Comparative effects of Backward walking training and standing balance training on balance and risk of fall among parkinson patients.

Abstract

Background: balance and risk of falls are common problems among People with Parkinson's disease (PD) which compromise their functional independence and quality of life. Various rehabilitation protocols are being used for these patients. 

Objective: To determine the effectiveness of backward walking training (BWT) and standing balance training (SBT) on balance, and risk of falls among Parkinson's patients.

Methodology: A randomized controlled trial was conducted at General Hospital Lahore from June 2020 to March 2021. The Parkinson's Patients of stage 3 or 4 of lower extremity on Brunnstrom motor recovery and the ability to walk 14 m with or without a walking aid or orthosis were included in the study. The Berg Balance Scale was used to evaluate the balance and fall risk. Group A (n=15) received backward walking training and Group B (n=15), standing balance training. The participants were assessed at the baseline, after the 6th week, and after 12 weeks of intervention. 

Results: The mean age of participants was 50.03+8.36 years. A total of n=17 participants were male while 13 were female. The result showed that group A received backward walking training (BWT) had a significantly large mean difference (22.13+-2.35 vs. 18.20.3.58, 95%CI (1.64,6.22) in BSS score as compared to group B received standing balance training (SBT).

Conclusion: The study concluded that standing balance training and backward walking training both are effective, but backward walking training is more effective in improving balance and the risk of falls in Parkinson's patients.

INTRODUCTION

Parkinson's disease is a neurodegenerative disorder, that presents with bradykinesia consisting of generalized slowing of movement[1]. Later, further progression symptoms such as resting tremor and rigidity are seen. Other symptoms include sleep problems, mood swings, increased salivation, loss of smell, and constipation. After Alzheimer's, it is the second most common neurodegenerative condition[2]. Falls are a significant issue for those with Parkinson's disease (PD). Every year, up to 68% of those with PD experience falls, with 50% experiencing several falls. Falls can result in accidents, the fear of falling, inactivity, and a lower quality of life [3].

In Parkinson's disease, gait dysfunction can be used to evaluate quality of life, fall risk, and even death. In PD, deficits in both forward and backward walking can be evaluated individually. Walking backward is a better way to spot elderly fallers than walking forwards[4]. Gait analysis in PD should incorporate extra walking tasks beyond forward walking due to the additional information offered by backward walking[5]. The first quantitative gait parameter changes during backward walking in people with PD are linked to shorter strides, lower swing percentages, and higher stance percentages[6]. Reporting the variations in certain gait metrics, such as step length or gait speed, falls short of capturing the complete complexity of gait mechanics. To clarify the relationship between different gait characteristics and walking situations, numerous factor analyses can be utilized[7].

Traditional physical therapy, which includes some balance exercises, may help PD patients with their postural control. To increase the autonomy, independence, and quality of life of these people, rehabilitation programs that demand sensorimotor dexterity and functionality with a focus on exercises involving coordination, proprioception, difficult balance tasks, gait training with speed variation, and cognitive tasks may also be most effective[8].

A randomized controlled trial reported that In comparison to controls, the standing balance training group demonstrated improved balance and decreased fall risk [9]. Another study found that walking backward improved balance more than forward walking did and that it also lowered the risk of falling. Standing balance training and backward walking both significantly improved balance and decreased the risk of falling in Parkinson's disease.[10] There was little to no difference between the therapies. The ability to walk backward suggests that gait and balance issues in PD may be addressed[11]. According to a study it has been observed that backward walking has potential benefits as a practical training alternative to enhance gait in people suffering from Parkinson's disease.). BW engages different muscle groups and sensory inputs compared to forward walking, potentially leading to improved gait parameters such as stride length, walking speed, and cadence [12]. 

Balance impairments and an increased risk of falling are common challenges faced by individuals with PD. It was hypothesized that backward walking may offer a more effective training approach than standing to address balance issues, as it requires enhanced proprioceptive awareness and balance control. By engaging in BW exercises, individuals with PD may improve their postural stability and decrease the risk of falls during challenging, multidirectional everyday tasks. So current study was conducted to compare the backward walking training and standing balance training on balance and risk of falls among Parkinson's patients.

METHODOLOGY

A randomized controlled trial was conducted at Lahore General Hospital after the approval from the Medical Superintendent and Ethical Committee (UIPT/202/487/2022) of the University Institute of Physical Therapy, The University of Lahore from June 2020 to March 2021. The approval of The Parkinson’s Patients of stage 3 or 4 of lower extremity on Brunnstrom motor recovery and the ability to walk 14 m with or without a walking aid or orthosis were included in the study.  The patients with cerebellar disease, vestibular lesions, and a previous history of neurological disorder, gait disorders, or unilateral neglect were excluded from the study.  

