Progressive supranuclear palsy (PSP) is a chronically progressive neurodegenera- tive disorder [1] and can, in part, be con- sidered as a representative model ...
Beiträge zum Themenschwerpunkt Z Gerontol Geriat 2010 DOI 10.1007/s00391-010-0125-6 © Springer-Verlag 2010
S. Nicolai1 · A. Mirelman2 · T. Herman2 · A. Zijlstra3 · M. Mancini4 · C. Becker1 · U. Lindemann1 · D. Berg5 · W. Maetzler1, 5 1 Clinic for Geriatric Rehabilitation, Robert-Bosch-Hospital, Stuttgart 2 Laboratory for Gait and Neurodynamics, Tel Aviv Sourasky Medical Center, Tel Aviv 3 Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen 4 DEIS, Department of Electronics, Computer Science and Systems, Università di Bologna 5 Center of Neurology, Department of Neurodegeneration, Hertie Institute for Clinical Brain Research and German Center for Neurodegenerative Diseases, University of Tuebingen
Improvement of balance after audio-biofeedback A 6-week intervention study in patients with progressive supranuclear palsy
Progressive supranuclear palsy (PSP) is a chronically progressive neurodegenerative disorder [1] and can, in part, be considered as a representative model of compressed aging [2, 3]. Postural instability and falls usually occur at an early disease stage and are the most disabling features [4, 5]. These deficits are most probably due to a synergistic deterioration of brainstem and higher cortical functions, i.e., a deficit of the central nervous system [6], and they lead to a wheelchair dependency within a few years. For PSP, there is no sufficient treatment option to date, including medical treatment. There is scarce literature on the effect of physical therapy in PSP. However, a few case reports are available. Steffen and colleagues [7] reported about a possible slower decline of physical performance after a locomotor training for gait and balance in a PSP patient over a 2.5-year training period. Another case study showed improved balance and a decrease in falls in 1 PSP patient after 8 weeks of body weight-supported treadmill training [8]. Two case reports in a total of 3 patients using programs of strengthening and range-of-motion exercises for the trunk and limbs, coordina-
tion exercises and balance activities, gait and transfer training, and fine motor activities reported an—at least short term— improvement in walking ability and safety [9, 10]. Thus, although the number of reports and patients included in the case studies are very small, it seems that at least some amelioration of postural instability can be reached by training. Biofeedback (BF), a training technique in which people are taught to improve one’s health and performance by using signals from one’s own body, can be used to augment sensory information. In particular, balance improvements may be achieved by adding artificial sensory information (sensory augmentation or substitution) that informs the brain about actual body posture and movements. This information may be coded into an appropriate sensory signal and provided in real time; in this case, brain and muscle activities that are not normally controlled voluntarily may be changed according to the new information available.
> Biofeedback is a training
technique to help improve health and performance by using signals from one’s own body
It has recently been shown that training with an audio-biofeedback (ABF) system has a positive effect on balance performance in patients with bilateral vestibular loss, i.e., a disorder of the peripheral nervous system leading to loss of postural control [11]. Based on the observation that physical therapy may have a positive effect in PSP, and considering the promising results of the ABF training in patients with peripheral vestibular deficits, we hypothesized that in the central nervous system disorder PSP deficits in postural control may also be influenced by ABF-based posture and dynamic balance training.
Methods Study design and participants In this uncontrolled intervention study, a repeated measures design with a 6-week Zeitschrift für Gerontologie und Geriatrie 2010
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Beiträge zum Themenschwerpunkt Tab. 1 Characteristics of the PSP patients (n=8)a Age (years) Height (cm) Weight (kg) BMI (kg/m2) MMSE (0–30)b Onset of disease (years) Duration of disease (years) PRS (0–100)c Postural stability (0–4)c
Median 66 160 77.8 28.9 26 57.7 4.8 46.5 2.5
Mean 66.4 160.5 78.0 30.4 26.3 60.3 6.2 45.4 2.5
SD 6.1 8.1 16.5 6.8 1.4 6.1 4.0 12.8 1.2
Min–Max 57–74 148.0–174.0 53.8–110.0 23.0–43.0 25–29 55.2–71.2 1.5–13.4 22–58 1–4
a6 females, b30=best value, c0=best value; BMI body mass index, MMSE Mini Mental Health Status Exam, PRS
PSP rating scale, postural stability measured by item 27 (pull test) of the PSP rating scale.
