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Vol. 3, No. 1; April 2011

A Case Study of Balance Rehabilitation in Parkinsons Disease

Stanley John Winser (Corresponding author)
Physiotherapy lecturer
Masterskill University College of Health Sciences (MUCH), Malaysia
Tel: 61-4927-1374

E-mail: stanley@masterskill.edu.my
Priya Kannan

Physiotherapy lecturer
Masterskill University College of Health Sciences (MUCH), Malaysia
Received: September 19, 2010

Accepted: October 12, 2010

doi:10.5539/gjhs.v3n1p90

Abstract
There is evidence to say that balance can be improved by manipulating peripheral sensory inputs. Our hypothesis
was, improvement in the inputs from proprioceptors using sensory specific balance training would improve
balance. We intend to document the influence of training proprioceptors in improving balance among
Parkinsonism. Single case study of a 65 years old parkinsons subject was considered. Trial was designed as a 4
week balance training program. Outcome measures were Bergs balance scale, Multidirectional reach test and
CTSIB. Balance was trained by making the subject perform balance exercises standing over a square foam
surface which reduces the quality of surface orientation input. Training was given for 15-20 mins/day, 5 days in a
week, for a period of 1 month. We observed a 25% increase in values of FFR, BFR, LFR & RFR for multi
directional reach test. Overall Bergs balance score improved from 48 to 54. CTSIB assessed before the training
showed a poor performance in conditions 5 & 6, post training assessment showed an improvement of 12 seconds
for condition 5 and 11 seconds for condition 6. The results suggest that sensory-specific balance exercise has a
positive training effect on balance among subjects with Parkinsonism.
Keywords: Parkinsons disease, Proprioceptive training, Balance exercises, CTSIB
1. Introduction
Parkinsons disease (PD) is a progressive neurologic disorder characterized by insidious onset. The first clinical
sign occurs when about 60% of the dopamine-producing cells in the substantia nigra have degenerated (Booij J
et al 1999). The mean age of onset of PD is in the mid fifties, with increasing incidence and prevalence as age
increases (Ng DC 1996). The disease features impairment of resting muscle tone and voluntary movement,
because of loss of striatal dopamine in the nigrostriatal dopamine pathway (Kish SJ, Shannnak K and
Hornykiewcz O 1988). Clinical signs of bradykinesia, rhythmic tremor, rigidity, and postural instability follow
dopamine depletion (Olanow CW and Koller WC 1998). Optimal management of Parkinsons disease (PD)
involves both pharmacologic treatment and encouragement of physical activity according to American Academy
of Neurology (1993). There is mounting evidence for the effects of physiotherapy in all stages of the disorder, yet
few well-controlled prospective studies have documented the benefits of physical activity in PD (Comella CL et
al 1994, Palmer SS et al 1986, Toole T et al 2000).
Physical therapists teach clients with PD, strategies to cope with impairments and disabilities, ideally allowing
them to move easier, minimize disability, and retain independent living skills. Physical therapists also play a role
in assessing the ability of people with PD to accomplish complex tasks, such as shopping, that are routinely
performed in everyday life. Therapists are called upon to measure and assess changes in function, disability,
activity, and response to therapy. In addition, therapists are often required to measure and assess changes in the
disease, including medication changes and surgical interventions, as well as to monitor the natural progression of
the disease (Canning CG et al 1997, Morris ME Iansek R Churchyard A 1998, Morris ME 2000, Schenkman M
et al 1989, and Schenkman M Butler RB 1998). Postural instability has been noted to be one of the major causes
for frequent falls among these subjects. Balance exercises have been frequently used among these subjects to