To determine the sample size, an effect size of 0.5, a significance level of 0.05, and a power of 0.80 were used for analysis. a sample size of n=28 participants was obtained in the priori analysis. The researcher recruited n=34 participants to account for potential dropouts. All participants were randomly allocated into the backward walking training group (n=17) and the standing balance training group (n=17). After the randomization process, n=34 and n=15 participants in each group completed the intervention period. There were n=2 dropouts in the follow-up in each group due to deterioration in health in PD patients. A total of n=30 participants were included in the data analysis resulting in a final analyzed sample size of n=30.

Figure 1: CONSORT diagram

A sample was selected through the non-probability purposive sampling technique.  The 14 tasks Berg Balance Scale is a reliable and valid tool for balance and risk of fall assessment in neurological conditions, used to assess various aspects of postural stability, including sitting, standing, transferring, and dynamic movements. Each task is scored on a 5-point Likert scale, ranging from 0 (unable to perform) to 4 (normal performance). The total score ranges from 0 to 56, with higher scores indicating better balance and lower fall risk. A higher BBS score indicates better balance performance and reduced risk of falls. Scores below 45 are associated with an increased risk of falling, while scores between 45 and 56 indicate moderate to good balance control. [13]. It also exhibits good construct validity, as it effectively differentiates between individuals with and without balance impairments.

The randomization process was performed using a computer-generated randomization table and concealed allocation envelopes. As the study was single-blinded, participants were unaware of groups about received interventions.

The routine physical therapy given to both groups included TENS and a hot pack with task-oriented training of lower extremities to address to initiate cutaneous afferent fibers and inhibit tremors of rehabilitation and functional improvement in individuals with Parkinson's disease. In this session, TENS with the frequency of 100 Hz and intensity of 200μs and hot pack were given for 15 minutes respectively. The task-oriented training for the lower extremity included walking training on the ground for 10 minutes, equal weight-bearing sit-to-stand exercises (10 repetitions, 2 sets), resistance exercises e.g., leg press, leg extension, and leg curl (10 rep, 2 sets) and reaching tasks for improving balance. There was a rest period of 5 minutes between each set of training.

In addition, group A received backward walking training (BWT) which involved walking over the ground without the aid of any assistive aids. The intervention therapist assisted the patient as needed with shifting their weight, controlling their paretic lower extremity, and maintaining their balance while walking. If necessary, a therapy assistant assisted with posture. As physical resistance decreased and gait speed and distance increased, intensity increased. Participants were asked to continuously walk backward while maintaining balance, increasing their cadence and/or step length as well as their overall distance. This was done for 4 days per week for 12 weeks for 30 minutes.

The Group B received the standing balance training (SBT). participants were advised to stand with their eyes open on their right leg for one minute, then their left leg for another minute, for a total of two minutes, three times per day. If a participant needed multiple breaks to be able to stand on one leg for one minute, they were told to stand on one leg until they were able to stand on one leg for one minute in total. Standing on the right leg for one minute and the left leg for one minute each made up a single set of this one-leg standing balance exercise. This protocol was done for 4 days per week for 12 weeks for 30 minutes. 

 the data was collected at the baseline, after the 6th week and 12th week by using the Berg balance scale. The data was entered and analyzed using SPSS Version 24. The data was presented as mean ±SD, n(%), median(IQR), and mean ranks. As the assumption of the normality was violated and baseline differences also existed, the Friedman test was used to compare the changes in balance from the baseline to the 12^th week, while for pairwise comparison, the Wilcoxon sign rank test was used for each level of assessment. As baseline differences exist, the mean differences of both groups were also compared with an independent t-test. The level of significance was set at p<0.05 and SPSS Ver 23 was used for data analysis.

RESULTS

The Mean age for the participants was 50.03+8.36 years. Among n=30 participants, 17 (56.7%) were male while 13 (43.3%) were female. Out of the participants were 28 (93.3%) married and 2 (6.7%) participants were unmarried. 

The Freidman test showed significant with-in-group improvement (p<0.001) in both groups from baseline to the 12^th week in the Berg balance scale. The pairwise comparison with the Wilcoxon sign rank test showed that each group was significantly improved (p<0.001) in the first month, and in the second month, no significant change (p≥0.05) was observed in the balance score.

