Natalie E. Allen

Recurrent Falls in Parkinson’s Disease: A Systematic Review

Most people with Parkinsons disease (PD) fall and many experience recurrent falls. The aim of this review was to examine the scope of recurrent falls and to identify factors associated with recurrent fallers. A database search for journal articles which reported prospectively collected information concerning recurrent falls in people with PD identified 22 studies. In these studies, 60.5% (range 35 to 90%) of participants reported at least one fall, with 39% (range 18 to 65%) reporting recurrent falls. Recurrent fallers reported an average of 4.7 to 67.6 falls per person per year (overall average 20.8 falls). Factors associated with recurrent falls include: a positive fall history, increased disease severity and duration, increased motor impairment, treatment with dopamine agonists, increased levodopa dosage, cognitive impairment, fear of falling, freezing of gait, impaired mobility and reduced physical activity. The wide range in the frequency of recurrent falls experienced by people with PD suggests that it would be beneficial to classify recurrent fallers into sub-groups based on fall frequency. Given that there are several factors particularly associated with recurrent falls, fall management and prevention strategies specifically targeting recurrent fallers require urgent evaluation in order to inform clinical practice.

The effects of an exercise program on fall risk factors in people with Parkinson's disease: a randomized controlled trial

This randomized controlled trial with blinded assessment aimed to determine the effect of a 6‐month minimally supervised exercise program on fall risk factors in people with Parkinsons disease (PD). Forty‐eight participants with PD who had fallen or were at risk of falling were randomized into exercise or control groups. The exercise group attended a monthly exercise class and exercised at home three times weekly. The intervention targeted leg muscle strength, balance, and freezing. The primary outcome measure was a PD falls risk score. The exercise group had no major adverse events and showed a greater improvement than the control group in the falls risk score, which was not statistically significant (between group mean difference = −7%, 95% CI −20 to 5, P = 0.26). There were statistically significant improvements in the exercise group compared with the control group for two secondary outcomes: Freezing of Gait Questionnaire (P = 0.03) and timed sit‐to‐stand (P = 0.03). There were statistically nonsignificant trends toward greater improvements in the exercise group for measures of muscle strength, walking, and fear of falling, but not for the measures of standing balance. Further investigation of theimpact of exercise on falls in people with PD is warranted.

Exercise for falls prevention in Parkinson disease: A randomized controlled trial

Objective: To determine whether falls can be prevented with minimally supervised exercise targeting potentially remediable fall risk factors, i.e., poor balance, reduced leg muscle strength, and freezing of gait, in people with Parkinson disease. Methods: Two hundred thirty-one people with Parkinson disease were randomized into exercise or usual-care control groups. Exercises were practiced for 40 to 60 minutes, 3 times weekly for 6 months. Primary outcomes were fall rates and proportion of fallers during the intervention period. Secondary outcomes were physical (balance, mobility, freezing of gait, habitual physical activity), psychological (fear of falling, affect), and quality-of-life measures. Results: There was no significant difference between groups in the rate of falls (incidence rate ratio [IRR] = 0.73, 95% confidence interval [CI] 0.45–1.17, p = 0.18) or proportion of fallers (p = 0.45). Preplanned subgroup analysis revealed a significant interaction for disease severity (p < 0.001). In the lower disease severity subgroup, there were fewer falls in the exercise group compared with controls (IRR = 0.31, 95% CI 0.15–0.62, p < 0.001), while in the higher disease severity subgroup, there was a trend toward more falls in the exercise group (IRR = 1.61, 95% CI 0.86–3.03, p = 0.13). Postintervention, the exercise group scored significantly (p < 0.05) better than controls on the Short Physical Performance Battery, sit-to-stand, fear of falling, affect, and quality of life, after adjusting for baseline performance. Conclusions: An exercise program targeting balance, leg strength, and freezing of gait did not reduce falls but improved physical and psychological health. Falls were reduced in people with milder disease but not in those with more severe Parkinson disease. Classification of evidence: This study provides Class III evidence that for patients with Parkinson disease, a minimally supervised exercise program does not reduce fall risk. This study lacked the precision to exclude a moderate reduction or modest increase in fall risk from exercise. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12608000303347).

Exercise therapy for prevention of falls in people with Parkinson's disease: a protocol for a randomised controlled trial and economic evaluation.

