The therapeutic potential of exercise to improve mood, cognition, and sleep in Parkinson's disease

Published in final edited form as: Mov Disord. 2016 January ; 31(1): 23–38. doi:10.1002/mds.26484.In addition to the classic motor symptoms, Parkinson's disease (PD) is associated with a variety of nonmotor symptoms that significantly reduce quality of life, even in the early stages of the disease. There is an urgent need to develop evidence‐based treatments for these symptoms, which include mood disturbances, cognitive dysfunction, and sleep disruption. We focus here on exercise interventions, which have been used to improve mood, cognition, and sleep in healthy older adults and clinical populations, but to date have primarily targeted motor symptoms in PD. We synthesize the existing literature on the benefits of aerobic exercise and strength training on mood, sleep, and cognition as demonstrated in healthy older adults and adults with PD, and suggest that these types of exercise offer a feasible and promising adjunct treatment for mood, cognition, and sleep difficulties in PD. Across stages of the disease, exercise interventions represent a treatment strategy with the unique ability to improve a range of nonmotor symptoms while also alleviating the classic motor symptoms of the disease. Future research in PD should include nonmotor outcomes in exercise trials with the goal of developing evidence‐based exercise interventions as a safe, broad‐spectrum treatment approach to improve mood, cognition, and sleep for individuals with PD.This work was supported by the National Institute of Mental Health (F31MH102961 to G.O.R.)

Peer coaching through mHealth targeting physical activity in people with Parkinson disease: feasibility study

BACKGROUND: Long-term engagement in exercise and physical activity mitigates the progression of disability and increases quality of life in people with Parkinson disease (PD). Despite this, the vast majority of individuals with PD are sedentary. There is a critical need for a feasible, safe, acceptable, and effective method to assist those with PD to engage in active lifestyles. Peer coaching through mobile health (mHealth) may be a viable approach. OBJECTIVE: The purpose of this study was to develop a PD-specific peer coach training program and a remote peer-mentored walking program using mHealth technology with the goal of increasing physical activity in persons with PD. We set out to examine the feasibility, safety, and acceptability of the programs along with preliminary evidence of individual-level changes in walking activity, self-efficacy, and disability in the peer mentees. METHODS: A peer coach training program and a remote peer-mentored walking program using mHealth was developed and tested in 10 individuals with PD. We matched physically active persons with PD (peer coaches) with sedentary persons with PD (peer mentees), resulting in 5 dyads. Using both Web-based and in-person delivery methods, we trained the peer coaches in basic knowledge of PD, exercise, active listening, and motivational interviewing. Peer coaches and mentees wore FitBit Zip activity trackers and participated in daily walking over 8 weeks. Peer dyads interacted daily via the FitBit friends mobile app and weekly via telephone calls. Feasibility was determined by examining recruitment, participation, and retention rates. Safety was assessed by monitoring adverse events during the study period. Acceptability was assessed via satisfaction surveys. Individual-level changes in physical activity were examined relative to clinically important differences. RESULTS: Four out of the 5 peer pairs used the FitBit activity tracker and friends function without difficulty. A total of 4 of the 5 pairs completed the 8 weekly phone conversations. There were no adverse events over the course of the study. All peer coaches were "satisfied" or "very satisfied" with the training program, and all participants were "satisfied" or "very satisfied" with the peer-mentored walking program. All participants would recommend this program to others with PD. Increases in average steps per day exceeding the clinically important difference occurred in 4 out of the 5 mentees. CONCLUSIONS: Remote peer coaching using mHealth is feasible, safe, and acceptable for persons with PD. Peer coaching using mHealth technology may be a viable method to increase physical activity in individuals with PD. Larger controlled trials are necessary to examine the effectiveness of this approach.This study is supported by Boston Roybal Center for Active Lifestyle Interventions (RALI Boston), Grant #P30 AG048785, and the American Parkinson Disease Association, Massachusetts chapter. The authors would like to thank Nicole Sullivan, SOT, for her assistance with data management and data collection and Nick Wendel, DPT, for his assistance with data collection. Additionally, the authors would like to thank the participants in this study for their time, effort, and insights. (P30 AG048785 - Boston Roybal Center for Active Lifestyle Interventions (RALI Boston); American Parkinson Disease Association, Massachusetts chapter)Accepted manuscrip

