Cognitive Rehabilitation as a Balance Rehabilitation Strategy in Patients With Parkinson's Disease

Universidad Francisco de Vitoria46 enrolled

Overview

Parkinson's disease (PD) is the second most common neurodegenerative disorder. PD is characterized by motor symptoms, such as bradykinesia, tremor, and rigidity. Although balance impairment is characteristic of advanced stages, it can be present with less intensity since the beginning of the disease. Approximately 60% of PD patients fall once a year and 40% recurrently These falls may be correlated with the inability to achieve compensatory movements to regain balance when their center of gravity tends to swing outside their range of stability, which is reduced in this disease. On the other hand, cognitive symptoms affect up to 20% of patients with PD in early stages and can even precede the onset of motor symptoms. There are cognitive requirements for balance and can be challenged when attention is diverted or reduced, linking a worse balance and a higher probability of falls with a slower cognitive processing speed and attentional problems. Cognitive rehabilitation of attention and processing speed can lead to an improvement in postural stability in patients with Parkinson's. The investigators present a parallel and controlled Randomized Clinical Trial (RCT) to assess the impact on balance of a protocol based on cognitive rehabilitation focused on sustained attention through the NeuronUP platform (Neuronup SI, La Rioja, España) in patients with PD. This therapy opens the possibility of new rehabilitation strategies for prevention of falls in PD, reducing morbidity and saving costs to the health system.

Parkinson's disease (PD) is the second most common neurodegenerative disorder. This disease is characterized by motor symptoms, such as bradykinesia, tremor, and rigidity. Non-motor symptoms such as cognitive impairment, anosmia, sleep disorders, or depression are also part of the disease, and although their prevalence is very high, non-motor symptomsare often underdiagnosed. One of the cognitive characteristics in PD is the slowness in the processing of information, which includes deficits in processing speed and attention, cognitive inflexibility, and forgetfulness. These symptoms may appear from the initial stages of the disease. Approximately 60% of PD patients fall once a year and 40% do so regularly. These falls may be correlated with the inability to achieve compensatory movements to regain balance when their center of gravity generally oscillates outside their limits of stability (LOS), which is reduced in this disease. Some authors point out that reaction times and processing speed may be a marker of postural instability since a reduced speed is associated with difficulty in making turns. This is in line with Pantall's findings, indicating that cognitive function and postural control normally progressively worsen with disease progression. The relationship between cognitive impairment and postural instability in PD patients may be specific for tasks that assess the dorsolateral prefrontal cortex and its frontal-subcortical connections. The main cognitive functions whose affectation would influence a worse balance and gait performance would be attention and executive functions. Varalta et al specified that balance is related to executive functions and attention, while functional mobility is more related to cognitive impairment, verbal fluency, and attentional capacity. Some authors point out that within the executive functions the component with the greatest weight in this relationship would be the inhibitory control. Dual-task performance has also been established as a good indicator of falls in patients with early-stage PD and no previous history of falls. The studies that carried out a one and a half years follow-up of the participants concluded that the deterioration of executive functions acts as a predictor of future falls in patients with PD. Cognitive rehabilitation through neurorehabilitation platforms and neuropsychological rehabilitation in patients with Parkinson's disease has shown to be effective in improving processing speed, attention, and executive functions. Although the relationship between cognitive deficits and postural stability seems to be demonstrated, the investigators have not found studies that, through cognitive rehabilitation, seek a stability improvement. The investigators working hypothesis is that the group that receives rehabilitation of the speed of information processing and sustained attention will improve their postural stability compared to the group that does not undergo any therapy.

Outcomes

Primary Outcomes

Change in Timed stand up and go test score

The timed "Up and Go" test measures, in seconds, the time it takes a person to get up from a chair, walk a distance of 3 meters, turn, walk back to the chair and sit down again.

Time frame: From Baseline at 5 weeks

Change in Berg Balance scale score

Consists of 14 items scored on an ordinal scale of 0 to 4 for a total of 56 points (a higher score indicates lower fall risk). Scale is designed to measure changes in functional standing balance over time. This scale measures the balance skills observed during tasks that involve sitting, standing, and changing positions.

Time frame: From Baseline at 5 weeks

Change in Stability limits test: The Biodex Stability Limits (LOS) score

This test is a challenge for the patient when it comes to moving and exercising control over gravity supported on a base. During each test the patient must change their weight to move the cursor from the center of the target to a new point that will flash on the screen and that will change as fast as the slightest movement or deviation is noticed. This same process will be repeated until another nine objectives are achieved. The test dependent variables provided by the machine are the time (seconds) it takes for the subject to complete the test and the directional control value which is the proportion of the distance travelled by the cursor from the center to each target (based on that 100% is a straight line from the center to the intended target). This means that the greater the distance travelled by the subject, the worse their stability.

Time frame: From Baseline at 5 weeks

Change in Fall risk test score

During the test, the patient undergoes three attempts of 20 seconds each, beginning with an initial platform mobility setting of 6 and ending with a platform setting of 2 (from least to most mobile), with rest periods ten seconds between each test. The patient stands with feet shoulder-width apart on the midline of the board. At the end of the index test it is calculated according to the degree of instability of the patient with each configuration. Own normative data are applied.

Time frame: From Baseline at 5 weeks

Finger tapping (FT)

The FT task has been used as a measure of motor function. In this task, following the Strauss application guidelines, participants are instructed to press the space bar on the keyboard as quickly as possible and repeatedly with the index finger. Five 10-second attempts are made with the dominant hand. The average time between two consecutive hits in the five trials is the dependent variable.

Time frame: Baseline

Finger tapping (FT)