Highly Challenging Balance Training for People With Parkinson's Disease (the BETA-PD Study): Non-randomized Hybrid Effectiveness-implementation Trial
Phase: NA
Conditions: Parkinson Disease
Sponsor: Karolinska Institutet

 
 
Effectiveness and Implementation of the HiBalance Program 
in Clinical Practice 
 
NCT02727478 
 
 
Documents approved by the ethical committee in Stockholm, Sweden 2nd March 2016 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Improving balance and physical activity in elderly with Parkinson’s 
disease –effectiveness in a clinical practice of the HiBalance 
program 
 
This study is a part of the larger BETA (Balance, Elderly, Training and Activity) study that consists of 
two parts: Osteoporosis and Parkinson’s disease (PD). The long-term goal of the larger BETA study is 
to reduce the risk of falls in elderly. We predict that increased balance control following training will 
lead to greater confidence in everyday life, increased levels of physical activity and an improved 
health related quality of life. The goal is also to establish evidence-based rehabilitation programs for 
balance and gait function and to further develop and implement an educational curriculum where 
health care professionals can learn to manage such programs for elderly nationwide.   
 
The BETA-PD study of which Erika Franzén is the PI of consists of several parts: method development 
and laboratory studies, efficacy study and an effectiveness/ implementation study. Here we are 
applying for the effectiveness and implementation part.  
 
The BETA-PD project aims to translate basic neuroscience into applied research and clinical 
understanding and implement the evaluation methods and training program into clinical practice. 
We hypothesize that increased balance control following training will lead to greater confidence in 
everyday life, increased levels of physical activity and an improved health related quality of life. The 
addition of physical activity on prescription will further improve the health benefits of this program 
in the long-term follow-up. With this new concept of balance training, our outcome measurements 
and educational curriculum, we foresee a paradigm shift in how balance training is applied and 
evaluated in clinical practice for elderly with balance deficits.  
 
BACKGROUND 
Falls are a major cause of ill-health and may lead to functional impairment, disability, a lower quality 
of life and fractures among elderly (Kannus, Uusi-Rasi et al. 2005, Madureira, Takayama et al. 2007). 
Injurious falls and fear of falling are especially common in elderly with Parkinson’s disease (PD) 
(Bloem, Grimbergen et al. 2001). The most is Parkinson’s disease (PD). Parkinson’s disease is the 
most common neurodegenerative disorder next to Alzheimer’s disease leading to a loss of dopamine 
producing cells in the basal ganglia and is mainly present around the age of 60 to 85 years of age. The 
basal ganglia are among the most important central structures for the control of posture and 
movement. The primary symptoms of PD are tremor, rigidity, bradykinesia and impaired postural 
stability (balance control) (Nutt, Hammerstad et al. 1992). Many of these symptoms affect balance 
and walking abilities in everyday tasks (Nutt, Hammerstad et al. 1992, Franzen, Paquette et al. 2009).  
Postural instability is not just one of the most disabling symptoms of PD it is also one factor that 
increase the risk of falling, which occurs in 38-68% of the people with PD (Balash, Peretz et al. 2005). 
Furthermore, elderly with PD have shown reduced levels of physical activity (Fertl, Doppelbauer et al. 
1993) and a nine times increased risk of injurious falls, compared with the healthy elderly (Bloem, 
Grimbergen et al. 2001). Balance and walking impairments are present even in the early stages of PD 
(Carpinella, Crenna et al. 2007) and have been shown to be associated with restrictions in everyday 
activities (Tan, McGinley et al. 2011) and reduced quality of life (Ellis, Cavanaugh et al. 2011). 
 
Balance problems may lead to physical inactivity, which in turn leads to increased unsteadiness and a 
vicious cycle with less mobility, muscle weakness, falls and fractures (King and Horak 2009). Physical 
activity is today considered a highly potent prevention of and treatment for a large number of 
conditions and diseases (PAGAC 2008, Ståhle 2010). Approximately 60% of the adult population in 
the world today does not meet the physical activity recommendations, (Balash, Peretz et al.). 
However, the level of physical activity in elderly with PD remains unclear. Accelerometer data from 

our study show that only 27% of the individuals with mild to moderate Parkinson’s disease meet the 
recommendations of physical activity (Wallén, Franzén et al. Submitted 2014). 
 
