Highly challenging balance program reduces fall rate in Parkinson disease

Published in final edited form as: J Neurol Phys Ther. 2016 January ; 40(1): 24–30. doi:10.1097/NPT.0000000000000111BACKGROUND AND PURPOSE: There is a paucity of effective treatment options to reduce falls in Parkinson disease (PD). Although a variety of rehabilitative approaches have been shown to improve balance, evidence of a reduction in falls has been mixed. Prior balance trials suggest that programs with highly challenging exercises had superior outcomes. We investigated the effects of a theory-driven, progressive, highly challenging group exercise program on fall rate, balance, and fear of falling. METHODS: Twenty-three subjects with PD participated in this randomized cross-over trial. Subjects were randomly allocated to 3 months of active balance exercises or usual care followed by the reverse. During the active condition, subjects participated in a progressive, highly challenging group exercise program twice weekly for 90 minutes. Outcomes included a change in fall rate over the 3-month active period and differences in balance (Mini-Balance Evaluation Systems Test [Mini-BESTest]), and fear of falling (Falls Efficacy Scale-International [FES-I]) between active and usual care conditions. RESULTS: The effect of time on falls was significant (regression coefficient = -0.015 per day, P < 0.001). The estimated rate ratio comparing incidence rates at time points 1 month apart was 0.632 (95% confidence interval, 0.524-0.763). Thus, there was an estimated 37% decline in fall rate per month (95% confidence interval, 24%-48%). Improvements were also observed on the Mini-BESTest (P = 0.037) and FES-I (P = 0.059). DISCUSSION AND CONCLUSIONS: The results of this study show that a theory-based, highly challenging, and progressive exercise program was effective in reducing falls, improving balance, and reducing fear of falling in PD.Video abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A120). TRIAL REGISTRATION: ClinicalTrials.gov NCT02302144.This study was funded by the Boston Claude D. Pepper Older Americans Independence Center (NIH 5P30AG031679). Additional support was provided by the American Parkinson Disease Association (ADPA); ADPAMA Chapter. (NIH 5P30AG031679 - Boston Claude D. Pepper Older Americans Independence Center; American Parkinson Disease Association (ADPA); ADPAMA Chapter

Cognitive-behavioral therapy for anxiety in Parkinson's disease

Parkinson's disease (PD) is characterized by motor symptoms, but nonmotor symptoms also significantly impair daily functioning and reduce quality of life. Anxiety is prevalent and debilitating in PD, but remains understudied and undertreated. Much affective research in PD focuses on depression rather than anxiety, and as such, there are no evidence-based treatments for anxiety in this population. Cognitive-behavioral therapy (CBT) has shown promise for treating depression in PD and may be efficacious for anxiety. This exploratory study implemented a multiple-baseline single-case experimental design to evaluate the utility and feasibility of CBT for individuals with PD who also met criteria for a DSM-5 anxiety disorder ( n = 9). Participants were randomized to a 2-, 4-, or 6-week baseline phase, followed by 12 CBT sessions, and two post treatment assessments (immediately post treatment and 6-week follow-up). Multiple outcome measures of anxiety and depression were administered weekly during baseline and intervention. Weekly CBT sessions were conducted in-person ( n = 5) or via secure videoconferencing ( n = 4). At post treatment, seven of the nine participants showed significant reductions in anxiety and/or depression, with changes functionally related to treatment and most improvements maintained at 6-week follow-up. Effects of CBT on secondary outcomes varied across participants, with preliminary evidence for reduction in fear of falling. Adherence and retention were high, as were treatment satisfaction and acceptability. The findings of this pilot study provide preliminary evidence for the utility of CBT as a feasible treatment for anxiety and comorbid depressive symptoms in PD and highlight the potential of telehealth interventions for mood in this population.Accepted manuscrip

