Subcortical Vascular Lesions Predict Functional Recovery After Rehabilitation in Patients with L-Dopa Refractory Parkinsonism

OBJECTIVES: To identify predictors of functional recovery after an intensive rehabilitation training in patients with gait disturbances and refractory parkinsonism. DESIGN: Observational study. SETTING: A hospital geriatric rehabilitation department ("Ancelle della Carità" hospital of Cremona). PARTICIPANTS: Thirty-eight subjects (mean age ± standard deviation of 78.9 ± 6.5; 66% women) with gait disturbances and L-dopa refractory parkinsonism consecutively admitted to a rehabilitation unit within 6 months were recruited. Exclusion criteria were obvious musculoskeletal disorders (severe leg arthritis, hemiparesis, recent stroke), recent surgery, delirium, physical impairment from other identifiable causes, and missing computed tomography (CT) scan. All subjects received an intensive standardized rehabilitative program including conventional physical therapy and specific gait training. MEASUREMENTS: The outcome measure of the rehabilitation training was the gain between admission and discharge on the Unified Parkinson Disease Rating Scale (delta-UPDRS). The following potential predictors were assessed using comprehensive geriatric assessment: physical health (Charlson Comorbidity Index, number of drugs), cognitive performance (Mini-Mental State Examination (MMSE)), functional status (Tinetti scale), depressive symptoms (Geriatric Depression Scale), nutritional status (serum albumin and body mass index), and subcortical cerebrovascular load (four classes of increasing severity based on diffuse leukoariosis, patchy lesions of the white matter, and lacunas on CT scan). Multivariate logistic regression with fixed adjustment for age, cognitive performance, and UPDRS on admission and stepwise selection of variables were used to identify independent predictors. RESULTS: Patients were divided into two groups of equal size based on the delta-UPDRS (high and low functional recovery: delta-UPDRS >8 and ≤8, respectively). Of all variables, only subcortical cerebrovascular load predicted functional recovery at discharge (odds ratio adjusted for age, MMSE, and UPDRS on admission = 2.3, 95% confidence interval = 1.0-5.1). The adjusted proportion of patients with high functional recovery decreased with increasing subcortical cerebrovascular load: 83%, 61%, 44%, and 27% (adjusted P for trend = 0.047). CONCLUSION: Subcortical cerebrovascular load is a predicting factor of successful rehabilitation in patients with L-dopa refractory parkinsonism.