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Background: Tablet formulations of Parkinson’s disease (PD) medications may become ineffective at managing motor fluctuations in advanced PD. The liquid formulation, levodopa carbidopa ascorbic acid solution, or LCAS, is an effective and inexpensive treatment for motor fluctuations however it remains underutilized. Objective: We compared the efficacy of LCAS with tablet formulations and Duodopa jejunal infusion through routine inpatient management using hourly functional status measures, the Timed Up and Go Test (TUG). The TUG differentiates between ‘off’ and ‘on’ states and quantifies motor fluctuations. Methods: Experienced nurses used the TUG times and functional observations recorded hourly throughout the waking day to optimize the LCAS hourly dose and the Duodopa flow rate over several days. When patients were stabilized on each of the interventions, the TUG measures were then recorded to compare the outcomes of the interventions. Results: Twenty-six participants had TUG times recorded while on one or more of the formulations: 19 had TUG times recorded on tablets, 23 on LCAS and 10 on Duodopa. TUG times on LCAS and Duodopa were significantly faster compared to tablets (p < 0.0001, p = 0.001 respectively). Severity of dyskinesia was not significantly different between formulations (p = 0.35). Daily dose for the three formulations and the hourly doses for LCAS and Duodopa did not differ significantly (p = 0.37, p = 0.19 respectively). Conclusion: This report demonstrated the efficacy of LCAS for improving motor complications and its equivalency with Duodopa jejunal infusion.

To explore the physical activity of people with Parkinson's disease (PD) with subthalamic nucleus deep brain stimulation (STN-DBS) and investigate factors associated with physical activity.Twenty-four participants who had STN-DBS for one or more years were recruited. Eligibility criteria included Hoehn and Yahr stage ≤ 4, continuation of STN-DBS, living at home and able to provide informed consent. Physical activity was measured using the self-report physical activity scale for the elderly (PASE). Motor and non-factors that influence physical activity in PD, such as gait disturbance and mood, were recorded using clinical measures.Participants had long-standing PD of moderate severity, mean Hoehn and Yahr 2.3, and mild to moderate functional disability, MDS-UPDRS M-EDL mean 16.2. PASE scores were significantly lower compared to norms for adults ≤ 70 years (115.2This study provides further evidence that physical activity levels in PD with STN-DBS remain low compared to PASE norms for older adults. Future research investigating interventions to improve factors associated with low physical activity levels should be considered.Implications for RehabilitationDespite the benefits of deep brain stimulation (DBS) on motor function and activities of daily living, physical activity levels remain low in people with Parkinson's disease (PD) with subthalamic nucleus (STN)-DBS compared to norms for older adults.A history of falls, greater fear of falling (FOF) and higher levels of fatigue are associated with lower levels of physical activity in people with PD with STN-DBS.When planning rehabilitation interventions consideration should be given to strategies that promote and support regular physical activity for people with PD with STN-DBS.Rehabilitation clinicians should consider using falls prevention programmes and include strategies to decrease FOF for people with PD with STN-DBS.Consideration should be given to the presence of fatigue when planning the rehabilitation programme for the person with PD with STN-DBS.

Purpose To investigate the feasibility and acceptability of the Health and Fitness Program (HFP), a long-term community gym program for people with mild to moderate Parkinson's disease (PD). Methods Physiotherapists, with PD expertise, developed individualised exercise programs for new HFP members in consultation with them. Gym instructors, with PD training, supervised the HFP sessions. Exercises included progressive strength training, aerobic, balance, and stretching. Participants who had been enrolled in the HFP for 12 months, were recruited to a single group pre/post design study to test the program's feasibility and acceptability. Feasibility included safety, retention, attendance, and compliance data and acceptability measured using a customised questionnaire. Results 17 of the 20 HFP members enrolled maintained membership for 12 months and participated in this study. The program was shown to be feasible with no falls reported during sessions, only one participant reported pain from exercising lasting more than 48 h, retention was high (85%) and most members complied with their program. Overall satisfaction with the program was high, with seven somewhat satisfied and 10 very satisfied. Conclusion The HFP demonstrated that a PD community gym program is feasible and acceptable when physiotherapists and PD-trained instructors collaborate to provide individualized exercise programs.IMPLICATIONS FOR REHABILITATIONPeople with Parkinson's disease need support to maintain long-term adherence to regular exercise which can be achieved with supervised community-based gym programs.A community-based PD-specific exercise program can be safe and acceptable to people with PD when PD specialist physiotherapists are involved in planning participants' exercise programs and PD-trained gym instructors supervise the exercise sessions.Members are satisfied with programs that have strategies in place to minimise barriers to participation, such as keeping costs to members low, providing a quality service, having supportive trained staff, and creating opportunities for social interaction between members.Evidence-based community exercise programs may result in improved strength and aerobic fitness and maintain quality of life in people with mild to moderate PD however further research using an RCT study is needed.