Size dependence of solar X-ray flare properties

Non-thermal and thermal parameters of 85 solar flares of GOES class B1 to M6 (background subtracted classes A1 to M6) have been compared to each other. The hard X-ray flux has been measured by RHESSI and a spectral fitting provided flux and spectral index of the non-thermal emission, as well as temperature and emission measure of the thermal emission. The soft X-ray flux was taken from GOES measurements. We find a linear correlation in a double logarithmic plot between the non-thermal flux and the spectral index. The higher the acceleration rate of a flare, the harder the non-thermal electron distribution. The relation is similar to the one found by a comparison of the same parameters from several sub-peaks of a single flare. Thus small flares behave like small subpeaks of large flares. Thermal flare properties such as temperature, emission measure and the soft X-ray flux also correlate with peak non-thermal flux. A large non-thermal peak flux entails an enhancement in both thermal parameters. The relation between spectral index and the non-thermal flux is an intrinsic feature of the particle acceleration process, depending on flare size. This property affects the reported frequency distribution of flare energies.Comment: Astronomy and Astrophysics, in pres

Numerical simulations of chromospheric hard X-ray source sizes in solar flares

X-ray observations are a powerful diagnostic tool for transport, acceleration, and heating of electrons in solar flares. Height and size measurements of X-ray footpoints sources can be used to determine the chromospheric density and constrain the parameters of magnetic field convergence and electron pitch-angle evolution. We investigate the influence of the chromospheric density, magnetic mirroring and collisional pitch-angle scattering on the size of X-ray sources. The time-independent Fokker-Planck equation for electron transport is solved numerically and analytically to find the electron distribution as a function of height above the photosphere. From this distribution, the expected X-ray flux as a function of height, its peak height and full width at half maximum are calculated and compared with RHESSI observations. A purely instrumental explanation for the observed source size was ruled out by using simulated RHESSI images. We find that magnetic mirroring and collisional pitch-angle scattering tend to change the electron flux such that electrons are stopped higher in the atmosphere compared with the simple case with collisional energy loss only. However, the resulting X-ray flux is dominated by the density structure in the chromosphere and only marginal increases in source width are found. Very high loop densities (>10^{11} cm^{-3}) could explain the observed sizes at higher energies, but are unrealistic and would result in no footpoint emission below about 40 keV, contrary to observations. We conclude that within a monolithic density model the vertical sizes are given mostly by the density scale-height and are predicted smaller than the RHESSI results show.Comment: 19 pages, 9 figures, accepted for publication in Ap

The spectral evolution of impulsive solar X-ray flares

The time evolution of the spectral index and the non-thermal flux in 24 impulsive solar hard X-ray flares of GOES class M was studied in RHESSI observations. The high spectral resolution allows for a clean separation of thermal and non-thermal components in the 10-30 keV range, where most of the non-thermal photons are emitted. Spectral index and flux can thus be determined with much better accuracy than before. The spectral soft-hard-soft behavior in rise-peak-decay phases is discovered not only in the general flare development, but even more pronounced in subpeaks. An empirically found power-law dependence between the spectral index and the normalization of the non-thermal flux holds during the rise and decay phases of the emission peaks. It is still present in the combined set of all flares. We find an asymmetry in this dependence between rise and decay phases of the non-thermal emission. There is no delay between flux peak and spectral index minimum. The soft-hard-soft behavior appears to be an intrinsic signature of the elementary electron acceleration process.Comment: 10 pages, 7 figures. Accepted for publication by A&

Exploring the connection between coronal and footpoint sources in a thin-thick target solar flare model

Context: Hard X-ray emission of coronal sources in solar flares has been observed and studied since its discovery in Yohkoh observations. Several models have been proposed to explain the physical mechanisms causing this emission and the relations between those sources and simultaneously observed footpoint sources. Aims: We investigate and test one of the models (intermediate thin-thick target model) developed on the basis of Yohkoh observations. The model makes precise predictions on the shape of coronal and footpoint spectra and the relations between them, that can be tested with new instruments such as RHESSI. Methods: RHESSI observations of well observed events are studied in imaging and spectroscopy and compared to the predictions from the intermediate thin-thick target model. Results: The results indicate that such a simple model cannot account for the observed relations between the non-thermal spectra of coronal and footpoint sources. Including non-collisional energy loss of the electrons in the flare loop due to an electric field can solve most of the inconsistencies

