Towards proactive active living: patients with Parkinson's disease experience of a multidisciplinary intensive rehabilitation treatment.

BACKGROUND: Non-pharmacological approaches to PD disease management seem to be a growing and promising field of investigation. Indeed interesting new perspectives are forthcoming from studies on physical rehabilitation and on physical exercise. AIM: To qualitatively describe the rehabilitation experience of Parkinson Disease patients taking part in a multidisciplinary intensive rehabilitation treatment (MIRT) consisting of four weeks of physical therapy and exercise, with three daily sessions, five days a week. DESIGN: Data from a qualitative observational study with patients' interviews were analyzed. SETTING: PD inpatients of a Neurorehabilitation Department. POPULATION: Convenient sample of 27 PD patients (13 male, 14 female), mean age 70.3±8.5 and mean disease duration 8.25±6.9 years; Hoehn-Yahr stage 3, hospitalized for the 4-week MIRT. METHODS: Verbatim transcriptions of 27 semi-structured interviews were analysed using the Grounded Theory methodology. RESULTS: Depressive symptoms were present in 55.5% of the patients measured by Geriatric Depression Scale: mild (N.=8; 30.0%), moderate (N.=6; 22.2%), severe (N.=1; 3.7%). The core category Efficacy of active living identified the becoming conscious of the usefulness of a proactive lifestyle to counterattack disease degeneration. The category Satisfaction described patients' satisfaction upon MIRT, resulting in a perceived enhanced functionality (coherently with quantitative functional parameters improvement at discharge) and a rediscovered autonomy. The category Future described the intention to continue the rehabilitation prescription at home embracing a more dynamic lifestyle. Of interest is that the majority in the interview used body related terms and described perceived changes through the body itself. Verbs of perception (to see, to feel, to perceive) were used in a spontaneous way by all inpatients. The inpatients experienced not only through their mind but also by means of body perceptions how a proactive lifestyle could become a means of disease control. CONCLUSIONS: The positive subjective response to rehabilitation described qualitatively in this study, opens perspectives for tailoring interventions focusing also on patients' self, self-efficacy and perceived efficacy of active living. CLINICAL REHABILITATION IMPACT: Patients' proactive disposition may widen the perspective on patients' motivation to rehabilitation. A multidisciplinary intervention may act both on physical and subjective disease aspects; paying attention to patients' subjective feedbacks could contribute reliably to guide for medical decisions in managing tailored and detailed interventions.

Intensive rehabilitation treatment in early Parkinson's disease: a randomized pilot study with a 2-year follow-up.

BACKGROUND: Although physical exercise improves motor aspects of Parkinson's disease (PD), it is not clear whether it may also have a neuroprotective effect. Objective. In this 2-year follow-up study, we determined whether intensive exercise in the early stages of the disease slows down PD progression. METHODS: Forty newly diagnosed patients with PD were treated with rasagiline and randomly assigned to 2 groups: MIRT Group (two 28-day multidisciplinary intensive rehabilitation treatments [MIRT], at 1-year interval) and Control Group (only drug). In both groups, Unified Parkinson's Disease Rating Scale Section II (UPDRS II), UPDRS III, 6-minute walking test (6MWT), Timed Up-and-Go test (TUG); PD Disability Scale (PDDS), and l-dopa equivalents were assessed at baseline (T0), 6 months (T1), 1 year (T2), 18 months (T3), and 2 years (T4) later. RESULTS: Over 2 years, UPDRS II, UPDRS III, TUG, and PDDS differentially progressed in the 2 groups: In the MIRT Group, all scores at T4 were better than at T0 (all Ps < .03). No changes were noted in the Control Group. l-dopa equivalent dosages increased significantly only in the Control Group (P = .0015), with a decrease in the percentages of patients in monotherapy (T1 40%; T2, T3, and T4 20%). In the MIRT Group, the percentages of such patients remained higher (T1 and T2 100%; T3 89%; T4 75%). CONCLUSIONS: These results suggest that MIRT might slow down the progression of motor decay, it might delay the need for increasing drug treatment, and thus, it might have a neuroprotective effect.

