Postural instability in patients with Parkinson's disease : epidemiology, pathophysiology and management
TL;DR: This paper showed that physical therapy, especially highly challenging balance exercises, can improve postural stability and reduce the risk of falls, although the long-term effects of physical therapy interventions on postural instability need to be explored given the progressive nature of PD.
Abstract: Postural instability is one of the cardinal signs in Parkinson's disease (PD). It can be present even at diagnosis, but becomes more prevalent and worsens with disease progression. It represents one of the most disabling symptoms in the advanced stages of the disease, as it is associated with increased falls and loss of independence. Clinical and posturographic studies have contributed to significant advances in unravelling the complex pathophysiology of postural instability in patients with PD, but it still remains yet to be fully clarified, partly due to the difficulty in distinguishing between the disease process and the compensatory mechanisms, but also due to the fact that non-standardized techniques are used to measure balance and postural instability. There is increasing evidence that physical therapy, especially highly challenging balance exercises, can improve postural stability and reduce the risk of falls, although the long-term effects of physical therapy interventions on postural stability need to be explored given the progressive nature of PD. Pharmacotherapy with dopaminergic medications can provide significant improvements in postural instability in early- to mid-stage PD but the effects tend to wane with time consistent with spread of the disease process to non-dopaminergic pathways in advanced PD. Donepezil has been associated with a reduced risk of falls and methylphenidate has shown potential benefit against freezing of gait, but the results are yet to be replicated in large randomized studies. Surgical treatments, including lesioning and deep brain stimulation surgery targeting the subthalamic nucleus and the globus pallidus internus, tend to only provide modest benefit for postural instability. New surgical targets such as the pedunculopontine nucleus have emerged as a potential specific therapy for postural instability and gait disorder but remain experimental.
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TL;DR: Preclinical research may provide powerful tools to quest the potential therapeutic and neuroprotective compounds for dopaminergic neurons and hence possible cure for the Parkinson's disease.
267 citations
TL;DR: Parkinson disease is the second most common neurodegenerative disorder after Alzheimer disease and occurs in 1%–2% of people over the age of 60 years, rising to 3.5% at age 85–89 years.
Abstract: Parkinson disease is the second most common neurodegenerative disorder after Alzheimer disease.[1][1] Parkinson disease typically develops between the ages of 55 and 65 years and occurs in 1%–2% of people over the age of 60 years, rising to 3.5% at age 85–89 years.[2][2]–[4][3] About 0.3% of
255 citations
TL;DR: The multiple regression normalization approach will assist in diagnosis and treatment of Parkinson's disease using spatial-temporal gait data.
Abstract: Quantitative gait assessment is important in diagnosis and management of Parkinson's disease (PD); however, gait characteristics of a cohort are dispersed by patient physical properties including age, height, body mass, and gender, as well as walking speed, which may limit capacity to discern some pathological features. The aim of this study was twofold. First, to use a multiple regression normalization strategy that accounts for subject age, height, body mass, gender, and self-selected walking speed to identify differences in spatial-temporal gait features between PD patients and controls; and second, to evaluate the effectiveness of machine learning strategies in classifying PD gait after gait normalization. Spatial-temporal gait data during self-selected walking were obtained from 23 PD patients and 26 aged-matched controls. Data were normalized using standard dimensionless equations and multiple regression normalization. Machine learning strategies were then employed to classify PD gait using the raw gait data, data normalized using dimensionless equations, and data normalized using the multiple regression approach. After normalizing data using the dimensionless equations, only stride length, step length, and double support time were significantly different between PD patients and controls ( p < 0.05); however, normalizing data using the multiple regression method revealed significant differences in stride length, cadence, stance time, and double support time. Random Forest resulted in a PD classification accuracy of 92.6% after normalizing gait data using the multiple regression approach, compared to 80.4% (support vector machine) and 86.2% (kernel Fisher discriminant) using raw data and data normalized using dimensionless equations, respectively. Our multiple regression normalization approach will assist in diagnosis and treatment of PD using spatial-temporal gait data.
175 citations
Cites background from "Postural instability in patients wi..."
...PARKINSON’s disease (PD) is a neurodegenerative disorder of the central nervous system that affects control of body movement including posture and balance [1]....
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TL;DR: The HiBalance program significantly benefited balance and gait abilities when compared with usual care and showed promising transfer effects to everyday living.
Abstract: Background. Highly challenging exercises have been suggested to induce neuroplasticity in individuals with Parkinson’s disease (PD); however, its effect on clinical outcomes remains largely unknown. Objective. To evaluate the short-term effects of the HiBalance program, a highly challenging balance-training regimen that incorporates both dual-tasking and PD-specific balance components, compared with usual care in elderly with mild to moderate PD. Methods. Participants with PD (n = 100) were randomized, either to the 10-week HiBalance program (n = 51) or to the control group (n = 49). Participants were evaluated before and after the intervention. The main outcomes were balance performance (Mini-BESTest), gait velocity (during normal and dual-task gait), and concerns about falling (Falls Efficacy Scale–International). Performance of a cognitive task while walking, physical activity level (average steps per day), and activities of daily living were secondary outcomes. Results. A total of 91 participants completed the study. After the intervention, the between group comparison showed significantly improved balance and gait performance in the training group. Moreover, although no significant between group difference was observed regarding gait performance during dual-tasking; the participants in the training group improved their performance of the cognitive task while walking, as compared with the control group. Regarding physical activity levels and activities of daily living, in comparison to the control group, favorable results were found for the training group. No group differences were found for concerns about falling. Conclusions. The HiBalance program significantly benefited balance and gait abilities when compared with usual care and showed promising transfer effects to everyday living. Long-term follow-up assessments will further explore these effects.
