Integrated Care in Parkinson's Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: Quality of life in Parkinson's disease (PD) is affected by motor and nonmotor symptoms, necessitating an integrated care approach. Existing care models vary considerably in numerous domains. The objectives of this study were to perform a systematic review and meta-analysis of PD integrated care models and develop recommendations for a representative model. METHODS: We conducted a systematic review of published integrated care models and a meta-analysis of randomized, controlled trials examining integrated care versus standard care. The primary outcome was health-related quality of life using a validated PD scale. We evaluated levels of care integration using the Rainbow Model of Integrated Care. RESULTS: Forty-eight publications were identified, including 8 randomized, controlled trials with health-related quality of life data (n = 1,149 total PD patients). Qualitative evaluation of individual care model integration guided by the Rainbow Model of Integrated Care revealed frequent clinical and professional integration, but infrequent organizational and population-based integration elements. Meta-analysis of randomized, controlled trials revealed significant heterogeneity (I2 = 90%, P < 0.0001). Subgroup analysis including only outpatient care models (n = 5) indicated homogeneity of effects (I2 = 0%, P = 0.52) and improved health-related quality of life favoring integrated care, with a small effect size (standardized mean difference [SMD], -0.17; 95% CI, -0.31 to -0.03; P = 0.02). CONCLUSIONS: Outpatient integrated PD care models may improve patient-reported health-related quality of life compared with standard care; however, because of variable methodological approaches and a high risk of bias related to inherent difficulties in study design (eg, blinding of participants and interventionists), generalizability of these results are difficult to establish. The Rainbow Model of Integrated Care is a promising method of evaluating elements and levels of integration from individual patient care to population health in a PD context. © 2020 The Authors. Movement Disorders published by Wiley Periodicals, LLC. on behalf of International Parkinson and Movement Disorder Society.

Cardiovascular Responses During Resistance Exercise in Patients With Parkinson Disease.

BACKGROUND: Patients with Parkinson disease (PD) present cardiovascular autonomic dysfunction that impairs blood pressure control. However, cardiovascular responses during resistance exercise are unknown in these patients. OBJECTIVE: To investigate cardiovascular responses during resistance exercise performed with different muscle masses in patients with PD. DESIGN: Prospective, repeated-measures. SETTING: Exercise Hemodynamic Laboratory, School of Physical Education and Sport, University of São Paulo. PARTICIPANTS: Thirteen patients with PD (4 women, 62.7 ± 1.3 years, stages 2-3 of the modified Hoehn and Yahr scale; "on" state of medication) and 13 paired control patients without PD (7 women, 66.2 ± 2.0 years). INTERVENTIONS: Both groups performed, in a random order, bilateral and unilateral knee extension exercises (2 sets, 10-12 maximal repetition, 2-minute intervals). MAIN OUTCOME MEASUREMENTS: Systolic blood pressure (SBP) and heart rate (HR) were assessed before (pre) and during the exercises. RESULTS: Independent of set and exercise type, SBP and HR increases were significantly lower in PD than the control group (combined values: +45 ± 2 versus +73 ± 4 mm Hg and +18 ± 1 versus +31 ± 2 bpm, P = .003 and .007, respectively). Independently of group and set, the SBP increase was greater in the bilateral than the unilateral exercise (combined values: +63 ± 4 versus +54 ± 3 mm Hg, P = .002), whereas the HR increase was similar. In addition, independently of group and exercise type, the SBP increase was greater in the second than the first set (combined values: +56 ± 4 versus +61 ± 4 mm Hg, P = .04), whereas the HR increases were similar. CONCLUSIONS: Patients with PD present attenuated increases in SBP and HR during resistance exercise in comparison with healthy subjects. These results support that resistance exercise is safe and well tolerated for patients with PD from a cardiovascular point of view supporting its recommendation for this population. LEVEL OF EVIDENCE: II.

Resistance Training Improves Sleep Quality in Subjects With Moderate Parkinson's Disease.

Silva-Batista, C, de Brito, LC, Corcos, DM, Roschel, H, de Mello, MT, Piemonte, MEP, Tricoli, V, and Ugrinowitsch, C. Resistance training improves sleep quality in subjects with moderate Parkinson's disease. J Strength Cond Res 31(8): 2270-2277, 2017-The objectives of this study were to test if 12 weeks of progressive resistance training (RT) improves sleep quality and muscle strength in subjects with moderate Parkinson's disease (PD) and if sleep quality values of subjects with moderate PD are closer to those of age-matched healthy controls (HC) at posttraining. This was a randomized controlled trial conducted between March 2013 and September 2014. Twenty-two subjects with moderate PD were randomly assigned to a nonexercising control group (n = 11) or an RT group (n = 11). Thirty-one HC were not randomized to any group. The RT group performed a RT program twice a week for 12 weeks, whereas the control group made no change to their weekly routine. For subjects with PD, sleep quality (i.e., Pittsburgh Sleep Quality Index [PSQI]) and knee-extensor peak torque were assessed before and after 12 weeks of intervention; for HC, these outcomes were assessed at pretest only. There were differences between RT and control groups in PSQI scores, PSQI subscores(i.e., subjective sleep quality and daytime dysfunction), and knee-extensor peak torque at posttraining (p ≤ 0.05). After RT, the average subjects with PD showed lower (i.e., improved) PSQI scores than the average HC (p ≤ 0.05). A negative association was observed between changes in PSQI scores and changes in knee-extensor peak torque at posttraining (r = -0.58, p = 0.028). No adverse events were reported. The RT is recommended as an adjunct therapeutic method for improving sleep quality of subjects with moderate PD and moving these levels to those observed in HC.

Resistance training with instability in multiple system atrophy: a case report.

This case report assessed quality of life, activities of daily living, motor symptoms, functional ability, neuromuscular parameters and mRNA expression of selected genes related to muscle protein synthesis and degradation in a patient with Multiple System Atrophy (MSA). The patient underwent resistance training with instability devices (i.e., bosu, dyna disk, balance disk, Swiss ball) for six months twice a week. After the six months training, the patient's left and right quadriceps muscle cross-sectional area and leg press one-repetition maximum increased 6.4%, 6.8%, and 40%, respectively; the patient's timed up and go, sit to stand, dynamic balance, and activities of daily living improved 33.3%, 28.6%, 42.3%, and 40.1%, respectively; the patient's severity of motor symptoms and risk of falls decreased 32% and 128.1%, respectively. Most of the subscales of quality of life demonstrated improvements as well, varying from 13.0% to 100.0%. mRNA expression of mechanogrowth factor and mammalian target of rapamycin increased 12.7-fold and 1.5-fold, respectively. This case report describes likely the first nonpharmacological therapeutic tool that might be able to decrease the severity of motor symptoms and risk of falls, and to improve functional ability, neuromuscular parameters, and quality of the life in a patient with MSA. Key pointsSix months of resistance training with instability alleviate the MSA-related effects and improve the quality of life in a patient with MSA.High complexity exercise intervention (i.e., resistance training with instability) may be very beneficial to individuals with impaired motor control and function as MSA patients.Caution should be exercised when interpreting our findings as they cannot be generalized to the entire MSA population and they do not allow establishing causal conclusions on the effects of this mode of exercise on MSA.