Table 1: With-in group changes in BBS

The independent t-test was applied to the mean differences (BBS) of both groups as baseline differences existed. The result showed that group (A) received backward walking training (BWT) had a significantly large mean difference (22.13+-2.35 vs. 18.20.3.58, 95%CI (1.64,6.22) in BSS score as compared to group (B) received standing balance training (SBT). (Figure 2)

Figure 2: Comparison of MD (BBS)

DISCUSSION

The results of this study provide valuable insights into the comparative effectiveness of backward walking training and standing balance training as gait strategies for balance training in individuals with Parkinson's disease. The positive outcomes observed in both intervention groups indicate the potential benefits of incorporating these exercises into rehabilitation programs for Parkinson's patients. However, backward walk training (BWT) showed a more significant improvement in BBS score than standing balance training (SBT).

Soke et al reported that in addition to conventional walking training (CWT), backward walking training more significantly Improves balance functional mobility[14]. In the current study, backward walk training has a significant positive impact on improving balance and reducing the risk of falls. With its distinct emphasis on activating various muscle groups and sensory inputs, backward walking training might have had an impact on the observed improvements in balance control. BW reduces the risk of falling during multidirectional daily activities and helps in neurological recovery[15].  Backward walking training is an effective rehabilitation method for Parkinson's patients that reduces the risk of falls and improves balance through a variety of mechanisms [16, 17]. BWT stimulates the neuroplastic changes in the brain by challenging the neuromuscular system in a novel way, leading to improved sensory integration and coordination. This process is essential for maintaining the good balance control [18, 19]. BWT also increases the demand for vestibular input and proprioception, which also improves postural stability and enhanced sensory integration [18, 20]. BWT also improved muscle strength and control of movement by activation of hip extensors and ankle dorsiflexors[21]. Dynamic stability and spatial awareness may also improve with BWT, as neurological patients practice around obstacles and change direction in real time[22]. The ability to move around obstacles helps the patients to feel confident and increases their participation in rehabilitation programs [23].

In the current study standing balance training program also improved the balance in Parkinson's patients. Standing balance training is essential to improve balance and reduce the risk of falls among neurological patients. SBTs have a crucial role in improving postural stability and balance control among PD activating core muscles and improving proprioception[24, 25]. SBT also improves neuroplasticity by increasing repetitive motor responses and sensory inputs. helps in reorganizing the brain networks responsible for balance control. Standing balance exercises improve visual, proprioceptive, and vestibular signal integration by challenging different sensory systems.[26, 27] It also helps in improving dynamic stability and functional abilities by incorporating dynamic movements and task-specific training necessary for daily activities[28]. 

When comparing the backward walking training and standing balance training on balance and risk of fall, backward walking training showed promising results over standing balance training. BWT training among PD provides a comprehensive approach for improvement in balance, lowering fall risk, and promoting overall quality of life by addressing muscle strength, sensory integration, dynamic stability, neuroplasticity, and psychological variables[29]. BWT provides better postural control and stability by strengthening key postural muscles including the ankle dorsiflexors and hip extensors. BWT also more actively engages Proprioceptive feedback, sensory integration, and spatial awareness, as compared to standing balance training, which is lacking in Parkinson's disease sufferers. [21, 30]. As the BWT challenges the dynamic balance the patients adjust to shifting environmental demands, enhancing reaction time and balance in routine activities[31]. Moreover, backward walking training lessons the abnormal gait pattern and increases postural stability among the PDs, by inducing novel motor patterns that trigger neuroplastic changes in the brain[32]. 

In the current study, the small sample size and duration of the study might have limited the more significant effects of the interventions. 

CONCLUSION

The study concluded that to improve balance and reduce the risk of falls in Parkinson's disease, both backward walking training and standing balance training are effective. But backward walking training proved to be more effective. Practical implications of these findings involve the development of more individualized and focused rehabilitation programs to improve the functional outcomes of Parkinson's patients with balance problems. 

DECLARATIONS & STATEMENTS

Author’s Contribution

MU, AL and SaS: substantial contributions to the conception and design of the study.

MU: acquisition of data for the study.

ShS and SN: analysis of the data for the study.

Sas, ShS, and SN: interpretation of data for the study.

MU: drafted the work.

MU, AL, SaS, ShS and SN: revised it critically for important intellectual content.

MU, AL, SaS, ShS and SN: final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors contributed to the article and approved the submitted version.