Disexecutive functions and depression in patients with Parkinson disease: the impact on rehabilitation outcome.

BACKGROUND: Studies relating to patients with Parkinson disease that assess neuropsychologic, psychologic, and clinical aspects are very uncommon. OBJECTIVE: The aim of this study was to analyze the impact of executive functioning (impaired vs. not impaired) or depression (depressed vs. nondepressed) on the outcome of rehabilitation treatment in patients with Parkinson disease without dementia at the medium stage of disease. METHODS: Forty consecutive inpatients affected by Parkinson disease were psychologically and neuropsychologically assessed by means of standardized tests during the first week of admission and at discharge after undergoing an intensive rehabilitation training. RESULTS: At baseline, the patients (mean [SD] age, 70.1 [8.0]; Mini-Mental State Examination [MMSE], ≥24) showed impairment in the following executive functions: frontal functions (32.5%), selective and divided attention (55.0% and 41.9%, respectively), and word fluency (17.5%). Depressive symptoms reported using the Geriatric Depression Scale were distributed as follows: mild (n = 13), 32.5%; moderate (n = 4), 10.0%; and severe (n = 5), 12.5%. As for the outcome of the intensive rehabilitation treatment, a general improvement in the Unified Parkinson's Disease Rating Scale, the Berg's scale, the 6-min walking test, and the Timed Up and Go test was observed (P < 0.0001). The improvement was homogeneous for all groupings of the patients for all of the considered variables, indicating that the changes in performance as a result of treatment were unaffected by the presence of executive function deficits or moderate-to-severe depression. CONCLUSIONS: The patients' executive function impairment or moderate-to-severe depressive symptoms did not seem to interfere with the outcome of the intensive physical and occupational rehabilitation. Therefore, these aspects in patients without dementia should not be considered a contraindication to an intensive rehabilitation program. Furthermore, despite the presence of impaired executive functions and/or of depressive symptoms, the 4-wk multidisciplinary rehabilitation program resulted to be highly effective.

Intensive rehabilitation increases BDNF serum levels in parkinsonian patients: a randomized study.

BACKGROUND: Exercise may decrease the risk of Parkinson's disease (PD) in humans and reduce PD symptoms in animal models. The beneficial effects have been linked to increased levels of neurotrophic factors. OBJECTIVE: We examined whether intensive rehabilitation treatment reduces motor disability in patients in the early stages of PD and increases brain-derived neurotrophic factor (BDNF) serum levels. METHODS: Thirty participants in the early stages of PD treated with rasagiline were randomly assigned to 3 hours of rehabilitation treatment that included aerobic exercise for 28 days (Group 1) or to not therapy (control; Group 2). BDNF serum levels were assessed at time T0 (baseline, before treatment), T1 (10 days), T2 (20 days), and T3 (28 days). At T0 and T3, we assessed the Unified Parkinson's Disease Rating Scale (UPDRS) III in both groups, as well as the UPDRS II and total, Berg Balance Scale, and 6-minute walking test only in Group 1. RESULTS: BDNF levels significantly increased at T1 in Group 1, an increase that was maintained throughout the treatment period. At T3 compared to T0, UPDRS III scores significantly improved in Group 1 along with scores for UPDRS II, total, Berg Balance Scale, and 6-minute walking test. CONCLUSIONS: Intensive rehabilitation treatment increases the BDNF levels and improves PD signs in patients in the early stages of the disease. These results are in line with studies on animal models of PD and healthy subjects.

Effectiveness of an intensive rehabilitation treatment on different Parkinson's disease subtypes.

