Exploring therapeutic neurogenic tremors with exercise as a treatment for selective motor and non-motor Parkinson's disease symptoms

Atterbury, Elizabeth Maria (2019-04)

Thesis (PhD)--Stellenbosch University, 2019.

Thesis

ENGLISH ABSTRACT: Intro: Parkinson‘s disease (PD) is a chronic neurological progressive disorder accompanied by a wide range of symptoms that affect independence and quality of life (QoL) [1]. Individuals with PD (IwPD) experience motor symptoms, including postural instability and gait disturbances, and non-motor symptoms (NMS), including depressive moods, anxiety and autonomic dysregulation [2]. Daily stress further exacerbates PD symptoms [3]. Therefore stress management is of particular importance for IwPD. Relaxation-based exercises might be a viable option, and recently the addition of therapeutic neurogenic tremors (TNT) to exercise have been shown to aid in the reduction of perceived stress as well as improvement in QoL [4–6]. These tremors are theorised to be a genetically-encoded mechanism part of the stress response [7], and a necessary process for the body to function optimally after stressful and traumatic events [8,9]. Therefore, the current study set out to investigate the effects of relaxation-based exercises with and without TNT on selective motor and non-motor symptoms of IwPD. Methods: Thirty-six individuals with idiopathic PD participated in this experimental study, with a double-blinded randomised time-series design. Participants were randomly allocated to three groups: 1)Exercises with TNT (TRE), 2) Exercises without TNT (EAR), and 3) a non-exercising waitlist controlgroup (n = 12, 69.6 ± 8.3 years). Group 1 (n = 14, 72.7 ± 7.5 years) participated in a Trauma and Tension Releasing Exercises (TRE) intervention, while Group 2 (n = 10, 70.3 ± 5.7 years) participated in the Exercise and Relaxation (EAR) intervention. Both interventions followed the same protocol except for the addition of TNT in the TRE group, and took place with tapered supervision over nine weeks. Participants, in all three groups, were tested every three weeks (i.e. baseline, 3, 6 and 9 weeks), and after a three week retention period. Primary outcome measures included postural instability, gait disturbances, domains of NMS, depressive moods, general anxiety, and somatisation. Assessments included the Mini Balance Evaluation Systems Test (BESTest), instrumented 2-Minute Walk (2MW), NMS Questionnaire (NMSQuest) and NMS Symptoms Scale (NMSS), as well as the Patient Health Questionnaire for somatic, anxiety and depressive symptoms (PHQ-SADS). Secondary outcome measures included disease severity (assessed with the Movement Disorder Society’s – Unified Parkinson’s Disease Rating Scale (MDS-UPDRS)), perceived balance confidence (assessed with the Activity-specific Balance Confidence (ABC) scale) and QoL (assessed by the 8-item Parkinson’s disease Questionnaire (PDQ-8)). Results: Groups did not differ in descriptive characteristics or outcome variables at baseline (p > 0.05), except for variability of trunk rotation, mood/cognition and attention/memory domains of NMSS between TRE and CON groups (p < 0.05). An interaction effect was observed for PDQ-8 (p = 0.01) with improvements seen for EAR group (p = 0.002, Hedges’ g = 0.45M) and a tendency for the TRE group to improve (p = 0.07, Hedges’ g = 0.35S) over time. The main findings with practical significance after the intervention period were improvements in gait speed of the EAR group (p = 0.005, Hedges’ g = 0.39S), and variability of trunk rotation during 2MW for TRE group (p = 0.048, Hedges’ g = 0.39S). The EAR and TRE groups showed improvement in gastrointestinal complaints and the severity of stress-related items in the mood/cognition domain of NMSS (p < 0.03, Hedges’ g > 0.48M), while TRE showed additional improvements for frequency stress-related items of NMSS (p < 0.05, Hedges’ g > 0.49M). Additionally significant practical improvements were observed for MDS-UPDRS II (motor experience of daily living) for TRE (p = 0.02, Hedges’ g = 0.29S) and control group (p = 0.01, Hedges’ g = 0.33S). The retention period showed improvements in Mini BESTest domains for EAR (p =0.04, Hedges’ g = 0.57M) and control (p = 0.02, Hedges’ g = 0.65M) groups, and improvement in NMSQuest for TRE (p = 0.04, Hedges’ g = 0.56M). Conclusion: This exploratory study shows promising preliminary results for relaxation-based exercises with TNT. The findings suggest that relaxation-based exercises were beneficial towards improving gait performance, decreasing the severity of selective NMS and possibly improving QoL. The addition of TNT could have the potential of further improvements in the motor experience of daily living, quality of gait, and the frequency of stress-related NMS. Therapies utilizing TNT could be an essential tool for IwPD to reduce the impact of motor and NMS, and manage stress. However, more research is needed to investigate the effects of TNT on populations vulnerable to stress.

