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Motion Machine’s Ability to Ease Motor Symptoms in Parkinson’s Entering Trial in Australia

Parkinson's and balance

A trial in Australia will test a motion machine, called the Reviver, to understand whether it can improve balance, mobility and sensory-motor coordination in people with moderate to advanced Parkinson’s disease and atypical parkinsonism.

Exercise has been shown to help ease Parkinson’s symptoms. The Reviver machine, by Isodymanics, is designed to stimulate the vestibular system, the sensory system that provides a sense of balance and information about body position.

The machine works by placing the user at a tilted angle and rotating them in a slow and radial, wave-like motion.

The reaction to being tilted off-balance can induce a brain response that activates muscles across the body, including those that may be dormant as a result of age, infrequent use, damage, or disability. Specifically, it activates nerve pathways that then aid in balance, enhance muscle strength, and help resist the effects of gravity.

Isodynamics reports early evidence suggesting the Reviver’s use can improve mobility and lessen Parkinson’s symptoms, with patients demonstrating a 22% increase in mobility; namely, quicker “up and go” test times over an average of 26 days. This test measures the time it takes for a person to rise from a chair, walk three meters (about 10 feet), turn around and return, then sit down again.

“The anecdotal results with our patients have been very positive,” Geoffrey Redmond, Reviver’s developer, said in a press release. “We’re really glad to see the Reviver being used in a formal trial.”

The trial will assess whether a 12-week program using the Reviver machine improves balance, mobility, and sensory-motor coordination. It plans to enroll 30 patients with moderate to advanced Parkinson’s disease or atypical parkinsonism. People with atypical disease have some evident Parkinson’s symptoms, like muscle stiffness or balance issues, but who do not respond well to standard medications. Their symptoms are caused by other disorders.

The trial is being overseen by Terry O’Brien, a neurologist at Monash University and led by Ben Sinclair, a brain imaging expert at Monash and with Alfred Health. Participants will be required to attend twice weekly sessions for 12 weeks at The Alfred in Melbourne.

Enrolled patients will be split into two groups, based on their diagnoses. One group will undertake the Reviver exercise regime on top of their standard of care, and the second (a control group) will continue with standard of care without using the Reviver.

Those interested in participating or receiving more information about the trial can call Isodynamics at 02-9524-2188 (in Australia, country code +61) or email the company.

“We now need to see what kind of results can be generated during a formal, randomised controlled trial,” Sinclair said.

“It’s an exciting project because people affected by Parkinson’s have a limited range of treatment options. This study provides a rare opportunity to explore and uncover a new possible treatment pathway for people affected by Parkinson’s,” he added.

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Be the Dancer and Be the Artist

dance

Would you — a person with Parkinson’s — ever call yourself a dancer? An artist? Graceful? Well, it’s possible. Be open to the idea. You may be surprised. I certainly was.

Recently, I met David Leventhal, the program director of Dance for PD. The program brings together trained dancers who are experts at moving alongside people with Parkinson’s who face movement challenges. Elements of dance addressing balance, gait, coordination, flexibility, isolation, depression, and other challenges of Parkinson’s are neatly interwoven throughout the entire class experience.

After a wonderful adventure on the subway, I arrived at the studios of the Mark Morris Dance Group in Brooklyn, New York, and waited for class to begin. I had seen videos of the program. I had also watched a documentary called “Capturing Grace,” which featured many of the dancers with Parkinson’s. Yes, dancers.

I would like to call myself a dancer. Thanks to weekly dance lessons with my husband, I am familiar with ballroom dancing, line dancing, etc. However, to say I am an artistic dancer is really stretching it. Hoping I would not draw attention to myself in the class, I settled on a seat near the back.

“When the dance class is going on, there are no patients … only dancers.” – Reggie, dancer, “Capturing Grace.”

The theme of the class was one of clay or dough. We reached, pulled, and used many variations of movement. With each movement, I was realizing that this program targeted Parkinson’s while also teaching artistry and grace.