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prevent falls and work done by Mark A. Hirsch et.al (2000) has shown that the use of high-intensity resistance
training and balance training can be safely used in improving balance and strength.
Balance is the ability to control the body mass or centre of mass or integrated sensory and musculoskeletal
system and is modified within the CNS in response to changing internal and external environmental conditions.
The upright postures like sitting, standing or walking requires proper functioning of central balancing
mechanisms. Afferent impulses of widespread origins, including signals from the periphery, play important role
in eliciting and guiding responses, while efferent pathways carry messages to the muscles for the execution of
the balancing act. Damage to any one of the central mechanisms or interruption anywhere along the sensory or
motor pathway may lead to an inability to maintain bodys COG within the base of support, but, no one system
directly specifies the position of COG as stated by Brunnstrom (1970). Shumway Cook (1986) stated
information from the vestibular system is a powerful source in maintaining postural control and it provides the
CNS with information about the position and movement of the head with reference to gravity and inertial force
providing gravito-inertial frame of reference for postural control. The visual inputs report information regarding
the position and motion of head with respect to supporting surface. The somatosensory system provides CNS
with position and motion information about body with reference to supporting surface and in addition provides
information about the relationship of body segments to each other. Each of the senses provides the CNS with
specific information about the relationship of body segments to each other and also a different frame of reference
for postural control. The differing roles of sensory inputs is controversial but it is likely that they are
co-ordinated in a task related manner which is dependent on environmental circumstances. Winter et al (1990)
stated that the redundancy present within the sensory systems in the maintenance of balance enables not only the
verification of inputs which may be conflicted but also allows for compensation. Work done by Richard D Di
Fabio (1991) stated that disease alters one sensory modality then balance reaction can be compensated through
the use of remaining sensory inputs.
Evidence (Stanley John Winser and Priya Stanley 2009) has shown that improving the influence of
proprioceptors among clients with stroke improves balance. Studies done on stroke (Isabelle V. Bonan et al 2004)
have administered balance exercises with deprived vision in order to reduce visual dependence in improving
balance. Standing over a smooth / compliant surface can be used to facilitate the proprioceptive inputs. And we
hypothesized that the improvement in the inputs from proprioceptors would improve balance. In the review done
we found a paucity of literature on the influence of proprioceptors on balance among subjects suffering from
Parkinsons disease. Thus this case study is intended to document the influence of training proprioceptor in
improving balance among Parkinsons disease.
2. Case report
A 65 year old ambulant subject presented with complaints of imbalance, early fatigue, lack of interest in all
social activities for the past 3 years. No history of infection/ illness or accidents in the past 5 years & he is on
medication for Diabetes mellitus for 7 years. He was diagnosed to have idiopathic Parkinsons disease in a local
hospital. Subject is a retired school teacher staying at home with his wife. He lives in the second floor of a 2
storied building, gets access to his home by climbing 2 flights of stairs having 24 steps. Currently he is
independent in all activities except bathing and toileting for which he requires supervision from his wife.
Motor examination revealed good muscle efficiency in all 4 limbs, both precision and power of hand were good,
all deep tendon reflexes (biceps, triceps, brachioradialis, quadriceps and tendo Achilles) were diminished. There
was a mild non velocity dependent increase in the muscle tone which could be graded as 1+ in MAS. All sensory
functions (peripheral and higher cortical) were normal. Co-ordination tests, including equilibrium and non
equilibrium were negative which can be accounted for normal functioning of the cerebellum. The subject
demonstrated an independent gait and the walking pattern showed mild features of festination. The walking
speed was 69.5 mts/min, with cadence of 128/min, stride length of 128cms and step length 62cms. Reciprocal
arm swing while walking was preserved. FIM score of all ADL were 7except bathing and toileting which were
grade 6. Based on the assessment the subject can be classified as stage 3 Parkinsonism in Hoehn and Yahr scale
(Christopher G. Goetz et.al 2004).
3. Material and methods
A single case study of a 65 years old Parkinsons subject was considered. Approval from the Institute research
board was obtained and the subject gave written consent to participate in the trial. The trial was designed as a 4
week balance training program. The inital assessment was done in May 2010 and the post training assessment
was done after 30 days. 3 outcome measures were considered to assess the progress of patients balance.

