Nienke M. de Vries

Neurorehabilitation for Parkinson's disease: Future perspectives for behavioural adaptation

Parkinsons disease is a common neurodegenerative disorder, resulting in both motor and non-motor symptoms that significantly reduce quality of life. Treatment consists of both pharmaceutical and non-pharmaceutical treatment approaches. Neurorehabilitation is an important non-pharmaceutical treatment approach, and a prime component of this is formed by the training of behavioural adaptations that can assist patients to cope better with their motor and non-motor symptoms. Optimal delivery of neurorehabilitation requires a tailor-made, personalized approach. In this review we discuss the great potential for growth in the field of neurorehabilitation. Specifically, we will focus on four relatively new developments: visual rehabilitation (because Parkinson patients are very dependent on optimal vision); cueing delivered by wearable devices (allowing for objective, continuous, and quantitative detection of mobility problems, such that cueing can be delivered effectively in an on-demand manner - i.e., with external cues being delivered only at a time when they are needed most); exergaming (to promote compliance with exercise programs); and telemedicine (allowing for delivery of expert rehabilitation advice to the patients own home). Evidence in these new fields is growing, based on good clinical trials, fuelling hope that state-of-the-art neurorehabilitation can make a real impact on improving the quality of life of patients affected by Parkinsons disease.

Patient‐centred physical therapy is (cost‐) effective in increasing physical activity and reducing frailty in older adults with mobility problems: a randomized controlled trial with 6 months follow‐up

Despite the well‐known health benefits of physical activity, it is a great challenge to stay physically active for frail–older adults with mobility limitations. The aim of this study was to test the (cost‐) effectiveness of a patient‐centred physical therapy strategy (Coach2Move) in which individualized treatment (motivational interviewing, physical examination, individualized goal setting, coaching and advice on self management, and physical training) is combined to increase physical activity level and physical fitness and, thereby, to decrease the level of frailty.

Evaluative Frailty Index for Physical Activity (EFIP): A Reliable and Valid Instrument to Measure Changes in Level of Frailty

Background Physical activity is assumed to be important in the prevention and treatment of frailty. It is unclear, however, to what extent frailty can be influenced because instruments designed to assess frailty have not been validated as evaluative outcome instruments in clinical practice. Objectives The aims of this study were: (1) to develop a frailty index (ie, the Evaluative Frailty Index for Physical Activity [EFIP]) based on the method of deficit accumulation and (2) to test the clinimetric properties of the EFIP. Design The content of the EFIP was determined using a written Delphi procedure. Intrarater reliability, interrater reliability, and construct validity were determined in an observational study (n=24). Method Intrarater reliability and interrater reliability were calculated using Cohen kappa and intraclass correlation coefficients (ICCs). Construct validity was determined by correlating the score on the EFIP with those on the Timed “Up & Go” Test (TUG), the Performance-Oriented Mobility Assessment (POMA), and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Results Fifty items were included in the EFIP. Interrater reliability (Cohen kappa=0.72, ICC=.96) and intrarater reliability (Cohen kappa=0.77 and 0.80, ICC=.93 and .98) were good. As expected, a fair to moderate correlation with the TUG, POMA, and CIRS-G was found (.61, −.70, and .66, respectively). Limitations Reliability and validity of the EFIP have been tested in a small sample. These and other clinimetric properties, such as responsiveness, will be assessed or reassessed in a larger study population. Conclusion The EFIP is a reliable and valid instrument to evaluate the effect of physical activity on frailty in research and in clinical practice.

