Ires Ghielen

126 Chapter 7 WRA is to optimize the DRT [16]. As the disease progresses, increasing dopaminergic medication (both frequency and dosage) becomes insufficient and complicated due to the increased occurrence of dyskinesias [17]. Also, random fluctuations appear to be more difficult to treat with pharmacotherapeutic approaches since they are unpredictable and not directly related to a lower level of dopamine [17]. Non-pharmaceutical approaches include exercise programs and physical therapy. These have shown to improve motor problems, daily functioning and quality of life in patients with PD [18-21]. While effective for improving mobility-related problems, current physical rehabilitation approaches typically do not offer tools to address the non-motor symptoms of wearing-off. Cognitive behavior therapy (CBT), mindfulness and acceptance & commitment- based therapies (ACT) have proven to be effective in reducing anxiety symptoms and avoidance behavior in patients with anxiety disorders, also enhancing quality of life [22,23]. Therefore, classic tools from CBT and ACT might be useful in the treatment of the debilitating effects of WRA. A reduction of anxiety symptoms in PD patients is observed in most of the CBT studies [24-26]. However, based on clinical experience, efficacy of classical CBT is limited in PD care, due to the fact that the cognitive methods are suboptimal in addressing the interaction between non- motor and motor symptoms during wearing-off. Moreover, the classical approaches aim to reduce the symptoms, whereas the inevitability of motor and non-motor fluctuations in PD demands the ability to maintain physical and mental balance despite the presence of those fluctuations. This is of great importance mainly in the more advanced stages of PD, where symptommanagement is more challenging [3]. Therefore, interventions need to focus on independence and self-efficacy more than on reducing symptoms. To address both the physical and the mental aspects of PD, Wahbeh et al. [27] 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 [28] tested a highly structured and standardized 3-day body-awareness program in 14 participants who suffered from chronic non-specific psychosomatic symptoms. An increase of body-awareness, self-efficacy and quality of life was found after the intervention. However, the researchers did not implement a control group in this study. Mindfulness-based therapies have been proven to be effective in many patient groups, such as patients with chronic pain, anxiety and depressive disorders, by