To identify gait and balance measures that are responsive to change during the timeline of a clinical trial in Friedreich ataxia (FRDA), we administered a battery of potential measures three times over a 12-month period. Sixty-one ambulant individuals with FRDA underwent assessment of gait and balance at baseline, 6 months and 12 months. Outcomes included GAITRite® spatiotemporal gait parameters; Biodex Balance System Postural Stability Test (PST) and Limits of Stability; Berg Balance Scale (BBS); Timed 25-Foot Walk Test; Dynamic Gait Index (DGI); SenseWear MF Armband step and energy activity; and the Friedreich Ataxia Rating Scale Upright Stability Subscale (FARS USS). The standardised response mean (SRM) or correlation coefficients were reported as effect size indices for comparison of internal responsiveness. Internal responsiveness was also analysed in subgroups. SenseWear Armband daily step count had the largest effect size of all the variables over 6 months (SRM = -0.615), while the PST medial-lateral index had the largest effect size (SRM = 0.829) over 12 months. The FARS USS (SRM = 0.824) and BBS (SRM = -0.720) were the only outcomes able to detect change over 12 months in all subgroups. The DGI was the most responsive outcome in children, detecting a mean change of -2.59 (95% CI -3.52 to -1.66, p < 0.001, SRM = -1.429). In conclusion, the FARS USS and BBS are highly responsive and can detect change in a wide range of ambulant individuals with FRDA. However, therapeutic effects in children may be best measured by the DGI.

ObjectiveTo identify gait and balance measures that are responsive to change during the timeline of a clinical trial in Friedreich ataxia (FRDA) we administered a battery of potential measures three times over a 12-month period.MethodsSixty-one ambulant individuals with FRDA underwent assessment of gait and balance at baseline, six months and 12 months. Outcomes included: GAITRite® spatiotemporal gait parameters; Biodex Balance System Postural Stability Test (PST) and Limits of Stability; Berg Balance Scale (BBS); Timed 25 Foot Walk Test; Dynamic Gait Index (DGI); SenseWear MF Armband step and energy activity; and the Friedreich Ataxia Rating Scale Upright Stability Subscale (FARS USS). The standardised response mean (SRM) or correlation coefficients were reported as effect size indices for comparison of internal responsiveness. Internal responsiveness was also analysed in subgroups.ResultsSenseWear Armband daily step count had the largest effect size of all the variables over six months (SRM=-0.615), while the PST medial-lateral index had the largest effect size (SRM=0.829) over 12 months. The FARS USS (SRM=0.824) and BBS (SRM=-0.720) were the only outcomes able to detect change over 12 months in all subgroups. The DGI was the most responsive outcome in children, detecting a mean change of −2.59 (95% CI −3.52 to −1.66, pConclusionsThe FARS USS and BBS are highly responsive and can detect change in a wide range of ambulant individuals with FRDA. However, therapeutic effects in children may be best measured by the DGI.