Some movements were big and made with amplitude while others were intentionally small. There were also variations in speed — some were fast, others were slow. However, at the same time, all of our movements made a statement. We were moving with a purpose. As the pianist played the music, there were crescendos and decrescendos. Our bodies responded with movements that were unintentionally choreographed perfectly.

Our dough became bread through a series of movements. We tore our imaginary bread and passed it to others around the room in a way that reflected how we felt. There were big, sweeping movements from one person who in turn gently reached and passed it to the next.

Next, it was time to move around the room during a segment using body language to invite each other to dance, and then it was time to waltz. I was excited. I knew how to waltz. However, there was an added element of pushing and pulling the hands and arms of my partner. This introduced an element of balance and being in touch with my body to have a connection with my partner.

Graceful is not a word I would use to describe myself. Yet, I found myself gliding, switching partners, and waltzing around the room. Together, the group transformed into a graceful, moving work of art.

We ended the class in a circle, passing our dough into the hands of the person beside us. Each pass was different and had its own expression. I was last to pass my dough to the teacher, David Leventhal. It was a pass of gratitude and thankfulness. I spent an hour with people I had never met but shared their experience of dancing as art. It was obvious that our Parkinson’s didn’t matter. It made each one of us unique and that was reflected in our movements and the art we created.

“One thing I’ve come to believe about Parkinson’s is that it’s a disease of subtraction. It takes things from you one by one. And one of the many things I learned from the people in the class is that if you are confronted with a disease of subtraction, you better believe in addition. You better start adding things back into your life.”Dave Iverson, producer, “Capturing Grace.”

I do believe that Parkinson’s can add things to life. Good things. You may have to look for them but they are out there somewhere. Like the dancers I met in class, for me dance has been one addition to offset the many subtractions.

What will be yours?

***

Note: Parkinson’s News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. The opinions expressed in this column are not those of Parkinson’s News Today or its parent company, BioNews Services, and are intended to spark discussion about issues pertaining to Parkinson’s disease.

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Alzheimer’s Treatment Not Seen to Aid Patients’ Balance After 6 Weeks, Small Study Suggests

Parkinson's and balance

Treatment with Aricept (donepezil) for six weeks does not seem to improve balance, either while standing or walking, for Parkinson’s patients with a minimal history of falls, according to results from a single-site Phase 2 trial.

The study, “Effects of augmenting cholinergic neurotransmission on balance in Parkinson’s Disease,” was published in the journal Parkinsonism and Related Disorders.

Motor and cognitive abilities depend on the coordinated interaction in the brain of two neurotransmitters — chemical substances that act as messengers and allow brain cells to communicate — called dopamine and acetylcholine.

In the brain of people with Parkinson’s, damage to neurons that produce dopamine and acetylcholine affect balance and gait. As the disease progresses, difficulties with such skills increase.

Impaired balance and gait impacts patients’ quality of life and risk falls. “Loss of mobility in the home and community affects tasks required for independent living and participation in family and community affairs. Falls cause minor to major trauma; the injuries restrict a person’s activities and add to the fear of falling which further reduces mobility,” the researchers wrote.

These symptoms cannot always be controlled by using dopaminergic therapies such as levodopa, suggesting the treatments targeting the production of acetylcholine might also help patients.

Aricept is a cholinesterase inhibitor that increases the levels of acetylcholine in the brain by preventing its breakdown. It is used to treat the symptoms of dementia caused by Alzheimer’s disease.

In a previous a small trial, Aricept (marketed by Eisai and Pfizer) was shown to lower the number of falls in Parkinson’s patients who were frequent fallers.

Researchers at Oregon Health & Science University hypothesized that measuring standing balance and dynamic (walking) balance, problems in both of which can cause falls, would allow them to assess if Aricept was of benefit to people with mild to moderately severe Parkinson’s disease.

Static balance is the ability to maintain postural stability and orientation with the body at rest, while dynamic balance is the ability to maintain postural stability and orientation while the body is in motion.

