Can sensory attention focused exercise facilitate the utilization of proprioception for improved balance control in PD?
Introduction
Impairments in sensory integration have been suggested to have an influence on motor symptoms and specifically balance control in Parkinson's disease (PD) [1], [2], [3], [4]. Interestingly, balance control deficits are exacerbated in dark environments or with eyes closed, suggesting that deficits in proprioception become an important factor that contribute to balance impairment in PD [5]. Given that postural instability becomes an increasing concern with disease progression, and is poorly responsive to drug therapies [2], [6], there is a need to identify alternative therapeutic interventions.
Therapeutic alternatives to pharmaceutical treatment in the form of physical activity and exercise have demonstrated additional benefits for motor symptoms in PD [7]. For example, treadmill training has shown improvements in gait parameters, such as stride length [8] and step variability [9]. It has been suggested that enhancing the utilization of intrinsic sensory feedback while exercising might alter cortical function through the release of neurotrophic factors or neurotransmitters [10]. The release of dopamine and neurotrophic factors in PD has been suggested to contribute to neural plasticity and repair [10]. Recognizing the benefits of sensory information during exercise, the PD SAFEx™ program was developed to promote the utilization of proprioceptive information in PD.
Given that balance control is heavily dependent on sensory inputs, if PD SAFEx™ is in fact increasing the utilization of proprioception, then a consequent improvement in balance control should be expected. Previous studies have demonstrated the effectiveness of the PD SAFEx™ program at improving motor symptoms by demonstrating a 25% improvement in Unified Parkinson's Disease Rating Scale (UPDRS) scores immediately following 12 weeks of training, with improvements persisting for a 6 week non-exercise period [11]. The program has also been shown to have increased benefits in motor symptom management when compared to lower limb aerobic exercise [12]. Interestingly, the ability of the PD SAFEx™ intervention to improve balance control has not yet been determined.
It was suggested by Sage and Almeida [12] that the underlying mechanism of PD SAFEx™ was plasticity driven, such that cortical changes might allow for incoming sensory information to develop a pathway to avoid the dysfunctional basal ganglia. This group alternatively suggested that the sensory load created by the program might act as a sufficient enough challenge to the basal ganglia that it might enhance the ability of the remaining dopaminergic neurons to aid in sensory processing [11], [12]. The benefits of PD SAFEx™ are widespread; however, the program has never been formally assessed for the ability of the program to specifically improve the use of sensory feedback in the absence of vision.
Thus, the aim of this study was to determine whether PD SAFEx™ can improve balance control with eyes open and eyes closed in PD. It was hypothesized that the PD SAFEx™ intervention would be successful at improving the utilization of proprioception, which would be detected through improved sway scores in the eyes closed balance condition. Since visual inputs would remain the dominant sensory resource when available, it was anticipated that improved proprioception might not have an effect on balance in the eyes open conditions. New outcome measures of exercise programs are a valuable means to providing better insight into some of the benefits associated with exercise, and the systems being targeted by the specific program.
Section snippets
Participants
This study was approved by the research ethics board at Wilfrid Laurier University, and all participants engaged following informed consent. Twenty-eight participants with idiopathic PD were randomly selected from the Sun Life Financial Movement Disorders Research and Rehabilitation Centre (MDRC), Waterloo, Ontario database and examined in this study. All participants were clinically diagnosed with PD, and had no other neurological deficits which would alter their ability to exercise safely. To
m-CTSIB
A significant interaction was found between time of assessment and vision (F(1,21) = 7.12, p = .014), Fig. 1. Post hoc analysis revealed significant improvement in balance scores during the eyes closed conditions only. Specifically, participants’ sway index improved by 12.7% from pre- to post-assessment (p = .0018).
There was also a significant main effect of surface (F(1,21) = 148.27, p < .001) such that the dynamic foam surface produced the poorest scores for balance control. Additionally, a significant
Discussion
The main finding of this study was that the PD SAFEx™ program significantly improved balance control only in the absence of vision, and hence, the ability of individuals with PD to utilize proprioceptive information. Given that proprioception is the predominant source of sensory information when the eyes are closed, improved balance control without vision can be argued to be the result of improvements in proprioceptive abilities. This can be inferred through improved sway scores in the eyes
Acknowledgements
This study was supported in part by a Parkinson's Disease Foundation Summer Student Fellowship, PDF-SFW-1476 to Shannon Lefaivre and Canada Foundation for Innovation to Quincy Almeida.
Conflict of interest: None to report.
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