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3.1 Outcome measures

Outcome measures considered are Bergs balance scale, Multidirectional reach test and Clinical test for Sensory
Integrity and Balance (CTSIB). Equipments used are shown in figure 1.
3.1.1 Bergs balance scale (BBS)
The BBS is an objective measure of balance abilities. It has been used to identify and evaluate balance
impairment. The scale consists of 14 tasks common in everyday life. The items test the subjects ability to
maintain positions or movements of increasing difficulty by diminishing the base of support from sitting and
standing to single-leg stance. Subjects ability to change positions is assessed as well. Works done by Abu A.
Qutubuddin et al concludes, BBS may be used as a screening and ongoing assessment tool for patients with PD.
3.1.2 Multidirectional reach test
This ingenious tool is a 250 cm inch tape stuck to the wall. The tool measures forward functional reach (FFR),
backward functional reach (BFR), and reach to the left and right of the subject to measure left functional reach
(LFR) and right functional reach (RFR), respectively. The subject was positioned adjacent to wall with the
shoulder at 0cm of the inch tape. Shoulder was flexed to 90 degrees with elbow and fingers in full extension. The
initial reading was taken from the tip of middle finger, then the subject was instructed to reach forward as far as
possible without lifting any part of his foot or loosing balance and at the end point of reach the final reading was
taken. Similarly backward reach was measured by instructing the patient to lean back. To assess right and left
reach the subject was positioned by facing the wall and was instructed to reach to his left and then to his right.
The subject's maximum reach was measured by calculating difference between the initial reach and the stretch
reach. Assistance was taken to ensure safety.
3.1.3 Clinical test for sensory integrity and balance (CTSIB)
The CTSIB test was used to assess the contribution from sensory inputs (vision, vestibular, somatosensory) for
maintaining balance. The test attempts to isolate the various sensory contributions, by either removing or
distorting (via sway referring the visual surround or the surface platform) the visual, vestibular and/or
somatosensory inputs needed for postural control. The resultant 6 conditions progress from the most stable (eye
open, solid support surface) to the least stable (sway referenced vision and surface), as shown in figures 2 to 7.
Conditions are as follows:
Condition 1: Eye open + Firm surface
Condition 2: Eye closed + Firm surface
Condition 3: Visual conflict + Firm surface
Condition 4: Eye open + Compliant surface
Condition 5: Eye closed + Compliant surface
Condition 6: Visual conflict + Compliant surface
The support surface condition consists of a hard flat floor and square foam that reduces the quality of surface
orientation input. The visual conflict dome was a custom made goggles with an opaque coving. By allowing the
subject to open his eyes while using the opaque covered goggles during the test, the subject is provided with an
altered visual reference. A stop watch was used to record the amount of time the subject maintained initial
equilibrium position in each condition. Assistance was taken to ensure safety of the subject. Test interpretation: A
poor score in conditions 1 and 2 indicated that the subject made poor use of somatosensory reference. A poor
score in conditions 4 and 1 indicates, the subject uses poor visual reference. A poor score in conditions 5 and 1
indicated that the subject makes poor use of vestibular cues and a poor score in conditions 2, 3, 5 and 6 with
inaccurate visual cues worse than no visual cue, indicates that the subject relies on visual cues even when they
are inaccurate.
3.2 Treatment protocol
The subjects balance was trained by making him stand over a square foam surface which reduces the quality of
surface orientation input and all activities related to balance were administered over the same mat. Training was
given for 15 20 minutes/day, 5 days a week for a period of 1 month. The sequence of balance activity was kept
constant for all treatment sessions. The sequence of activities are as follows: 2 to 3 minutes of warm ups for
upper and lower limbs followed by repetition of the same set of activities with foot placed closer and then in
tandem standing for 5 minutes. For the next 5 minutes the subject was asked to keep his eyes closed and repeat
the same set of exercises. Help from an assistant was taken to ensure safety of the subject. The subject was given