Randomized controlled trial of a home-based action observation intervention to improve walking in Parkinson disease

Published in final edited form as: Arch Phys Med Rehabil. 2016 May ; 97(5): 665–673. doi:10.1016/j.apmr.2015.12.029.OBJECTIVE: To examine the feasibility and efficacy of a home-based gait observation intervention for improving walking in Parkinson disease (PD). DESIGN: Participants were randomly assigned to an intervention or control condition. A baseline walking assessment, a training period at home, and a posttraining assessment were conducted. SETTING: The laboratory and participants' home and community environments. PARTICIPANTS: Nondemented individuals with PD (N=23) experiencing walking difficulty. INTERVENTION: In the gait observation (intervention) condition, participants viewed videos of healthy and parkinsonian gait. In the landscape observation (control) condition, participants viewed videos of moving water. These tasks were completed daily for 8 days. MAIN OUTCOME MEASURES: Spatiotemporal walking variables were assessed using accelerometers in the laboratory (baseline and posttraining assessments) and continuously at home during the training period. Variables included daily activity, walking speed, stride length, stride frequency, leg swing time, and gait asymmetry. Questionnaires including the 39-item Parkinson Disease Questionnaire (PDQ-39) were administered to determine self-reported change in walking, as well as feasibility. RESULTS: At posttraining assessment, only the gait observation group reported significantly improved mobility (PDQ-39). No improvements were seen in accelerometer-derived walking data. Participants found the at-home training tasks and accelerometer feasible to use. CONCLUSIONS: Participants found procedures feasible and reported improved mobility, suggesting that observational training holds promise in the rehabilitation of walking in PD. Observational training alone, however, may not be sufficient to enhance walking in PD. A more challenging and adaptive task, and the use of explicit perceptual learning and practice of actions, may be required to effect change

Dual tasking in Parkinson's disease: cognitive consequences while walking

Published in final edited form as: Neuropsychology. 2017 September; 31(6): 613–623. doi:10.1037/neu0000331.OBJECTIVE: Cognitive deficits are common in Parkinson's disease (PD) and exacerbate the functional limitations imposed by PD's hallmark motor symptoms, including impairments in walking. Though much research has addressed the effect of dual cognitive-locomotor tasks on walking, less is known about their effect on cognition. The purpose of this study was to investigate the relation between gait and executive function, with the hypothesis that dual tasking would exacerbate cognitive vulnerabilities in PD as well as being associated with gait disturbances. METHOD: Nineteen individuals with mild-moderate PD without dementia and 13 age- and education-matched normal control adults (NC) participated. Executive function (set-shifting) and walking were assessed singly and during dual tasking. RESULTS: Dual tasking had a significant effect on cognition (reduced set-shifting) and on walking (speed, stride length) for both PD and NC, and also on stride frequency for PD only. The impact of dual tasking on walking speed and stride frequency was significantly greater for PD than NC. Though the group by condition interaction was not significant, PD had fewer set-shifts than NC on dual task. Further, relative to NC, PD showed significantly greater variability in cognitive performance under dual tasking, whereas variability in motor performance remained unaffected by dual tasking. CONCLUSIONS: Dual tasking had a significantly greater effect in PD than in NC on cognition as well as on walking. The results suggest that assessment and treatment of PD should consider the cognitive as well as the gait components of PD-related deficits under dual-task conditions. (PsycINFO Database Record)