They designed a randomized, crossover Phase 2 trial (NCT02206620) in 49 Parkinson’s patients, mean age of 69. Participants were randomly assigned to a six-week treatment with Aricept, followed by a six-week treatment with placebo, or vice-versa, with six weeks of “washout” between each treatment. A washout period is the time in a clinical study during which a participant is taken off the investigative therapy, or other medication/placebo, so as to eliminate its effects on further treatment.

Oral capsules of Aricept were initially given at 5 milligrams (mg) a day, increasing to 10 mg a day after the first three weeks. Forty-five people completed the study; all had no or a limited fall history (could stand and walk unassisted for at least one minute) and reasonably healthy cognition.

The study’s main goal (endpoint) was to measure patients’ static and dynamic balance. Static balance was evaluated while they were standing with their feet together looking straight ahead at a fixed point with eyes open.

For dynamic balance assessments, participants were instructed to walk for two minutes at a comfortable pace up and down a 20-meter hallway.

As secondary goals researchers measured two parameters used as a readout of acetylcholine levels: the Attention Network Test, a 15-minute computerized test that measures attention and can determine whether changes in gait and balance are associated with changes in attention; and the Short Latency Afferent Inhibition (SAI), a transcranial magnetic stimulation method to evaluate cortical cholinergic activity.

Results showed that Aricept treatment had no effects on patients’ static and dynamic balance compared to the placebo. Secondary outcome measures of attention and SAI were also not significantly affected by treatment. Only one single parameter of static balance — postural sway — improved after treatment with donepezil.

“Contrary to our hypothesis, cholinergic augmentation with [Aricept] at 10 mg/day for 6 weeks did not affect measures of static or dynamic balance in people with PD,” the researchers wrote.

These results are in contrast with previous trials but a possible explanation, the researchers said, is the fact that “our participants may have had less impairment of cholinergic systems than the participants in the other studies.” Parkinson’s patients those studies, they added, all had an average history of at least one fall each week, and some had gait “freezing, indicating more advanced” disease.

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Balance Issues Are Inevitable with Parkinson’s Disease

balance

Years ago, Harrison Ford played the role of Henry Turner, the main character in the movie “Regarding Henry.”

Henry’s entire world shifts when he is shot in the head during a robbery at the convenience store where he was buying cigarettes. The nearly fatal injury puts him into cardiac arrest and he ends up with brain damage, specifically retrograde amnesia.

It takes several months for Henry to recover. When he is finally released from the hospital, he is not the man he used to be — an arrogant playboy who steps on others to get what he wants. The Henry from before was unfaithful to his wife, and his daughter was afraid of him. Henry post-injury is almost childlike, and upon learning who he was before the accident, tries to right some of his wrongs.

In the first few days home, Henry is sitting at the table with his daughter eating breakfast when she accidentally spills her milk on the kitchen table. Fear seizes her as she awaits Henry’s reaction. He sees the fear in her eyes, and to put her at ease, says, “It’s OK. I do that all the time.” He then tips over his glass of milk as well.

A few months ago, I read about a woman who had Parkinson’s disease (PD). She, like so many of us, was frequently dropping things, including her meals, which made her feel humiliated and embarrassed. Unfortunately, that’s what PD does. It gives you plenty of opportunities to be humiliated and embarrassed, always when you least expect it. But what we need to do is learn to go easy on ourselves. It’s not like we are doing these things on purpose.

The fact is that we all spill things, Parkinson’s or not. We all lose our balance and drop things or fall to the ground. Having PD just makes the opportunities more probable. We need to recognize that spills and falls are going to happen sooner or later, and we should try to be ready for it.

Here’s what you will need:

  • A cane or a walker
  • A helmet
  • Knee pads
  • Body armor
  • Elbow pads
  • Shin guards
  • Safety goggles
  • Leather gloves
  • Steel-toe boots
  • Brawny paper towels for those tough spills
  • Medic alert device to alert people that you have fallen and can’t get up
  • A sense of humor

A dog to lick up those spills wouldn’t be bad, either. Just decide that you are going to turn that 5-second rule into 20 — as we all know, things take just a little bit longer to do with PD!