Balance control relies on the interaction of several physiological systems (musculoskeletal, 
neuromuscular, cognitive and sensory systems) with environmental factors and the performed task 
(Horak F 1996). However, as degeneration of the basal ganglia affects many physiological systems 
essential for balance control, balance disorders in PD cannot be addressed to one single function but, 
rather, are the result of impairments of multiple systems such as impaired sensory integration, 
poorly timed an scaled anticipatory postural adjustments, reduced reactive control and motor 
coordination as well as decreased stability limits (Franzen, Paquette et al. 2009, King and Horak 
2009). Another critical aspect of balance control in PD is the ability to divide attention and 
simultaneously process multiple tasks (motor or cognitive), i.e. multi-tasking. While performing a 
dual- or a multi-task activity, individuals with PD compared with healthy subjects are more inclined to 
shift attention away from the balance task, which can lead to falls (Bloem, Grimbergen et al. 2006). 
 
As PD progresses, balance problems gradually increase and are generally non-responsive to or 
worsen with levodopa treatment (Horak F 1996, Franzen, Paquette et al. 2009, Wright, Gurfinkel et 
al. 2010). Currently, there is a growing body of research that highlights the role of physical exercise 
as an essential part of managing the disease, with potential neuroprotective mechanisms (Hirsch and 
Farley 2009, Ahlskog 2011, Petzinger, Fisher et al. 2013). Furthermore, exciting new findings in 
neuroscience regarding the effects of exercise on neural plasticity and neuroprotection of the brain 
against neural degeneration suggests that exercise can improve brain function in patients with 
neurological disorders (King and Horak 2009, Petzinger, Fisher et al. 2013). Moreover, the effects of 
balance training on balance and gait performance are promising for individuals with PD (Dibble, 
Addison et al. 2009, Allen, Sherrington et al. 2011), although several questions remain unanswered, 
particularly regarding dose, intensity and duration, as well as regarding specific exercises to improve 
balance control in the different stages of the disease (Kwakkel, de Goede et al. 2007, Goodwin, 
Richards et al. 2008, Allen, Sherrington et al. 2011). The training stimuli used in previous training 
interventions have been criticized for not being challenging or intensive enough (Allen, Sherrington 
et al. 2011). Furthermore, it is unclear whether specific training effects on balance can be generalized 
to restrictions in everyday living or enhance physical activity level in PD, especially in a long-term 
perspective (Lees, Hardy et al. 2009).  
 
We have therefore designed a program that emphasizes highly challenging aspects of balance 
control, the HiBalance program, based on a translational approach, incorporating knowledge from 
basic science, motor learning, and clinical practice (Conradsson, Löfgren et al. 2012). To address PD-
specific balance impairments, this program was developed by linking PD symptoms to core areas of 
balance control and was subsequently translated into principles of training (Conradsson, Löfgren et 
al. 2012, Conradsson, Löfgren et al. 2013). Together with physical activity on prescription, we found 
the program to significantly improve balance performance, gait velocity, step length and dual-tasking 
ability. In addition, favorable transfer effects were seen in relation to physical activity levels as well 
as to performance in activities of daily living (Conradsson, Lofgren et al. 2015). 
 
Preliminary results of the short-term effects show that this program is not only improving balance 
and gait ability in elderly with mild to moderate PD but also has beneficial effects to everyday 
living seen as improved physical activity level and activities of daily living.  
 
In the literature there are many studies reporting on the efficacy of certain treatments, methods or 
training programs, which often may take years for the researchers to develop. Few of the researchers 
take their results further into clinical practice and, if so, it may take years for them to come into daily 
use (Nilsen 2010). This delay means that possible health gains are not achieved as quickly as one 
would have hoped for (Guldbrandsson 2007), i.e. there is a large gap between what is known and 

what is consistently done (Bhattacharyya, Estey et al. 2011). It is, therefore, of great importance that 
programs proven to have beneficial impact on health and health related quality of life in a clinical 
trial setting, are being implemented as soon as possible into clinical practice. Furthermore, it is of 
importance to identify relevant facilitators and barriers for implementation, in order  to develop 
effective implementaion strategies. Intervention fidelity describes the extent to which an 
intervention is carried out as it was intended (Fraser 2009). Knowing if an intervention was carried 
out as planned it is essential to understand which factors that contributed to an effect. To be able to 
study fidelity it is important  to define the core components of an intervention.  
 
Hence, we are now planning an effectiveness study, during which we will test the effectiveness of the 
HiBalance program in clinical settings such as primary geriatric care and neurorehabilitation centres 
while simultaniously gathering information on barriers and facilitators (hybrid design). This will 
provide information on the effectiveness of the program, but also on which factors influence the 
implementation  of the program in practice. This information can in turn be used to develop 
implementation strategies that support the implementation of the program into rutine clinical 
practice.   
 
OBJECTIVES 
The specific aims related to Step 3:  
 
1. 
Describe the utilization and satisfaction regarding balance training and physiotherapy in 
individuals with PD as well as the treatment characteristics and knowledge regarding PD 
among physiotherapists in Sweden (surveys). 
 
2. 
Evaluate the effectiveness of the balance training program regarding gait, balance function, 
physical activity levels and health related quality of life in clinical settings (case-control study).  
3. 
Conduct a process-evaluation and identify relevant facilitators and barriers for implementation 
the program into clinical practice (effectiveness-implementation hybrid design).  
4. 
Develop and test educational material for dissemination of the intervention to physioterapists 
working with PD and to promote exercise for people with PD 
 
CONNECTION TO PREVIOUS PROJECTS / PRELIMINARY RESULTS 
During the first years (2011-2013) of the project we have tested the validity and reliability of the 
measurement methods that we use. For example, we have translated, culturally adapted and tested 
the validity of the new clinical balance test called, Mini-BEST test, for use in patients with PD. We are 
now in the process of evaluating its feasibility and reliability. Preliminary results shows high 
concurrent validity, inter- (ICC= 0.775, SEM= 1.78) as well as test-retest reliability (ICC=0.895, SEM = 
1.22) in this group of mild to moderate PD. To be able to analyze physical activity measured with 
accelerometers, methodology studies in PD are also required. We have therefore compared common 
free-living physical activity parameters assessed with accelerometers and processed with two 
different filter settings as well as conducted a calibration study in a sample of elderly individuals with 
PD (Nero et al., accepted Plos One). Furthermore, we have compared self-reported pedometer steps 
with accelerometer steps in patients with PD and shown that the steps were found to agree poorly 
with accelerometer steps (Wallen, Dohrn et al. 2013).   
 
We have also conducted a kinematic study in a movement laboratory in which we have investigated 
turning strategies as well as the effect of levodopa on these strategies in 20 with individuals with PD 
(ON and OFF their medication) and 20 healthy controls. Preliminary results show an improvement in 
turning performance due to ant-parkinson medication however no effects on axial coordination 
(manuscript in preparation). 
 

We have during 2011 developed this intervention related to PD symptoms (Conradsson, Löfgren et 
al. 2012) and conducted a pilot study with subjects with PD and showed the training program to be 
feasible (safety, intervention compliance, pain and general fatigue) and exercise progression was 
easily performed during training (Conradsson, Löfgren et al. 2013). Thereafter (2012- ongoing), 100 
elderly with PD (Hoehn & Yahr 2-3) were assessed and randomized to a training group (n=51) with 
10-week (3 times/week) of highly balance exercises, or to a control group (n=49) that carried on with 
their normal life-style activities. Results of the short-term effects show that the training group, 
compared to the control group, significantly improved in domains specifically targeted in this 
intervention: balance performance, gait velocity, step length, cognitive performance while dual-
tasking, as well as beneficial transfer effects to everyday living, seen as increased physical activity 
level and improved activities of daily living. No significant group differences were found for fear of 
falling and health related quality of life (submitted mamnuscript). Long-term follow-up assessments 
will further explore these effects. 
 
We have also conducted a qualitative study to describe perceptions, experiences and beliefs of 
balance and physical activity in the daily life after participating in our balance intervention by means 
of semi-structured interviews with open-ended questions. We have interviewed 13 individuals with 
PD, which have been transcribed and are under analysis. Preliminary data show that they have a 
good coping strategy to keep their balance and avoid falls. Moreover, they express that physical 
activity and training is beneficial for them although they see limitations in keeping active such as the 
progression of the disease, aging and also a limited range of training opportunities. 
 
STUDY DESIGN, METHODS AND WORKPLAN 
We use a wide range of novel methodologies in the BETA-PD study, from laboratory (motion analysis 
and force plates), to semi-laboratory (pressure sensitive gait analysis mat and accelerometers) to 
clinical measures (Mini-BESTest, one-leg stance, disease rating scales) as well as questionnaires (fear 
of falling and health related quality of life) and qualitative approaches (interviews and focus groups).  
 