BackgroundPeople with Parkinsons disease are twice as likely to be recurrent fallers compared to other older people. As these falls have devastating consequences, there is an urgent need to identify and test innovative interventions with the potential to reduce falls in people with Parkinsons disease. The main objective of this randomised controlled trial is to determine whether fall rates can be reduced in people with Parkinsons disease using exercise targeting three potentially remediable risk factors for falls (reduced balance, reduced leg muscle strength and freezing of gait). In addition we will establish the cost effectiveness of the exercise program from the health providers perspective.Methods/Design230 community-dwelling participants with idiopathic Parkinsons disease will be recruited. Eligible participants will also have a history of falls or be identified as being at risk of falls on assessment. Participants will be randomly allocated to a usual-care control group or an intervention group which will undertake weight-bearing balance and strengthening exercises and use cueing strategies to address freezing of gait. The intervention group will choose between the home-based or support group-based mode of the program. Participants in both groups will receive standardized falls prevention advice. The primary outcome measure will be fall rates. Participants will record falls and medical interventions in a diary for the duration of the 6-month intervention period. Secondary measures include the Parkinsons Disease Falls Risk Score, maximal leg muscle strength, standing balance, the Short Physical Performance Battery, freezing of gait, health and well being, habitual physical activity and positive and negative affect schedule.DiscussionNo adequately powered studies have investigated exercise interventions aimed at reducing falls in people with Parkinsons disease. This trial will determine the effectiveness of the exercise intervention in reducing falls and its cost effectiveness. This pragmatic program, if found to be effective, has the potential to be implemented within existing community services.Trial registrationThe protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12608000303347).

Postural Instability in Patients with Parkinson's Disease : Epidemiology, Pathophysiology and Management.

Postural instability is one of the cardinal signs in Parkinson’s disease (PD). It can be present even at diagnosis, but becomes more prevalent and worsens with disease progression. It represents one of the most disabling symptoms in the advanced stages of the disease, as it is associated with increased falls and loss of independence. Clinical and posturographic studies have contributed to significant advances in unravelling the complex pathophysiology of postural instability in patients with PD, but it still remains yet to be fully clarified, partly due to the difficulty in distinguishing between the disease process and the compensatory mechanisms, but also due to the fact that non-standardized techniques are used to measure balance and postural instability. There is increasing evidence that physical therapy, especially highly challenging balance exercises, can improve postural stability and reduce the risk of falls, although the long-term effects of physical therapy interventions on postural stability need to be explored given the progressive nature of PD. Pharmacotherapy with dopaminergic medications can provide significant improvements in postural instability in early- to mid-stage PD but the effects tend to wane with time consistent with spread of the disease process to non-dopaminergic pathways in advanced PD. Donepezil has been associated with a reduced risk of falls and methylphenidate has shown potential benefit against freezing of gait, but the results are yet to be replicated in large randomized studies. Surgical treatments, including lesioning and deep brain stimulation surgery targeting the subthalamic nucleus and the globus pallidus internus, tend to only provide modest benefit for postural instability. New surgical targets such as the pedunculopontine nucleus have emerged as a potential specific therapy for postural instability and gait disorder but remain experimental.

Exercise and Motor Training in People with Parkinson's Disease: A Systematic Review of Participant Characteristics, Intervention Delivery, Retention Rates, Adherence, and Adverse Events in Clinical Trials

There is research evidence that exercise and motor training are beneficial for people with Parkinsons disease (PD), and clinicians seek to implement optimal programs. This paper summarizes important factors about the nature and reporting of randomized controlled trials of exercise and/or motor training for people with PD which are likely to influence the translation of research into clinical practice. Searches identified 53 relevant trials with 90 interventions conducted for an average duration of 8.3 (SD 4.2) weeks. Most interventions were fully supervised (74%) and conducted at a facility (79%). Retention rates were high with 69% of interventions retaining ≥85% of their participants; however adherence was infrequently reported, and 72% of trials did not report adverse events. Overall, the labor-intensive nature of most interventions tested in these trials and the sparse reporting of adherence and adverse events are likely to pose difficulties for therapists attempting to balance benefits and costs when selecting protocols that translate to sustainable clinical practice for people with PD.

Bradykinesia, muscle weakness and reduced muscle power in Parkinson's disease†

Muscle power (force × velocity) could clarify the relationship between weakness and bradykinesia in Parkinsons disease (PD). The aims of this study were to determine if patients with PD were weaker and/or less powerful in their leg extensor muscles than a neurologically normal control group and to determine the relative contributions of force and movement velocity/bradykinesia to muscle power in PD. Forty patients with PD and 40 controls were assessed. Strength in Newtons (N) was measured as the heaviest load the participant could lift. Power in Watts (W) was measured by having the participant perform lifts as fast as possible. The PD group were 172 N weaker (95% CI 28–315) and 124 W less powerful at peak power (95% CI 32–216) than controls. However, velocity at maximal power was only reduced compared with controls when lifting light to medium loads. When lifting heavy loads bradykinesia was no longer apparent in the PD group. These results suggest that reduced muscle power in PD at lighter loads arises from weakness and bradykinesia combined, but at heavier loads arises only from weakness. The absence of bradykinesia in the PD group when lifting heavy loads warrants further investigation.

