Improving Dexterous Skills in Parkinson's Disease
Condition: Parkinson Disease
MeSH terms: Parkinson Disease
Study type: Interventional

Summary: 
      Background and aim: Patients with Parkinson's disease (PD) exhibit disturbed manual
      dexterity. This impairment leads to difficulties in activities of daily living (ADL) such as
      buttoning a T-shirt or hand-writing. The aim of the present research project is to
      investigate the effectiveness of a high intensity home based exercise intervention focusing
      on fine motor skills (HOMEDEXT), in patients with PD.

      Design: A single blinded randomized controlled trial (RCT) will be performed. Randomization
      will be done by an independent biostatistician who will use a computerized randomization
      protocol. A baseline assessment and a follow-up measurement 4 weeks immediately after
      intervention (end of rehabilitation) will be performed. A follow-up measurement, 12 weeks
      later, will be done to assess long-lasting effects. Assessments will be performed by
      investigators who are blinded for the intervention.

      Participants: One hundred and four out-patients with PD will be recruited who report specific
      difficulties in manual dexterity when executing ADL. Intervention: The patients will be
      allocated to either an intervention group (n = 52) or control group (n = 52). In the
      intervention group PD patients will exercise, over a period of four weeks, once/day during 30
      minutes a treatment with specific exercises for dexterity. The PD patients, who will be
      allocated to the control group, will exercise Theraband exercises.

      Outcome measures: The primary outcome measures for manual dexterity will be the Nine Hole Peg
      test. Secondary outcome measures will be the Coin Rotation task, a sensitive screening for
      dexterity. Furthermore for ADL a modified version of the subscale II of the Movement
      Disorders Society unified Parkinson's Disease Rating Scale (MDS-UPDRS) will be used.
      Parkinsonian symptoms will be assessed by the MDS-UPDRS subscale III. To assess improvements
      in quality of life a modified version of the Parkinson's Disease Questionnaire (PDQ-39) will
      be used.
    

Detailed description: 
      Parkinson's disease (PD) is a progressive neurodegenerative disorder that affects both motor
      and non-motor basal ganglia circuitry (Stern et al., 2012). The degeneration of dopaminergic
      neurons in the substantia nigra leads to the clinical manifestation of the cardinal motor
      features of PD: bradykinesia, muscle rigidity, tremor at rest and impairment of postural
      reflexes (Bohlhalter & Kägi, 2011). While dopaminergic therapy improves some symptoms of PD,
      other symptoms, such as impaired finger dexterity, may be less responsive to pharmacological
      treatment (Quencer et al., 2007; Gebhardt et al., 2008). Patients with PD often report
      difficulties in activities of daily living (ADL), such as fastening T-shirt buttons or tying
      shoe laces, activities which require dexterous skills (Peto et al., 2001; Nijkrake et al.,
      2009). The exact mechanisms for the loss in finger dexterity are not known. Elementary motor
      deficits such as bradykinesia (Agostino et al., 2003), reduced strength and finger torque
      production (Fellows et al., 1998; de Oliveira et al., 2008) certainly play a role. However,
      these deficits do not fully account for the motor impairment and it has been suggested that
      an apraxic disorder called limb kinetic apraxia, may significantly contribute to the
      dexterous deficits observed in PD (Quencer et al., 2007; Gebhardt et al. 2008; Vanbellingen
      et al., 2011, 2012).

      Only limited data exist on therapeutic interventions of dexterous problems in PD (Dixon et
      al., 2007; Rao, 2010). However, there is increasing evidence that allied health care, which
      includes physical therapy (PT), speech-language therapy and occupational therapy (OT), may
      complement the standard pharmacological and surgical treatments (Van der Marck et al., 2009).
      These therapies aim to minimize the impact of the disease process, and improve the patient's
      participation in ADL. Two major treatment approaches are most commonly used for PD: movement
      strategy training and muskuloskeletal exercises (Morris et al., 2009). By using movement
      strategies, patients with PD may bypass the defective basal ganglia, by engaging alternative
      neural circuits that are still intact (frontal and parietal cortical pathways). Examples are
      mental rehearsing and focusing attention (Morris et al., 2009) or using sensory cues to
      initiate and maintain movements (Nieuwboer et al. 2007). However, a disadvantage of this
      treatment approaches, particularly the recruitment of frontal cortex, is its dependence on
      preserved cognitive abilities. As the disease progress, many patients with PD eventually
      develop cognitive impairments (Aarsland et al., 2010), which could negatively influence the
      learning of movement strategies (Nieuwboer et al., 2009). Musculoskeletal exercises aim to
      improve strength, joint range of movement, muscle length and endurance (Trend et al. 2002).
      High intensity exercise programs have been successful and showed either short or long-term
      effects for balance and gait for patients with PD (Hirsch et al., 2003; Morris et al., 2009;
      Ebersbach et al., 2010), of which most training modes were consistent with principles
      promoting activity-dependent neuroplasticity (Petzinger et al. 2010). Activity-dependent
      neuroplasticity is defined as the modifications within the central nervous system, in
      response to physical activity that promotes a skill acquisition process (Adkins et al.,
      2006). As such intensity, specificity, difficulty; and complexity of practice appear to be
      important parameters for driving neuroplasticity and a potential lasting effect on both brain
      and behavior (Petzinger et al. 2010). In contrast to the significant short and long-term
      improvements which were found after high intensity training for gait and balance (Hirsch et
      al., 2003; Morris et al., 2009; Ebersbach et al., 2010), there is little evidence for fine
      motor skills in patients with PD (Gauthier et al., 1987). However, no well-designed study has
      been conducted, so far, which focused on these aspects of motor skills in PD.

      Until date no well designed trial has been performed, in patients with PD, to investigate
      whether a high intensity exercise program, focusing on fine motor skills, could improve
      dexterous skills. As described above, patients with PD often experience impaired dexterity
      which leads to significant disability in several ADL, contributing to a reduced quality of
      life. For gait and balance disorders, high intensity training programs have been shown to be
      successful in patients with PD, based on training modes driving activity-dependent
      plasticity. However, the question remains open whether a high intensity exercise program,
      focusing on fine motor skills, could be effective as well in patients with PD.

      The aims of the present project are to assess the outcomes of a high intensity exercise
      intervention, focusing on fine motor skills, in in-patients with PD. The short and long-term
      benefits of this training program will be compared with conventional training, which patients
      already receive during their hospital stay. For this purposes, a single blinded randomized
      controlled trial (RCT) will be performed.

      Based on the literature we hypothesize that the specific home based dexterity program
      (HOMEDEXT) will improve fine motor skills both at short term and long-term, detected by the
      primary outcome measurement nine-hole peg test (Earhart et al. 2011). The improved finger and
      hand functions will also lead to improved ADL functioning as assessed by a modified version
      of the subscale II of the Movement Disorders Society unified Parkinson's Disease Rating Scale
      (MDS-UPDRS) (Goetz et al., 2008). Furthermore, we expect that patients with PD will report a
      higher quality of life (QoL), as assessed by the secondary outcome measures, a modified
      version of the Parkinson's Disease Questionnaire (PDQ-39) (Peto et al., 2001).
    

Intervention name(s): Dexterity training program (HOMEDEXT); Theraband training program
Intervention type(s): Behavioral; Behavioral
Intervention description(s): The dexterity training program contains 7 exercises which focus on improving fine motor skills.; The Theraband training program contains 7 exercises which focus on improving upper limb strength
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment