Instrumental or Physical-Exercise Rehabilitation of Balance in Parkinson's Disease? (IPER-PD)
Condition: Parkinson's Disease; Rehabilitation
MeSH terms: Parkinson Disease
Study type: Interventional

Summary: 
      We hypothesized that rehabilitation specifically addressing balance in Parkinson ́s disease
      patients might improve not only balance, but locomotion as well. Two balance training
      protocols (standing on a moving platform, and traditional balance exercises) were compared by
      assigning patients to two groups: moving platform (n=15) and balance exercises (n=17).
      Platform moved periodically in antero-posterior, latero-lateral and oblique direction, with
      and without vision in different trials. Balance exercises were based on Otago Exercise
      Program. Both platform and exercises sessions were administered from easy to difficult.
      Outcome measures were: a) balancing behaviour, assessed both by index of stability (IS) on
      platform and by Mini-BESTest, b) gait, assessed both by baropodometry and by Timed Up and Go
      (TUG) test. Falls Efficacy Scale-International (FES-I) and Parkinson's Disease Questionnaire
      (PDQ-8) were administered. Both groups exhibited better balance control, as assessed both by
      IS and by Mini-BESTest. Gait speed at both baropodometry and TUG also improved in both
      groups. Scores of FES-I and PDQ-8 showed a marginal improvement. A four-week treatment
      featuring no gait training, but focussed on challenging balance tasks produces considerable
      gait enhancement in mildly to moderately affected patients. Walking problems in PD depend on
      postural instability and are successfully relieved by appropriate balance rehabilitation.
    

Detailed description: 
      The importance for training balance in connection with rehabilitation aimed at improving gait
      is easily stressed by considering the complex motor behaviour underpinning more challenging
      conditions than linear walking, as walking-and-turning, where the turn-related changes in
      feet, trunk and head movements are integral part of he kinematics of the steering body
      (Courtine and M. Schieppati, 2003; Crenna et al, 2007). It is no wonder that freezing of gait
      and increased risk of falling (Schlenstedt et al., 2016) is associated with abnormal
      bilateral coordination and turning. Hence, the present investigation somehow diverges from
      the theory of the task-specific training (Bayona et al., 2005), but considers instead the
      relevance for locomotion enhancement of training balance control, by hypothesising that
      specific balance rehabilitation might be sufficient for gait improvement. Here, we trained PD
      patients with two different treatments, both specifically addressing balance. A platform onto
      which subjects stood moved in antero-posterior, latero-lateral and diagonal direction in the
      horizontal plane. A simpler moving-platform protocol had been previously exploited for
      testing and enhancing balance capacities in patients with PD and with vestibular deficit
      (Nardone et al., 2010; De Nunzio 2007). This platform protocol challenges both the
      anticipatory and the reactive capacities to the ongoing postural perturbations, thereby
      training dynamic balance control, aiming at the balance problems encountered during every day
      activity.

      The outcome of the platform treatment was compared to that obtained in another group of
      matched patients with PD by standardized and validated exercises aimed at training balance
      and dynamic balance (Renfro et al., 2016). Of note, these exercises contained no dynamic
      component (i.e. gait-related exercises) of balance training, contrary to Conradsson et al.
      2017. Both treatments (platform and exercises) were tailored to the patient individual
      capacities, and their difficulty gradually increased all along the duration of the treatment
      (Conradsson et al., 2017). In this context, we estimated any improvement in balance control
      by indexes of dynamic stability during a balance perturbation test on the mobile platform and
      by clinical scores related to dynamic balance control. Gait improvement was both evaluated
      instrumentally and assessed by a functional clinical test.
    

Intervention name(s): Balance exercise; Mobile platform exercise
Intervention type(s): Other; Other
Intervention description(s): Patients in the balance exercise group received a personalized exercise program developed by an expert physiotherapist. There was no predefined duration for each item of the set of exercises, but all patients underwent an overall 45 min period training per day according to the same schedule. This schedule was based on the Otago Exercise Program and Practice Guidelines for the treatment of Parkinson's disease. Patients did not wear shoes for balance training. All exercises were performed without upper-limb support and with the supervision of a physiotherapist.; Patients entered the mobile platform and put on a security harness (no weight unloading), which they wore during the entire session on the platform training. The arms were free to move, but they were asked not to reach out for support. Each patient underwent 45 minutes of training (resting periods included), in which from 6 to 8 perturbation patterns were administered, each one lasting about 4 minutes. During training, the platform moved in the antero-posterior, latero-lateral and diagonal (45 deg) direction with respect to the body. The periodic platform displacement was 10 cm, regardless of the frequency, which could range from 0.3 to 0.6 Hz. Patients stood with eyes open and closed and feet together or 20 cm apart depending on the perturbation subtype.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment