Elsevier

Gait & Posture

Volume 37, Issue 2, February 2013, Pages 195-200
Gait & Posture

Vibrotactile neurofeedback balance training in patients with Parkinson's disease: Reducing the number of falls

https://doi.org/10.1016/j.gaitpost.2012.07.002Get rights and content

Abstract

The aim of this study was to assess effectiveness of balance training with a vibrotactile neurofeedback system in improving overall stability in patients with Parkinson's disease (PD).

Ten patients diagnosed with idiopathic PD were included. Individualization of the rehabilitation program started with a body sway analysis of stance and gait tasks (Standard Balance Deficit Test, SBDT) by using the diagnostic tool of the applied device (Vertiguard®-RT). Those tasks with the poorest outcome as related to age- and gender-related controls were included in the training program (not more than six tasks). Improvement of postural stability was assessed by performing SBDT, Sensory Organization Test (SOT) of Computerized Dynamic Posturography (CDP), Dizziness Handicap Inventory (DHI), activity-specific balance confidence scale and recording the number of falls over the past three months. Furthermore, scores of SOT and DHI of 10 PD patients previously trained in an earlier study (by using CDP) were compared with results of those in the present study.

After neurofeedback training (NFT), there was a statistically significant improvement in body sway (calculated over all training tasks), number of falls, and scores of SOT, DHI and ABC. In comparison with CDP-training, a statistically significant higher increase of SOT score was observed for patients after NFT with the Vertiguard-RT device compared to CDP training.

Our results showed that a free-field vibrotactile NFT with Vertiguard®-RT device can improve balance in PD patients in everyday life conditions very effectively, which might led in turn to a reduction 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).

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