GOAL AND OBJECTIVES: Parkinsonian patients can be classified in two main subgroups: tremor dominant and akinetic-rigid. The aim of this study was to evaluate whether intensive rehabilitation treatment has the same efficacy in the two subtypes. MATERIAL AND METHODS: Patients were classified according to tremor: 65 patients with absence of tremor in "on" and "off" state were assigned to Group_1 and 65 patients with tremor were assigned to Group_2. All patients underwent a 4-week intensive multidisciplinary rehabilitation treatment. The primary outcome measures were: the Unified Parkinson's Disease Rating Scale (UPDRS) II, III, UPDRS akinetic-rigid score and UPDRS tremor score. The secondary outcome measures were: the Berg Balance Scale, 6-minute walking test, self-assessment Parkinson's Disease Disability Scale, Abnormal Involuntary Movement Scale, Freezing of Gait Questionnaire. RESULTS: Patients in Group_1 tended to be more affected than patients in Group_2 by dyskinesias (45% vs 29% p = 0.069) and freezing (46% vs 29%, p = 0.046). Levodopa-equivalent dosages were higher in Group_1 (802 vs 670 mg/day, p = 0.008). Considering the effect of rehabilitation, an homogeneous improvement was observed in all variables in both groups of patients (p < 0.0001). CONCLUSION: Intensive rehabilitation treatment is effective in improving motor performance in both groups. The anatomical and biochemical differences existing between the two subgroups appear to not determine different clinical outcomes.

Short- and long-term efficacy of intensive rehabilitation treatment on balance and gait in parkinsonian patients: a preliminary study with a 1-year followup.

Parkinson's disease (PD) is a neurodegenerative disease in which gait and balance disturbances are relevant symptoms that respond poorly to pharmacological treatment. The aim of this study was to investigate whether a 4-week inpatient multidisciplinary intensive rehabilitation treatment (MIRT) is effective in improving balance and gait and whether improvements persist at a one-year followup. We studied 20 PD inpatients (stage 3 Hoehn-Yahr) who underwent a MIRT. Outcome measures were UPDRS items for balance (30), falls (13), and walk (29), Berg Balance Scale, six-minute walking test, Timed Up and Go Test, and Comfortable-Fast gait speeds. Patients were evaluated at admission, at the end of the 4-week treatment, and at a 1-year followup. Pharmacological therapy was unchanged during MIRT and follow-up. All outcome measures improved significantly at the end of treatment. At 1-year follow-up control, UPDRS walk and Comfortable-Fast gait speeds still maintained better values with respect to admission (P = 0.009, P = 0.03, and P = 0.02, resp.), while the remaining scales did not differ significantly. Our results demonstrate that the MIRT was effective in improving balance and gait and that the improvement in gait performances was partially maintained also after 1 year.

The beneficial role of intensive exercise on Parkinson disease progression.

In the last decade, a considerable number of articles has shown that exercise is effective in improving motor performance in Parkinson disease. In particular, recent studies have focused on the efficacy of intensive exercise in achieving optimal results in the rehabilitation of patients with Parkinson disease. The effects of intensive exercise in promoting cell proliferation and neuronal differentiation in animal models are reported in a large cohort of studies, and these neuroplastic effects are probably related to increased expression of a variety of neurotrophic factors. The authors outline the relation between intensive exercises and neuroplastic activity on animal models of Parkinson disease and discuss the clinical results of different intensive strategies on motor performance and disease progression in patients with Parkinson disease.

Asymmetry and freezing of gait in parkinsonian patients.

It has been hypothesized that freezing of gait (FOG) in parkinsonian patients (PD) might be triggered by a breakdown in the normal symmetry of gait. In this study, we evaluated the relationship between asymmetry of gait and FOG and the effects of intensive treadmill treatment on asymmetry. We studied 30 patients with (FOG+) and 30 without (FOG-) freezing in "on" stage. Patients underwent a 4-week rehabilitation treatment using a treadmill with auditory and visual cues and were evaluated at enrollment and at the end of rehabilitation. Outcome measures were gait speed, stride length, asymmetry of gait, Six-minute walking test (6MWT), Unified Parkinson's Disease Rating Scale (UPDRS) II-III, Berg Balance Scale, Timed Up and Go Test, comfortable-fast gait speeds, freezing of gait questionnaire (FOGQ). At enrollment, no differences in gait parameters were observed between the two groups, which differed only in UPDRS_II and BBS. Both FOG+ and FOG- patients spent more time on the left foot (time on left/time on right foot 1.37, p = 0.002, 1.18, p = 0.016, respectively). Rehabilitation determined a homogeneous improvement in both groups of patients for all variables except UPDRS_II and balance, for which a better improvement was observed in FOG+ patients. The improvement in FOGQ in FOG+ patients was significantly correlated to the improvement in asymmetry of gait (Spearman R = 0.46, p = 0.013). Our data support a direct involvement of the asymmetry of gait in the development of FOG in PD. Treadmill training is effective in improving gait and balance in PD FOG+ patients and this might be related to a reduction of asymmetric gait.