Home-based treadmill training for individuals with Parkinson’s disease: a randomized controlled pilot trial

Objective: To investigate the feasibility and effectiveness of six weeks of home-based treadmill training in people with mild Parkinson’s disease. Design: Pilot randomized controlled trial of a six-week intervention followed by a further six weeks follow-up. Setting: Home-based treadmill training with outcome measures taken at a hospital clinic. Participants: Twenty cognitively intact participants with mild Parkinson’s disease and gait disturbance. Two participants from the treadmill training group and one from the control group dropped out. Interventions: The treadmill training group undertook a semi-supervised home-based programme of treadmill walking for 20–40 minutes, four times a week for six weeks. The control group received usual care. Main outcome measures: The feasibility of the intervention was assessed by recording exercise adherence and acceptability, exercise intensity, fatigue, muscle soreness and adverse events. The primary outcome measure of efficacy was walking capacity (6-minute walk test distance). Results: Home-based treadmill training was feasible, acceptable and safe with participants completing 78% (SD 36) of the prescribed training sessions. The treadmill training group did not improve their walking capacity compared to the control group. The treadmill training group showed a greater improvement than the control group in fatigue at post test (P = 0.04) and in quality of life at six weeks follow-up testing (P = 0.02). Conclusions: Semi-supervised home-based treadmill training is a feasible and safe form of exercise for cognitively intact people with mild Parkinson’s disease. Further investigation regarding the effectiveness of home-based treadmill training is warranted.

The Rationale for Exercise in the Management of Pain in Parkinson’s Disease

Abstract Pain is a distressing non-motor symptom experienced by up to 85% of people with Parkinson’s disease (PD), yet it is often untreated. This pain is likely to be influenced by many factors, including the disease process, PD impairments as well as co-existing musculoskeletal and/or neuropathic pain conditions. Expert opinion recommends that exercise is included as one component of pain management programs; however, the effect of exercise on pain in this population is unclear. This review presents evidence describing the potential influence of exercise on the pain-related pathophysiological processes present in PD. Emerging evidence from both animal and human studies suggests that exercise might contribute to neuroplasticity and neuro-restoration by increasing brain neurotrophic factors, synaptic strength and angiogenesis, as well as stimulating neurogenesis and improving metabolism and the immune response. These changes may be beneficial in improving the central processing of pain. There is also evidence that exercise can activate both the dopaminergic and non-dopaminergic pain inhibitory pathways, suggesting that exercise may help to modulate the experience of pain in PD. Whilst clinical data on the effects of exercise for pain relief in people with PD are scarce, and are urgently needed, preliminary guidelines are presented for exercise prescription for the management of central neuropathic, peripheral neuropathic and musculoskeletal pain in PD.

Structured exercise improves mobility after hip fracture: a meta-analysis with meta-regression.

Objectives To determine the effect of structured exercise on overall mobility in people after hip fracture. To explore associations between trial-level characteristics and overall mobility. Design Systematic review, meta-analysis and meta-regression. Data sources MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials, the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register and the Physiotherapy Evidence Database to May 2014. Study eligibility criteria, participants and interventions Randomised controlled trials of structured exercise, which aimed to improve mobility compared with a control intervention in adult participants after surgery for hip fracture were included. Data extraction and synthesis Data were extracted by one investigator and checked by an independent investigator. Standardised mean differences (SMD) of overall mobility were meta-analysed using random effects models. Random effects meta-regression was used to explore associations between trial-level characteristics and overall mobility. Results 13 trials included in the meta-analysis involved 1903 participants. The pooled Hedges’ g SMD for overall mobility was 0.35 (95% CI 0.12 to 0.58, p=0.002) in favour of the intervention. Meta-regression showed greater treatment effects in trials that included progressive resistance exercise (change in SMD=0.58, 95% CI 0.17 to 0.98, p=0.008, adjusted R2=60%) and delivered interventions in settings other than hospital alone (change in SMD=0.50, 95% CI 0.08 to 0.93, p=0.024, adjusted R2=49%). Conclusions and implications Structured exercise produced small improvements on overall mobility after hip fracture. Interventions that included progressive resistance training and were delivered in other settings were more effective, although the latter may have been confounded by duration of interventions.