The HiBalance program is based on scientifically well-established principles of exercise training and 
postural control as well as current research on training in PD (Franzen, Paquette et al. 2009, Allen, 
Sherrington et al. 2011, Petzinger, Fisher et al. 2013). The program is based on the current 
knowledge of the neurophysiology and the inevitable constraints on mobility and postural control 
resulting from basal ganglia degeneration. The training was conducted as a progressive individually 
adjusted group program, led by experienced physiotherapists and researchers in order to challenge 
the specific balance disorder of every participant and endorse progression. In this training program, 
four main subsystems underlying balance control (stability limits, anticipatory postural adjustments, 
sensory integration, motor agility) are used to target symptom specific balance impairments, see 
Figure 4. Intermittent presence of reactive postural adjustments is used as an indicator of the 
relevant level of difficulty. This 10-week intervention is performed three times/week in groups of six 
to seven participants and is divided into three phases where movement complexity in combination 
with multitasking is increased. To ensure highly challenging exercises, each task is individually 
adapted e.g. by changing area of base of support, increasing movement speed/amplitude, restricting 
vision and varying the grade of multitasking.  
 
After the last training session, a meeting will take place, where the participants will take part in a 
group discussion, led by physiotherapists, on how to sustain or increase their level of physical 
activity.  
 
Here we are descibing the effectiveness and implementation of the program into clinical practise. 
  

EFFECTIVENESS AND IMPLEMENTATION IN CLINICAL SETTINGS 
This part consists of a clinical effectiveness trial together with implementation research. We are here 
planning to use a hybrid design, testing effects of the HiBalance training program delivered in clinical 
setting on relevant patient outcome measure while observing and gathering information on the 
implementation process, including barriers and facilitators (Curran, Bauer et al. 2012). This approach 
can provide more rapid translational gains, more effective implementation strategies and more 
useful information for decision makers than pursuing effectiveness trials and implementation 
research independently. 
Since the HiBalance program has shown beneficial effects in a controlled hospital setting, we foresee 
an immediate need to test the effectiveness of the program under less controlled conditions (Fraser 
2009) i.e., in other settings, such as primary and elderly care settings and delivered by 
Physiotherapists in these clinics. By use of a hybrid design, we will be able to collect information on 
effectiveness on patient level, whether the program was implemented as intended by conducting a 
process evaluation and which factors might have influenced the implementation (Curran, Bauer et al. 
2012). The collected information on barriers and facilitators will serve as the foundation for 
development of implementation strategies and educational material. 
 
Survey 
Initially a survey among individuals with PD will be performed to describe the utilization and patient 
satisfaction of balance training and physiotherapy treatments. In addition, a survey among 
physiotherapists will describe treatment characteristics, knowledge and skills with regards to PD. 
Despite several efficacy studies on exercise and physiotherapy in PD, only limited data regarding the 
utilization and patient satisfaction of physiotherapy by patients with PD are available (Keus, Bloem et 
al. 2004). There is also limited information about knowledge / skills and self-efficacy regarding 
training and treatments among physiotherapists as well as the nature of the treatments given by 
physiotherapists. Better insight into the quantity (e. g. referral rates and treatment duration) and 
quality (e. g. contents of treatment, therapist expertise and patient satisfaction) of physiotherapy in 
PD is therefore needed before an efficacy study can be performed in clinical settings. Web-based 
questionnaires will therefore be sent out to physiotherapists and individuals with PD living in 
Sweden. Recruitment will be made through the member directory of the Swedish Parkinson 
association (survey for people with Parkinson’s disease) and the Swedish physiotherapist association 
(survey for physiotherapists). For feasibility purposes, the questionnaires will be piloted among 10 
patients and 10 physiotherapists before the final version of the questionnaires will be drawn up. The 
questionnaire to patients will consist of items regarding socio-demographic status, diagnosis, 
activities of daily living, utilization of and satisfaction with physiotherapy treatment. In the 
questionnaire to physiotherapists they will be asked about general therapist and treatment 
characteristics (e. g. working experience and interest in PD) and specific treatment characteristics 
such as treatment goals, intensity and duration. (The questionnaire for physiotherapists has ethical 
approval see Dnr:2015/570-32)   
 
