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Invited Commentary

Judith E. Deutsch, Anat Mirelman, Jeffrey M. Hausdorff
DOI: 10.2522/ptj.20100050.ic Published 1 June 2011
Judith E. Deutsch
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Anat Mirelman
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Jeffrey M. Hausdorff
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Patients with Parkinson disease (PD) have motor and cognitive impairments that lead to a heightened risk of falls. The annual incidence may reach 60% to 80%,1–3 more than twice that of the general elderly population. Traditional treatment approaches in PD generally have focused on symptom relief to maximize function and minimize secondary complications. Indeed, until recently, the assumption has been that motor learning cannot take place in the presence of impaired basal ganglia.4,5 Exciting evidence from animal models and patient studies suggests, instead, that the pathways involving the basal ganglia in people with PD may be capable of plasticity6–9 and that their activity patterns may be partly corrected with appropriate intensive training.10–12 For example, some studies have demonstrated improvements in gait speed and stride length following treadmill training.10,13,14 Despite promising initial results, many questions remain. It is not fully clear whether training in patients with PD can transfer beyond the task that was specifically trained, whether long-term retention is possible, or whether the risk of falls can be reduced.9,15

Yen et al16 describe a different approach to improving motor control and reducing fall risk among patients with PD. They evaluated the potential of using training using virtual reality (VR) to improve postural control. Forty-two patients were randomly assigned to 1 of 3 study arms: VR-augmented balance training, conventional balance (CB) training, or a placebo control (no training). Scores on the Sensory Organization Test (SOT) (ie, postural sway with eyes open on a firm surface and under conditions that challenge vision, vestibular function, or proprioception) were the outcomes. The main findings were that, after 6 weeks of training, individuals in the CB group performed better than those in the other 2 groups in a sensory condition that had vision occluded (SOT-5) and that the VR group performed better in the sensory condition when vision and somato-sensation were distorted (SOT-6). The SOT-6 generally is considered the most challenging condition.

A major strength of this report is the study design. Randomization into 3 study arms allowed the authors to tease apart the added benefits of VR-based training compared with CB training and with no training. The results suggest specificity of training and a potential benefit of using VR. When considering the advantages of VR-based training, it is important to keep in mind that virtual environments are not uniformly superior to conventional training, and each approach may offer specific elements that are critical components to building a comprehensive intervention. There were, however, no differences among the groups with respect to the dual-task or other sensory conditions, nor were there any long-term effects. The authors acknowledge that the study likely was underpowered, that the dual-task administration could be modified, and that the VR system could be enhanced by providing individualized interventions.

When considering VR applications for treating balance and mobility, we suggest a number of issues that should inform the intervention. These issues include dosing intensity, equivalence between real-world and virtual tasks, baseline assessments, and tailored progressions. Dosing intensity can be guided by findings from previous work in the real world and by the increasing body of work on VR. Yen et al speculated that the intensity of their VR training might not have been sufficient. A total of 6 hours of training over 6 weeks is relatively low compared with the body of work on using VR to improve walking for individuals poststroke17 and about 30% of the training time used in our work on VR and with individuals with PD.18 Exercise and treadmill studies in PD also suggest that more is better.10,12–14

In other VR work, care has been taken to address the important issues of equivalence between virtual and real-world tasks. Addressing these issues is particularly challenging, as activities in virtual environments cannot always be perfectly matched with real-world activities. An excellent example of treatment equivalence can be found in the work of Jaffee and colleagues,19 who used a head-mounted display to deliver a virtual stepping task that was matched with an identical real-world task. Because the 2 interventions were motorically equivalent, they could tease out the specific benefits of the VR approach. In the work by Yen and colleagues, static balance, dynamic weight shifting, and external perturbations were applied in the CB group, but it is unclear how these 3 categories mapped to the VR games and whether the number of movement repetitions and exposure to the exercises were similar in the 2 groups. If the goal of comparing CB and VR interventions is to sort out mechanisms and the added value of VR training, considerations of treatment equivalence should be taken into account in the study design.

