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Critique of Article:The Effects of Highly Challenging Balance Training in Elderly With Parkinson's Disease: A Randomized Controlled Trial by Conradsson D, Lofgren N, Nero H, Hagstromer M, Stahle A, Lokk J, et al. Neurorehabil Neural Repair. 2015;29(8):827-836.

What is the background to this research?

Parkinson’s Disease (Parkinson’s) is a progressive neurodegenerative disorder resulting from the death of neurons of the substantia nigra, which is largely responsible for the coordination of movement. Parkinson’s is characterised by a range symptoms, including motor impairments such as balance problems and gait pathologies. And as gait and balance abilities deteriorate with disease progression, there is an underlying fear of falling, which results in the decline of physical activity, and ultimately a reduction in quality of life. Currently, there is no cure, nor standardised treatment; but usual treatment involves pharmacological and surgical interventions. However, physical activity is important to managing disease progression, especially if it involves cognitively challenging elements as it is thought to confer neuroprotective benefits.

Given that impaired balance often limits activity levels and leaves people with Parkinson's vulnerable to falls, challenging balancing exercises have been recommended (REF 21, 22), particularly whilst simultaneously engaging in a cognitively demanding task, i.e. dual tasking (REF 26, 68). Based upon the critical aspects involved in balance control, the authors of this study have developed a novel conceptual framework for balance training “by using highly challenging, progressive and varying training conditions” termed the HiBalance program.

Where is the research from?

The study was completed at Karolinska Institute and Karolinska University Hospital, the largest Swedish medical university involved in teaching and academic research. The lead author, Dr. Conradsson is a lecturer at the Karolinska Institute and a widely published academic specialising in neurological disorders, particularly Parkinson's. The study received financial funding from several Research and Foundations associated with the Karolinska Institute; and Parkinson’s groups. The study disclosed receipt of financial funding from several Research and Foundations associated with the Karolinska Institute and Parkinson’s groups. However, there were no reference to the level of involvement regarding the role of the funders. There were no declared conflicts of interests.

What kind of research was this?

The study was a Randomised Control Trial and prepared in accordance to the CONSORT Statement, which is an evidence-based standard for reporting randomised trials. However, it was not a blinded trial as the assessors were unmasked during post-test assessments, and so bias was a possibility during physical testing.

In comparison to the studies within balance training (ref MA and SR), the sample size is quite large and the assessable outcomes are comparable. The clinical tests used to assess balance and gait in the Parkinson’s population are also widely used in literature and recommended. However, apart from one qualitative study, there are no other studies specifically examining the success of the HiBalance program aside from the authors themselves, who are also the developers of the program.

What did the research involve?

The study involved 100 elderly patients with mild to moderate Parkinson’s, presenting with impaired balance. It evaluated the short-term effects of the HiBalance Program – which is a balance training regime that targets cognitive impairments by adding concurrent cognitive and/or motor tasks (dual-tasking) – compared with usual care, and whether any effects transferred to everyday living. The intervention group had 51 participants and the control group had 49 participants. The intervention was ten weeks in duration, with three 60 minute sessions per week.

The methodology of the study was generally well prepared and in accordance with the CONSORT Statement, which allows for transparency and replication. However, the objectives of the study were clearly stated in the body of the paper, the abstract of the paper was less clear as it omitted an important aspect of the authors’ research, that is, whether intervention effects would transfer to everyday living. In addition, whilst sufficient detail was given with respect to the intervention to allow for replication, there may be some difficulties in doing so, as the intervention is based upon a novel framework which is somewhat broad in nature, and required the trainers (physiotherapists) to have undergone specific training regarding the underlying theory and practice.

Other limitations identified by the authors include:

• Recruitment of subjects by advertisements in local newspapers which leads itself to a sample consisting of those interested in training and seeking improvements.
• Results pertain a specific Parkinson's population: elderly (mean age in study ~ 73 years of age) with mild to moderate disease classification.

What were the basic results?

Primary and secondary outcomes measured

Primary Outcome	Variables Measured
Balance performance	Mini Balance Evaluation Systems Test (Mini-BESTest)
Gait - normal and whilst dual tasking	Velocity
Gait - normal and whilst dual tasking	Step Length
Gait - normal and whilst dual tasking	Cadence
Fear of falling	Falls Efficacy Scale-International (FES-I)
Secondary Outcome
Activities of Daily Living (ADLs)	Unified Parkinson's Disease Rating Scale (UPDRS)
Physical activity levels	Steps per day

Important Findings
The training group had statistical significant improvements in balance performance and gait velocity. There was also (SIGNIFICANT OR NOT SIGNIFICANT?) improvement in secondary outcomes where there was an increase in physical activity levels and better self-perceived disability scores with respect to ADLs. However, there was no changes in concerns about falling. The control group receiving usual care did not see any statistically significant improvements in any categories. In fact, there was a decline in physical activity levels.

There were no changes in improvement of gait performance whilst dual-tasking in both groups, but the intervention group improved their performance on the cognitive aspects whilst dual-tasking. An inference was drawn that it could be explained by increased automaticity of motor components.

Interpretation of Results
The authors placed emphasis on the resulting increase in gait velocity as it is usually a vital indicator of health in older adults. The effect of exercise on Parkinson’s patients had a pooled increase effect of 0.04-0.05m/s whereas the current study saw an 0.10m/s improvement. Other gait characteristics were somewhat disregarded as there were no statistically significant changes. Nevertheless, the authors considered the small increase of step length (0.04m) to be an indication that the intervention efficiently targeted gait impairments since step length has rarely been improved in training interventions. However, there has been evidence that step length can be increased with specific training in patients with Parkinson's.

Although the secondary outcomes showed improvement, the results must be cautiously considered as to whether they are transferrable to real-life settings. This is especially since the increase in physical activity levels between the intervention and control group were very small in absolute terms. In addition, the baseline and post-intervention figures of the HiBalance group had higher physical activity levels in the first instance. The decrease of perceived disabilities affecting ADLs were also low. The authors disregarded the non-change with respect to concerns about falling as it was considered that the current literature's position was that balance exercises had no effect on concerns about falling. It appears that since then, research has found that fear of calling can be improved with exercises involving high motor complexity. [1]

What conclusions can we take from this research?

• Provide your own insights on the conclusion (it may not quite be the same as the authors)
• How do the findings align with other research in the area (in particular more recent publications that won't be mentioned in the paper)

Practical advice

• What real-world implications does this research have?
• Are there other considerations readers should know about before taking on this practical advice? Perhaps health/safety more information/resources?
  • What further reading may interested readers benefit from?
  • What website, or online organisations, offer further information/support to groups that are linked to your assignment?

References

References are as linked in text and sources can be accessed by following the hyperlinks.