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Essay: Parkinson's disease (PD)

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  • Published: 18 October 2015*
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Patients with Parkinson’s disease (PD) encounter a lot of difficulties, such as tremor, rigidity, slower movements and impaired coordination. Many of these are caused by a dopamine loss in the substantia nigra (Vandenberghe W 2005). [G] One of the major problems PD patients have to deal with is the risk of falling, as this may often lead to severe injuries.
A fall can be defined as:

”an unexpected event in which the participants come to rest on the ground, floor or lower level.”

(Lamb SE, J??rstad-Stein EC, Hauer K, Becker C; Prevention of Falls Network. Europe and Outcomes Consensus Group. Development of a common outcome data set for fall injury prevention trials: the Prevention of Falls Network Europe consensus. J Am Geriatr Soc. 2005 Sep;53(9):1618-22.)[I]

Between 35% and 90% (with an average of 60.5%) of the PD patients are prone to falling. [L] Is het voldoende om hier naar de review te refereren of moeten alle studies die in die review kwamen, gerefereerd worden? For example, previous research from Balash et al (Balash 2005) showed that from 350 included PD patients, 161 reported one fall in the last year, equivalent to an increased fall risk in 46% of the patients. [A] 115 patients (33.9%) even had two or more falls. Other studies even show a fall rate up to 70% within a 1-year follow-up, with a 50% chance of recurrent falls. [B-F]
One of the main causes of falling in PD is an underlying balance disorder. The falls are primarily caused by shifts in posture, trunk movements or combining walking or balancing with another activity, known as dual-tasking. [K]
In a biomechanical view, postural control can be described as the capability to regulate the link between the centre of mass and the base of support. In more clinical words, it’s the operation of maintaining, achieving or restoring balance while moving or holding a posture without oscillations or falls. [P] The postural control in patients with PD is overall impaired. This impairment is mostly characterized by a difference in weight distribution, postural sway, synchronization in oscillation movements and fall rate. [H]
Another prominent risk factor for falling in PD is freezing of gait (FOG), which can be defined as an episodic incompetence to generate sufficient stepping.[M] When walking, the forward progression of the feet is reduced or even absent.[N-O] Although this specific symptom is seen in 21-27% in the beginning and 70-80% at the end of the disease within the PD patients, it is still a poorly understood phenomenon. [Q-R] There are three clinical presentations of FOG. [J] The first is ‘akinesia’. In this subtype, patients are unable to continue their movements all at once. The most seen display of FOG is the second subtype, the ‘trembling in place’, frequently associated with an effort to overcome the block. The last type of presentation is the shuffling forward with little steps. This is called ‘festination’. There are different situations which cause FOG: narrow spaces, turning, starting and stopping. [X]
The order of magnitude of the FOG can be measured by the footstep latency, which is defined as the time taken between two alternate steps. When there are environmental cues, freezers have a greater maximal footstep latency (MFSL), as opposed to non-freezers. [U]
In previous research there was shown that six weeks of intensive treadmill training can give improvements on the UPDRS motor score, PDQ-39 score, SPPB score, VAS gait rating, gait speed, stride length and swing time variability. This can be summarized as an enhancement of quality of life (QOL), physical performance and gait stability. [S] An other study shows us a reduction in sway area in PD patients, so we can decide that treadmill training has an effect on the balance as well. After the treadmill training (five weeks) PD patients are able to raise their centre of pressure (CoP) which is also linked with improvement of balance. [V]
Purdon Martin earlier concluded that every condition that includes stepping is postural in nature and serves a postural function. The reason for this transfer of skills is the posture and locomotion coupling. [W] Bastian et al. even said that when the stepping is disrupted repetitively for a long enough period, there occurs an adaptation.
Bastian AJ. Understanding sensorimotor adaptation and learning for rehabilitation. Curr Opin Neurol 21: 628’633, 2008.
In our study, we combine the treadmill training with virtual reality. Virtual reality (VR) has proven to be an excellent modality to improve balance (Berg Balance Scale) and daily activities (Modified Barthel Index). [T] We like to know if VR gives a supplementary value to the treadmill training. More specific, we are curious if there is a difference for freezers and non-freezers.

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