Introduction. There is a higher prevalence of Parkinson’s disease (PD) in rural Australia and a poorer perceived quality of life of rural Australians with PD. Coordinated multidisciplinary teams specialised and experienced in the treatment of PD are recommended as the preferred model of care best able to manage the complexities of this disorder. There remains a lack of team-based specialised PD services in rural Australia available to people living with PD. This study aims to explore how the lack of specialised PD services impacts on the person’s experiences of the health care they receive in rural Victoria. This study compared the health-care experiences of two different cohorts of people with PD living in rural Victoria; one cohort living in East Gippsland have had an established comprehensive care model implemented with local trained teams and supported by a metropolitan PD centre, and the other cohort was recruited from the remainder of Victoria who had received standard rural care. Methods. This descriptive study used a survey to explore health-care experiences. Questionnaires were mailed to participants living in rural Victoria. Eligibility criteria included having a diagnosis of PD or Parkinsonism and sufficient English to respond to the survey. The validated Patient-Centred Questionnaire for PD was used to measure health-care experiences. The questions are grouped accordingly under one of the 6 subscales or domains. Outcomes from the questionnaire included summary experience scores (SES) for 6 subscales; overall patient-centeredness score (OPS); and quality improvement scores (QIS). Secondary outcomes included health-related quality of life using the disease-specific questionnaire PDQ39; disease severity using the Hoehn and Yahr staging tool; and disability using the Movement Disorders Society-Unified Parkinson’s Disease Rating Scale, part II. Results. Thirty-nine surveys were returned from the East Gippsland group and 68 from the rural group. The East Gippsland group rated significantly more positive the subscales “empathy and PD expertise,” P=0.02, and “continuity and collaboration of professionals,” P=0.01. The groups did not differ significantly for the remaining 4 subscales (P>0.05) nor for the OPS (P=0.17). The QIS showed both groups prioritised the health-care aspect “provision of tailored information” for improvement. Quality of life was greater (P<0.05) and impairment (P=0.012) and disability were less (P=0.002) in the East Gippsland group. Conclusion. Participants who received health care from the East Gippsland program had better key health-care experiences along with better QOL and less impairment and disability. Participants prioritised provision of information as needing further improvement.

Questions: Among older people receiving inpatient rehabilitation, does additional supervised physical activity lead to faster self-selected gait speed at discharge? Does additional supervised physical activity lead to better mobility, function and quality of life at discharge and 6 months following discharge? Design: Multi-centre, parallel-group, randomised controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis. Participants: Older people (age > 60 years) from two Australian hospitals undergoing rehabilitation to improve mobility. Intervention: Participants received multidisciplinary care, including physiotherapy. During hospital rehabilitation, the experimental group (n = 99) spent additional time daily performing physical activities that emphasised upright mobility tasks; the control group (n = 99) spent equal time participating in social activities. Outcome measures: Self-selected gait speed was the primary outcome at discharge and a secondary outcome at the 6-month follow-up. Timed Up and Go, De Morton Mobility Index, Functional Independence Measure and quality of life were secondary outcomes at discharge and tertiary outcomes at the 6-month follow-up. Results: The experimental group received a median of 20 additional minutes per day (IQR 15.0 to 22.5) of upright activities for a median of 16.5 days (IQR 10.0 to 25.0). Gait speed did not differ between groups at discharge. Mean gait speed was 0.51 m/s (SD 0.29) in the experimental group and 0.56 m/s (SD 0.28) in the control group (effect size −0.06 m/s, 95% CI −0.12 to 0.01, p = 0.096). No significant differences were detected in other secondary measures. Conclusion: While substantial gains in mobility were achieved by older people receiving inpatient rehabilitation, additional physical activity sessions did not lead to better walking outcomes at discharge or 6 months. Trial registration: ACTRN12613000884707. [Said CM, Morris ME, McGinley JL, Szoeke C, Workman B, Liew D, Hill KD, Woodward M, Wittwer JE, Churilov L, Danoudis M, Bernhardt J (2018) Additional structured physical activity does not improve walking in older people (> 60 years) undergoing inpatient rehabilitation: a randomised trial. Journal of Physiotherapy 64: 237–244] Key words: Mobility limitation, Rehabilitation, Exercise therapy, Hospitalisation, Randomised controlled trial

