Niklas Löfgren

The Effects of Highly Challenging Balance Training in Elderly With Parkinson’s Disease A Randomized Controlled Trial

Background. Highly challenging exercises have been suggested to induce neuroplasticity in individuals with Parkinson’s disease (PD); however, its effect on clinical outcomes remains largely unknown. Objective. To evaluate the short-term effects of the HiBalance program, a highly challenging balance-training regimen that incorporates both dual-tasking and PD-specific balance components, compared with usual care in elderly with mild to moderate PD. Methods. Participants with PD (n = 100) were randomized, either to the 10-week HiBalance program (n = 51) or to the control group (n = 49). Participants were evaluated before and after the intervention. The main outcomes were balance performance (Mini-BESTest), gait velocity (during normal and dual-task gait), and concerns about falling (Falls Efficacy Scale–International). Performance of a cognitive task while walking, physical activity level (average steps per day), and activities of daily living were secondary outcomes. Results. A total of 91 participants completed the study. After the intervention, the between group comparison showed significantly improved balance and gait performance in the training group. Moreover, although no significant between group difference was observed regarding gait performance during dual-tasking; the participants in the training group improved their performance of the cognitive task while walking, as compared with the control group. Regarding physical activity levels and activities of daily living, in comparison to the control group, favorable results were found for the training group. No group differences were found for concerns about falling. Conclusions. The HiBalance program significantly benefited balance and gait abilities when compared with usual care and showed promising transfer effects to everyday living. Long-term follow-up assessments will further explore these effects.

A novel conceptual framework for balance training in Parkinson’s disease-study protocol for a randomised controlled trial

BackgroundThere is increasing scientific knowledge about the interaction between physiological (musculoskeletal, neuromuscular, cognitive and sensory) systems and their influence on balance and walking impairments in Parkinson’s disease. We have developed a new conceptual framework for balance training, emphasising specific components of balance control related to Parkinson’s disease symptoms by using highly challenging, progressive and varying training conditions. The primary aim of this proposed randomised controlled trial will be to investigate the short-term and long-term effects of a 10-week balance training regime in elderly with Parkinson’s disease.Methods/DesignEighty participants with mild to moderate idiopathic Parkinson’s disease will be recruited and randomly allocated to an intervention group receiving balance training or a control group whose participants will continue to receive their usual care. The intervention will consist of a 10-week group training regime (1-hour training, three times per week), which will be led by two physiotherapists to ensure training progression and safety. The conceptual framework will be applied by addressing specific balance components (sensory integration, anticipatory postural adjustments, motor agility, stability limits) through varying training conditions and structured progression. Assessment will be conducted through a multi-dimensional battery of outcomes, prior to and immediately after the 10-week intervention, and at 9 and 15 months’ follow-up after entering the study. Primary outcome measures will be balance performance (assessed using the Mini Balance Evaluation Systems Test), change in gait velocity (m/s) between single and dual task walking, and fear of falling (evaluated using the Fall Efficacy Scale International).DiscussionThis study has the potential to provide new insight and knowledge of the effects of specific, varied and challenging balance training on a wide health spectrum in elderly with PD. If found to be effective, this pragmatic approach with translation of theory into practice, can be implemented in existing outpatient care.Trial registrationNCT01417598

The Mini-BESTest - a clinically reproducible tool for balance evaluations in mild to moderate Parkinson’s disease?