Ethical Statement

The study was conducted at Lahore General hospital after the approval from Medical Superintendent and Ethical committee (UIPT/202/487/2022) of university Institute of Physical Therapy, The University of Lahore

Consent Statement

Written Informed consent was obtained from all subjects involved in the study prior to the study.

Data Availability Statement 

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Acknowledgments 

The authors declare no acknowledgment. 

Conflicts of Interest 

The authors declare no conflict of interest. 

Funding

The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

REFERENCES 

1. Kalia LV, Lang AE. Parkinson's disease. The Lancet. 2015;386(9996):896-912. [CrossRef] [PubMed]
2. Bloem BR, Okun MS, Klein C. Parkinson's disease. The Lancet. 2021;397(10291):2284-303. [CrossRef] [PubMed]
3. Kordower JH, Olanow CW, Dodiya HB, Chu Y, Beach TG, Adler CH, et al. Disease duration and the integrity of the nigrostriatal system in Parkinson’s disease. Brain. 2013;136(8):2419-31. [CrossRef] [PubMed]
4. Beitz JM. Parkinson's disease: a review. Frontiers in Bioscience-Scholar. 2014;6(1):65-74. [CrossRef] [PubMed]
5. Schoneburg B, Mancini M, Horak F, Nutt JG. Framework for understanding balance dysfunction in Parkinson's disease. Movement disorders. 2013;28(11):1474-82. [CrossRef] [PubMed]
6. Rinalduzzi S, Trompetto C, Marinelli L, Alibardi A, Missori P, Fattapposta F, et al. Balance dysfunction in Parkinson’s disease. BioMed research international. 2015;2015. [CrossRef] [PubMed]
7. Allen NE, Sherrington C, Paul SS, Canning CG. Balance and falls in Parkinson's disease: a meta‐analysis of the effect of exercise and motor training. Movement disorders. 2011;26(9):1605-15. [CrossRef] [PubMed]
8. Kalia LV, Kalia SK, Lang AE. Disease‐modifying strategies for Parkinson's disease. Movement disorders. 2015;30(11):1442-50. [CrossRef] [PubMed]
9. Jones CA, Ciucci MR, Abdelhalim SM, McCulloch TM. Swallowing Pressure Variability as a Function of Pharyngeal Region, Bolus Volume, Age, and Sex. Laryngoscope. 2021 Jan;131(1):E52-E58. [CrossRef] [PubMed]
10. Kim C-Y, Lee J-S, Kim H-D. Comparison of the effect of lateral and backward walking training on walking function in patients with poststroke hemiplegia: a pilot randomized controlled trial. American journal of physical medicine & rehabilitation. 2017;96(2):61-7. [CrossRef] [PubMed]
11. Radder DL, Lígia Silva de Lima A, Domingos J, Keus SH, van Nimwegen M, Bloem BR, et al. Physiotherapy in Parkinson’s disease: a meta-analysis of present treatment modalities. Neurorehabilitation and neural repair. 2020;34(10):871-80. [CrossRef] [PubMed]
12. Adcock M, Fankhauser M, Post J, Lutz K, Zizlsperger L, Luft AR, et al. Effects of an in-home multicomponent exergame training on physical functions, cognition, and brain volume of older adults: a randomized controlled trial. Frontiers in medicine. 2020;6:321. [CrossRef] [PubMed]
13. Godi M, Franchignoni F, Caligari M, Giordano A, Turcato AM, Nardone A. Comparison of reliability, validity, and responsiveness of the mini-BESTest and Berg Balance Scale in patients with balance disorders. Physical therapy. 2013;93(2):158-67. [CrossRef] [PubMed]
14. Soke F, Aydin F, Karakoc S, Gulsen C, Yasa ME, Ersoy N, et al. Effects of backward walking training on balance, gait, and functional mobility in people with multiple sclerosis: A randomized controlled study. Multiple Sclerosis and Related Disorders. 2023;79:104961. [CrossRef] [PubMed]
15. Grobbelaar R, Venter R, Welman KE. Backward compared to forward over ground gait retraining have additional benefits for gait in individuals with mild to moderate Parkinson’s disease: a randomized controlled trial. Gait & posture. 2017;58:294-9. [CrossRef] [PubMed]