The underlying mechanisms responsible for the gait changes in frontal gait disorder (FGD), a form of higher level gait disorders, are poorly understood. We investigated the relationship between stride length and cadence (SLCrel) in people with FGD (n=15) in comparison to healthy older adults (n=21) to improve our understanding of the changes to gait in FGD. Gait data was captured using an electronic walkway system as participants walked at five self-selected speed conditions: preferred, very slow, slow, fast and very fast. Linear regression was used to determine the strength of the relationship (R(2)), slope and intercept. In the FGD group 9 participants had a strong SLCrel (linear group) (R(2)0.8) and 6 a weak relationship (R(2)0.8) (nonlinear group). The linear FGD group did not differ to healthy control for slope (p0.05) but did have a lower intercept (p0.001). The linear FGD group modulated gait speed by adjusting stride length and cadence similar to controls whereas the nonlinear FGD participants adjusted stride length but not cadence similar to controls. The non-linear FGD group had greater disturbance to their gait, poorer postural control and greater fear of falling compared to the linear FGD group. Investigation of the SLCrel resulted in new insights into the underlying mechanisms responsible for the gait changes found in FGD. The findings suggest stride length regulation was disrupted in milder FGD but as the disorder worsened, cadence control also became disordered resulting in a break down in the relationship between stride length and cadence.

Background. Falls are common and disabling in people with Parkinson’s disease (PD). There is a need to quantify the effects of movement rehabilitation on falls in PD. Objective. To evaluate 2 physical therapy interventions in reducing falls in PD. Methods. We randomized 210 people with PD to 3 groups: progressive resistance strength training coupled with falls prevention education, movement strategy training combined with falls prevention education, and life-skills information (control). All received 8 weeks of out-patient therapy once per week and a structured home program. The primary end point was the falls rate, recorded prospectively over a 12 month period, starting from the completion of the intervention. Secondary outcomes were walking speed, disability, and quality of life. Results. A total of 1547 falls were reported for the trial. The falls rate was higher in the control group compared with the groups that received strength training or strategy training. There were 193 falls for the progressive resistance strength training group, 441 for the movement strategy group and 913 for the control group. The strength training group had 84.9% fewer falls than controls (incidence rate ratio [IRR] = 0.151, 95% CI 0.071-0.322, P < .001). The movement strategy training group had 61.5% fewer falls than controls (IRR = 0.385, 95% CI 0.184-0.808, P = .012). Disability scores improved in the intervention groups following therapy while deteriorating in the control group. Conclusions. Rehabilitation combining falls prevention education with strength training or movement strategy training reduces the rate of falls in people with mild to moderately severe PD and is feasible.

Questions For people with idiopathic Parkinson's disease, does a 6-week, comprehensive, home exercise program reduce falls and disability and improve health-related quality of life? Is the program cost-effective? Design Randomised, controlled trial with concealed allocation and assessor blinding. Participants One hundred and thirty-three community-dwelling adults with Parkinson's disease. Intervention The experimental group completed a 6-week home program comprising progressive resistance strength training, movement strategy training and falls education. The control group completed 6 weeks of non-specific life skills training. Participants in both groups received weekly therapist-guided sessions for 6 consecutive weeks and a weekly self-directed home program. Outcome measures The primary outcome was the rate of falls, documented for the 12-month period immediately after therapy. Secondary outcomes were disability and health-related quality of life, assessed before and after intervention and at a 12-month follow-up. Results A total of 2255 falls were reported by the 12-month follow-up. The proportion of fallers in the experimental and control groups was 61 and 72%, respectively, which was not statistically significantly different (RR=0.85, 95% CI 0.66 to 1.09). There was no significant between-group difference in the rate of falls (incidence rate ratio=1.58, 95% CI 0.73 to 3.43). A survival analysis of participant time to first fall did not show a significant between-group difference (log-rank test χ 2 =0.79, p =0.37). No significant between-group differences occurred for mobility, disability or quality of life. The mean cost of delivering the experimental intervention was AUD1596. Conclusion A home program of strength and movement strategy training and falls education does not prevent falls when applied at the dose used in this study. Arguably, the dosage of therapy was insufficient. Future trials need to explore further therapy content, repetitions and duration, in order to optimise outcomes and cost-effectiveness. [Morris ME, Taylor NF, Watts JJ, Evans A, Horne M, Kempster P, Danoudis M, McGinley J, Martin C, Menz HB (2017) A home program of strength training, movement strategy training and education did not prevent falls in people with Parkinson's disease: a randomised trial. Journal of Physiotherapy 63: 94–100]

Background Freezing of gait (FOG) in Parkinson's disease (PD) is poorly understood, yet with the established understanding of basal ganglia function, its manifestations should be more easily interpretable. This review examines freezing of gait (FOG) from such a perspective. Methods A MEDLINE and EMBASE search from year 2000 onwards for review articles was used, focused on pathophysiology of FOG, to determine current concepts. A previously established model of basal ganglia function was used to determine the concepts’ validities. At the core of the model are deficits in motor set maintenance and timing cue production for automatic movement. It includes the shift between attention and automation to the predominant attention control of gait in PD. Findings The difficulties of the found concepts to explain FOG stem from failure to characterize different FOG components; from the assumption that all components share a similar pathophysiology; from a failure to separate basic deficits from compensatory mechanisms and from the assumption that cognitive deficits are the cause of FOG rather than representing an inadequate compensation to FOG. Pragmatic approaches to management utilize the attention shift with the provision of visual information about correct amplitude of step to correct initiation deficits, and motor blocks during gait. It also emphasizes the need to prevent step length reduction on turns, environmental situations and cognitive overload. Conclusions The concept of automatic deficits in set maintenance and cue production best describe FOG manifestations in PD and with the use of attention the concept also provides pragmatic strategies for management. This article is protected by copyright. All rights reserved.

Introduction Freezing of gait in Parkinson's disease (PD) was found to occur in the presence of the sequence effect (a decrease in length of consecutive footsteps) and a shortened step length. Gait asymmetry and reduced coordination of gait have also been implicated in freezing of gait. The aim of this study was to determine the effect of controlling for step length on asymmetry and coordination of gait. A second aim was to determine if asymmetry and bilateral coordination predicted freezing. Methods Data for sixteen participants with PD and freezing of gait, ten people with PD but no history of freezing and ten controls was analyzed. Participants, in their ‘off’ state, had their gait recorded walking at preferred and normalized step lengths of 100%, 75%, 50% and 25%. Results Asymmetry of swing time increased in all groups as step length decreased from 100% to 25% and did not differ between the PD group with freezing compared to the PD group without freezing in the preferred and normalized step length conditions after adjusting for step length and disease severity. Coordination of walking worsened in all groups at the shorter normalized step lengths with no difference between PD groups in the 25% condition where the frequency of freezing was highest. Asymmetry and coordination of gait were not predictive of freezing in the 25% condition. Conclusions These results suggest asymmetry and decreased coordination of gait are affected by step length and may not be factors in determining freezing of gait in PD.

Gait disorders are common in people with Parkinson's disease (PD) yet their associations with activity limitations remain poorly understood. The objective of this review is to investigate the relationships between gait impairments and activity limitations in people with idiopathic PD. Six electronic databases (MEDLINE ISI, CINAHL, Web of Science ISI, EMBASE, PsycINFO and Scopus) were systematically searched using relevant terms to source for English-language studies published between 1900 and January 2011. Only studies that reported associations between impairments and activity limitations were considered for the review. The methodological quality of eligible studies was evaluated using a customized checklist by two independent reviewers. Data on participant characteristics, disease severity and associations between variables were extracted using a standardized data extraction form. Correlation coefficients were transformed to standardized scores and pooled using the fixed or random effects models. 16 of the 1735 studies screened were included, comprising 1882 participants. Large effect sizes were found between postural instability measured by the Berg Balance scale and activity limitation measured by the Unified Parkinson's Disease Rating Scale Activities of Daily Living (UPDRS ADL) section (-0.81; 95% CI, -0.99 to -0.63; p 0.001). Gait hypokinesia measured by gait speed was significantly correlated with UPDRS ADL (-0.41; 95% CI, -0.56 to -0.26; p 0.001). Gait freezing measured by the Freezing of Gait Questionnaire was associated with reduction in ADL (0.45; 95% CI, 0.36 to 0.54; p 0.001). Knowledge of gait disturbances and their associations with disability may help to guide clinicians in assessing patients to optimize functional outcomes.

