Huntington disease is a neurodegenerative disorder that involves preferential atrophy in the striatal complex and related subcortical nuclei. In this paper, which is based on a dataset extracted from the PREDICT-HD study, we use statistical shape analysis with deformation markers obtained through Large Deformation Diffeomorphic Metric Mapping of cortical surfaces to highlight specific atrophy patterns in the caudate, putamen, and globus pallidus, at different prodromal stages of the disease. Based on the relation to cortico-basal-ganglia circuitry, we propose that statistical shape analysis, along with other structural and functional imaging studies, may help expand our understanding of the brain circuitry affected and other aspects of the neurobiology of HD, and also guide the most effective strategies for intervention.

ImportanceEpisodic memory and executive function are essential aspects of cognitive functioning that decline with aging. This decline may be ameliorable with lifestyle interventions.ObjectiveTo determine whether mindfulness-based stress reduction (MBSR), exercise, or a combination of both improve cognitive function in older adults.Design, Setting, and ParticipantsThis 2 × 2 factorial randomized clinical trial was conducted at 2 US sites (Washington University in St Louis and University of California, San Diego). A total of 585 older adults (aged 65-84 y) with subjective cognitive concerns, but not dementia, were randomized (enrollment from November 19, 2015, to January 23, 2019; final follow-up on March 16, 2020).InterventionsParticipants were randomized to undergo the following interventions: MBSR with a target of 60 minutes daily of meditation (n = 150); exercise with aerobic, strength, and functional components with a target of at least 300 minutes weekly (n = 138); combined MBSR and exercise (n = 144); or a health education control group (n = 153). Interventions lasted 18 months and consisted of group-based classes and home practice.Main Outcomes and MeasuresThe 2 primary outcomes were composites of episodic memory and executive function (standardized to a mean [SD] of 0 [1]; higher composite scores indicate better cognitive performance) from neuropsychological testing; the primary end point was 6 months and the secondary end point was 18 months. There were 5 reported secondary outcomes: hippocampal volume and dorsolateral prefrontal cortex thickness and surface area from structural magnetic resonance imaging and functional cognitive capacity and self-reported cognitive concerns.ResultsAmong 585 randomized participants (mean age, 71.5 years; 424 [72.5%] women), 568 (97.1%) completed 6 months in the trial and 475 (81.2%) completed 18 months. At 6 months, there was no significant effect of mindfulness training or exercise on episodic memory (MBSR vs no MBSR: 0.44 vs 0.48; mean difference, –0.04 points [95% CI, –0.15 to 0.07]; P = .50; exercise vs no exercise: 0.49 vs 0.42; difference, 0.07 [95% CI, –0.04 to 0.17]; P = .23) or executive function (MBSR vs no MBSR: 0.39 vs 0.31; mean difference, 0.08 points [95% CI, –0.02 to 0.19]; P = .12; exercise vs no exercise: 0.39 vs 0.32; difference, 0.07 [95% CI, –0.03 to 0.18]; P = .17) and there were no intervention effects at the secondary end point of 18 months. There was no significant interaction between mindfulness training and exercise (P = .93 for memory and P = .29 for executive function) at 6 months. Of the 5 prespecified secondary outcomes, none showed a significant improvement with either intervention compared with those not receiving the intervention.Conclusions and RelevanceAmong older adults with subjective cognitive concerns, mindfulness training, exercise, or both did not result in significant differences in improvement in episodic memory or executive function at 6 months. The findings do not support the use of these interventions for improving cognition in older adults with subjective cognitive concerns.Trial RegistrationClinicalTrials.gov Identifier: NCT02665481

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AimsThis study aims to identify implementation determinants, mechanisms of action, implementation strategies, and implementation outcome evaluation plans for a new theory-based rehabilitation goal setting and goal management intervention system, called MyGoals, using Implementation Mapping with community-based participatory research principles.MethodsWe completed Implementation Mapping tasks 1 to 4 as a planning team consisting of MyGoals target implementers (occupational therapists (OTs), MyGoals intervention target clients (adults with chronic conditions), and the research team. We are currently conducting mapping task 5. These processes were guided by the Consolidated Framework for Implementation Research, social cognitive theory, the taxonomy of behavior change methods, and Proctor's implementation research framework.ResultsWe identified intervention-level determinants (MyGoals' evidence strength & quality, relative advantages) and OT-level determinants (knowledge, awareness, skills, self-efficacy, outcome expectancy). We selected the MyGoals implementation outcome (OTs will deliver MyGoals completely and competently), outcome variables (acceptability, appropriateness, feasibility, fidelity), and process outcomes. We also determined three performance objectives (e.g., OTs will deliver all MyGoals intervention components) and 15 change objectives (e.g., OTs will demonstrate skills for delivering all MyGoals intervention components). Based on the identified outcomes, objectives, and determinants, we specified the mechanisms of change (e.g., active learning). To address these determinants and achieve the implementation outcomes, we produced two tailored MyGoals implementation strategies: MyGoals Clinician Education and MyGoals Clinician Audit & Feedback. We developed evaluation plans to explore and evaluate how these two MyGoals implementation strategies perform using a mixed-methods study of OT-client dyads.ConclusionWe produced tailored implementation strategies for a rehabilitation goal setting and goal management intervention by using Implementation Mapping with community-based participatory research principles. The MyGoals implementation strategies may help OTs implement high-quality goal setting and goal management practice and thus contribute to bridging current research-practice gaps. Our findings can provide insight on how to apply implementation science in rehabilitation to improve the development and translation of evidence-based interventions to enhance health in adults with chronic conditions.

Importance: Occupational therapy practitioners address the occupational performance and participation needs of people with Parkinson’s disease (PD) and their care partners. Objective: This Practice Guideline is informed by systematic reviews on the use of occupational therapy interventions to promote participation in occupations for people with PD and to facilitate their caregivers’ participation in the caregiver role. This guideline is meant to support practitioners’ clinical decision making when working with people with PD and their care partners. Method: We examined and synthesized the results of four systematic reviews and integrated those results into clinical recommendations for practice. Results: Thirty-three articles from the systematic reviews served as the basis for the clinical recommendations in this Practice Guideline. Clinical recommendations are provided for interventions that have strong or moderate supporting evidence. Conclusion and Recommendations: Multidisciplinary, tailored, goal-oriented intervention is recommended for people with PD. Various forms of exercise can be used to improve activities of daily living and instrumental activities of daily living performance and social participation, and interventions should incorporate health behavior change techniques to support adequate physical activity levels in daily life. Mindfulness meditation and exercise can be used to support sleep, and task-oriented training can be used to improve performance of specific tasks. Occupational therapy practitioners should incorporate self-management, coaching, compensatory, cognitive–behavioral, and other approaches into multicomponent treatment plans depending on the client’s needs and goals. Additional potentially appropriate intervention approaches or areas to address are discussed on the basis of existing or emerging evidence and expert opinion. What This Article Adds: This Practice Guideline provides a summary and applications of the current evidence supporting occupational therapy intervention for people with PD. It includes case examples and suggested decision-making algorithms to support practitioners in addressing client goals.