BackgroundThe Mini-BESTest is a clinical balance test that has shown a high sensitivity in detecting balance impairments in elderly with Parkinsons disease (PD). However, its reproducibility between different raters and between test occasions has yet to be investigated in a clinical context. Moreover, no one has investigated the reproducibility of the Mini-BESTests subcomponents (i.e. anticipatory postural adjustments; postural responses; sensory orientation and dynamic gait).We aimed to investigate the inter-rater and test-retest reproducibility (reliability as well as agreement) of the Mini-BESTest, as well as its subcomponents, in elderly with mild to moderate PD, performed under conditions assimilating clinical practice.MethodThis was an observational measurement study with a test-retest design.Twenty-seven individuals with idiopathic PD (66 - 80 years, mean age: 73; Hoehn & Yahr: 2-3; 1-15 years since diagnosis) were included. Two test administrators, having different experiences with the Mini-BESTest, administered the test individually, in separate rooms in a hospital setting. For the test-retest assessment, all participants returned 7 days after the first test session to perform the Mini-BESTest under similar conditions. Intra-class correlation coefficients (ICC2.1), standard error of measurement (SEMagreement), and smallest real difference (SRD) were analyzed.ResultsThe Mini-BESTest showed good reliability for both inter-rater and test-retest reproducibility (ICC = 0.72 and 0.80). Regarding agreement, the measurement error (SRD) was found to be 4.1 points (accounting for 15% of the maximal total score) for inter-rater reproducibility and 3.4 points (12% of the maximal total score) for test-retest reproducibility. The investigation of the Mini-BESTests subcomponents showed a similar pattern for both inter-rater and test-retest reproducibility, where postural responses had the largest proportional measurement error, and sensory orientation showed the highest agreement.ConclusionsOur findings indicate that the Mini-BESTest is able to distinguish between individuals with mild to moderate PD; however, when used in clinical balance assessments, the large measurement error needs to be accounted for.

Investigating the Mini-BESTest's construct validity in elderly with Parkinson's disease.

The Mini‐BESTest consists of items relevant to balance deficiencies among people with Parkinsons disease (PwPD). However, the Mini‐BESTests construct validity has been sparsely evaluated in this population.

Structural Validity of the Mini-Balance Evaluation Systems Test (Mini-BESTest) in People With Mild to Moderate Parkinson Disease

Background The Mini-Balance Evaluation Systems Test (Mini-BESTest) is a clinical balance test comprising 14 items assumed to reflect the unidimensional construct “dynamic balance.” Objective The study objective was to examine the dimensionality of the test and the properties of each item and their interrelationships in elderly people with mild to moderate Parkinson disease (PD). Design This was a cross-sectional study in a laboratory setting. Methods A total of 112 participants (mean age=73 years) with idiopathic PD (Hoehn and Yahr stages 1–3) were assessed by physical therapists. Local independence among items was examined with Rasch modeling. Unidimensionality was tested by running a principal component analysis on the residuals. An exploratory factor analysis was used to examine the structure of the test, and a confirmatory factor analysis was used to evaluate the fit of the derived model. Results The first residual component of the principal component analysis, with an eigenvalue of greater than 2, superseded the assumption of unidimensionality. After the omission of item 7 because of convergence problems, the exploratory factor analysis suggested that a 3-factor solution best fit the data. A confirmatory factor analysis demonstrated acceptable fit of the final model, although item 14 loaded poorly on its factor. Limitations The sample size was on the lower end of what is generally recommended. Conclusions This study could not confirm that the Mini-BESTest is unidimensional. Gait items were dispersed over all factors, indicating that they may reflect different constructs. Nonetheless, as there arguably is no clinical balance test superior to the Mini-BESTest today, we recommend using the total score for assessing gross balance in this population and individual items to identify specific weaknesses. Moreover, dual tasks should be assessed separately because they are an important aspect of balance control in people with PD, reflected in only one item of the test.

The reliability of gait variability measures for individuals with Parkinson’s disease and healthy older adults – The effect of gait speed

BACKGROUND Step-to-step variability is a marker of reduced motor control and a frequently studied outcome measure in neurodegenerative disorders such as Parkinsons disease (PD) as compared to healthy older adults (HOA). To challenge motor control of gait, walking should be tested at different gait speeds. Good reliability is essential, and gait variability estimates show good reproducibility when sampled at normal gait speed. The aim was therefore to investigate if gait variability could be reliably sampled at slow and fast speeds for individuals with PD and HOA by evaluating test-retest reliability. METHODS 29 (14 males) subjects with idiopathic PD, Hoehn &Yahr 2 (n = 18) and 3, ≥ 60 years, and 25 age matched HOAwere included. Spatiotemporal gait data was collected (GAITRite) during slow, normal, and fast walking on two occasions. RESULTS Measurement error was lowest for gait variability estimates based on 40 steps in both groups. This was true across all speeds in HOA, but only for normal and fast gait speeds in the PD cohort. Due to increased homogeneity in the variability estimates intraclass correlation coefficients (ICC) were low for HOA, except for step width variability. In the PD cohort ICCs were good to excellent for temporal- and step width gait variability across speeds. CONCLUSION HOA demonstrated reliable gait variability estimates across all speeds, whereas Individuals with PD were reliable at normal and fast gait speeds only Estimates should be based on at least 40 steps. Step width variability was overall the most reliable variable across groups and speed conditions.