One of the potential advantages of VR-based training is the ability to match the level of training to the individual. This matching frequently can be achieved by having a baseline assessment and task progression. In the study by Yen et al, the CB group had a clear progression. It is not clear, however, whether this progression was comparable for the VR group or how the difficulty was set in the virtual games. Did participants have a test each day that set the thresholds for performance? In studies of lower-extremity training to improve walking for people poststroke,20,21 baseline performance of range of motion and force generation was set for each session, allowing the clinician to set training targets that were flexible and adaptable. Similarly, in a study that used VR in patients with PD, the treadmill gait speed was reassessed once a week, and the training speed was adjusted accordingly.18

Task difficulty also was updated continuously. For example, the orientation, size, frequency of appearance, and shape of the targets were manipulated according to individual needs following a standardized protocol designed to achieve a success rate of 80% in order to promote engagement and motor learning and to allow for a graded, but individualized, progression. In VR work designed to improve upper-extremity use in individuals poststroke, algorithms used measurements of proximal and distal movement kinematics to adjust and progress difficulty (online and offline) of tasks.22 In the present work, platform sensitivity and movement direction were varied, but it was not fully clear how decisions about training progression were made or standardized. Periodic reassessment of the patients' abilities or extraction of relevant performance parameters to drive an algorithm should help to maximize progression.

An additional beneficial study design feature in the study by Yen et al is the inclusion of preintervention and postintervention testing in a dual-task condition. Parkinson disease typically is considered a motor disease, but cognitive impairment frequently occurs. Reduced dopaminergic input from the ventral tegmental mesencephalic area to the frontal and limbic regions likely contributes to cognitive-behavioral dysfunction in people with PD,23 mainly affecting executive function and attention. Diminished executive function and attention negatively affect gait and increase the risk of falls in individuals with PD and older adults.24–33 Recent evidence has shown that interventions aimed at dual-task training in individuals with PD can show immediate benefits and even some retention effects in both motor and cognitive domains.18,34–36 In the present study, a laudable attempt was made at assessing the effects of attention on balance control. However, the task chosen was likely not ideal—as noted by the authors, it was too simple and not continuous, and the VR and CB training did not specifically manipulate attention or dual-task abilities.

Virtual environments may address multiple facets of motor behavior and cognition. Thus, when considering future intervention studies that build on the findings of Yen et al, it may be better to create systems that address not only postural sway, but also other capabilities that are critical to balance, mobility, and fall risk among patients with PD. Because safe mobility is not simply a motor task,33,37–39 VR interventions should take advantage of the simulated environment to concomitantly challenge and train cognitive and motor abilities. A VR-based intervention that targets both of these domains and adequately addresses key issues such as dosing, retention, transfer, and biofeedback may yet prove to be more beneficial than CB training for patients with PD.