***

Note: Parkinson’s News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. The opinions expressed in this column are not those of Parkinson’s News Today or its parent company, BioNews Services, and are intended to spark discussion about issues pertaining to Parkinson’s disease.

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Frustrated and Angry? It’s Not People, It’s Parkinson’s

angry

I get angry if he does and frustrated when he doesn’t. “He” is my husband.

I am getting rather self-conscious about going out in public. Sometimes, I feel like people who don’t know me perceive me as being a little drunk because I’m off balance when I walk. 

Other times, I feel people view me as ignorant because I’m unable to finish some of my sentences or I lose my train of thought. That’s where he — my husband — comes into play. When we are out in public, I sometimes get angry when he finishes my sentences for me, and at other times, I get frustrated when he doesn’t.

He can’t read my mind, so he won’t always know when I want him to step up and help me out or when I want him to let me communicate on my own. 

The other day, someone asked me an important question. I got so flustered over my response that I stewed over it for two days.

When I saw the person again, my husband was there. I posed the question to him so she could get a clearer, more logical answer. Then I stewed over whether I should have done that. Just as I had anticipated, however, he answered it with knowledge, wisdom, logic, and clarity. I find that harder to do at times with this scatterbrained kind of disease, and it makes me want to cry.

I have never considered myself a genius, but I have never thought I was stupid, either — until now.

I feel that’s how others perceive me, probably because I tend to view myself that way nowadays.

For example, when I am out for a walk with my neighbor and I am sharing something with her, poof! Just like that, the thought is gone. Or my words feel jumbled and sticky. Or I trip over the silliest things, like my own two feet, and I end up breaking my toe.  

Yes, that was a recent occurrence. 

In my own home. 

In front of all my grandchildren. 

It’s frustrating, and I do grieve the things I’ve lost to this disease — not just speech and balance, but all the things that were mine to use and refine and are now gone or on their way out.  

With all that said, I try to treasure what is still here and make the most of it because I know it could be much, much worse. I also know that if I want to finish my own sentences and feel I am not always given that opportunity, I should actually be grateful there is someone who cares enough to not leave me standing and looking foolish. All I have to do is look at him with “Help” written in my expression, and he comes to my rescue. My hero.

I get angry and frustrated sometimes. I have to remember that Parkinson’s is the cause, not people.

***

Note: Parkinson’s News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. The opinions expressed in this column are not those of Parkinson’s News Today or its parent company, BioNews Services, and are intended to spark discussion about issues pertaining to Parkinson’s disease.

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Imbalance in Dopamine and Acetylcholine Levels May Drive Disease Progression, Study Finds

neurotransmitters

Therapies against motor loss and progression in Parkinson’s’ disease (PD) may need to tackle the imbalance between two neurotransmitters, dopamine and acetylcholine, instead of focusing on dopamine alone, an early study suggests.

The study, “Dopamine Deficiency Reduces Striatal Cholinergic Interneuron Function in Models of Parkinson’s Disease,” was published in the journal Neuron.

Motor and cognitive functions depends on the coordinated interaction in the brain of two neurotransmitters — substances produced in response to nerve signals that act as chemical messengers — called dopamine and acetylcholine.

In Parkinson’s, the degeneration of motor neurons that produce dopamine in a brain region called the striatum results in difficulties with voluntary movement control.

Therapies that increase dopamine or activate dopamine receptors, such as levodopa, are currently used to restore motor skills. However, these treatments are not fully effective and their benefits wear off over time.

Researchers have thought that a decline in dopamine levels would increase acetylcholine production. Higher levels of acetylcholine are suggested to cause the dyskinesia — uncontrolled, involuntary movements — observed in Parkinson’s patients under long-term dopamine therapy.