Freezing of gait (FOG) has been identified as one of the main contributors to gait disturbances in Parkinson's disease. While the pathophysiology remains enigmatic, several factors such as step length and the sequence effect (step to step reduction in amplitude) may lead to the occurrence of FOG. It was hypothesized that by reducing step length, FOG episodes would present more frequently if a significant sequence effect (measured as a regression slope) was co-existent in the subject. Twenty-six participants with Parkinson's disease were separated clinically into a freezing (PD + FOG, n = 16) and non-freezing (PD-FOG, n = 10) group, with 10 age-matched control participants. Testing involved walking trials where preferred step length was set at 100%, 75%, 50% and 25% of normalized step length. The number of FOG episodes increased in the 50% condition and further increased in the 25% condition compared to other conditions. The participants with FOG also demonstrated a larger average regression slope, with significant differences in the 75%, 50% and 25% conditions when compared to the PD-FOG and control groups. There were no significant differences when comparing the slope of the PD-FOG and control group, indicating the reduced step length and the sequence effect may have led to the occurrence of FOG. These findings support the possible dual requirement of a reduced step length and a successive step to step amplitude reduction to lead to FOG.

Background The progressive deterioration of gait in Huntington’s disease (HD) leads to functional decline and loss of function. To understand the underlying mechanisms responsible for the gait changes in HD, we examined the automatic control of gait by measuring the relationship between stride length and cadence. The relationship is strongly linked in healthy adults during automatic gait but disrupted in pathological gait disorders, such as Parkinson’s disease (PD). Methods The stride length cadence relationship was compared between seventeen participants with HD, twenty with PD and twenty one healthy older adults (HOA). Participants had their gait recorded at self-selected preferred, very slow, slow, fast and very fast speeds. Linear regression analysis was used to determine the slope and intercept of the relationship which were compared between groups. The adjustment of stride length and cadence when changing gait speeds was measured and compared within and between groups. Results Linearity was strong in all but two participants with HD and one with PD. Slope did not differ between groups (p > 0.05) but intercept was lower in the HD and PD groups compared to HOA (p 0.05) regardless of speed. The HD group adjusted stride length and cadence similar to HOA when changing speed. The range of cadence across speed conditions did not differ between groups. Conclusion Scaling of stride length but not the regulation of cadence was found to be disrupted in participants with HD.

Individuals with movement disorders often present with progressive or fluctuating symptoms that vary over time. Clinical teams who work with these individuals aim to minimize the impact of associated impairments and to optimize everyday activity, participation, and quality of life. Due to the varied and complex needs of people with a movement disorder, specialist clinical teams are often established to provide patient-centered care tailored to the individual. These clinicians are often in contact with the person over a long period of time and are well positioned to monitor change in order to address the changing needs of the individual across the lifespan and disease course. Assessment typically includes the use of standardized instruments to measure a person’s symptoms or signs, and ability to perform activities such as mobility, personal care, and social participation. The measurement instruments used to measure change in a person’s ability over time, or in response to interventions, are commonly referred to as outcome measures [1]. Outcome measurements have an essential role to play in the provision of optimal care to people with a movement disorder. This chapter aims to provide an overview of some of the factors that clinicians can consider prior to selecting outcome measures for people with movement disorders. Appropriate outcome assessment in clinical practice is a core component of both multidisciplinary and discipline-specific evidence-based practice, with the use of standardized outcome measures widely recommended by many professional associations. The rapid expansion in the number of available tools has provided clinicians with greater opportunities but also larger challenges in selecting the most suitable outcome tools that match their aims and client group. Careful and thoughtful consideration is important in the selection of outcome measurements as they can be both time-consuming and resource-intensive.