Effectiveness 
This effectiveness study will be based on the knowledge gained based on the survey and are planned 
to comprise four to six different clinical settings such as primary care facilities and 
neurorehabilitation centres. We have already established contacts with primary care and 
rehabilitation facilities in Stockholm (Stockholms sjukhem, Karolinska universitetssjukhuset, Bromma 
geriatriken, Stora Sköndal). The academic primary care facilities (Akademiska vårdcentralerna) in 
Stockholm will also be an interesting partner in the implementation. We expect clinics to join the 
study in a sequence and are here starting with Stockholms sjukhem, Karolinska universitetssjukhuset 
and Stora Sköndal. One hundred participants will be recruited through the participating clinics.  
 

100 participants will be recruited from the participating clinics. 50 patients will act as a training group 
and 50 as a control group. The control group will consist of patients waiting to participate in a 
training group and will be offered training after a control period of 10 weeks.  
 
The 10-week balance training program (HiBalance) will be performed two or three times per week 
for one hour each. A pilotstudy will compare the feasibility, the progression using accelerometers 
during the session as well as explore barriers and facilitators for performing the traning two or three 
times/week (ethical approval for the pilot Dnr:2015/570-32). The training will be lead by 
physiotherapists in the clinics. Patient level outcome variables will be adapted to the clinical 
environment and will be balance performance (Mini-BESTest), gait ability (10 meter walk-test and 
Timed Up and Go with and without concomitant cognitive and motor tasks), physical activity level 
and intensity (accelerometers/pedometers), health related quality of life (EQ5D). The tests will be 
performed by the physiotherapists in the clinic and conducted before and after the training period. 
As a part of the implementation, we will choose measurements developed and tested in clinical 
practice.  
 
To evaluate the effectiveness of the HiBalance program in clinical settings mixed models will be used. 
Sample size is based on the key outcome variable (Mini-BESTest) and based on data from the pilot 
study of the effectiveness study. With a 80% power andan alfa level of 0.05, a minimum of 37 
subjects in each group will be required dectect a change of 1 point between groups. The dropout rate 
was set at 15%, Taken together, to ensure adequate statistical power the sample size for this study 
would optimally be 50 per group (total 
n = 80).  
 
Implementation 
A participatory approach will be used for implementation of the HiBalance program, where the 
clinics and physiotherapist will be engaged in an early face (Scheirer, Hartling et al. 2008). The 
strategies for implementation will include: 1) meetings with the head of Physical therapy at each 
clinic, 2) discussions and involvement with physical therapists in the clinic and 3) education of the 
training program and outcome measures to physical therapists who will be involved in the training. 
 
An educational curriculum consisting of movies/pictures of the exercises and a clinical handbook of 
the program and its theoretical framework will be developed. In addition, a digital tool (webpage or 
mobile application) to disseminate the training program to physiotherapists will be developed 
through a series of developmental workshops using an ideation method. The participants of the 
workshops will consist of physiotherapists working with people with Parkinson’s disease and familiar 
to group training. Data from the workshops will be collected through video and sound recordings as 
well as by observers and will be analyzed with qualitative content analysis. After developing the 
digital tool a pilot study will be performed with physiotherapists. Data will be collected through 
surveys, statistics from the digital tool and from focus groups (ethical approval 2015/1804-32). As a 
second step, a digital tool to promote balance training and physical activity in individuals will also be 
developed using the same technique i.e., developmental workshops with end-users (patients with 
Parkinson’s disease), develop the tool and thereafter testing the tool with a pilot study.  
 
Fidelity to the program will be assessed by process evaluation. This will be performed by 
investigating the compliance to the training for the patients and the adherance to the training 
concept itself and its theoretical framework in regards to the trainers/physical therapists. The 
patients compliance will be measured as number of sessions attending. For the trainers/physical 
therapist adherence to the concept and theoretical framework will be assessed by reviewing the 
documentation of the traing sessions (logbooks) and observations. Obeservations of trainers will be 
used to provide an insight into interactions and progression (Mulhall 2003), which makes it a 
preferable method when exploring what is happening during the training sessions. Barriers and 

facilitators will also involve feasibility i.e., the extent of which the program is regarded as satisfactory 
in terms of content and complexity/challenging by the patients and trainers (Durlak and DuPre 2008). 
 