AFRIKAANSE OPSOMMING: Inleiding: Parkinson se siekte (PD) is 'n chroniese neurologiese progressiewe versteuring, wat gepaard gaan met 'n wye verskeidenheid simptome wat onafhanklikheid en lewenskwaliteit beïnvloed [1]. Individue met PD (IwPD) ervaar motoriese simptome, insluitende posturale onstabiliteit en loopgangversteurings, en nie-motoriese simptome (NMS), insluitend depressiewe buie, angs en outonomiese-senuweestelsel wanfunksie [2]. Daaglikse stres kan PD-simptome toenemend vererger [3]. Daarom is stresbestuur vir IwPD van besondere belang. Ontspanningsgebaseerde oefeninge kan 'n moontlike opsie van waarde wees, en onlangs het die toevoeging van terapeutiese neurogene bewing (TNT) tot oefeninge getoon dat dit help met die vermindering van waargenome stres asook verbetering in lewenskwaliteit [4–6]. Dit word teoreties voorgestel dat hierdie bewinge 'n geneties-gekodeerde meganisme deel van die stresrespons vorm [7], en 'n noodsaaklike proses van die liggaam is om optimaal te funksioneer na stresvolle en traumatiese gebeure [8,9]. Daarom het die huidige studie ondersoek ingestel na die uitwerking van ontspanninggebaseerde oefeninge met en sonder TNT op selektiewe motoriese en nie-motoriese simptome van IwPD. Metodes: Ses-en-dertig individue met idiopatiese PD het aan hierdie eksperimentele studie deelgeneem, met 'n dubbelblinde willekeurige tydreeksontwerp. Deelnemers is willekeurig toegewys aan een van drie groepe: 1) Oefeninge met TNT, 2) Oefeninge sonder TNT (EAR), en 3) 'n nie-oefenende waglys kontrole groep (n = 12, 69.6 ± 8.3 jaar). Groep 1 (n = 14, 72.7 ± 7.5 jaar) het deelgeneem aan ʼn “Trauma and Tension Releasing Exercises” (TRE) intervensie, terwyl die EAR-groep (n = 10, 70.3 ± 5.7 jaar) aan ʼn oefening en ontspanningsintervensie (EAR) deelgeneem het. Beide intervensies het dieselfde protokol gevolg, behalwe vir die byvoeging van TNT in die TRE-groep, en het oor nege weke met afnemende toesig plaasgevind. Deelnemers, in al drie groepe, was elke drie weke getoets (dws basislyn, 3, 6 en 9 weke), en na 'n drie weke retensieperiode. Primêre uitkomsmates het posturale onstabiliteit, loopgangversteurings, areas van NMS, depressiewe buie, angs en somtiese simptome ingesluit. Assesserings het die Minibalansevalueringstoets (Mini BESTest), Instrumentiewe 2-Minute-Stap (2MW), NMS-vraelys (NMSQuest) en NMS-simptoomskaal (NMSS) ingesluit, sowel as die “Patient Health Questionnaire” vir somatiese, angs en depressiewe simptome (PHQ-SADS). Sekondêre uitkomsmates het siekte-erns (gemeet deur die “Movement Disorder Society’s – Unified Parkinson’s Disease Rating Scale” (MDS-UPDRS)), waargeneome balance vertroue (gemeet deur die Aktiwiteits-spesifieke Balansvertroue (ABC) skaal) en lewenskwaliteit (gemeet deur die 8-item Parkinson se siekte vraelys (PDQ-8)) ingesluit. Resultate: Groepe het nie verskil in beskrywende eienskappe of uitkomsveranderlikes by basislyn nie (p > 0.05), behalwe vir variasie van romprotasie, gemoedstoestand/kognitiewe en aandag/geheue areas van die NMSS tussen TRE and CON groepe (p < 0.05). ʼn Interaksie-effek is waargeneem vir PDQ-8 (p = 0.01) met verbeteringe vir die EAR-groep (p = 0.002, Hedges’ g = 0.45M) en 'n tendens tot verbetering vir die TRE-groep oor die verloop van die intervensie (p = 0.07, Hedges’ g = 0.35S). Die hoof bevindings wat praktiese betekenisvol was na die intervensieperiode, was die verbeteringe in stapspoed van die EAR-groep (p = 0.005, Hedges’ g = 0.39S), en variasie van romprotasie gedurende 2MW vir die TRE groep (p = 0.048, Hedges’ g = 0.39S). Die EAR- en TRE-groepe het verbeterings in gastro-intestinale klagtes getoon asook in die intensiteit van stresverwante items in die gemoedstoestand/kognitiewe-area van die NMSS (p <0.03, Hedges’ g > 0.48M), terwyl TRE bykomende verbeterings teweeg gebring het vir die frekwensie van stresverwante items van NMSS (p <0.05, Hedges’ g > 0.49M). . Addisionele verbeteringe was gevind vir MDS-UPDRS II (motoriese ervaring van daaglikse lewe) vir die TRE (p = 0.02, Hedges’ g = 0.29S) en kontrole groep (p = 0.01, Hedges’ g = 0.33S). Die retensieperiode het verbeteringe in Mini BESTest aspekte vir die EAR groep (p = 0.04, Hedges’ g = 0.57M) en die kontrolegroep (p = 0.02, Hedges’ g = 0.65M) getoon, asook verbetering in NMSQuest vir die TRE groep (p = 0.04, Hedges’ g = 0.56M). Gevolgtrekking: Hierdie verkennende studie toon belowende voorlopige resultate vir ontspanninggebaseerde oefeninge met TNT. Die bevindinge dui daarop dat ontspanningsgebaseerde oefeninge voordelig is vir die verbetering van loopgangprestasie, die vermindering in intensiteit van selektiewe NMS en moontlik verbeterde lewenskwaliteit. Die toevoeging van TNT het moontlik die potensiaal om die motoriese ervaring van die daaglikse lewe, loopangkwaliteit, en die frekwensie van stresverwante NMS te verbeter. Terapieë wat TNT gebruik, kan 'n noodsaaklike hulpmiddel vir IwPD wees om die impak van motoriese simptome en NMS te verminder en stres te bestuur. Meer navorsing is egter nodig om die effekte van TNT op bevolkinggroepe, wat meer vatbaar is vir stres, te ondersoek.

wa201907

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