Researchers at Yale University questioned points in these assumptions. They investigated how dopamine affects acetylcholine by looking at a specific type of nerve cell, called striatal interneurons, that is the main source of acetylcholine in the striatum.

To test the effects of dopamine loss, the team used a mouse model genetically modified to mimic Parkinson’s that has a progressive decline in dopamine levels. When motor symptoms appear in these mice, it is estimated that about 30% of dopamine is already lost, increasing to 60–80% at their death.

This progressive dopamine loss, the researchers saw, was matched in the animals by an initial and smaller decrease in the production of acetylcholine by striatal interneurons, creating an imbalance.

“While the concentrations of both dopamine and acetylcholine decline, the balance between these two neurotransmitters shifts to favor acetylcholine,” the researchers wrote.

Subsequent release of dopamine from remaining axon terminals push an increase of acetylcholine, worsening the imbalance between both neurotransmitters.

Under dopamine depleted conditions, proper motor function is dependent on adequate levels of both acetylcholine and dopamine, the study concluded.

Its findings suggest that progressive dopamine deficiency reduces the activity of striatal cholinergic interneurons, resulting in progressive motor difficulties.

Future treatments aiming to slow Parkinson’s progression should include those targeting the balance between acetylcholine and dopamine.

“Our findings suggest that targeted cholinergic therapy [those that mimic the action of acetylcholine] has a place in the management PD and highlight the need for additional experiments that will offer therapeutic options distinct from disease prevention,” the researchers wrote.

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Torso Exercises Helped Reduce Severity of Forward Stoop in Parkinson’s Patients

torso exercises

Torso-specific exercises can help improve posture and balance by significantly reducing the severity of forward stoop in patients with Parkinson’s disease.

The study with that finding, “Four-week trunk-specific exercise program decreases forward trunk flexion in Parkinson’s disease: A single-blinded, randomized controlled trial,” was published in the journal Parkinsonism and Related Disorders.

Forward bending of the spine, known as disease-related forward trunk flexion (FTF), is a common complication observed in patients with Parkinson’s disease. FTF can result in permanent postural imbalance, pain, frequent falls, and irreversible deformities. Early detection and rehabilitation efforts through focused physical therapy can help in reducing pain and delay motor symptoms progression. However, information is limited on FTF rehabilitative efforts in Parkinson’s patients.

In a controlled trial (NCT03741959), researchers assessed the impact of a four-week trunk-specific rehabilitation program in correcting the posture of  37 Parkinson’s patients with FTF. Patients were assigned randomly to the experimental group (19 patients) or the control group (18 patients).

The exercise regimen for the experimental group consisted of three routines. First was a 20-minute session of self-correction exercises in three levels of difficulty to be performed in front of a mirror (visual feedback), while measuring the muscle activity using electromyogram (proprioceptive feedback), or without any feedback. The second routine included 20 minutes of trunk stability exercise and improving muscle strength and coordination. The third set of exercises included functional tasks that were meant to trigger behavior changes to unconsciously correct posture and movement to aid daily activities.

In the four-week program, the exercise regimen was performed in 60-minute sessions for five days a week.

The control group performed 20 minutes of joint movements, exercise for muscle strength, and stretching, followed by gait training and balance exercises.

All the exercise routines were performed under the guidance of a trained physical therapist, and each treatment session consisted of 10 exercises with repetitions based on the patient’s capacity.

In the four-week program, the exercise regimen was 60-minute sessions five days a week.

Patients who underwent the four-week program showed a significant decrease in the degree of forward bend compared to the control group, indicating a positive effect from the trunk-specific exercises. The exercise regimen helped them straighten up by a mean of 9.73 degrees by the end of the program, and 8.84 degrees at the one-month follow-up. In contrast, the control group exercises corrected posture by a mean of only 1.62 degrees and 0.95 degrees at the same time intervals.

“The main findings of the present study are that the four-week trunk-specific exercise program reduced the degrees of FTF in patients with Parkinson’s disease more than the conventional treatment, and the training effects were maintained at one-month post-treatment,” researchers wrote.

