Vibrotactile neurofeedback balance training in patients with Parkinson's disease: Reducing the number of falls☆
Highlights
► A free-field vibrotactile neurofeedback training can improve balance in PD patients. ► An important outcome was a significant reduction in falls during daily life. ► Training with more than 6 tasks would possibly further enhance the effectiveness. ► Future studies should investigate the long-term follow up.
Introduction
In patients with Parkinson's disease (PD), balance impairment represents a considerable mortality risk from the numerous falls that possibly result. Specifically, 50.8–68.3% of patients experience falls in PD [1], [2]. One of the most important associated injuries resulting from falls is hip fracture due to the impaired protective arm reflexes [3]. Falls also have significant psychological and social consequences and represent severe risks for the patients [4].
Furthermore, it is a well-known fact that pharmacological treatment does not decisively improve balance and gait impairments in PD patients [5]. The same holds true for surgical measures [6]. It was even reported that some PD patients tended to fall more often after deep brain stimulation surgery [7].
The present study was initiated as a result of our earlier investigations in postural stability of PD patients. Patients with PD suffer from balance disorders basically because of deficient processing of visual and vestibular inputs [8]. In some of them, Computerized Dynamic Posturography (CDP) can detect alterations in balance that cannot be detected by routine clinical examination [8]. Deterioration in processing vestibular information in PD does not depend on the stage of the disease [8]. Patients also have reduced limits of body stability, i.e., they are more likely to fall as a result of their diminished base of support [8].
When our patients were assessed by VOR (caloric and rotatory tests) and oculomotor testing, they showed a central vestibular processing deficit [9].
Finally, we reported in a previous study [10] that vestibular rehabilitation with CDP in patients with PD can significantly improve activities of daily life, gait velocity and balance. Moreover, these benefits can persist over a certain period of time.
Therefore, rehabilitation with neurofeedback training (NFT) in every-day life conditions seems to be well suited to increase and improve performance of PD patients in dynamic tasks. In these free-field conditions, falls among PD patients commonly occur (e.g., sitting down or standing up). Trunk sway measurements at center of body mass (hip) under such everyday-life conditions showed an increased risk of fall and a much higher trunk sway of PD patients compared to controls [11]. Earlier studies showed a high effectiveness of a free-field auditory NFT to reduce body sway in patients with different peripheral vestibular disorders [12], [13]. This type of NFT has distinct disadvantages. In this approach, body sway is encoded as an auditory signal; the patient should maintain postural control in a normal range by responding to an emitted sound (in two dimensions). This is impossible for PD patients since they cannot react in an adequate manner to this non-intuitive information. In contrast to auditory neurofeedback, an intuitive, vibrotactile neurofeedback stimulus (which has a very short reaction time [14]) seems more appropriate to encode individual sway during everyday-life conditions in PD patients.
Thus, the aim of this study was to assess effectiveness of balance training with a vibrotactile NFT system in improving overall stability in PD patients.
Section snippets
Patients
10 patients diagnosed with idiopathic PD were categorised according to criteria established by Gelb [15] (Hoehn and Yahr [16] III, 6 patients; Hoehn and Yahr IV, 4 patients). The patients (eight male, two female) had an average age of 67 years (53–79 years). On examination, balance was impaired in all patients, with at least 2 points in item 33 of UPDRS [17].
Nine of the PD patients were classified as a “faller” because they had suffered at least one fall over the past three months. All
Free-field body sway analysis (mobile posturography)
Total body sway data (as calculated over all training tasks) before, immediately after cessation of training sessions and after 3 months are shown for pitch and roll directions in Fig. 2A. Immediately after ending the training, a significant decrease in body sway by 43.5% in pitch (p = 0.001, Wilcoxon test) and by 42.2% in roll direction, respectively, (p = 0.001, Wilcoxon test) were found. After 3 months, these differences continued to be statistically significant (pitch: p = 0.03, roll: p = 0.01).
Discussion
Balance training may be an effective way to improve postural instability in PD patients. Previously, Cochrane review found that there was insufficient evidence to support or refute the efficacy of physiotherapy in PD [24]. Subsequently, there are different rehabilitation groups that have reported improvement in postural stability in PD patients with different kinds of exercises [10], [25], [26].
An important outcome of our study was a significant reduction in falls during daily life in patients
Conflict of interest statement
I would like to inform you that there are not conflicts of interest. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.
Acknowledgement
This study was supported by a grant of the German Ministry of Education and Research (BMBF-01EZ0754).
References (30)
- et al.
A prospective study of alteration of balance among patients with Parkinson's disease: protocol of the postural evaluation
European Neurology
(2009) - et al.
Trunk sway measurements during stance and gait tasks in Parkinson's disease
Gait and Posture
(2005) - et al.
Vestibular rehabilitation by auditory feedback in otolith disorders
Gait and Posture
(2008) - et al.
“Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician
Journal of Psychiatric Research
(1975) - et al.
Programmatic vestibular rehabilitation
Otolaryngology: Head and Neck Surgery
(1995) - et al.
Postural instability and falls in Parkinson's disease
Advances in Neurology
(2001) - et al.
A community-dwelling sample of people with Parkinson's disease: characteristics of fallers and non-fallers
Age and Ageing
(2001) - et al.
The impact of comorbid disease and injuries on resource use and expenditures in Parkinson's disease
Neurology
(2003) - et al.
Preventing falls in elderly persons
New England Journal of Medicine
(2003) - et al.
Postural instability in idiopathic Parkinson's disease: the role of medication and unilateral pallidotomy
Brain
(2002)
A meta-regression of the long-term effect of deep. Brain stimulation on balance and gait in PD
Neurology
Bilateral deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease
JAMA
Análisis de la función vestibular en la enfermedad de Parkinson: exploración del reflejo vestíbulo-ocular y su correlación con el estudio posturográfico
Rev Port ORL
Vestibular rehabilitation with computerized dynamic posturography in patients with Parkinson's disease: improving balance impairment
Disability and Rehabilitation
The balance control of bilateral peripheral vestibular loss subjects and its improvement with auditory prosthetic feedback
Journal of Vestibular Research
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A preliminary report was presented at XXVI Bárány Society Meeting (Reykjavik 20th August 2010).