Robyn Lamont

Single and dual task gait training in people with Parkinson's disease: a protocol for a randomised controlled trial.

BackgroundDifficulty performing more than one task at a time (dual tasking) is a common and disabling problem experienced by people with Parkinson disease (PD). If asked to perform another task when walking, people with PD often take shorter steps or walk more slowly. Currently there is uncertainty about whether clinicians should teach people with PD to avoid dual tasking or whether they should encourage them to practice dual tasking with the hope that practice will lead to enhanced performance. This study will address this issue by comparing single to dual task gait training.Methods and designA prospective randomised clinical trial is being conducted. Sixty participants with idiopathic PD will be recruited, provided they score I-IV on the modified Hoehn and Yahr (1967) scale, and fulfil other inclusion criteria. Participants will be randomly allocated to either a single or dual task gait training group. Both groups will receive 12 hours of walking training over 4 weeks. The single task group will undertake gait training with cueing strategies to increase step length. The dual task group will train to improve step length when walking and performing a variety of added tasks. Both groups will receive a tailored home program for 6 months. Blinded assessors will conduct four assessments: two baseline assessments, one post intervention and one at 6 months follow-up. The primary outcome measure will be step length when dual tasking over 8 m. Secondary outcome measures include: spatiotemporal gait parameters when walking under single and dual task conditions, measures of executive function, the timed up and go test, measures of community mobility, and quality of life. All analyses will be based on intention to treat principle.DiscussionThis trial will examine the immediate and longer term effect of dual task walking training as compared to single task training in people with idiopathic PD, at the impairment, activity, and participation levels. It has the potential to identify a new intervention that may improve and maintain walking beyond the laboratory. The results of this trial will provide guidance for clinicians in the development of walking training programs for people with PD.Trial RegistrationACTRN12609000791235

Community Walking in People with Parkinson's Disease

People with Parkinsons disease often have walking difficulty, and this is likely to be exacerbated while walking in places in the community, where people are likely to face greater and more varied challenges. This study aims to understand the facilitators and the barriers to walking in the community perceived by people with Parkinsons disease. This qualitative study involved 5 focus groups (n = 34) of people with Parkinsons disease and their partners residing in metropolitan and rural regions in Queensland, Australia. Results found that people with PD reported to use internal personal strategies as facilitators to community walking, but identified primarily external factors, particularly the environmental factors as barriers. The adoption of strategies or the use of facilitators allows people with Parkinsons disease to cope so that participants often did not report disability.

Falls in people with Parkinson’s disease: A prospective comparison of community and home-based falls

BACKGROUND Falls are common and debilitating in people with Parkinsons disease (PD) and restrict participation in daily activities. Understanding circumstances of falls in the community and at home may assist clinicians to target therapy more effectively. OBJECTIVE To compare the characteristics of community and home fallers and the circumstances that contribute to falls in people living with PD. METHODS People with mild-moderately severe PD (n=196) used a daily falls diary and telephone hotline to report prospectively the occurrence, location and circumstances of falls over 14 months. RESULTS 62% of people with PD fell, with most falling at least once in the community. Compared to people who fell at home, the community-only fallers had shorter durations of PD (p=0.012), less severe disease (p=0.008) and reported fewer falls in the year prior to the study (p=0.003). Most falls occurred while people were ambulant, during postural transitions and when medication was working well. Community-based falls were frequently attributed to environmental factors such as challenging terrains (p<0.001), high attention demands (p=0.029), busy or cluttered areas (p<0.001) and tasks requiring speed (p=0.020). Physical loads were more often present in home than community-based falls (p=0.027). CONCLUSION Falls that occur in the community typically affect people with earlier PD and less severe disease than home-based falls. Individuals experiencing community-based falls may benefit from physiotherapy to manage challenging environments and high attention demands.

Transcranial Direct Current Stimulation to Enhance Dual-Task Gait Training in Parkinson's Disease: A Pilot RCT.

