Body awareness training in the treatment of wearing-off related anxiety in patients with Parkinson's disease: Results from a pilot randomized controlled trial
Introduction
The typical motor symptoms in Parkinson's disease (PD) include tremor, rigidity, slowness of movement, postural instability, and freezing. Besides these symptoms, PD is accompanied by non-motor symptoms, such as autonomic failure, fatigue, pain, cognitive rigidity, depression and anxiety. Non-motor symptoms often have a higher impact on patients' quality of life than motor symptoms [1]. First line treatment for PD symptoms is dopamine replacement therapy (DRT), e.g., levodopa [2]. In reaction to chronic DRT, PD patients eventually develop response fluctuations, including wearing-off. During wearing-off, both motor and non-motor symptoms can occur and/or become more prominent. Wearing-off is common already at the early stages of PD and is underestimated by routine neurological clinical evaluation. The number of wearing-off symptoms, both motor and non-motor, increases along with disease duration and has a negative impact on quality of life [3].
In PD, motor and non-motor symptoms have reciprocal influences [4]. About 75% of patients with motor fluctuations experience fluctuations in mood and/or anxiety in parallel [5], and anxiety is more common in patients that experience motor fluctuations compared to those who do not [6]. Anxiety associated with wearing-off, referred to as wearing-off related anxiety (WRA), is characterized not only by subjective feelings of anxiety but also by physical complaints, such as sweating, abdominal distress and shortness of breath. According to Rutten et al. [7], anxiety symptoms in PD show significant overlap with both autonomic and motor symptoms, which makes it difficult to disentangle them.
The high impact of the physical symptoms accompanying WRA on daily life functioning is often incongruent with the actual severity of the motor symptoms of wearing-off. This suggests heightened body awareness in these patients. Body awareness involves an attentional focus on and awareness of internal bodily sensations [8]. An abnormal increase in body awareness can be maladaptive [8] and is common in anxiety disorders [9]. Normalizing body awareness may therefore help patients to cope with WRA.
A first therapeutic approach to treat WRA is optimization of DRT [10], since the anxiety symptoms experienced by PD patients are sometimes responsive to dopaminergic medication [11], [12], [13]. As the disease progresses, this becomes insufficient and is complicated by response fluctuations and increased occurrence of dyskinesias that become unpredictable in nature [14]. Such random fluctuations are difficult to treat with pharmacotherapeutic approaches since they are not directly related to a low level of dopamine [14]. In addition, treating anxiety symptoms with pharmaceutics, such as psychotropic medication, might interfere with DRT and result in increased tremor or rigidity, which is undesirable.
Non-pharmaceutical approaches to treat wearing-off include exercise programs and physical therapy. These have been shown to improve motor problems, daily functioning and quality of life in PD patients [15], [16], [17], [18]. While effective in improving mobility-related problems, current physical rehabilitation approaches typically do not offer tools to address the (interaction with) non-motor symptoms, such as WRA.
Cognitive Behavior Therapy (CBT), mindfulness and Acceptance & Commitment-based therapies (ACT) are effective in reducing anxiety symptoms, distress and avoidance behavior and enhancing quality of life in patients with anxiety disorders and PD [19], [20], [21], [22], [23]. Therefore, tools from CBT and ACT might also be useful in the treatment of the debilitating effects of WRA in PD. However, the classical approach aims to reduce symptoms, whereas the inevitability of motor and non-motor fluctuations in PD demands a coping strategy on dealing with these fluctuations. In addition, cognitive rigidity becomes more prominent with disease progression and complicates a mono-disciplinary cognitive treatment approach.
To address both the physical and the mental aspects of PD, Wahbeh et al. [24] reviewed mind-body interventions in the treatment of PD and showed that participating in tai chi classes improved the patients' physical condition. Landsman-Dijkstra and colleagues [25] tested a highly structured and standardized 3-day body-awareness program in 14 participants who suffered from chronic non-specific psychosomatic symptoms. After the intervention body awareness, self-efficacy and quality of life had significantly improved. The main limitation of this study, apart from the small sample size, was the lack of a control group. In summary, mind-body interventions seem promising for the treatment of WRA in PD patients, but the therapeutic efficacy has yet not been investigated.
We therefore developed an integrated body awareness training combining ACT with physical therapy for patients with PD, named BEWARE. We investigated the feasibility and the efficacy of this group intervention using a pilot randomized controlled study, with conventional group physical therapy as active control condition.
Section snippets
Methods
For a detailed description of the methodology, including the intervention protocol, we refer to the article of Ghielen et al. [26].
Participant characteristics
Table 1 shows the descriptive statistics of the 38 patients that completed the study, per condition. No significant baseline differences between the two conditions were found on demographic, disease related, or outcome measures. All participants had a Hoehn & Yahr (H&Y) staging of 2 or 3 in the ON stage, as retrospectively assessed by the physical therapists. We assessed this retrospectively over 12 treatment sessions to obtain a reliable indicator of the disease stage, since H&Y scores are
Discussion
This pilot randomized controlled phase II study investigated a newly developed intervention involving body awareness training (BEWARE) for WRA in patients with PD. Patients that participated in the BEWARE treatment (compared with TAU) showed improved emotional wellbeing as well as standing balance, both at post-treatment and follow-up. Feelings of social stigmatization trend-significantly decreased in the BEWARE condition compared with the TAU condition.
The BEWARE treatment was not superior to
Author's contributions
IG: junior researcher, local project coordination, patient recruitment, data collection and analysis, manuscript writing. EEHvW: principal investigator and movement scientist, randomization set-up, obtained funding, concept and design of the study, overall project coordination, critical revision of the manuscript, supervision junior researcher. SR: psychiatry resident, epidemiologist, concept and design of the study, data analysis, critical revision of the manuscript. CJTdG: physical therapist,
Conflicts of interest and source of funding
The authors declare that they have no competing interests.
Funding
This project has been financially supported by the Dutch Parkinson Patient Association (Parkinson Vereniging(MvhH/110-2013/MvhH) and Project number: 2013-R16, awarded to Dr. E.E.H. van Wegen and Prof. Dr. O.A. van den Heuvel).
Acknowledgements
The authors wish to acknowledge the patients that participated in this study, Anita C. van Loenhoud and Tim D. van Balkom for their help with the physical assessments, and Simone Dobbelaar for entering the data.
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