Fig. 1 8 Components of the audio-biofeedback device
intervention to improve posture and dynamic balance was applied. Assessments were performed within 1 week before the beginning of the intervention (T1), within 1 week after the last training session (T2), and 4 weeks after the completion of the intervention (T3). The intervention was conducted in a 1:1 setting three times per week for approximately 45 minutes in a geriatric rehabilitation center in southern Germany. The inclusion criteria were the ability to stand at least with technical support, such as grab/handrail or walking aids, but without another person’s assistance, and absence of serious co-morbidities. The exclusion criteria were major depression (defined by a Beck’s Depression Inventory Score >15 [12]), de-
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Zeitschrift für Gerontologie und Geriatrie 2010
mentia (defined by the ICD-10 criteria [13] and by a Mini-Mental Status examination score Goals were to improve not
only posture control and postural stability, but also to improve dynamic balance
All participants started with category 1. The order of the six categories was predefined, but the progression within the categories was decided individually depending on physical ability, individual needs, and individual physical progression during the training. Every training session included various exercises of the most difficult category that the patient was able to perform and the repetition of exercises which were performed in the previous sessions. One exercise took 2–3 minutes depending on the alertness and motor disability of the patient and was repeated in accordance with the abilities of the patient.
Assessments
The Berg Balance Scale (BBS) was used for assessing standing balance during functional activities. The BBS consists of 14 different balance tasks which basically test standing, reaching, bending, and transferring abilities and has an overall score range from 0 (severely impaired) to 56 points (excellent) [16]. The Timed Up-and-Go (TUG) test was used to assess functional mobility. The patients were instructed to stand up from a chair, walk for a distance of 3 m at comfortable speed, turn, walk back, and finally to sit down on the chair again [17]. The use of a walking aid was allowed. Time was taken by a stopwatch. The average of two trials was taken. A modified Five Chair Rise (5CR) test (the patients were allowed to use the arm rests) was used to assess the ability to perform sit-to-stand and stand-to-sit transfers. Patients were instructed to stand up and sit down five times as fast as possible starting in the sitting position and stopping after sitting down the fifth time [18]. Time was taken by a stopwatch. The average of two trials was taken. The motor part of the Unified Parkinson’s Disease Rating Scale (UPDRS) was used to measure Parkinson-specific features such as bradykinesia, postural control, and rigidity [19]. This scale recently has been used successfully to measure disease progression in PSP [20].
Z Gerontol Geriat 2010 DOI 10.1007/s00391-010-0125-6 © Springer-Verlag 2010 S. Nicolai · A. Mirelman · T. Herman · A. Zijlstra · M. Mancini · C. Becker · U. Lindemann · D. Berg · W. Maetzler
Improvement of balance after audio-biofeedback. A 6-week intervention study in patients with progressive supranuclear palsy Abstract Progressive supranuclear palsy (PSP) is a neurodegenerative disease with no sufficient treatment options to date. The most devastating symptom is the loss of balance with consecutive falls. Based on the observation that postural control improved in patients with vestibular dysfunction after audio-biofeedback training, we tested the effects of this training in PSP patients. Eight PSP patients were included into an uncontrolled 6week intervention trial. The focus of the training was the improvement of posture and dynamic balance by using audio-biofeedback. The device was well accepted. No adverse events occurred. A significant improvement in the Berg Balance Scale was observed (T2