Survey on solar X-ray flares and associated coherent radio emissions

The radio emission during 201 X-ray selected solar flares was surveyed from 100 MHz to 4 GHz with the Phoenix-2 spectrometer of ETH Zurich. The selection includes all RHESSI flares larger than C5.0 jointly observed from launch until June 30, 2003. Detailed association rates of radio emission during X-ray flares are reported. In the decimeter wavelength range, type III bursts and the genuinely decimetric emissions (pulsations, continua, and narrowband spikes) were found equally frequently. Both occur predominantly in the peak phase of hard X-ray (HXR) emission, but are less in tune with HXRs than the high-frequency continuum exceeding 4 GHz, attributed to gyrosynchrotron radiation. In 10% of the HXR flares, an intense radiation of the above genuine decimetric types followed in the decay phase or later. Classic meter-wave type III bursts are associated in 33% of all HXR flares, but only in 4% they are the exclusive radio emission. Noise storms were the only radio emission in 5% of the HXR flares, some of them with extended duration. Despite the spatial association (same active region), the noise storm variations are found to be only loosely correlated in time with the X-ray flux. In a surprising 17% of the HXR flares, no coherent radio emission was found in the extremely broad band surveyed. The association but loose correlation between HXR and coherent radio emission is interpreted by multiple reconnection sites connected by common field lines.Comment: Solar Physics, in pres

Fast electron slowing-down and diffusion in a high temperature coronal X-ray source

Finite thermal velocity modifications to electron slowing-down rates may be important for the deduction of solar flare total electron energy. Here we treat both slowing-down and velocity diffusion of electrons in the corona at flare temperatures, for the case of a simple, spatially homogeneous source. Including velocity diffusion yields a consistent treatment of both "accelerated" and "thermal" electrons. It also emphasises that one may not invoke finite thermal velocity target effects on electron lifetimes without simultaneously treating the contribution to the observed X-ray spectrum from thermal electrons. We present model calculations of the X-ray spectra resulting from injection of a power-law energy distribution of electrons into a source with finite temperature. Reducing the power-law distribution low-energy cutoff to lower and lower energies only increases the relative magnitude of the thermal component of the spectrum, because the lowest energy electrons simply join the background thermal distribution. Acceptable fits to RHESSI flare data are obtained using this model. These also demonstrate, however, that observed spectra may in consequence be acceptably consistent with rather a wide range of injected electron parameters

Relations between concurrent hard X-ray sources in solar flares

Context: Solar flares release a large fraction of their energy into non-thermal electrons, but it is not clear where and how. Bremsstrahlung X-rays are observed from the corona and chromosphere. Aims: We aim to characterize the acceleration process by the coronal source and its leakage toward the footpoints in the chromosphere. The relations between the sources reflect the geometry and constrict the configuration of the flare. Methods: We studied solar flares of GOES class larger than M1 with three or more hard X-ray sources observed simultaneously in the course of the flare. The events were observed with the X-ray satellite RHESSI from February 2002 until July 2005. We used imaging spectroscopy methods to determine the spectral evolution of each source in each event. The images of all of the five events show two sources visible only at high energies (footpoints) and one source only visible at low energies (coronal or looptop source, in two cases situated over the limb). Results: We find soft-hard-soft behavior in both, coronal source and footpoints. The coronal source is nearly always softer than the footpoints. The footpoint spectra differ significantly only in one event out of five. Conclusions: The observations are consistent with acceleration in the coronal source and an intricate connection between the corona and chromosphere.Comment: accepted for publication in A&A, 11 pages, 9 figure