Consecutive and integrated dual-task training led to similar and sustained improvements in dual-task gait velocity without increasing fall risk. These novel findings support adoption of dual-task training in clinical practice. © 2017 International Parkinson and Movement Disorder Society.
In contrast to continued BMT, STN-DBS reduced FOG occurrence and severity at 6 months postsurgery with largely sustained effects at 12 months follow-up. Longer follow-up periods are needed to test whether FOG improvements after STN-DBS persist with disease progression.
Dual-task (DT) circumstances aggravate gait disorders in Parkinson's disease (PD) and are associated with an increased risk of falling and reduced functional mobility. Clinical rehabilitation guidelines for PD consider DT interventions as potentially hazardous and recommend avoiding them in daily life. The current article challenges this notion and addresses the necessity of implementing DT training in PD. First, underlying reasons for DT interference in PD and current theoretical models are discussed. Subsequently, different training approaches to tackle DT difficulties are put forward. Finally, the effectiveness and limitations of DT training in PD are reviewed. We conclude that there is a need for DT interventions in PD and recommend randomized, power-based studies to further test their efficacy.
In people with PD, DT measures proved to be reliable for use in clinical studies and look promising for use in clinical practice to assess improvements after DT training. Large effects, however, are needed to obtain meaningful effect sizes.
Freezing of gait (FOG) is part of a complex clinical picture in Parkinson's disease (PD) and is largely refractory to standard care. Diverging hypotheses exist about its origins, but a consolidated view on what determines FOG is lacking. The aim of this study was to develop an integrative model of FOG in people with PD. This cross-sectional study included 51 Parkinson subjects: 24 patients without FOG and 27 with FOG matched for age, gender, and disease severity. Subjects underwent an extensive clinical test battery evaluating general disease characteristics, gait and balance, nongait freezing, and cognitive functions. The relative contribution of these outcomes to FOG was determined using logistic regression analysis. The combination of the following four independent contributors provided the best explanatory model of FOG (R(2) = 0.49): nongait freezing; levodopa equivalent dose (LED); cognitive impairment; and falls and balance problems. The model yields a high-risk profile for FOG (P > 95%) when Parkinson patients are affected by at least one type of nongait freezing (e.g., freezing of other repetitive movements), falls or balance problems during the last 3 months, and a Scales for Outcomes in Parkinson's Disease-Cognition score below 28. A high LED further increases the risk of FOG to 99%. Nongait freezing, increased dopaminergic drug dose, cognitive deficits, and falls and balance problems are independent determinants of FOG in people with PD and may play a synergistic role in its manifestation.
Background and Purpose: Dual-task interventions show positive effects in people with Parkinson disease (PD), but it remains unclear which factors determine the size of these benefits. As a secondary analysis of the DUALITY trial, the aim of this study was to assess the determinants of the effect size after 2 types of dual-task practice. Methods: We randomly allocated 121 participants with PD to receive either integrated or consecutive dual-task training. Dual-task walking performance was assessed during (i) a backward digit span task (digit), (ii) an auditory Stroop task (Stroop), and (iii) a functional mobile phone task. Baseline descriptive, motor, and cognitive variables were correlated with the change in dual-task gait velocity after the intervention. Factors correlated with the change in dual-task gait velocity postintervention (P < 0.20) were entered into a stepwise forward multiple linear regression model. Results: Lower dual-task gait velocity and higher cognitive capacity (Scales for Outcomes in Parkinson's Disease-Cognition [ScopaCog]) at baseline were related to larger improvements in dual-task gait velocity after both integrated and consecutive dual-task training for all 3 tasks (β[gait] = −0.45, β[ScopaCog] = 0.34, R 2 = 0.23, P < 0.001, for digit; β[gait] = −0.52, β[ScopaCog] = 0.29, R 2 = 0.26, P < 0.001, for Stroop; and β[gait] = −0.40, β[ScopaCog] = 0.30, R 2 = 0.18, P < 0.001, for mobile phone task). Discussion and Conclusions: Participants with PD who showed a slow dual-task gait velocity and good cognitive functioning at baseline benefited most from the dual-task training, irrespective of the type of training and type of dual-task outcome. Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A242).
BackgroundMultiple tasking is an integral part of daily mobility. Patients with Parkinson’s disease have dual tasking difficulties due to their combined motor and cognitive deficits. Two contrasting physiotherapy interventions have been proposed to alleviate dual tasking difficulties: either to discourage simultaneous execution of dual tasks (consecutive training); or to practice their concurrent use (integrated training). It is currently unclear which of these training methods should be adopted to achieve safe and consolidated dual task performance in daily life. Therefore, the proposed randomized controlled trial will compare the effects of integrated versus consecutive training of dual tasking (tested by combining walking with cognitive exercises).Methods and designHundred and twenty patients with Parkinson’s disease will be recruited to participate in this multi-centered, single blind, randomized controlled trial. Patients in Hoehn & Yahr stage II-III, with or without freezing of gait, and who report dual task difficulties will be included. All patients will undergo a six-week control period without intervention after which they will be randomized to integrated or consecutive task practice. Training will consist of standardized walking and cognitive exercises delivered at home four times a week during six weeks. Treatment is guided by a physiotherapist twice a week and consists of two sessions of self-practice using an MP3 player. Blinded testers will assess patients before and after the control period, after the intervention period and after a 12-week follow-up period. The primary outcome measure is dual task gait velocity, i.e. walking combined with a novel untrained cognitive task to evaluate the consolidation of learning. Secondary outcomes include several single and dual task gait and cognitive measures, functional outcomes and a quality of life scale. Falling will be recorded as a possible adverse event using a weekly phone call for the entire study period.DiscussionThis randomized study will evaluate the effectiveness and safety of integrated versus consecutive task training in patients with Parkinson’s disease. The study will also highlight whether dual task gait training leads to robust motor learning effects, and whether these can be retained and carried-over to untrained dual tasks and functional mobility.Trial registrationClinicaltrials.gov NCT01375413.
Single-task gait velocity and executive function as measured by a verbal fluency switching task were independent determinants of dual-task gait performance in people with PD. In contrast to expectation, these factors were the same across different tasks, supporting the robustness of the findings. Future study needs to determine whether these factors predict dual-task abnormalities prospectively.
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