An increasing awareness of the interaction between gait and cognition has occurred over recent time. This interaction is even more prominent in Parkinson ' s disease (PD), where the alteration of striatal dopamine deficiency places a greater emphasis on cognition to com- pensate for the gait disturbances seen in PD. This disser- tation aims to provide an insight into this interaction in PD and demonstrate how normal gait control mechanisms are altered in PD to more cognitive control. Evidence will be provided which demonstrates a shift between attention and automatic gait control mechanisms toward attention. In addition, it will be demonstrated that, because of the cognitive dysfunction that also occurs in PD, the capa- city to normalize gait still remains impaired and becomes more subject to the effects of external environmental influences. Further, a rationale will be provided to utilize this interaction in a more beneficial manner, to assist the attention control mechanisms to return gait towards nor- mal. This latter approach is applicable to all aspects of gait disorders in PD and forms a basis for possible inter- vention therapies. gait, in a constantly changing environment. In Parkin- son ' s disease (PD), this interaction with the environment is exaggerated, due to malfunction of the basal ganglia, resulting in cognitive processes playing a much larger role in gait regulation than normal. This review will present a theoretical basis for the impact of cognition on gait in PD, based on an understanding of normal gait control mecha- nisms and how malfunction in PD shifts control of gait to cognitive processes. This increased dependency on cogni- tion to improve gait in PD, makes gait more vulnerable to external influences. The impact of worsening cognition, brought about by the disease process itself, erodes com- pensatory effects. Our focus will therefore be on normal gait control mechanisms, their malfunction in PD and the impact of change in cognitive function. A detailed expla- nation of cognitive problems in PD will illustrate how this compensatory capacity can be eroded and how gait dete- riorates. Finally, clinical examples will be used to demon- strate how focused attention can improve gait, but at the expense of concurrent tasks.

Both efficacy and clinical feasibility deserve consideration in translation of research outcomes. This study evaluated the feasibility of rehabilitation programs within the context of a large randomized controlled trial of physical therapy. Ambulant participants with Parkinson's disease (PD) (n=210) were randomized into three groups: (1) progressive strength training (PST); (2) movement strategy training (MST); or (3) control (“life skills”). PST and MST included fall prevention education. Feasibility was evaluated in terms of safety, retention, adherence, and compliance measures. Time to first fall during the intervention phase did not differ across groups, and adverse effects were minimal. Retention was high; only eight participants withdrew during or after the intervention phase. Strong adherence (attendance>80%) did not differ between groups(P=.435). Compliance in the therapy groups was high. All three programs proved feasible, suggesting they may be safely implemented for people with PD in community-based clinical practice.

The stride length - cadence relationship (SLCrel) was investigated to explore a theory of two alternate but inter-related pathways for gait control. Sixty-three healthy people in three age groups walked along a computerized walkway (GAITRite(®)) at five self-selected speeds from very slow to very fast, five cadences from 70 to 150 steps/min and five stride lengths from 0.8 to 1.6m. The data points from two walks in each level of each condition were examined for linear and quadratic relationships. In the self-selected speed condition 97% of participants had a positive linear or quadratic relationship of R(2)≥0.90. The quadratic relationships showed stride length decreased with very high cadences. When walks with cadences above 150 steps/min were removed, 95% of participants had a positive linear relationship of R(2)≥0.90. No age-related differences were found in slope or intercept of linear relationships or in maximum, minimum or range of stride length or cadence in the self-selected speed condition. In the cadence and stride length conditions, only 32% and 14% of positive linear or quadratic relationships were R(2)≥0.90. The near-invariant SLCrel, unaffected by ageing that exists for nearly all individuals when walking at self-selected speeds, indicates that the SLCrel may be used to simplify central control of automatic gait in healthy individuals. The current investigation also provides SLCrel data for healthy people which can be compared with patient populations.

To determine the efficacy of standard levodopa combined with controlled release levodopa and entacapone in controlling end-of-dose symptoms in Parkinson's disease.A single-blind cross over design was used to compare the duration of action for three pharmacological combinations: standard levodopa (L/DDC); standard levodopa combined with entacapone (L/DDC/E); and standard levodopa combined with controlled release levodopa (CR) and entacapone (L/DDC/CR/E). Thirty two participants with wearing-off symptoms and inadequate symptom control with L/DDC/E had their optimum dose of L/DDC determined at base line. Entacapone was added to the optimal L/DDC dose and duration of action determined. Levodopa CR dosage was adjusted to match the optimal L/DDC dose for each participant. All participants were then trialed on L/DDC/CR/E and duration of response calculated. Timed Up and Go (TUG) times and magnitude of extra movements were recorded hourly throughout the day over several days to determine the optimum interval between doses for each combination. The UPDRS (Sections 2 and 3), PDQ39 and fatigue scale, the PDF-16, were recorded at base line and when dosage intervals had stabilized on L/DDC/CR/E.Duration of response was greatest with L/DDC/CR/E compared to L/DDC/E (p 0.001) and number of daily doses were less on L/DDC/CR/E compared to L/DDC/E (p 0.001). UPDRS, PDQ39 and fatigue scores also improved on L/DDC/CR/E compared to L/DDC (p 0.001). Dyskinesia increased on L/DDC/CR/E (p = 0.001) however magnitude was mild.Combining standard levodopa and levodopa CR preparations with entacapone is an additional treatment strategy to manage motor fluctuations in advanced PD.