Intensive rehabilitation treatment in parkinsonian patients with dyskinesias: a preliminary study with 6-month followup.

A major adverse effect of levodopa therapy is the development of dyskinesia, which affects 30-40% of chronically treated Parkinsonian patients. We hypothesized that our rehabilitation protocol might allow a reduction in levodopa dosage without worsening motor performances, thus reducing frequency and severity of dyskinesias. Ten Parkinsonian patients underwent a 4-week intensive rehabilitation treatment (IRT). Patients were evaluated at baseline, at the end of the rehabilitation treatment and at 6-month followup. Outcome measures were the Unified Parkinson's Disease Rating Scale Sections II, III, and IV (UPDRS II, III, IV) and the Abnormal Involuntary Movement Scale (AIMS). At the end of the IRT, levodopa dosage was significantly reduced (P = 0.0035), passing from 1016 ± 327 to 777 ± 333 mg/day. All outcome variables improved significantly (P < 0.0005 all) by the end of IRT. At followup, all variables still maintained better values with respect to admission (P < 0.02 all). In particular AIMS score improved passing from 11.90 ± 6.5 at admission to 3.10 ± 2.3 at discharge and to 4.20 ± 2.7 at followup. Our results suggest that it is possible to act on dyskinesias in Parkinsonian patients with properly designed rehabilitation protocols. Intensive rehabilitation treatment, whose acute beneficial effects are maintained over time, might be considered a valid noninvasive therapeutic support for Parkinsonian patients suffering from diskinesia, allowing a reduction in drugs dosage and related adverse effects.

Rehabilitation improves dyskinesias in Parkinsonian patients: a pilot study comparing two different rehabilitative treatments.

GOAL AND OBJECTIVES: The present study was devised: (a) to test whether an intensive (60 hours in 4 weeks) multidisciplinary rehabilitation treatment (involving physiotherapy, exercises to improve gait and balance using treadmill and stabilometric platform, occupational therapy) for Parkinsonian patients is effective in improving dyskinesia and motor performance compared to a control group undergoing a non-intensive non multidisciplinary rehabilitation treatment (30 hours in 4 weeks involving physiotherapy only); and (b) to verify whether rehabilitation may lead to a reduction in levodopa dosage. MATERIAL AND METHODS: Forty Parkinsonian patients suffering from dyskinesias were admitted to study: 20 for an intensive multidisciplinary (Group1) and 20 for a non-intensive non multidisciplinary rehabilitation treatment (Group2). The rating scales used for the clinical evaluation were: Unified Parkinson's Disease Rating Scales (UPDRS) II, III, IV, Parkinson's disease disability scale (PDDS), Abnormal Involuntary Movement Scale (AIMS). RESULTS: All outcome measurements improved in both groups of patients, but patients Group1 presented better results: UPDRS II was reduced by 33% in Group1 and by 22% in Group2, UPDRS III 29% vs. 22%, UPDRS IV 74% vs. 10%, PDDS 18% vs. 12%, and AIMS 71% vs. 8%. A different behaviour was observed for levodopa dosage at baseline and after treatment: dosage decreased by an average value of 210 mg (p< 0.0001) in Group1 and was virtually unchanged (30 mg reduction, p=0.08) in Group2. CONCLUSION: Our findings suggest that a rehabilitation protocol should be considered as a valid non-invasive therapeutic support for patients who show dyskinesias and that there are better results when the treatment is intensive.

Effectiveness of intensive inpatient rehabilitation treatment on disease progression in parkinsonian patients: a randomized controlled trial with 1-year follow-up.