Toward understanding ambulatory activity decline in Parkinson disease

BACKGROUND: Declining ambulatory activity represents an important facet of disablement in Parkinson disease (PD). OBJECTIVE: The primary study aim was to compare the 2-year trajectory of ambulatory activity decline with concurrently evolving facets of disability in a small cohort of people with PD. The secondary aim was to identify baseline variables associated with ambulatory activity at 1- and 2-year follow-up assessments. DESIGN: This was a prospective, longitudinal cohort study. METHODS: Seventeen people with PD (Hoehn and Yahr stages 1-3) were recruited from 2 outpatient settings. Ambulatory activity data were collected at baseline and at 1- and 2-year annual assessments. Motor, mood, balance, gait, upper extremity function, quality of life, self-efficacy, and levodopa equivalent daily dose data and data on activities of daily living also were collected. RESULTS: Participants displayed significant 1- and 2-year declines in the amount and intensity of ambulatory activity concurrently with increasing levodopa equivalent daily dose. Worsening motor symptoms and slowing of gait were apparent only after 2 years. Concurrent changes in the remaining clinical variables were not observed. Baseline ambulatory activity and physical performance variables had the strongest relationships with 1- and 2-year mean daily steps. LIMITATIONS: The sample was small and homogeneous. CONCLUSIONS: Future research that combines ambulatory activity monitoring with a broader and more balanced array of measures would further illuminate the dynamic interactions among evolving facets of disablement and help determine the extent to which sustained patterns of recommended daily physical activity might slow the rate of disablement in PD.This study was funded primarily by the Davis Phinney Foundation and the Parkinson Disease Foundation. Additional funding was provided by Boston University Building Interdisciplinary Research Careers in Women's Health (K12 HD043444), the National Institutes of Health (R01NS077959), the Utah Chapter of the American Parkinson Disease Association (APDA), the Greater St Louis Chapter of the APDA, and the APDA Center for Advanced PD Research at Washington University. (Davis Phinney Foundation; Parkinson Disease Foundation; K12 HD043444 - Boston University Building Interdisciplinary Research Careers in Women's Health; R01NS077959 - National Institutes of Health; Utah Chapter of the American Parkinson Disease Association (APDA); Greater St Louis Chapter of the APDA; APDA Center for Advanced PD Research at Washington University

A Mobile App Specifically Designed to Facilitate Exercise in Parkinson Disease: Single-Cohort Pilot Study on Feasibility, Safety, and Signal of Efficacy

Background: Many people with Parkinson disease do not have access to exercise programs that are specifically tailored to their needs and capabilities. This mobile app allows people with Parkinson disease to access Parkinson disease–specific exercises that are individually tailored using in-app demographic questions and performance tests which are fed into an algorithm which in turn produces a video-guided exercise program. Objective: To test the feasibility, safety, and signal of efficacy of a mobile app that facilitates exercise for people with Parkinson disease. Methods: A prospective, single-cohort design of people with Parkinson disease who had downloaded the 9zest app for exercise was used for this 12-week pilot study. Participants, who were recruited online, were encouraged to exercise with the full automated app for ≥150 minutes each week. The primary endpoints were feasibility (app usage and usability questions) and safety (adverse events and falls). The primary endpoints for signal of efficacy were a comparison of the in-app baseline and 8-week outcomes on the 30-second Sit-To-Stand (STS) test, Timed Up and Go (TUG) test, and the Parkinson’s Disease Questionnaire 8 (PDQ8). Results: For feasibility, of the 28 participants that completed the study, 12 participants averaged... (See full article for abstract)

Balance differences in people with Parkinson disease with and without freezing of gait