Further assessments showed that both groups exhibited significant improvement in patients’ ability to perform daily activities, as determined by the Unified Parkinson’s Disease Rating Scale III (score range 0-132, with higher scores representing worsened symptoms), compared to before the intervention.

Also, significant reduction in pain was reported in both the groups at one month of follow-up. However, there was no statistical difference between the two groups, researchers noted.

The team also assessed the impact of the exercise in improving static balance (ability to balance while standing still) and dynamic balance (ability to balance while moving or switching positions). No difference was noted in both groups immediately after completion of the four-week program. But, at the one-month follow-up, the static and dynamic balance was significantly improved in the experimental group compared with the control group.

In addition, patients in the experimental group reported a marked overall decrease in the number of falls per month at the one-month follow-up, as well as an overall improvement in their health-related quality of life at the one-month follow-up; the control group experienced a decline.

“The four-week trunk-specific rehabilitation training decreased the forward trunk flexion severity and increased postural control in patients with Parkinson’s disease,” researchers stated.

More studies are warranted to further validate these preliminary findings and explore more extensively the potential of torso-specific exercises for Parkinson’s patients, they added.

 

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Ballet Not Seen to Greatly Improve Gait or Balance in Small Study in Parkinson’s Patients

Ballet practice may not improve balance and gait in people with Parkinson’s disease — at least not over the long term, a small study in patients engaged in dance for at least a year suggests, possibly contradicting earlier research reporting evidence of such benefits.

But the work did find probable social and psychological gains, noting a “high levels of adherence” among the Parkinson’s group, indicating motivation “to continue attending.”

Researchers for this study, “Effects of a ballet-based dance intervention on gait variability and balance confidence of people with Parkinson’s,” published in the journal Arts & Health, suggesting that more research needs to be done to understand whether and how dance therapy can be effective.

Dance can be beneficial for many, and especially people with neurodegenerative diseases. It is a form of physical movement that is often easier to “stick with” than just exercising, and offers social contact that rewards a person’s mental health and psychological well-being. Some previous studies specifically indicated that dance may improve motor skills in people with Parkinson’s.

The U.K. team here wondered whether ballet — a dance form that requires many balancing movements, like stabilizing weight on one leg while moving the other  — would be of benefit for Parkinson’s patients.

They recruited 19 patients already enrolled in weekly “dance for Parkinson’s” classes. Participants had to have been dancing for at least three months, although most had already been participating for over a year.

Another 13 patients who refrained from ballet classes for the study’s duration served as a control group.

Over the course of a year, people in both groups were examined for changes in gait and balance. To analyze gait, a sensor was placed on a participant’s lower back when they walked across the room, allowing for measurements of stability as they walked.

For balance, the Activities-specific Balance Confidence Scale was given to participants. This questionnaire is a measurement of confidence in balance, not balance itself, since it’s asking participants questions about their perceptions of their own balance.

No significant difference in all of the above measures was seen between the two groups over the study’s year. This contradicted pro-benefit findings of previous research, and the investigators offer two likely explanations for this disparity.

“First,” they write in their study, “gait variability as an indication of dynamic stability has not been assessed in previous dance for Parkinson’s research.” Further, measures of gait variability used in this study might “not be comparable” to “commonly used clinical rating scales” that look more at “static balance tasks,” and reliance on their  different variables may make all the difference.

“Secondly,” the researchers said, “previous studies evidencing changes to balance, gait, and functional mobility have often included a class frequency of two to three dance classes per week,” while participants in this study had one class per week.

They also suggested that a study limitation was the fact that its patient group had been taking the weekly classes for about a year prior to the study’s start. Regular long-term dance classes made it “possible that a ceiling effect may have occurred whereby any resulting change in gait variability as a result of the ballet-based sessions was no longer visible,” the researchers concluded.