vs. T1, p=0.016), which remained significant at the 4-week follow-up (T3 vs. T1, p=0.008). Significant improvement of the Parkinson’s disease questionnaire was demonstrated. No significant changes were found in the Timed Up-and-Go Test, the Five Chair Rise Test, and in specific clinical scales. To our knowledge, the present study is the first to demonstrate that audio-biofeedback training with PSP patients is associated with improvements of balance and psychosocial aspects. Keywords Intervention · Mobility · Neurodegenerative disease · Posture control · Postural stability
Verbesserung des Gleichgewichts durch Audiobiofeedback. Eine 6-wöchige Interventionsstudie mit Patienten mit progressiver supranucleärer Blickparese Zusammenfassung Progressive supranukleäre Blickparese (PSP) ist eine neurodegenerative Erkrankung, für die es zurzeit noch keine geeigneten Behandlungsmethoden gibt. Der Verlust der Gleichgewichtsfähigkeit und die daraus resultierenden Stürze sind die Hauptsymptome. Ausgehend von einer Studie, die eine Verbesserung der Gleichgewichtsfähigkeit nach einem Audiobiofeedback- (ABF-)Training bei Patienten mit beidseitigem Vestibularisausfall zeigte, überprüften wir, ob dieser Effekt auch bei PSP-Patienten nachweisbar ist. Acht PSP-Patienten wurden in eine nichtkontrollierte 6wöchige Interventionsstudie eingeschlossen. Ziel des Trainings war die Verbesserung der Haltung und des dynamischen Gleichgewichts mithilfe von ABF. Das Gerät wurde gut akz-
eptiert. Die Berg-Balance-Skala zeigte eine Verbesserung (T2 vs. T1, p=0,016), die auch beim Follow-up nachweisbar war (T3 vs. T1, p=0,008). Auch im Parkinson’s Disease Questionnaire ließen sich Verbesserungen finden. Der Timed Up-and-Go Test, der Five Chair Rise Test und spezifische klinische Einschätzungen ergaben keine signifikanten Veränderungen. Unseres Wissens ist dies die erste Studie mit PSP-Patienten, die durch ein ABF-Training Verbesserungen des Gleichgewichts und psychosozialer Aspekte zeigt. Schlüsselwörter Intervention · Mobilität · Neurodegenerative Erkrankung · Haltungskontrolle · Haltungsstabilität
Zeitschrift für Gerontologie und Geriatrie 2010
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Beiträge zum Themenschwerpunkt Tab. 2 Intervention effects and follow-up Measures BBS (n=8) TUG (n=6) 5CR (n=5) UPDRS (n=8) PDQ-39 (n=8) Summary index Mobility ADL Wellbeing Stigma Social support Cognition Communication Bodily discomfort ABC (n=8) GDS (n=8)
T1 35 (6–50)* 24.5 (19.3–50.7) 40.1 (30.5–93.7) 33 (19–70) 36.2 (28.6–55.4) 90.0 (62.5–100) 58.3 (25.0–87.5) 8.3 (0.0–62.5) 0.0 (0.0–31.3) 0.0 (0.0–41.7) 37.5 (0.0–50.0) 66.7 (50.0–75.0)* 16.7 (0.0–25.0) 13.8 (1.3–28.1)* 4 (1–11)
T2 44 (9–50)* 22.5 (15.3–66.7) 46.2 (28.6–89.5) 41 (33–60) 26.7 (22.3–44.0) 90.0 (67.5–100) 54.2 (29.2–87.5) 4.2 (0.0–75.0) 0.0 (0.0–12.5) 0.0 (0.0–41.7) 12.5 (0.0–56.3) 41.7 (16.7–66.7) 0.0 (0.0–50.0) 6.9 (0.0–21.3) 6 (3–10)
T3 41 (10–52)* 24.95 (16.6–95.7) 51.6 (29.8–122.4) 39 (28–67) 24.5 (21.3–40.1)* 90.0 (82.5–100) 50.0 (33.3–91.7) 4.2 (0.0–50.0) 0.0 (0.0–6.3) 0.00 (0.0–33.3) 18.8 (0.0–31.3)* 50.0 (25.0–66.7)* 0.0 (0.0–16.7) 16.3 (0.0–37.5) 5 (2–9)
Values are median (min–max); T1 pre-training, T2 post-training, T3 follow-up, ABC Activities-specific Balance Confidence ranging from 0–100% where 100%=best, ADL Activities of Daily Living ranging from 0–100 points where 0=best, BBS Berg Balance Scale ranging from 0–56 points where 56=best, 5CR Five Chair Rise Test, GDS Geriatric Depression Scale ranging from 0–15 where 15=worst, Summary index of the PDQ-39 ranging from 0–100 where 100=worst, TUG Timed Up-and-Go Test, UPDRS Unified Parkinson’s Disease Rating Scale ranging from 0–100 where 100=worst, *p