Tan DM, McGinley JL, Danoudis ME, Iansek R, Morris ME. Freezing of gait and activity limitations in people with Parkinson's disease. Objectives To investigate the relationships between freezing of gait (FOG) and activity limitations in ambulant people with Parkinson's disease (PD), and to explore the contribution of FOG and gait hypokinesia to activity limitations after adjusting for the effects of disease severity. Design Retrospective, cross-sectional design. Setting Participants were recruited from neurologists' clinics and the general public in metropolitan Melbourne, Australia. Participants Volunteers were screened for eligibility using the following inclusion criteria: diagnosis of idiopathic PD, modified Hoehn and Yahr stages 0 to IV, without dementia. Participants (N=210) were tested (mean age ± SD, 67.9±9.6y; mean PD duration ± SD, 6.7±5.6y; median Hoehn and Yahr stage=2.5). Interventions Not applicable. Main Outcome Measures FOG was measured using the FOG questionnaire. Gait hypokinesia was quantified using both the 6-meter walk test and the Timed Up and Go test. Activity limitation was measured using the modified Unified Parkinson's Disease Rating Scale activities of daily living (ADL) section and the Schwab and England ADL scale. Results Severity of gait freezing correlated significantly with the level of activity limitation (Spearman correlation coefficient, ρ=−.49 to .48; P P R 2 change=.091; P Conclusions FOG severity and gait hypokinesia were associated with reduced levels of activity after adjusting for disease severity.

Background The relationship between health-related quality of life (HRQoL) in people with Parkinson’s disease and their caregivers is little understood and any effects on caregiver strain remain unclear. This paper examines these relationships in an Australian sample. Methods Using the generic EuroQol (EQ-5D) and disease-specific Parkinson’s Disease Questionnaire-39 Item (PDQ-39), HRQoL was evaluated in a sample of 97 people with PD and their caregivers. Caregiver strain was assessed using the Modified Caregiver Strain Index. Associations were evaluated between: (i) caregiver and care-recipient HRQoL; (ii) caregiver HRQoL and caregiver strain, and; (iii) between caregiver strain and care-recipient HRQoL. Results No statistically significant relationships were found between caregiver and care-recipient HRQoL, or between caregiver HRQoL and caregiver strain. Although this Australian sample of caregivers experienced relatively good HRQoL and moderately low strain, a significant correlation was found between HRQoL of people with PD and caregiver strain (rho 0.43, p Conclusion Poor HRQoL in people with PD is associated with higher strain in caregivers. Therapy interventions may target problems reported as most troublesome by people with PD, with potential to reduce strain on the caregiver.

Background The high incidence of falls associated with Parkinson’s disease (PD) increases the risk of injuries and immobility and compromises quality of life. Although falls education and strengthening programs have shown some benefit in healthy older people, the ability of physical therapy interventions in home settings to reduce falls and improve mobility in people with Parkinson’s has not been convincingly demonstrated. Methods/design 180 community living people with PD will be randomly allocated to receive either a home-based integrated rehabilitation program (progressive resistance strength training, movement strategy training and falls education) or a home-based life skills program (control intervention). Both programs comprise one hour of treatment and one hour of structured homework per week over six weeks of home therapy. Blinded assessments occurring before therapy commences, the week after completion of therapy and 12 months following intervention will establish both the immediate and long-term benefits of home-based rehabilitation. The number of falls, number of repeat falls, falls rate and time to first fall will be the primary measures used to quantify outcome. The economic costs associated with injurious falls, and the costs of running the integrated rehabilitation program from a health system perspective will be established. The effects of intervention on motor and global disability and on quality of life will also be examined. Discussion This study will provide new evidence on the outcomes and cost effectiveness of home-based movement rehabilitation programs for people living with PD. Trial registration The trial is registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12608000390381).