“It is possible that the ballet-based sessions had a positive affect on gait variability for the participants; however, the measurements were not able to capture this early change at the beginning of their dance programme.”

 

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Hydrotherapy Improves Balance, Mobility in Parkinson’s Patients, Study Reports

hydrotherapy

Hydrotherapy may provide significant balance and mobility benefits in patients with Parkinson’s disease compared to medication and land-based exercises, according to a review study.

The research, “The Effects of Hydrotherapy on Balance, Functional Mobility, Motor Status, and Quality of Life in Patients with Parkinson Disease: A Systematic Review and Meta-analysis,” was published in the journal PM&R.

Impairments such as muscle rigidity and tremor affect the balance and mobility of people with Parkinson’s. Combined with fear of falling, it promotes a sedentary lifestyle and reduces quality of life.

Water-based exercise is often prescribed to these patients, providing a safe environment that reduces the risk of falling. Prior studies have reported that hydrotherapy improves motor symptoms. However, the evidence about  hydrotherapy as a treatment strategy in Parkinson’s is scarce.

To address this gap, researchers conducted a systematic review of the available scientific literature and a meta-analysis — a type of statistical analysis that combines the results of various studies.

The scientists focused on hydrotherapy’s effectiveness on patients’ balance, mobility, quality of life and motor function.

For this purpose, the investigators searched seven online databases as well as unpublished or ongoing clinical trials from inception through December 2017. Nineteen studies were identified, of which eight were randomized controlled trials (RCTs). Overall, the studies had 484 participants, with a mean age ranging from 54 to 78 years and an average disease duration ranging from three to 10 years.

The studies had different designs, which included comparisons of hydrotherapy with land-based exercises or medications, combinations of hydrotherapy with land-based therapy, and assessments of low-intensity and muscular resistance water-based exercises.

Hydrotherapy could include balance training, stretching, strengthening, trunk mobility, and gait exercises. The sessions ranged from 40 to 60 minutes, one to five days per week, for three to 20 weeks, for a total of eight to 60 sessions. Water temperature was set between 28ºC (82ºF) and 34ºC (93ºF) in the 12 studies that reported this parameter.

All but two studies with available information on levodopa usage evaluated patients’ in the “on” phase, which refers to the period when this medication is effective and has not yet worn off.

The meta-analysis on balance and mobility included five RCTs, which had a total of 133 patients. The results showed that hydrotherapy with or without land-based exercises significantly improved both balance and mobility compared to land-based therapy or usual care with medication alone.

Three other studies not included in the meta-analysis due to lacking a control group also found significant benefits with hydrotherapy in balance. One RCT not included in the statistical comparison did not report differences with hydrotherapy and land-based therapy, while another showed that aquatic obstacles training is more beneficial for balance than traditional water-based exercises.

In turn, two RCTs not included in the respective analysis failed to show mobility improvements with hydrotherapy.

As for quality of life, an analysis of three RCTs with 76 patients showed no benefits with hydrotherapy compared to land-based treatment, which the researchers attributed to the small number of studies included. This also was observed in one RCT not included in the meta-analysis. In contrast, five other studies, including two non-randomized trials, found significant improvements with water-based treatment.

Results of a meta-analysis of five RCTs with 140 patients also did not reveal improvements in motor function in comparison to land-based exercise. This can be explained by patients having types of motor complications not expected to improve with hydrotherapy, the team said.

Of note, two other RCTs and a non-randomized trial also did not find different results with hydrotherapy compared to other approaches in motor function.

Overall, the scientists wrote, “hydrotherapy, combined or not with other therapies, may improve balance and functional mobility of patients with [Parkinson’s] when compared to land-based therapy alone or usual care.”

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Freedom of Movement May Be Misinterpreted as Balance Instability, Parkinson’s Study Suggests

balance instability

Antiparkinsonian medicines may allow patients with mild to moderate Parkinson’s disease to experience freedom of movement, which could be confused with balance issues if measured by traditional postural stability testing, researchers suggest.