Unmasking levodopa resistance in Parkinson's disease

Some motor and nonmotor features associated with Parkinsons disease (PD) do not seem to respond well to levodopa (or other forms of dopaminergic medication) or appear to become resistant to levodopa treatment with disease progression and longer disease duration. In this narrative review, we elaborate on this issue of levodopa resistance in PD. First, we discuss the possibility of pseudoresistance, which refers to dopamine‐sensitive symptoms or signs that falsely appear to be (or have become) resistant to levodopa, when in fact other mechanisms are at play, resulting in suboptimal dopaminergic efficacy. Examples include interindividual differences in pharmacodynamics and pharmacokinetics and underdosing because of dose‐limiting side effects or because of levodopa phobia. Moreover, pseudoresistance can emerge as not all features of PD respond adequately to the same dosage of levodopa. Second, we address that for several motor features (eg, freezing of gait or tremor) and several nonmotor features (eg, specific cognitive functions), the response to levodopa is fairly complex, with a combination of levodopa‐responsive, levodopa‐resistant, and even levodopa‐induced characteristics. A possible explanation relates to the mixed presence of underlying dopaminergic and nondopaminergic brain lesions. We suggest that clinicians take these possibilities into account before concluding that symptoms or signs of PD are totally levodopa resistant.

Physiotherapy to improve physical activity in community-dwelling older adults with mobility problems (Coach2Move): study protocol for a randomized controlled trial

BackgroundOlder adults can benefit from physical activity in numerous ways. Physical activity is considered to be one of the few ways to influence the level of frailty. Standardized exercise programs do not necessarily lead to more physical activity in daily life, however, and a more personalized approach seems appropriate. The main objective of this study is to investigate whether a focused, problem-oriented coaching intervention (‘Coach2Move’) delivered by a physiotherapist specializing in geriatrics is more effective for improving physical activity, mobility and health status in community-dwelling older adults than usual physiotherapy care. In addition, cost-effectiveness will be determined.Methods/DesignThe design of this study is a single-blind randomized controlled trial in thirteen physiotherapy practices. Randomization will take place at the individual patient level. The study population consists of older adults, ≥70 years of age, with decreased physical functioning and mobility and/or a physically inactive lifestyle. The intervention group will receive geriatric physiotherapy according to the Coach2Move strategy. The control group will receive the usual physiotherapy care. Measurements will be performed by research assistants not aware of group assignment. The results will be evaluated on the amount of physical activity (LASA Physical Activity Questionnaire), mobility (modified ‘get up and go’ test, walking speed and six-minute walking test), quality of life (SF-36), degree of frailty (Evaluative Frailty Index for Physical Activity), fatigue (NRS-fatigue), perceived effect (Global Perceived Effect and Patient Specific Complaints questionnaire) and health care costs.DiscussionMost studies on the effect of exercise or physical activity consist of standardized programs. In this study, a personalized approach is evaluated within a group of frail older adults, many of whom suffer from multiple and complex diseases and problems. A complicating factor in evaluating a new approach is that it may not be automatically adopted by clinicians. Specific actions are undertaken to optimize implementation of the Coach2Move strategy during the trial. Whether or not these will be sufficient is a matter we will consider subsequently, using quality indicators and process analysis.Trial RegistrationThe Netherlands National Trial Register: NTR3527.

Feasibility of large-scale deployment of multiple wearable sensors in Parkinson's disease

Wearable devices can capture objective day-to-day data about Parkinson’s Disease (PD). This study aims to assess the feasibility of implementing wearable technology to collect data from multiple sensors during the daily lives of PD patients. The Parkinson@home study is an observational, two-cohort (North America, NAM; The Netherlands, NL) study. To recruit participants, different strategies were used between sites. Main enrolment criteria were self-reported diagnosis of PD, possession of a smartphone and age≥18 years. Participants used the Fox Wearable Companion app on a smartwatch and smartphone for a minimum of 6 weeks (NAM) or 13 weeks (NL). Sensor-derived measures estimated information about movement. Additionally, medication intake and symptoms were collected via self-reports in the app. A total of 953 participants were included (NL: 304, NAM: 649). Enrolment rate was 88% in the NL (n = 304) and 51% (n = 649) in NAM. Overall, 84% (n = 805) of participants contributed sensor data. Participants were compliant for 68% (16.3 hours/participant/day) of the study period in NL and for 62% (14.8 hours/participant/day) in NAM. Daily accelerometer data collection decreased 23% in the NL after 13 weeks, and 27% in NAM after 6 weeks. Data contribution was not affected by demographics, clinical characteristics or attitude towards technology, but was by the platform usability score in the NL (χ2 (2) = 32.014, p<0.001), and self-reported depression in NAM (χ2(2) = 6.397, p = .04). The Parkinson@home study shows that it is feasible to collect objective data using multiple wearable sensors in PD during daily life in a large cohort.

The Coach2Move Approach: Development and Acceptability of an Individually Tailored Physical Therapy Strategy to Increase Activity Levels in Older Adults With Mobility Problems

Background and Purpose:Despite the positive effects of physical activity on numerous aspects of health, many older adults remain sedentary even after participating in physical activity interventions. Standardized exercise programs do not necessarily bring about the behavioral change that is necessary. Therefore, a patient-centered approach is needed. The purpose of this study was to develop and assess the acceptability and potential effectiveness of the Coach2Move strategy; a physical therapy (PT) approach aimed at improving the long-term level of physical activity in mobility-limited older adults. Methods:The Coach2Move strategy was developed on the basis of 2 systematic literature studies and expert consultations. Multiple focus group meetings and a Delphi procedure were organized to gain consensus on the Coach2Move strategy. Acceptability and potential effectiveness were studied in a pilot study with a pre-/postdesign in which 2 physical therapists and 12 patients participated. To assess acceptability, patients were interviewed, discussion were held with the involved physical therapists was held, and health records were studied. Potential effectiveness was tested measuring the level of physical activity, frailty, quality of life, and mobility before and after treatment. Results:On the basis of the literature study and expert consultations, an algorithm based on the Hypothesis Oriented Algorithm for Clinicians Part II was developed: the Coach2Move approach. Key elements of the Coach2Move approach include an extensive intake using motivational interviewing, clinical reasoning, coaching to increase physical activity and self-management, focusing on meaningful activities, and working according to 3 patient-tailored intervention profiles with a predefined number of sessions. The pilot study showed high appraisal of the strategy by both physical therapists and patients. Moreover, a potential effect on the level of physical activity, frailty, quality of life, and mobility was observed. Discussion and Conclusion:Because the pilot study was not randomized or controlled and included a small sample, no conclusions can be drawn about the effectiveness of the Coach2Move strategy. However, all suggestions made in this study were implemented in an ongoing, randomized controlled trial in which the Coach2Move strategy will be compared to usual care PT. In conclusion, the Coach2Move strategy can be considered acceptable in PT practice and showed potential benefits. The results on the (cost-)effectiveness of this strategy based on a large, randomized, controlled trial are expected in 2014.

Effectiveness and costs of specialised physiotherapy given via ParkinsonNet: a retrospective analysis of medical claims data