Gait characteristics in older women with osteoporosis and fear of falling

Abstract Ageing affects gait characteristics during walking under single- and dual-task conditions. Osteoporosis in elderly with fear of falling may further implicate gait alterations. The aims were to characterize spatiotemporal gait parameters, by comparing gait performance at comfortable speed to gait at maximal speed and while performing a dual task, respectively, and to investigate the relationship between gait characteristics and ageing in older women with osteoporosis and self-reported fear of falling. Seventy-nine elderly women (mean age 76 years, range 65–87), with osteoporosis and fear of falling, walked at comfortable and maximal speed and during a cognitive dual task, using the GAITRite® walkway system. Subjects were divided into three age groups (65–69, 70–79, 80 + years). Divergences were analysed with analysis of variance. At maximal gait speed participants increased velocity, cadence, step length and swing phase, and reduced both double support and stance phase (p < 0.001). Dual-task walking decreased cadence (p < 0.001), increased step width (p = 0.007) and step length variability (p < 0.001). Gait performance, especially during a dual task diverged most in the oldest subjects, indicating that they are at a higher risk of falling. This study only found minute alterations compared with normative gait data in healthy elderly.

Cost-effectiveness of the HiBalance training program for elderly with Parkinson’s disease: analysis of data from a randomized controlled trial

Objective: To determine the cost-effectiveness of the HiBalance training program for managing Parkinson’s disease (PD)-related balance and gait disorders. Design: Cost comparison design following the randomized controlled trial comparing a novel balance training intervention with care as usual. Subjects: A total of 100 participants with mild–moderate PD were randomized to either the intervention (n = 51) or the control group (n = 49). Intervention: A 10-week (three times per week), group-based, progressive balance training program, led by two physical therapists. Main outcomes: All program costs were collected for both groups. Cost-utility was evaluated using quality-adjusted life years (QALYs) and cost-effectiveness measures were the Mini Balance Evaluation Systems Test (Mini-BESTest; assessing balance performance) and gait velocity. Incremental cost-effectiveness ratios were calculated and a probabilistic sensitivity analysis was conducted. Results: The between-group difference in QALYs was 0.043 (95% confidence interval (CI): 0.011–0.075), favoring the intervention group. Between-group differences in balance performance and gait velocity were 2.16 points (95% CI: 1.19–3.13) and 8.2 cm/second (95% CI: 2.9–13.6), respectively, favoring the intervention group. The mean cost per participant in the intervention group was 16,222 SEK (€1649) compared to 2696 SEK (€274) for controls. The estimated incremental cost-effectiveness ratios were 314,558 SEK (€31,969) for an additional QALY, 6262 SEK (€631) for one point improvement in balance performance, and 1650 SEK (€166) for 1 cm/second increase in gait velocity. Sensitivity analyses indicated a high probability (85%) of program success. Conclusion: In terms of QALYs, the HiBalance program demonstrated a high probability of cost-effectiveness in the short-term perspective when considering the willingness-to-pay thresholds used in Europe.

Patient-reported and performance-based measures of walking in mild-moderate Parkinson's disease

Knowledge of the relationships between patient‐reported and performance‐based walking measures in Parkinsons disease (PD) should inform clinical decision‐making. The Walk‐12G reliably captures perceived walking difficulties but has not been compared to performance‐based walking in laboratory or free‐living settings or across different groups.