Their findings were published in the study, “The influence of dopaminergic medication on balance automaticity in Parkinson’s disease,” in the journal Gait & Posture.

Dopaminergic medications can help control Parkinson’s motor symptoms, but as the disease progresses, patients typically need to gradually increase the treatment dose for maximum benefit. Even after increasing the dose, they might sometimes experience a reappearance or worsening of symptoms (off periods) due to the diminishing effects of the therapy.

It is known that Parkinson’s patients have difficulty performing learned motor skills automatically, a phenomenon referred to as decreased motor automaticity. Automaticity is the ability to perform movements without having to pay attention to the details of the movement, particularly for actions that require low levels of precision or for movements that are frequently made.

Studies also report that the ability to perform two or more tasks at the same time, called dual-tasking, is impaired in Parkinson’s disease.

“Dual-tasking involves performing a primary motor task (e.g., standing) and a secondary task (e.g., conversing) simultaneously and is the primary means of assessing the automaticity of a given motor task,” the researchers wrote.

In theory, if a primary task is automatic, performing another task simultaneously should not interfere with the first one.

Although dopaminergic medication seems to improve dynamic balance (the ability to maintain postural stability while in motion), there is still little evidence on how it influences standing balance (the ability to maintain the body in a fixed posture).

University of Houston researchers set out to evaluate how dopaminergic medication influenced long-duration standing balance with the eyes open or closed while dual-tasking in Parkinson’s disease.

They recruited 16 Parkinson’s patients with mild to moderate disease (four women and 12 men, with a mean age of 67.1 years) for the study.

Before dual-task testing, the participants underwent a minimum 12-hour overnight medication withdrawal, so that researchers could assess patients’ status in an off state.

Single- and dual-task tests were conducted. For dual-task testing, patients had to stand in silence (primary task), both with their eyes open and then with them closed, while listening on headphones to a pre-recorded unfamiliar speech and mentally counting the number of times a specific word occurred (secondary task). This is known as phoneme monitoring. They also had to listen to the details of the story so that they could answer a few questions about it at the end of the testing session.

Under the protocol, participants were asked to perform the following tasks in random order: 1) phoneme monitoring while seated comfortably in a quiet room, 2) single-task standing eyes open, 3) single-task standing eyes closed, 4) dual-task standing eyes open, and 5) dual-task standing eyes closed.

“After the [off] trials were completed, the subjects took their dopaminergic medication as prescribed for their first/morning dose and waited until they achieved a stable ‘on’ feeling (minimum of 45 [minutes]) before commencing the on-medication testing,” the researchers said.

Every trial session was performed once for three minutes, and participants were given at least a minute between sessions to sit down and rest.

Data on motor variables of interest were obtained by the NeuroCom Balance Master, a system that uses a fixed force plate to measure the vertical forces exerted through the patient’s feet to measure the center of gravity position and postural control.

Results revealed that antiparkinsonian medicines significantly increased center of pressure movement. The center of pressure is a point, inside or outside the body, where the resulting vector of all forces (including gravity) acting on the body is considered to act.

Patients’ performance in the secondary task was reduced after they took the medications.

Additionally, having the eyes closed or open significantly increased the patients’ back and forth plus lateral sway velocities and the integrated time to boundary.

In biomechanics, time to boundary estimates the time required for the center of pressure to reach the boundary of the base of support if it were to continue its instantaneous trajectory and velocity. Higher integrated time indicates poorer balance.

Postural sway was also increased during the on state. Scientists often interpret increases in sway velocity and integrated time to boundary as indications of impaired balance; however, the researchers suggest that their findings could indicate an increase in freedom of movement rather than compromised stability.

Importantly, medication did not improve balance automaticity.

“The data did not support a medication-induced improvement in automaticity, as measured by significant medication by task interactions. An alternate interpretation for medication-induced balance changes in PD [Parkinson’s disease] includes an increase in maneuverability without sacrificing stability after taking dopaminergic medication,” the researchers concluded.

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