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the freedom to open eyes when he felt excessive imbalance. Finally the last 3-5 minutes was utilized to train
dynamic balance by asking the subject to catch ball and throw it back to the therapist as shown in figure 8.
4. Results
Increment of score in all the 3 outcomes was observed. The multi directional reach test showed an overall
increase in reach distance in all directions. We observed an average of 25% increase in values between pre and
post training assessment. Bergs balance score of the patient was healthy during pre training assessment with an
overall score of 48 and at the end of the trial the patient scored a maximum score of 54. CTSIB assessed before
the training showed a poor performance in conditions 5 & 6 i.e the subject had difficulty in integrating
proprioceptive inputs when the visual input is removed. Post training assessment showed an improvement of 12
seconds for condition 5 and 11 seconds for condition 6.
5. Discussion
The results of this experiment provide evidence that, the balance exercises dedicated to stimulate and facilitate
the peripheral proprioceptors have beneficial effects in improving balance among individuals suffering from PD.
Our investigation represent the first systematic evaluation of balance training by manipulating peripheral sensory
inputs among the target population. Numerous findings emerged that were relevant to clinical practice. The most
notable finding of our study were 1- Subjects with PD have difficulty in integrating peripheral sensory inputs
especially the proprioceptive inputs which could be one of the contributing factors for impaired balance, 2- The
contribution from the peripheral proprioceptors for maintaining equilibrium are trainable and 3- Balance training
on a compliant surface can be used to facilitate proprioceptors to improve balance.
The results of the case study are interesting in several aspects. Firstly, the comparison of the results for the
multidirectional reach test at the beginning and end of the training period showed increase in all direction.
Newton RA, in his work had stated the muiltidirectional reach test to be an inexpensive, reliable, and valid tool
that can be used to assess the stability of individuals. The results of this test reflects the increment in limits of
stability in all directions. From the results it is apparent that the limits of stability has increased for all 4 domains.
Secondly, we observed an increase in the overall score of the Bergs balance score. The BBS was designed to
measure changes in functional standing balance over time. It is a 14-item scale that rates each function from 0
(worst) to 4 (best) along a dependence-independence continuum. This summative scale measures balance
abilities seen during tasks involving sitting, standing, and positional changes. Total scores are indicative of
overall balance abilities, with scores interpreted in the following manner: 0 to 20, wheelchair bound; 21 to 40,
walking with assistance; and 41 to 56, independent (Berg KO et al 1998 and Berg K Wood-Dauphinee S
Williams JI 1995). The subject was having an overall score of 48 before the trial with scores lacking in activities
like Turning to look behind, Turning 360 degrees, placing alternate foot on stool, standing with one foot in front
and standing on one foot. An inability to score maximum in these tasks could be due an inability to terminate the
sequential activity. Meg E Morris states, these subjects have sustained discharge in the supplementary motor area
(SMA), rather than the rapid drop in neural activity in the SMA that normally allows movements to be
terminated. Difficulty terminating locomotor actions such as walking, running, or turning during walking is
thought to be one of the major factors that predisposes people with PD to slips, trips, and falls (Morris ME and
Iansek R 1997). The increase in the overall score following therapy incicates an improvement in the patients
ability to terminate sequential activity effectively However we could not explain the reason for this phenomenon.
Further studies are warranted to explore this phenomenon. Finally the CTSIB showed an improvement in
conditions 5 & 6. Our previous studies done on stroke subjects revealed that this improvement could be because
of unmasking of the somatosensory and vestibular systems in maintaining balance. Same explanation can be
adopted to explain the phenomenon behind improvement in balance among the patients suffering from
Parkinsons disease.
6. Conclusion
The results of this study suggested that sensory-specific balance exercise had a positive training effect on balance.
However, 2 limitations should be mentioned. This was a pilot trial done on a single case, the results of which
cannot be generalized therefore further studies can be carried out on more number of subjects. Secondly,
blinding can be considered in future.
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Winter, D.A., Patla, A.E and Frank, J.S. (1990). Assessment of balance control in Humans. Medical Progress
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Table 1.
Outcomes

Pre test score

Post test score

Multi directional reach

FFR- 16cms

FFR- 20cms

BFR- 7cms

BFR- 8cms

LFR- 18cms

LFR- 21cms

RFR- 14cms

RFR- 19cms

Bergs balance score (overall)

48

54

CTSIB

Condition 1- 30 sec

Condition 1- 30 sec

Condition 2- 30 sec

Condition 2- 30 sec

Condition 3- 30 sec

Condition 3- 30 sec

Condition 4- 30 sec

Condition 4- 30 sec

Condition 5- 15 sec

Condition 5- 27 sec

Condition 6- 19 sec

Condition 6- 30 sec

Shows the progress in outcomes pre and post training

Figure 1. Equipments used (square red mat- compliant surface, opaque goggles- altered visual reference, ball
to train balance, scarf to blind vision, stop watch)

Figure 2. Condition 1of CTSIB (Eye open + Firm surface)

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Figure 3. Condition 2 (Eye closed + Firm surface)

Figure 4. Condition 3 (altered visual reference + Firm surface)

Figure 5. Condition 4 (eye open + compliant surface)

Figure 6. Condition 5 (eye closed + compliant surface)

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Figure 7. Condition 6 (altered visual reference + compliant surface)

Figure 8. Subject undergoing conventional balance training standing over a compliant surface.

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