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Capato TTC1,2, de Vries NM1, in ’t Hout J3, Barbosa ER2, Nonnekes J4, Bloem BR1
1Radboud University Medical Center, Neurology, Nijmegem, Netherlands, 2University of São Paulo, Neurology, São Paulo, Brazil, 3Radboud University Medical Center, Health Evidence, Nijmegem, Netherlands, 4Radboud University Medical Center, Rehabilitation, Nijmegem, Netherlands
Background: Because balance impairments in Parkinson' s disease (PD) only partially improve by dopaminergic medication, non-pharmacological interventions including physiotherapy, are increasingly being recognised as an essential element in the management of these problems. External cues are often applied in PD to improve gait. However, it is unclear what the effect of external cueing on balance control in PD is. Moreover, it is unclear whether balance impairments (a measure closely associated with the risk of falling and injuries), can improve with Physicaltherapy.
Purpose: To
1) investigate the effect of physiotherapy involving functional balance exercises (multimodal balance training-MBT) on balance control in patients with PD,
2) investigate whether the effects retain in the long-term, and
3) investigate whether the intervention is more effective when auditory cues are provided.
Methods: We performed a parallel, prospective, single-blind, randomized controlled trial. Individuals from outpatient clinics were enrolled from July 2015 through May 2017 with the primary and end point at 6 months. Individuals with idiopathic PD (Hoehn and Yahr stages 1 to 3), with falls history and stable medication. A total of 185 volunteers were screened by telephone; 154 were randomly assigned into three groups:
(1) MBT with rhythmical auditory cues delivered by a metronome (MBTR);
(2) MBT without rhythmical cues (MBT); and
(3) no intervention control group (Control).
Balance Training was performed for 5 weeks, two times a week using a personalized protocol. MBRT (n=52); MBT (n=44); Control (n=37) were assessed at baseline, post intervention, 9 and 35 weeks after the training. Our primary outcome was the Mini-BESTest score. Secondary outcomes included BBS, TUG, UPDRS and LEDD. Assessments were performed by a single, blinded assessor at baseline and after 5, 9 and 35 weeks follow-up. Treatment effects were estimated with a linear mixed model, adjusted for Mini-BESTest baseline and LEDD. The study and was registered at clinicaltrials.gov (NCT02488265).
Results: A total of 133 patients were included in the study (mean age of 70 years (SD 13). Groups were comparable at baseline. Compared to the Control, at 5 weeks follow-up, both the MBTR and the MBT group had improved on the Mini-Best Test (primary outcome) (estimated mean difference MBTR-CG 6.7 (SE 0.7), P 0.001; MBT-CG 3.0 (SE 0.7), P 0.001). The MBTR group showed a significantly larger improvement than the MBT group (MBTR-MBT 3.7 (SE 0.6), P 0.001). The improvements were retained at 9 weeks follow-up (MBTR-CG 6.2 (SE 0.7), P 0.001; MBTR-CG 2.0 (SE 0.7), P 0.004). Only the MBTR group maintained its improvement at 35 weeks (MBTR-CG 5.0 (SE 0.7), P 0.001). The same trends were found for the secondary outcomes (BBS, Retropulsion Test, PRT and FES-I). Less falls and injuries were reported after the study in comparison to baseline by all groups.
Conclusion(s): The multimodal balance training with rhythmical auditory cues is effective to balance control in long-term and reduce falls and injuries.
Implications: This study can support the importance of physicaltherapy as a non-pharmacological intervention on management of balance and contribute to the increasing evidence base for physiotherapy, eventually leading to optimized care in PD.
Keywords: Parkinson's Disease, Balance, External cues
Funding acknowledgements: No funding.
Purpose: To
1) investigate the effect of physiotherapy involving functional balance exercises (multimodal balance training-MBT) on balance control in patients with PD,
2) investigate whether the effects retain in the long-term, and
3) investigate whether the intervention is more effective when auditory cues are provided.
Methods: We performed a parallel, prospective, single-blind, randomized controlled trial. Individuals from outpatient clinics were enrolled from July 2015 through May 2017 with the primary and end point at 6 months. Individuals with idiopathic PD (Hoehn and Yahr stages 1 to 3), with falls history and stable medication. A total of 185 volunteers were screened by telephone; 154 were randomly assigned into three groups:
(1) MBT with rhythmical auditory cues delivered by a metronome (MBTR);
(2) MBT without rhythmical cues (MBT); and
(3) no intervention control group (Control).
Balance Training was performed for 5 weeks, two times a week using a personalized protocol. MBRT (n=52); MBT (n=44); Control (n=37) were assessed at baseline, post intervention, 9 and 35 weeks after the training. Our primary outcome was the Mini-BESTest score. Secondary outcomes included BBS, TUG, UPDRS and LEDD. Assessments were performed by a single, blinded assessor at baseline and after 5, 9 and 35 weeks follow-up. Treatment effects were estimated with a linear mixed model, adjusted for Mini-BESTest baseline and LEDD. The study and was registered at clinicaltrials.gov (NCT02488265).
Results: A total of 133 patients were included in the study (mean age of 70 years (SD 13). Groups were comparable at baseline. Compared to the Control, at 5 weeks follow-up, both the MBTR and the MBT group had improved on the Mini-Best Test (primary outcome) (estimated mean difference MBTR-CG 6.7 (SE 0.7), P 0.001; MBT-CG 3.0 (SE 0.7), P 0.001). The MBTR group showed a significantly larger improvement than the MBT group (MBTR-MBT 3.7 (SE 0.6), P 0.001). The improvements were retained at 9 weeks follow-up (MBTR-CG 6.2 (SE 0.7), P 0.001; MBTR-CG 2.0 (SE 0.7), P 0.004). Only the MBTR group maintained its improvement at 35 weeks (MBTR-CG 5.0 (SE 0.7), P 0.001). The same trends were found for the secondary outcomes (BBS, Retropulsion Test, PRT and FES-I). Less falls and injuries were reported after the study in comparison to baseline by all groups.
Conclusion(s): The multimodal balance training with rhythmical auditory cues is effective to balance control in long-term and reduce falls and injuries.
Implications: This study can support the importance of physicaltherapy as a non-pharmacological intervention on management of balance and contribute to the increasing evidence base for physiotherapy, eventually leading to optimized care in PD.
Keywords: Parkinson's Disease, Balance, External cues
Funding acknowledgements: No funding.
Topic: Neurology; Neurology; Disability & rehabilitation
Ethics approval required: Yes
Institution: University of São Paulo
Ethics committee: Comissão de Ética para Análise de Projetos de Pesquisa
Ethics number: 1.102.464.
All authors, affiliations and abstracts have been published as submitted.