Objective To investigate the feasibility and safety of a combined anodal transcranial direct current stimulation (tDCS) and dual task gait training intervention in people with Parkinson’s Disease (PD) and to provide data to support a sample size calculation for a fully powered trial should trends of effectiveness be present. Design A pilot, randomized, double-blind, sham-controlled parallel group trial with 12 week follow-up. Setting A university physiotherapy department. Interventions Sixteen participants diagnosed with PD received nine dual task gait training sessions over 3 weeks. Participants were randomized to receive either active or sham tDCS applied for the first 20 minutes of each session. Main Measures The primary outcome was gait speed while undertaking concurrent cognitive tasks (word lists, counting, conversation). Secondary measures included step length, cadence, Timed Up and Go, bradykinesia and motor speed. Results Gait speed, step length and cadence improved in both groups, under all dual task conditions. This effect was maintained at follow-up. There was no difference between the active and sham tDCS groups. Time taken to perform the TUGwords also improved, with no difference between groups. The active tDCS group did however increase their correct cognitive response rate during the TUGwords and TUGcount. Bradykinesia improved after training in both groups. Conclusion Three weeks of dual task gait training resulted in improved gait under dual task conditions, and bradykinesia, immediately following training and at 12 weeks follow-up. The only parameter enhanced by tDCS was the number of correct responses while performing the dual task TUG. tDCS applied to M1 may not be an effective adjunct to dual task gait training in PD. Trial Registration Australia-New Zealand Clinical Trials Registry ACTRN12613001093774

Could everyday technology improve access to assessments? A pilot study on the feasibility of screening cognition in people with Parkinson's disease using the Montreal Cognitive Assessment via Internet videoconferencing.

BACKGROUND The distances and distribution of people, and pressures on the health system in Australia mean that access to services for people living with a neurodegenerative condition may be inadequate. Telehealth may offer ways to provide timely and efficient monitoring and support. People with Parkinsons disease require regular screening of their symptoms and needs, but may have limited access to health professionals. Cognitive changes can impact on occupational performance, thus timely monitoring of cognition is important for informing occupational therapy interventions. AIM To evaluate the feasibility of screening cognition in people with Parkinsons disease using available technology in their homes. METHOD Eleven participants with Parkinsons disease completed the Montreal Cognitive Assessment face-to-face and then via videoconferencing one week later using the technology available at their home. Participants and assessors provided feedback on their experience. RESULTS All Montreal Cognitive Assessment items could be completed over videoconference (e.g. Skype), with a median difference of 2 (IQR: 1-2.5) between face-to-face and videoconference scores. Higher scores were not favoured by either mode of assessment. Three participants received inconsistent cognitive classifications between the two assessment methods. Participant and assessor feedback indicated reported benefits including convenience as well as technological limitations. CONCLUSIONS Given the pressures on the health system and the apparent acceptability to consumers, occupational therapists may explore the utility of readily accessible technology to enable timely monitoring of cognition for people with Parkinsons disease. Further research is needed to develop and demonstrate the reliability and validity of this approach.

Accuracy of wearable physical activity trackers in people with Parkinson's disease

INTRODUCTION The purpose of this study was to determine the accuracy of the Fitbit Charge HR™ and Garmin vívosmart® HR in measuring steps and reflecting intensity of activity in people with Parkinsons disease (PD). METHODS Thirty-three people with mild-moderate PD performed six, two-minute indoor walks at their self-selected walking pace, and at target cadences of 60, 80, 100, 120 and 140 beats/min. A 500 m outdoor walk with terrain challenges was also performed. Step count was recorded by the two wrist-worn activity trackers (Fitbit Charge HR™ and Garmin vívosmart® HR) and compared to an accelerometer (ActivPAL3™). Intensity was recorded by a portable breath-by-breath gas analyser (VO2), heart rate and Borg scale. RESULTS Both commercial activity trackers had low error (<3%) and moderate to high consistency at self-selected pace both indoors and outdoors (ICC 0.88-0.97; p < 0.05) compared to the ActivPAL3™. The Garmin recorded low error (<5%) and high agreement (ICCs > 0.68; p < 0.001) for all target cadences ≥80steps/min. The Fitbit had higher error was less consistent for all target cadences ≥80steps/min. Cadence measured by the Fitbit and Garmin weakly reflected increases in heart rate (ICCs 0.27-0.28; p < 0.05), and did not reflect VO2 or Borg (ICCs 0.08-0.15, p > 0.05). CONCLUSION The Garmin device was more accurate at reflecting step count across a broader range of walking cadences than the Fitbit, but neither strongly reflected intensity of activity. While not intended to replace research grade devices, these wrist-worn devices may be a clinically useful adjunct to exercise therapy to increase physical activity in people with PD.

Classification of movement of people with parkinsons disease using wearable inertial movement units and machine learning

In this work, inertial movement units were placed on people with Parkinsons disease (PwPD) who subsequently performed a standard test of walking endurance (six-minute walk test - 6MWT). Five devices were placed on each the limbs and small of the back. These devices captured the acceleration and rotational motion while the person walked as far as they can in six minutes. The wearable devices can objectively indicate the pattern and rhythmicity of limb and body movements. It is possible that this data, when subject to machine learning could provide additional objective measures that may support clinical observations related to the quality of movement. The aim of this work is two fold. First, to identify the most useful features of the captured signals; second, to identify the accuracy of using these features to predict the severity of PD as measured by standard clinical assessment.

