplied complete data, 7(41%) reported reduced working hours. Participants incurred a mean wage loss of 44% against pre-stroke earnings. 10/17(59%) participants were in the same job with the same employer and 6(35%) were working in different/modified jobs (1 missing:). 10/17(59%) had work-place adjustments. 18/46 (39%) participants were happy with their work situation. Discussion: Participants experienced marked changes in work status post-stroke, with implications for job-satisfaction, financial security and quality of life. Research into psychological adjustment following altered vocational status in SS is warranted. Conclusion: RTW is a complex outcome and may not translate to a return to pre-stroke vocational status. It is important to consider what constitutes a RTW following stroke.