BACKGROUND: Rehabilitation treatments have acute beneficial effects in Parkinson's disease (PD) patients, but whether the effects persist over time is unclear. OBJECTIVE: To assess whether an intensive rehabilitation treatment (IRT) is effective in improving motor performance compared with a control group in a 12-month follow-up, to investigate whether a second cycle administered after 1 year has the same efficacy as the first treatment, and to determine whether IRT reduces the need for increasing levodopa dosage. METHODS: A total of 50 PD patients were randomly assigned to 2 groups; 25 participants had 4 weeks of inpatient physical therapy that included treadmill and stabilometric platform training. At discharge, these patients were invited to continue doing the learned exercises. After 12 months, the same treatment was repeated. The control group of 25 patients received only pharmacological treatment and was invited to practice generic physical exercise at home. The rating scales used for the clinical evaluation were the Unified Parkinson's Disease Rating Scale Sections II and III (UPDRS II and III) and total (UPDRS tot). RESULTS: The authors found that the beneficial effects of IRT persisted over time. A second rehabilitation cycle administered after 1 year was as effective as the first treatment. At the end of the study, daily medication dosage was reduced in treated patients, whereas it was significantly increased in control patients. CONCLUSION: These findings suggest that the natural worsening of symptoms associated with PD can be effectively counteracted by a properly designed IRT.

Rehabilitation in Parkinson's disease: assessing the outcome using objective metabolic measurements.

Objective measurements to assess the efficacy of rehabilitation treatment in Parkinson's disease, suitable to be carried out routinely in the clinical setting, are lacking. Metabolic parameters, reflecting the recruitment and co-ordination of muscle fibers, might be simple instrumental measurements suitable for use as outcome markers. Twenty parkinsonian patients underwent a 4-week rehabilitation treatment. Functional evaluation was based on Unified Parkinson's Disease Rating Scale Motor Section (UPDRS III), Berg's scale, 6-minute walking test (6MWT), and the metabolic data recorded during the 6MWT namely the active energy expenditure (AEE), the kinetics of the energy consumption curve, and the peak value of energy consumption. Both rating scales and gait improved significantly (UPDRS III decreased by 32%, Berg increased by 21% and the 6MWT increased by 17%). We observed significant improvements also in metabolic measurements (35, 18, and 15 improvement in the kinetics of the energy consumption, AEE, and peak value of energy consumption, respectively). Hence, the rehabilitation protocol improved functional characteristics of the patients and these improvements were clearly reflected also by the metabolic measurements. The improvement in clinical scores corresponded with an increase in energy consumption during the 6MWT, indicating greater speed in the recruitment of motor units and of a capacity to maintain this recruitment over time.

Rehabilitation treatment of gait in patients with Parkinson's disease with freezing: a comparison between two physical therapy protocols using visual and auditory cues with or without treadmill training.

Freezing is a disabling symptom in patients with Parkinson's disease. We investigated the effectiveness of a new rehabilitation strategy based on treadmill training associated with auditory and visual cues. Forty Parkinsonian patients with freezing were randomly assigned to two groups: Group 1 underwent a rehabilitation program based on treadmill training associated with auditory and visual cues, while Group 2 followed a rehabilitation protocol using cues and not associated with treadmill. Functional evaluation was based on the Unified Parkinson's Disease Rating Scale Motor Section (UPDRS III), Freezing of Gait Questionnaire (FOGQ), 6-minute walking test (6MWT), gait speed, and stride cycle. Patients in both the groups had significant improvements in all variables considered by the end of the rehabilitation program (all P = 0.0001). Patients treated with the protocol including treadmill, had more improvement than patients in Group 2 in most functional indicators (P = 0.007, P = 0.0004, P = 0.0126, and P = 0.0263 for FOGQ, 6MWT, gait speed, stride cycle, respectively). The most striking result was obtained for 6MWT, with a mean increase of 130 m in Group 1 compared with 57 m in Group 2. Our results suggest that treadmill training associated with auditory and visual cues might give better results than more conventional treatments. Treadmill training probably acts as a supplementary external cue.