Effects of balance training on balance, gait and non-motor symptoms in individuals with Parkinson's disease

Postural instability (PI) is one of the most disabling symptoms of Parkinson’s disease (PD). PI is a well-known risk factor for falls in individuals with PD that worsens with disease progression. About 50-70% of people with PD fall once or more in a year, which is much higher than the 30% fall rate reported for community dwelling older individuals. Impaired balance associated with PI and fear of falling are factors related to decreased mobility and poor quality of life in individuals with PD. Several studies have examined the effects of exercise particularly strengthening and aerobic training on various motor and non-motor symptoms of PD. However to date, few studies have examined effects of balance specific interventions on balance, spatiotemporal gait, and non-motor symptoms such as fatigue, pain and depression. Moreover, none have used a commercially available device, Biodex Balance System (BSS) to implement a challenging balance training protocol. BSS consists of a moving platform that can be used to progressively challenge one’s balance while providing visual feedback. Finally, most of the previous studies did not report information pertaining to clinically meaningful changes in balance and its implications to physical function and quality of life in individuals with PD. The overall objective of this study was to evaluate whether short term progressively challenging balance specific training using the BSS improves balance, spatiotemporal gait and non-motor symptoms including fatigue, pain and depression in individuals with PD compared to usual non-progressive balance exercises. The central hypothesis is that challenging balance exercises, where individuals with PD are challenged out of their comfort zone for static and dynamic balance can significantly improve balance and spatiotemporal gait. Chapter 2 describes aims 1 and 2, utilizing 4 weeks of BBS balance training to determine changes in sway measures and spatio-temporal gait variables in individuals with PD. Ten individuals in a balance exercise group using the BSS and 10 individuals in general balance exercise group without Biodex (Non-BSS) completed the study. This study showed that 4 weeks of balance exercises using BSS resulted in significant within group improvement in sway area, center of pressure (CoP), path length in antero-posterior (AP) direction in the BSS group. We also found significant within group improvements in the balance measured by Berg Balance Scale, gait velocity, and step length in both groups. Additionally, we found significant within group improvements in functional scores measured by the Timed Up and Go and 6 Minute Walk Test in both groups. However, we did not find significant between group differences for any of the outcome variables. Due to technical failure in the system, we were not able to report force plate data from the non-BSS group. Chapter 3 describes aim 3, where 4 weeks of BSS training was utilized to determine changes in fatigue, pain, depression, fear of falling and quality of life in individuals with PD. Although motor symptoms of PD are described widely in the literature, and several studies report improvement in motor symptoms following various exercise trainings, little has been done to determine the efficacy of exercise interventions on the non - motor symptoms of PD. Aerobic exercise, strengthening, gait, tai-chi, qigong, and yoga therapy have been shown to improve motor deficits in PD. However, no study has examined the effects of balance training with BSS on non-motor features such as depression, fatigue, pain and fear of falling in individuals with PD. In our study, we determined the effects of balance training on non - motor symptoms of PD. The results demonstrated that 4 weeks of balance training resulted in a non-significant trend toward improvement in depression, pain, and fear of falling, and only the BSS training group demonstrated statistically significant improvement in fatigue. In summary, this dissertation work provides evidence that the use of the BSS is feasible, safe, and effective in improving balance, gait, and function in individuals with PD. However further study with a larger sample size, randomized control design, and biomechanical (force plate) data in both groups is required to better understand the role of challenging balance training in this population. The findings of this dissertation work have implications about designing future studies with specific intensity of balance exercises needed to make meaningful changes in balance, gait and non-motor symptoms of not only the individuals with PD but also in individuals with other neurological disorders resulting in PI.