16. DeMark L, Fox EJ, Spigel PM, Osborne J, Rose DK. Clinical application of backward walking training to improve walking function, balance, and fall-risk in acute stroke: a case series. Top Stroke Rehabil. 2019;26(7):497-502. [CrossRef] [PubMed]
17. Wang J, Xu J, An R. Effectiveness of backward walking training on balance performance: A systematic review and meta-analysis. Gait Posture. 2019;68:466-75.[CrossRef] [PubMed]
18. Rose DK, DeMark L, Fox EJ, Clark DJ, Wludyka P. A Backward Walking Training Program to Improve Balance and Mobility in Acute Stroke: A Pilot Randomized Controlled Trial. J Neurol Phys Ther. 2018;42(1):12-21. [CrossRef] [PubMed]
19. Cabral DF, Fried P, Koch S, Rice J, Rundek T, Pascual-Leone A, et al. Efficacy of mechanisms of neuroplasticity after a stroke. Restor Neurol Neurosci. 2022;40(2):73-84. [CrossRef] [PubMed]
20. Winkler P, DeMarch E, Campbell H, Smith M. Use of real-time multimodal sensory feedback home program improved backward stride and retention for people with Parkinson Disease: A pilot study. Clin Park Relat Disord. 2022;6:100132. [CrossRef] [PubMed]
21. Grobbelaar R, Venter R, Welman KE. Backward compared to forward over ground gait retraining have additional benefits for gait in individuals with mild to moderate Parkinson's disease: A randomized controlled trial. Gait Posture. 2017;58:294-9. [CrossRef] [PubMed]
22. Olson M, Lockhart TE, Lieberman A. Motor Learning Deficits in Parkinson's Disease (PD) and Their Effect on Training Response in Gait and Balance: A Narrative Review. Front Neurol. 2019;10:62. [CrossRef] [PubMed]
23. Dos Santos Delabary M, Komeroski IG, Monteiro EP, Costa RR, Haas AN. Effects of dance practice on functional mobility, motor symptoms and quality of life in people with Parkinson's disease: a systematic review with meta-analysis. Aging Clin Exp Res. 2018;30(7):727-35. [CrossRef] [PubMed]
24. Haruyama K, Kawakami M, Otsuka T. Effect of Core Stability Training on Trunk Function, Standing Balance, and Mobility in Stroke Patients. Neurorehabil Neural Repair. 2017;31(3):240-9. [CrossRef] [PubMed]
25. Papalia GF, Papalia R, Diaz Balzani LA, Torre G, Zampogna B, Vasta S, et al. The Effects of Physical Exercise on Balance and Prevention of Falls in Older People: A Systematic Review and Meta-Analysis. J Clin Med. 2020;9(8). [CrossRef] [PubMed]
26. Gerards MHG, Marcellis RGJ, Poeze M, Lenssen AF, Meijer K, de Bie RA. Perturbation-based balance training to improve balance control and reduce falls in older adults - study protocol for a randomized controlled trial. BMC Geriatr. 2021;21(1):9. [CrossRef] [PubMed]
27. Allin LJ, Brolinson PG, Beach BM, Kim S, Nussbaum MA, Roberto KA, et al. Perturbation-based balance training targeting both slip- and trip-induced falls among older adults: a randomized controlled trial. BMC Geriatr. 2020;20(1):205. [CrossRef] [PubMed]
28. Dunsky A. The Effect of Balance and Coordination Exercises on Quality of Life in Older Adults: A Mini-Review. Front Aging Neurosci. 2019;11:318. [CrossRef] [PubMed]
29. DelMastro HM, Ruiz JA, Simaitis LB, Gromisch ES, Neto LO, Cohen ET, et al. Effect of Backward and Forward Walking on Lower Limb Strength, Balance, and Gait in Multiple Sclerosis: A Randomized Feasibility Trial. Int J MS Care. 2023;25(2):45-50. [CrossRef] [PubMed]
30. Balasukumaran T, Olivier B, Ntsiea MV. The effectiveness of backward walking as a treatment for people with gait impairments: a systematic review and meta-analysis. Clin Rehabil. 2019;33(2):171-82. [CrossRef] [PubMed]
31. Vistamehr A, Balasubramanian CK, Clark DJ, Neptune RR, Fox EJ. Dynamic balance during walking adaptability tasks in individuals post-stroke. J Biomech. 2018;74:106-15. [CrossRef] [PubMed]
32. Lin NH, Liu CH, Lee P, Guo LY, Sung JL, Yen CW, et al. Backward Walking Induces Significantly Larger Upper-Mu-Rhythm Suppression Effects Than Forward Walking Does. Sensors (Basel). 2020;20(24). [CrossRef] [PubMed]