Multimodal Balance Training Improves Freezing of Gait in PD

Daniel M. Keller, PhD

September 25, 2019

NICE, France — Both Parkinson's patients who have freezing of gait, known as "freezers," and those who do not, "non-freezers," benefit from multimodal balance training (MBT) with rhythmic cues, a new study shows.

"The multimodal training is effective to train balance, and the effect can be long term," physical therapist Tamine Capato, MS, a PhD candidate working at Radboud University Medical Center, Nijmegen, the Netherlands, reported.

The strategy worked for freezers and non-freezers, Capato added, "[but] the freezers looked like [they] had extra benefit." They improved more with MBT on the Mini Balance Evaluation Systems Test (MBEST) score — the primary endpoint — compared with standard training, whereas non-freezers did about equally well with either training modality.

Their findings were presented here at the International Congress of Parkinson's Disease and Movement Disorders.

Freezing and Balance

Freezing and loss of balance can both limit mobility and may lead to injury. Nonpharmacologic interventions are important, and MBT has been shown to improve balance and gait in Parkinson's, but it was unclear whether it worked for both freezers and non-freezers.

This collaborative study by researchers at the Radboud Medical Center and the University of São Paulo, Brazil randomly assigned 154 patients with Hoehn and Yahr stage 1-3 Parkinson's disease to three groups: MBT (n = 54), standard balance training without auditory cues (n = 50), or a control intervention group (n = 48) that received just an educational program.

The MBT consisted of standard balance training plus rhythmical auditory cues provided by a metronome. Blinded assessments were performed at baseline, post-intervention, and at 1 and 6 months of follow-up while patients were in an ON period on medication.

Interventions were performed twice a week for 5 weeks. The MBEST score was the primary outcome measure, as determined by a single, blinded assessor.

On the MBEST primary outcome measure, "when compared with the control group, both the multimodal and the standard group improved," Capato said. However, the effect of the multimodal balance training was greatest, and the effects were maintained at 1 month and 6 months follow up for both active interventions.

Non-freezers in both active intervention groups had higher MBEST scores at baseline and at all later time points compared with freezers. The education-only control group had no improvement in MBEST scores at any time.

Although the standard balance training group was somewhat better at baseline than the MBT group on the Timed Up and Go test — which measures a person's ability to rise from a seated position, walk, turn, walk back, and sit down — both groups showed improvements to about the same levels post-intervention and at 1 and 6 months' follow-up.

Non-freezers did better than freezers at baseline and at all time points for both active intervention groups. Levodopa equivalent daily doses for all three groups remained relatively unchanged over the course of the study.

"Huge Explosion" in Exercise Trials

Poster tour guides Susan Fox, MB ChB, PhD, of University Health Network, Toronto, Canada, and Michael Schwarzschild, MD, PhD, of Massachusetts General Hospital, Boston, commented on the study findings for Medscape Medical News and offered their perspectives on training modalities for Parkinson's patients in general.

Fox, who has recently reviewed several clinical trials of exercise in Parkinson's disease, said there has been a "huge explosion" in such work in the last few years.

"I think any intervention you do in a Parkinson patient seems to have a positive outcome," she said. "So the freezers, the non-freezers, they all seem to improve on whatever measures you use…it's very hard to get a good measure that can really bring out whether the exercise is truly having a biological effect or just makes the patient feel better because you're doing something with them."

Nonetheless, Fox commended the researchers for their trial design, having included an active control group and a best medical practice group. "So I think they are trying to improve the design of trials in exercise, which has been a criticism of trials we've reviewed. But whether this specific intervention is going to be better than tai chi or some other exercise, I think it's too early to know," she said.

Schwarzschild noted that physicians have recommended exercise to their patients, but now "the quality of research is improving to the point where we can make much more informed recommendations."

He agreed that the MBT study had a rigorous design but noted that it is inherently difficult to design good trials for treatments that can't be blinded very easily. "But it is impressive how clinical trials for exercise and physical activity are overcoming some of those hurdles," he said.

When asked if exercise or training interventions slow progression of Parkinson's, Fox said she doubts at the moment that they change the biology of the disease. Preclinical evidence suggests they may improve dopaminergic function, "but translating that into clinical trials I think is challenging," she said.

And although clinicians continue to recommend exercise to their Parkinson's patients based on less than satisfying evidence, good studies may instill more confidence in the advice. "Having solid data of a benefit would give the recommendations more weight," Schwartzschild said.

There was no commercial funding of the study. Capato, Fox, and Schwarzschild have disclosed no relevant financial relationships.

International Congress of Parkinson's Disease and Movement Disorders (MDS) 2019: Abstract 71. Presented September 23, 2019.

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