BACKGROUND Parkinsons disease is a complex condition that is best managed by specialised professionals. Trials show that specialised allied health interventions are cost-effective, as compared with usual care. We aimed to study the long-term benefits of specialised physiotherapy using the ParkinsonNet approach in real-world practice. METHODS We did an observational study, retrospectively analysing a database of health insurance claims that included a representative population of Dutch patients with Parkinsons disease, who were followed for up to 3 years (Jan 1, 2013, to Dec 31, 2015). Eligibility criteria included having both a diagnosis of Parkinsons disease and having received physiotherapy for the disease. Allocation to specialised or usual care physiotherapy was based on the choices of patients and referring physicians. We used a mixed-effects model to compare health-care use and outcomes between patients treated by specialised or usual care physiotherapists. The primary outcome was the percentage of patients with a Parkinsons disease-related complication (ie, visit or admission to hospital because of fracture, other orthopaedic injuries, or pneumonia) adjusted for baseline variables. We compared physiotherapist caseload, the number of physiotherapy sessions, physiotherapy costs, and total health-care costs (including hospital care, but excluding community care, long-term care, and informal care) between the groups, and used a Coxs proportional hazard model for survival time to establish whether mortality was influenced by treatment by a specialised physiotherapist. FINDINGS We analysed 2129 patients (4649 observations) receiving specialised physiotherapy and 2252 patients (5353 observations) receiving usual care physiotherapy. Significantly fewer patients treated by a specialised physiotherapist had a Parkinsons disease-related complication (n=368 [17%]) than patients treated by a usual care physiotherapist (n=480 [21%]; odds ratio 0·67, 95% CI 0·56-0·81, p<0·0001). The annual caseload of patients per therapist was significantly higher for specialised physiotherapists (mean 3·89 patients per therapist [SD 3·91]) than usual care physiotherapists (1·48 [1·24]). Patients who saw specialised physiotherapists received fewer treatment sessions (mean 33·72 [SD 26·70]) than usual care physiotherapists (47·97 [32·11]). Consequently, expenditure was lower for specialised than usual care physiotherapists, both for direct costs (mean €933 [SD 843] vs €1329 [1021]; annual difference €395, 95% CI 358-432, p<0·0001) and total health-care expenditure (€2056 [3272] vs €2586 [3756]; €530, 391-669, p<0·0001). Mortality risk was lower for patients receiving specialised physiotherapy (134 [6%]) compared with patients receiving usual care physiotherapy (205 [9%], p=0·001) before correction for baseline variables, although Coxs survival model showed no significant difference between the two (hazard ratio 0·86, 95% CI 0·69-1·07, p=0·195). INTERPRETATION These results confirm the findings from controlled trials, and offer evidence that specialised physiotherapy as delivered through ParkinsonNet is associated with fewer Parkinsons disease-related complications and lower costs in real-world practice. Neurologists can facilitate specialised physiotherapy by specific referral to such experts. FUNDING None.

Development of a framework to describe goals and content of exercise interventions in physical therapy: a mixed method approach including a systematic review

Abstract Background: Exercise interventions in physical therapy (PT) are often not well described in research reports. Omitting details of the intervention hampers the transfer to daily clinical practice. Objective: To develop a framework for describing goals and content of exercise interventions, in order to provide structured and detailed information for use in research reports. Methods: A framework was developed in three steps using a mixed method approach. First, the scientific literature was systematically searched for available methods to describe PT interventions. An inventory of these methods was made and relevant elements were extracted. Second, based on the results of the literature search, a global framework was developed by a focus group of experts in the field of PT. Third, the framework was field tested by describing four different exercise interventions, leading to a final version. Results: In the developed framework intervention goals at the level of body functions and activities/participation were listed using the International Classification of Functioning, Disability and Health. To guide the description of the content of the exercise intervention a list of intervention details was developed, which was derived from an existing classification of PT interventions. Goals and content of exercise interventions were linked. Field testing of the framework led to adequate descriptions of exercise interventions. Conclusion: The developed framework is a promising first step in offering a feasible guide for a structured and detailed description of goals and content of exercise interventions within research reports.

Standard set of health outcome measures for older persons

BackgroundThe International Consortium for Health Outcomes Measurement (ICHOM) was founded in 2012 to propose consensus-based measurement tools and documentation for different conditions and populations.This article describes how the ICHOM Older Person Working Group followed a consensus-driven modified Delphi technique to develop multiple global outcome measures in older persons.The standard set of outcome measures developed by this group will support the ability of healthcare systems to improve their care pathways and quality of care. An additional benefit will be the opportunity to compare variations in outcomes which encourages and supports learning between different health care systems that drives quality improvement. These outcome measures were not developed for use in research. They are aimed at non researchers in healthcare provision and those who pay for these services.MethodsA modified Delphi technique utilising a value based healthcare framework was applied by an international panel to arrive at consensus decisions.To inform the panel meetings, information was sought from literature reviews, longitudinal ageing surveys and a focus group.ResultsThe outcome measures developed and recommended were participation in decision making, autonomy and control, mood and emotional health, loneliness and isolation, pain, activities of daily living, frailty, time spent in hospital, overall survival, carer burden, polypharmacy, falls and place of death mapped to a three tier value based healthcare framework.ConclusionsThe first global health standard set of outcome measures in older persons has been developed to enable health care systems improve the quality of care provided to older persons.