  • © 2011 American Physical Therapy Association

References

  1. ↵
    1. Balash Y,
    2. Peretz C,
    3. Leibovich G,
    4. et al
    . Falls in outpatients with Parkinson's disease: frequency, impact and identifying factors. J Neurol. 2005;252:1310–1315.
    OpenUrlCrossRefPubMedWeb of Science
  2. ↵
    1. Bloem BR,
    2. Hausdorff JM,
    3. Visser JE,
    4. Giladi N
    . Falls and freezing of gait in Parkinson's disease: a review of two interconnected, episodic phenomena. Mov Disord. 2004;19:871–884.
    OpenUrlCrossRefPubMedWeb of Science
  3. ↵
    1. Wood BH,
    2. Bilclough JA,
    3. Bowron A,
    4. Walker RW
    . Incidence and prediction of falls in Parkinson's disease: a prospective multidisciplinary study. J Neurol Neurosurg Psychiatry. 2002;72:721–725.
    OpenUrlAbstract/FREE Full Text
  4. ↵
    1. Siegert RJ,
    2. Taylor KD,
    3. Weatherall M,
    4. Abernethy DA
    . Is implicit sequence learning impaired in Parkinson's disease? A meta-analysis. Neuropsychology. 2006;20:490–495.
    OpenUrlCrossRefPubMedWeb of Science
  5. ↵
    1. Vakil E,
    2. Kahan S,
    3. Huberman M,
    4. Osimani A
    . Motor and non-motor sequence learning in patients with basal ganglia lesions: the case of serial reaction time (SRT). Neuropsychologia. 2000;38:1–10.
    OpenUrlCrossRefPubMedWeb of Science
  6. ↵
    1. Fisher BE,
    2. Wu AD,
    3. Salem GJ,
    4. et al
    . The effect of exercise training in improving motor performance and corticomotor excitability in people with early Parkinson's disease. Arch Phys Med Rehabil. 2008;89:1221–1229.
    OpenUrlCrossRefPubMedWeb of Science
  7. ↵
    1. Petzinger GM,
    2. Walsh JP,
    3. Akopian G,
    4. et al
    . Effects of treadmill exercise on dopaminergic transmission in the 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-lesioned mouse model of basal ganglia injury. J Neurosci. 2007;27:5291–5300.
    OpenUrlAbstract/FREE Full Text
  8. ↵
    1. Ramig LO,
    2. Sapir S,
    3. Countryman S,
    4. et al
    . Intensive voice treatment (LSVT) for patients with Parkinson's disease: a 2 year follow up. J Neurol Neurosurg Psychiatry. 2001;71:493–498.
    OpenUrlAbstract/FREE Full Text
  9. ↵
    1. Rochester L,
    2. Baker K,
    3. Hetherington V,
    4. et al
    . Evidence for motor learning in Parkinson's disease: acquisition, automaticity and retention of cued gait performance after training with external rhythmical cues. Brain Res. 2010;1319:103–111.
    OpenUrlCrossRefPubMedWeb of Science
  10. ↵
    1. Herman T,
    2. Giladi N,
    3. Gruendlinger L,
    4. Hausdorff JM
    . Six weeks of intensive treadmill training improves gait and quality of life in patients with Parkinson's disease: a pilot study. Arch Phys Med Rehabil. 2007;88:1154–1158.
    OpenUrlCrossRefPubMedWeb of Science
  11. ↵
    1. Morris ME,
    2. Huxham FE,
    3. McGinley J,
    4. Iansek R
    . Gait disorders and gait rehabilitation in Parkinson's disease. Adv Neurol. 2001;87:347–361.
    OpenUrlPubMedWeb of Science
  12. ↵
    1. Nieuwboer A,
    2. Kwakkel G,
    3. Rochester L,
    4. et al
    . Cueing training in the home improves gait-related mobility in Parkinson's disease: the RESCUE trial. J Neurol Neurosurg Psychiatry. 2007;78:134–140.
    OpenUrlAbstract/FREE Full Text
  13. ↵
    1. Mehrholz J,
    2. Friis R,
    3. Kugler J,
    4. et al
    . Treadmill training for patients with Parkinson's disease. Cochrane Database Syst Rev. 2010;(1):CD007830.
  14. ↵
    1. Herman T,
    2. Giladi N,
    3. Hausdorff JM
    . Treadmill training for the treatment of gait disturbances in people with Parkinson's disease: a mini-review. J Neural Transm. 2009;116:307–318.
    OpenUrlCrossRefPubMedWeb of Science
  15. ↵
    1. Nieuwboer A,
    2. Rochester L,
    3. Muncks L,
    4. Swinnen SP
    . Motor learning in Parkinson's disease: limitations and potential for rehabilitation. Parkinsonism Relat Disord. 2009;15(suppl 3):S53–S58.
    OpenUrlWeb of Science
  16. ↵
    1. Yen C-Y,
    2. Lin K-H,
    3. Hu M-H,
    4. et al
    . Effects of virtual reality–augmented balance training on sensory organization and attentional demand for postural control in people with Parkinson disease: a randomized controlled trial. Phys Ther. 2011;91:862–874.
    OpenUrlAbstract/FREE Full Text
  17. ↵
    1. Deutsch JE
    . Using virtual reality to improve walking post stroke: translation to individuals with diabetes. J Diabetes Sci Technol. 2011;5:309–315.
    OpenUrlAbstract/FREE Full Text
  18. ↵
    1. Mirelman A,
    2. Maidan I,
    3. Herman T,
    4. et al
    . Virtual reality for gait training: can it induce motor learning to enhance complex walking and reduce fall risk in patients with Parkinson's disease? J Gerontol A Biol Sci Med Sci. 2011;66:234–240.
    OpenUrlPubMedWeb of Science
  19. ↵
    1. Jaffe DL,
    2. Brown DA,
    3. Pierson-Carey CD,
    4. et al
    . Stepping over obstacles to improve walking in individuals with poststroke hemiplegia. J Rehabil Res Dev. 2004;41:283–292.
    OpenUrlCrossRefPubMedWeb of Science