In the implementation study, we will study facilitators and barriers to “real-world” implementation of 
the intervention. We will collect information on possible barriers that might have influenced the 
implementation of the program and facilitators that might have supported the implementation. This 
information can in turn be used to identify possible implementation strategies that can be used to 
facilitate the implementation of the program into current clinical practice. Both qualitative (focus 
groups and individual semi-structured interviews) and quantitative (questionnaires) methodologies 
will be posed to representatives of different stakeholders (patients, physiotherapists/trainers and 
managers/directors). By using several sources for data collection, triangulation can be achieved, 
which supports trustworthiness of the study (Patton 2002). To form the interview guide we will 
follow the guidelines posed by Durlak and DuPre (2008) with a focus on barriers and facilitators. The 
transcripts from the qualitative data will be analysed by the use of qualitative content analysis. 
 
RELEVANCE 
With an improved balance and gait, increased level of physical activity and an improved health 
related quality of life, individuals participating in the program will not only reduce their risk of falling, 
but also gain other health benefits related to an active lifestyle and, thereby, a good and active 
ageing. The results from this project will have an immediate application and clinical relevance for all 
elderly at risk of falling. Our evaluation methods and training program fills a gap in everyday clinical 
practice and will in a very near future, have the potential to reach a large number of elderly, and thus 
reduce the risk of falls and fall-related injuries. 
 
The long-term goal of this project is to improve balance and gait ability in individuals with PD by 
exposure to a new challenging and progressive balance training program in combination with 
physical activity and thereby reduce the risk of falling. In the short-term perspective this proposed 
research could directly contribute to a change in focus concerning balance interventions in PD and 
other neurological disorders. In a medium perspective it has a potential to contribute to new clinical 
tests to balance disorders, physical inactivity and predict falls in elderly. An improvement in balance 
function, physical activity might prevent or postpone the incidence of a hazardous fall, thus reducing 
the burden on the health care system and the society as well as for the individual. 
Our model for balance training and outcome methods will expand techniques and measurements 
tools available to physical therapists and other health care professionals treating and evaluating 
patients with balance disorders. In addition, participating in the study will increase the knowledge 
and skills of the clinicians and patients involved. 
 
ETHICAL CONSIDERATIONS 
As shown in the project plan some parts are already approved by the Regional board of ethics in 
Stockholm, dnr 2015/1804-32 and 2015/570-32. These have been applied for as an amendment to 
the former ethical approvals in the BETA project (2006/151-31, 2009/819-32, 2010/1472-32 and 
2012/1829-32. We are now applying for ethical approvement from a broader perspective of the 
whole implementation part and are therfore incorporating also these parts since they are a part of 
theat perspective. In addition, the BETA projekct has divided into two parts: an osteoporosis part 
with Agneta Ståhle as PI and a Parkinson’s disease part (BETA-PD) with Erika Franzén as PI.  This 
application does only concern the BETA-PD part and therefore Erika Franzén is the main responsible 
researcher/PI. 
 
We are conscious of the increased risks for falls compared to usual balance training of elderly and 
have taken special precautions by having 2 trainers and small group of 5-6 patients, we estimate the 
risk as very small in comparison to the benefit of the training.  

 
CONTACTS AND COLLABORATION IN THIS PROJECT 
The project is conducted by a multidisciplinary team of experts representing different disciplines 
(physical therapy, geriatrics, neurology and public health.The investigators and collaborators involved 
in this project possess a unique knowledge necessary for both clinical and laboratory research and 
implementation of the results. The investigators also have the clinical knowledge- and the patients- 
to transfer the results directly to the clinic in a multidisciplinary way. 
 
Erika Franzén, is the principal investigator for this project, with main responsibility for project 
planning, administration, intervention, evaluation, writing papers, supervision of students at PhD, 
master and bachelor level. Dr. Franzén is an associate professor, has her own research group 
(http://ki.se/en/nvs/franzen-group)  and holds a research associate position (forskarassistent-tjänst) 
from the Swedish Research Council. Dr. Franzén is head of the Motor Control Laboratory, Karolinska 
Institutet, KI, which have excellent resources for analyzing gait, balance and motion. Dr. Franzén is an 
expert in balance control and movement in elderly and Parkinson’s disease, in both clinical and 
laboratory settings. Currently, she supervises four PhD students working fulltime within the project, 
three postdoc’s and several master students. She also holds positions at Karolinska University 
hospital and Stockholms Sjukhem.  
 
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