Monitoring the impact of Parkinson's disease on community life using everyday technology: Development of a remote monitoring platform using smartphones

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

Reliability and validity of the ambulatory Self Confidence questionnaire in people with Parkinson's disease

Degeneration of the nigrostriatal dopaminergic system has traditionally been considered the pathological hallmark of Parkinson’s disease (PD). Recent neuropathological work, however, revealed that PD specific brain pathology extends far beyond the nigrostriatal dopaminergic system and affects widespread brain areas, including the olfactory system, autonomic and gain setting brainstem nuclei, and the cerebral cortex. In parallel, there has been a revival of interest in the non-motor features of PD. PD is now considered as a multisystem disorder, manifesting itself by a combination of the classical motor deficits and a wide range of non-motor disturbances, including autonomic dysregulation, hyposmia, sleep disturbances, depression, cognitive dysfunction, and psychosis. Evidence is accumulating that certain non-motor features of PD can develop at least several years before the onset of the motor symptoms. This has most convincingly been demonstrated for impaired olfaction and REM sleep behaviour disorder (RBD). Retrospective studies suggest that other symptoms, such as depression, autonomic dysfunction, and excessive daytime sleepiness may also antedate the motor symptoms. These so-called pre-motor symptoms most likely reflect early pathological changes in the olfactory bulb and tract, the lower brainstem, and possibly the peripheral autonomic nervous system, prior to the involvement of the substantia nigra. As such, pre-motor symptoms are an interesting target for the development of clinical screening tests to detect PD in the pre-motor phase. One of the most promising clinical pre-motor markers of PD is an impairment of the sense of smell, because of its high prevalence (8090% in the motor phase) and the non-invasiveness and low cost of olfactory testing. Prospective studies in first-degree relatives of PD patients and in a population-based cohort have established hyposmia as a risk factor for the development of PD, although the positive predictive value is low and the lead time appears to be relatively short. Idiopathic RBD has a higher positive predictive value than hyposmia and a longer lead time, but lacks sensitivity as only up to one third of PD patients suffer from this disorder. Although at this point no single pre-motor symptom is able to predict PD with high sensitivity and specificity, it is clear that clinical pre-motor markers of PD will be crucial to the development of neuroprotective treatment strategies.

Community-based falls in people with PD: a prospective analysis of the first reported fall Over 12 months

Degeneration of the nigrostriatal dopaminergic system has traditionally been considered the pathological hallmark of Parkinson’s disease (PD). Recent neuropathological work, however, revealed that PD specific brain pathology extends far beyond the nigrostriatal dopaminergic system and affects widespread brain areas, including the olfactory system, autonomic and gain setting brainstem nuclei, and the cerebral cortex. In parallel, there has been a revival of interest in the non-motor features of PD. PD is now considered as a multisystem disorder, manifesting itself by a combination of the classical motor deficits and a wide range of non-motor disturbances, including autonomic dysregulation, hyposmia, sleep disturbances, depression, cognitive dysfunction, and psychosis. Evidence is accumulating that certain non-motor features of PD can develop at least several years before the onset of the motor symptoms. This has most convincingly been demonstrated for impaired olfaction and REM sleep behaviour disorder (RBD). Retrospective studies suggest that other symptoms, such as depression, autonomic dysfunction, and excessive daytime sleepiness may also antedate the motor symptoms. These so-called pre-motor symptoms most likely reflect early pathological changes in the olfactory bulb and tract, the lower brainstem, and possibly the peripheral autonomic nervous system, prior to the involvement of the substantia nigra. As such, pre-motor symptoms are an interesting target for the development of clinical screening tests to detect PD in the pre-motor phase. One of the most promising clinical pre-motor markers of PD is an impairment of the sense of smell, because of its high prevalence (8090% in the motor phase) and the non-invasiveness and low cost of olfactory testing. Prospective studies in first-degree relatives of PD patients and in a population-based cohort have established hyposmia as a risk factor for the development of PD, although the positive predictive value is low and the lead time appears to be relatively short. Idiopathic RBD has a higher positive predictive value than hyposmia and a longer lead time, but lacks sensitivity as only up to one third of PD patients suffer from this disorder. Although at this point no single pre-motor symptom is able to predict PD with high sensitivity and specificity, it is clear that clinical pre-motor markers of PD will be crucial to the development of neuroprotective treatment strategies.