  20. ↵
    1. Deutsch JE,
    2. Merians AS,
    3. Adamovich S,
    4. et al
    . Development and application of virtual reality technology to improve hand use and gait of individuals post-stroke. Restor Neurol Neurosci. 2004;22:371–386.
    OpenUrlPubMedWeb of Science
  21. ↵
    1. Mirelman A,
    2. Bonato P,
    3. Deutsch JE
    . Effects of training with a robot-virtual reality system compared with a robot alone on the gait of individuals after stroke. Stroke. 2009;40:169–174.
    OpenUrlAbstract/FREE Full Text
  22. ↵
    1. Adamovich SV,
    2. Fluet GG,
    3. Merians AS,
    4. et al
    . Incorporating haptic effects into three-dimensional virtual environments to train the hemiparetic upper extremity. IEEE Trans Neural Syst Rehabil Eng. 2009;17:512–520.
    OpenUrlCrossRefPubMedWeb of Science
  23. ↵
    1. Campos-Sousa IS,
    2. Campos-Sousa RN,
    3. Ataide JL,
    4. et al
    . Executive dysfunction and motor symptoms in Parkinson's disease. Arq Neuropsiquiatr. 2010;68:246–251.
    OpenUrlCrossRefPubMed
  24. ↵
    1. Adams R,
    2. Parsons O
    . Neuropsychology for Clinical Practice: Etiology, Assessment, and Treatment of Common Neurologic Disorders. Washington, DC: American Psychological Association; 2003.
  25. ↵
    1. Bloem BR,
    2. Valkenburg VV,
    3. Slabbekoorn M,
    4. van Dijk JG
    . The Multiple Tasks Test: strategies in Parkinson's disease. Exp Brain Res. 2001;137:478–486.
    OpenUrlCrossRefPubMedWeb of Science
  26. ↵
    1. Brauer SG,
    2. Woollacott M,
    3. Shumway-Cook A
    . The interacting effects of cognitive demand and recovery of postural stability in balance-impaired elderly persons. J Gerontol A Biol Sci Med Sci. 2001;56:M489–M496.
    OpenUrlAbstract/FREE Full Text
  27. ↵
    1. Brauer SG,
    2. Woollacott M,
    3. Shumway-Cook A
    . The influence of a concurrent cognitive task on the compensatory stepping response to a perturbation in balance-impaired and healthy elders. Gait Posture. 2002;15:83–93.
    OpenUrlCrossRefPubMedWeb of Science
  28. ↵
    1. Hausdorff JM,
    2. Balash J,
    3. Giladi N
    . Effects of cognitive challenge on gait variability in patients with Parkinson's disease. J Geriatr Psychiatry Neurol. 2003;16:53–58.
    OpenUrlAbstract
  29. ↵
    1. Hausdorff JM,
    2. Yogev G
    . Cognitive function may be important for fall injury prevention trials. J Am Geriatr Soc. 2006;54:865–866.
    OpenUrlPubMedWeb of Science
  30. ↵
    1. Hausdorff JM,
    2. Herman T,
    3. Inbar-Borovsky N,
    4. et al
    . Cognitive and motor mediators of the changes in gait stability during dual tasking in healthy older adults. Mov Disord. 2007;22:S163–S164.
    OpenUrl
  31. ↵
    1. Shumway-Cook A,
    2. Woollacott M,
    3. Kerns KA,
    4. Baldwin M
    . The effects of two types of cognitive tasks on postural stability in older adults with and without a history of falls. J Gerontol A Biol Sci Med Sci. 1997;52:M232–M240.
    OpenUrlPubMedWeb of Science
  32. ↵
    1. Woollacott M,
    2. Shumway-Cook A
    . Attention and the control of posture and gait: a review of an emerging area of research. Gait Posture. 2002;16:1–14.
    OpenUrlPubMedWeb of Science
  33. ↵
    1. Yogev G,
    2. Giladi N,
    3. Peretz C,
    4. et al
    . Dual tasking, gait rhythmicity, and Parkinson's disease: which aspects of gait are attention demanding? Eur J Neurosci. 2005;22:1248–1256.
    OpenUrlCrossRefPubMedWeb of Science
  34. ↵
    1. Nieuwboer A,
    2. Baker K,
    3. Willems AM,
    4. et al
    . The short-term effects of different cueing modalities on turn speed in people with Parkinson's disease. Neurorehabil Neural Repair. 2009;23:831–836.
    OpenUrlAbstract/FREE Full Text
  35. ↵
    1. Rochester L,
    2. Hetherington V,
    3. Jones D,
    4. et al
    . The effect of rhythmical cues on walking during a simple and dual functional motor task in a complex environment in people with Parkinson's disease. Arch Phys Med Rehabil. In press.
  36. ↵
    1. Rochester L,
    2. Baker K,
    3. Hetherington V,
    4. et al
    . Evidence for motor learning in Parkinson's disease: acquisition, automaticity and retention of cued gait performance after training with external rhythmical cues. Brain Res. 2010;1319:103–111.
    OpenUrlCrossRefPubMedWeb of Science
  37. ↵
    1. Alexander NB,
    2. Hausdorff JM
    . Guest editorial: linking thinking, walking, and falling. J Gerontol A Biol Sci Med Sci. 2008;63:1325–1328.
    OpenUrlFREE Full Text
  38. ↵
    1. Allcock LM,
    2. Rowan EN,
    3. Steen IN,
    4. et al
    . Impaired attention predicts falling in Parkinson's disease. Parkinsonism Relat Disord. 2009;15:110–115.
    OpenUrlCrossRefPubMedWeb of Science
  39. ↵
    1. Yogev-Seligmann G,
    2. Hausdorff JM,
    3. Giladi N
    . The role of executive function and attention in gait. Mov Disord. 2008;23:329–342.
    OpenUrlCrossRefPubMedWeb of Science
View Abstract
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Vol 96 Issue 12 Table of Contents
Physical Therapy: 96 (12)