Published in final edited form as: Gait Posture. 2015 September ; 42(3): 306–309. doi:10.1016/j.gaitpost.2015.06.007.BACKGROUND: Freezing of gait (FOG) is a relatively common and remarkably disabling impairment associated with Parkinson disease (PD). Laboratory-based measures indicate that individuals with FOG (PD+FOG) have greater balance deficits than those without FOG (PD-FOG). Whether such differences also can be detected using clinical balance tests has not been investigated. We sought to determine if balance and specific aspects of balance, measured using Balance Evaluation Systems Test (BESTest), differs between PD+FOG and PD-FOG. Furthermore, we aimed to determine if time-efficient clinical balance measures (i.e. Mini-BESTest, Berg Balance Scale (BBS)) could detect balance differences between PD+FOG and PD-FOG. METHODS: Balance of 78 individuals with PD, grouped as either PD+FOG (n=32) or PD-FOG (n=46), was measured using the BESTest, Mini-BESTest, and BBS. Between-groups comparisons were conducted for these measures and for the six sections of the BESTest using analysis of covariance. A PD composite score was used as a covariate. RESULTS: Controlling for motor sign severity, PD duration, and age, PD+FOG had worse balance than PD-FOG when measured using the BESTest (p=0.008, F=7.35) and Mini-BESTest (p=0.002, F=10.37), but not the BBS (p=0.27, F=1.26). BESTest section differences were noted between PD+FOG and PD-FOG for reactive postural responses (p<0.001, F=14.42) and stability in gait (p=0.003, F=9.18). CONCLUSIONS: The BESTest and Mini-BESTest, which specifically assessed reactive postural responses and stability in gait, were more likely than the BBS to detect differences in balance between PD+FOG and PD-FOG. Because it is more time efficient to administer, the Mini-BESTest may be the preferred tool for assessing balance deficits associated with FOG.This study was conducted with funding from the Davis Phinney Foundation, Parkinson's Disease Foundation, NIH R01 NS077959, NIH UL1 TR000448, Greater St. Louis American Parkinson Disease Association (APDA), APDA Center for Advanced PD Research at Washington University in St. Louis. The funding sources had no role in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication. (Davis Phinney Foundation; Parkinson's Disease Foundation; R01 NS077959 - NIH; UL1 TR000448 - NIH; Greater St. Louis American Parkinson Disease Association (APDA); APDA Center for Advanced PD Research at Washington University in St. Louis

Fluency boost from walking in Parkinson's disease

OBJECTIVE: Examine the impact of a motor task on verbal fluency in individuals with Parkinson’s disease (PD) Background: Dual-tasking, in which individuals engage simultaneously in motor and cognitive tasks, has long been known to impair motor performance in PD; recent evidence indicates that it also impairs cognition (set-shifting). In healthy adults without PD, motor activity can improve performance on tasks of ideational fluency. Performance on phonemic verbal fluency (VF), an executive-function task widely used in clinical evaluation and in research studies of PD, is correlated with ideational fluency in healthy young adults and in those with focal frontal-lobe lesions. VF may likewise be enhanced by motor activity, perhaps even in PD, in which both motor and executive functions are impaired. METHODS: Non-demented individuals with mild-moderate idiopathic PD (n=18, 10 men, mean age 64 [SD=10]) performed the Timed Up and Go (TUG), a brief motor task that taxes both motor and executive function. The order was single-task TUG; cognitive/motor dual-task VF/TUG; single-task VF. VF was measured in words per second (wps), calculated for single-task VF for the time the participant needed to complete the dual-task condition. Proportionate words per second (pwps) measured dual-task impact as a percentage of single-task VF. We also examined correlations between the dual-task effect and disease severity: Hoehn & Yahr stage and United Parkinson’s Disease Rating Scale (UPDRS) total score. RESULTS: Mean wps was higher for dual-task than single-task VF (t=3.5, p=.003). The size of this dual-task benefit inversely correlated with UPDRS total score (ρ=-.50, p= .03). Mean pwps also showed an advantage for dual-task VF (t=3.7, p=.002) and an inverse correlation with UPDRS total score (ρ=-.47, p=.05). CONCLUSIONS: Individuals with PD may perform better on verbal fluency when it is performed simultaneously with a motor task. A potential explanation is the reported premotor-parietal hyperconnectivity in PD that is associated with fewer motor difficulties during dual-tasking. In mild PD, this presumably compensatory connectivity may facilitate prefrontal-parietal arousal and central executive network processing, leading to improved function or regulation of attention or fluency. In later stages of PD, this compensation may decline or be insufficient to aid fluency when basal ganglia dysfunction worsens.Accepted manuscrip