171 citations
Cites background from "Postural instability in patients wi..."
...For physical activity levels, a significant interaction effect was found for the average number of steps per day, F(1, 67) = 4....
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...We found highly significant interaction effects for the MiniBESTest, F(1, 89) = 15....
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...009, and step length during normal walking, F(1, 88) = 7....
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...Regarding activities of daily living, a significant interaction effect was found, F(1, 89) = 10....
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Journal Article•
140 citations
References
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TL;DR: A simplified, scored form of the cognitive mental status examination, the “Mini-Mental State” (MMS) which includes eleven questions, requires only 5-10 min to administer, and is therefore practical to use serially and routinely.
76,181 citations
"Postural instability in patients wi..." refers methods in this paper
...Frontal cognitive impairment as assessed using the Frontal Assessment Battery [47] was also identified as an independent risk factor for falls [25], more so than low scores on the Mini-Mental State Examination (MMSE) [48]....
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01 Jan 2002
TL;DR: The Mini-Mental State (MMS) as mentioned in this paper is a simplified version of the standard WAIS with eleven questions and requires only 5-10 min to administer, and is therefore practical to use serially and routinely.
Abstract: EXAMINATION of the mental state is essential in evaluating psychiatric patients.1 Many investigators have added quantitative assessment of cognitive performance to the standard examination, and have documented reliability and validity of the several “clinical tests of the sensorium”.2*3 The available batteries are lengthy. For example, WITHERS and HINTON’S test includes 33 questions and requires about 30 min to administer and score. The standard WAIS requires even more time. However, elderly patients, particularly those with delirium or dementia syndromes, cooperate well only for short periods.4 Therefore, we devised a simplified, scored form of the cognitive mental status examination, the “Mini-Mental State” (MMS) which includes eleven questions, requires only 5-10 min to administer, and is therefore practical to use serially and routinely. It is “mini” because it concentrates only on the cognitive aspects of mental functions, and excludes questions concerning mood, abnormal mental experiences and the form of thinking. But within the cognitive realm it is thorough. We have documented the validity and reliability of the MMS when given to 206 patients with dementia syndromes, affective disorder, affective disorder with cognitive impairment “pseudodementia”5T6), mania, schizophrenia, personality disorders, and in 63 normal subjects.
70,887 citations
TL;DR: A thorough understanding of the broad spectrum of clinical manifestations of PD is essential to the proper diagnosis of the disease and genetic mutations or variants, neuroimaging abnormalities and other tests are potential biomarkers that may improve diagnosis and allow the identification of persons at risk.
Abstract: Objective: Parkinson’s disease (PD) is a progressive neurological disorder characterised by a large number of motor and non-motor features that can impact on function to a variable degree. This review describes the clinical characteristics of PD with emphasis on those features that differentiate the disease from other parkinsonian disorders. Methods: A MedLine search was performed to identify studies that assess the clinical characteristics of PD. Search terms included “Parkinson’s disease”, “diagnosis” and “signs and symptoms”. Results: Because there is no definitive test for the diagnosis of PD, the disease must be diagnosed based on clinical criteria. Rest tremor, bradykinesia, rigidity and loss of postural reflexes are generally considered the cardinal signs of PD. The presence and specific presentation of these features are used to differentiate PD from related parkinsonian disorders. Other clinical features include secondary motor symptoms (eg, hypomimia, dysarthria, dysphagia, sialorrhoea, micrographia, shuffling gait, festination, freezing, dystonia, glabellar reflexes), non-motor symptoms (eg, autonomic dysfunction, cognitive/neurobehavioral abnormalities, sleep disorders and sensory abnormalities such as anosmia, paresthesias and pain). Absence of rest tremor, early occurrence of gait difficulty, postural instability, dementia, hallucinations, and the presence of dysautonomia, ophthalmoparesis, ataxia and other atypical features, coupled with poor or no response to levodopa, suggest diagnoses other than PD. Conclusions: A thorough understanding of the broad spectrum of clinical manifestations of PD is essential to the proper diagnosis of the disease. Genetic mutations or variants, neuroimaging abnormalities and other tests are potential biomarkers that may improve diagnosis and allow the identification of persons at risk.
4,349 citations
"Postural instability in patients wi..." refers background in this paper
...dinal features of Parkinson’s disease (PD) together with rest tremor, rigidity and bradykinesia [4]....
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TL;DR: The Frontal Assessment Battery is easy to administer at bedside and is sensitive to frontal lobe dysfunction.
Abstract: Objective: To devise a short bedside cognitive and behavioral battery to assess frontal lobe functions. Methods: The designed battery consists of six subtests exploring the following: conceptualization, mental flexibility, motor programming, sensitivity to interference, inhibitory control, and environmental autonomy. It takes approximately 10 minutes to administer. The authors studied 42 normal subjects and 121 patients with various degrees of frontal lobe dysfunction (PD, n = 24; multiple system atrophy, n = 6; corticobasal degeneration, n = 21; progressive supranuclear palsy, n = 47; frontotemporal dementia, n = 23). Results: The Frontal Assessment Battery scores correlated with the Mattis Dementia Rating Scale scores (rho = 0.82, p p p p Conclusion: The Frontal Assessment Battery is easy to administer at bedside and is sensitive to frontal lobe dysfunction.
3,203 citations