Issue highlights

  • Musculoskeletal Impairments Are Often Unrecognized and Underappreciated Complications From Diabetes
  • Physical Therapist–Led Ambulatory Rehabilitation for Patients Receiving CentriMag Short-Term Ventricular Assist Device Support: Retrospective Case Series
  • Education Research in Physical Therapy: Visions of the Possible
  • Predictors of Reduced Frequency of Physical Activity 3 Months After Injury: Findings From the Prospective Outcomes of Injury Study
  • Use of Perturbation-Based Gait Training in a Virtual Environment to Address Mediolateral Instability in an Individual With Unilateral Transfemoral Amputation
  • Effect of Virtual Reality Training on Balance and Gait Ability in Patients With Stroke: Systematic Review and Meta-Analysis
  • Effects of Locomotor Exercise Intensity on Gait Performance in Individuals With Incomplete Spinal Cord Injury
  • Case Series of a Knowledge Translation Intervention to Increase Upper Limb Exercise in Stroke Rehabilitation
  • Effectiveness of Rehabilitation Interventions to Improve Gait Speed in Children With Cerebral Palsy: Systematic Review and Meta-analysis
  • Reliability and Validity of Force Platform Measures of Balance Impairment in Individuals With Parkinson Disease
  • Measurement Properties of Instruments for Measuring of Lymphedema: Systematic Review
  • myMoves Program: Feasibility and Acceptability Study of a Remotely Delivered Self-Management Program for Increasing Physical Activity Among Adults With Acquired Brain Injury Living in the Community
  • Application of Intervention Mapping to the Development of a Complex Physical Therapist Intervention
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Invited Commentary
Judith E. Deutsch, Anat Mirelman, Jeffrey M. Hausdorff
Physical Therapy Jun 2011, 91 (6) 875-877; DOI: 10.2522/ptj.20100050.ic

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Invited Commentary
Judith E. Deutsch, Anat Mirelman, Jeffrey M. Hausdorff
Physical Therapy Jun 2011, 91 (6) 875-877; DOI: 10.2522/ptj.20100050.ic
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  • Reliability and Validity of Force Platform Measures of Balance Impairment in Individuals With Parkinson Disease
  • Predictors of Reduced Frequency of Physical Activity 3 Months After Injury: Findings From the Prospective Outcomes of Injury Study
  • Effects of Locomotor Exercise Intensity on Gait Performance in Individuals With Incomplete Spinal Cord Injury
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