Today is World Parkinson’s Day, where organizations throughout the world come together to raise awareness of what it’s like to live with Parkinson’s. With more than 45% of Parkinson’s patients falling each year, it is important for Parkinson’s sufferers, their families, and their Care Team (primary care physician, neurologist, physical therapist, etc.) to be fully aware of the latest clinical data on how to prevent falls in Parkinson’s. Especially the increasing evidence that selective use of virtual reality (VR) in gait training in parkinson’s disease is very effective in reducing falls.

What is Parkinson’s disease?

Parkinson’s disease (PD) is a neurodegenerative disorder that occurs when certain nerve cells in the brain that produce dopamine and norepinephrine die. The loss of dopamine, which is responsible for the body’s command of muscle movement, leads to shaking, stiffness, and movement impairments such as difficulty with walking, gait control, balance, and coordination. Parkinson’s symptoms usually begin gradually and become worse over time. As the disease progresses, people have increasing difficulty walking and talking.

How prevalent is Parkinson’s disease in the population?

Nearly 1 million people have Parkinson’s in the US, making it the second most common neurological disease after Alzeheimer’s. The prevalence of Parkinson’s also increases with age. While only 0.3% of the overall population has Parkinson’s, this rises to 1% for people over 60 and 3% for people over 80. What is most concerning is that the rate of Parkinson’s among younger people (30 to 64) has grown by over 50% in the past five years.

How is Parkinson’s treated?

Multidisciplinary input is increasingly recognized as important in PD management with physiotherapy encouraged as an additional treatment alongside pharmacological (such as Levodopa) and surgical interventions (such as deep brain stimulation).

Yet, this serious neurological condition still has no cure and only limited treatments are available. This makes adopting innovative treatment approaches a key priority for rehabilitation and physical therapist professionals.

Can Parkinson’s Disease cause falls?

In people with Parkinson’s disease, falls are one of the most common causes of disability, loss of independence, and poor quality of life. More than 45% of people with PD fall each year, with a large proportion falling recurrently (50–86%). Moreover, their risk of falls and fractures increases steadily from 40 years of age, much earlier than that of healthy individuals. (1)

Falls can have devastating effects, including an inability to perform daily activities, fear of falling, and high levels of caregiver stress and injury. The incidence of hip fractures for older people with Parkinson’s disease is four times that of older people without the disease. In addition, the cost of fall-related fractures in people with PD is close to double that of healthy older people.

Why do Parkinson’s patients fall?

How to prevent falls in Parkinson’s Disease patients is a key priority for any care team.  There are a number of reasons that contribute to the risk of falls in PD patients and result in impaired motor-cognitive functions and a loss of balance leading to falls.

The primary motor symptoms that lead to falls are:
Rigidity
Bradykinesia
Posture changes
Axial rigidity
Problems with center of mass, or center of gravity
impaired postural reflexes
Vision (double and blurry vision and changes in depth perception)

Non-motor and cognitive symptoms leading to increase risk of falls may include:
Low blood pressure
Constipation
Fatigue
Problems with executive function in PD.

When we consider that PD is known to impair gait and motor function as well as impact cognition, especially executive function and attention, it is not surprising that these problems further exacerbate difficulties with mobility. This is especially true during complex and dual-task gait activities when patients are required to walk while performing another task.

For example, a complex walking condition in real life may include obstacle crossing, such as stepping over a crack in the ground or going up a curb. Accurate motor planning and adequate attention to relevant stimuli are essential for correct performance of these complex tasks.

 

How to prevent falls with gait training in Parkinson’s Disease 

As falls can be a dangerous complication of PD, preventing them is imperative. Growing evidence clearly suggests that for fall prevention approaches to be effective, they must address both the cognitive and motor components that contribute to falls. This is where virtual reality (VR) combined with treadmill gait training in parkinson’s disease may provide a worthy additional or alternative approach.

 

Clinical Evidence behind VR and Parkinson’s

VR technology is a promising rehabilitation tool with a wide range of applications. By replicating real-life scenarios with VR, patients can perform individualized repetitive practice of motor function that stimulate both motor and cognitive processes simultaneously in a safe and motivating environment. VR supports patients to learn new motor strategies and to relearn motor abilities that were lost as a result of injury or disease.

VR has been shown to enhance rehabilitation efficiency and may help overcome functional limitations due to the disability. A systematic review of over 55 articles showed that all studies reported gait improvement after VR training. Furthermore, VR dual-task gait training was effective and and is now recommended to included as a part of standard rehabilitation protocols for PD. (2)

 

How Virtual Reality helps reduce falls with gait training in parkinson’s disease

Many studies have indicated that adding a semi-immersive VR component to treadmill training improves motor-cognitive function, increases functional abilities and reduces fall risk.

The research below specifically reviews the findings from the semi-immersive motor-cognitive VR system, V-Time, now called GaitBetter. This system has been well researched on 150 patients over 10 years with highly promising results.

1. Reduces fall rate by nearly 60%. A randomized controlled trial published in the Lancet showed that the use of a semi-immersive VR with real life scenarios in combination with treadmill training reduced fall rates by nearly 60% while also improving executive functioning.
2. Improves balance and reduces fall risk for people with FOG. Another paper researched the impact of VR and treadmill training on freezing of gait (FOG) in PD patients. FOG is an abnormal gait pattern that can accompany PD and associated disorders in which there are sudden, short and temporary episodes of an inability to move the feet forward despite the intention to walk. In a sense, you’re stuck – frozen. This research found that treadmill walking with VR improved fall risk in and reduced the occurrence of FOG among PD patients more than treadmill walking alone.
3. Increases inhibition of SAI. A dysfunction in the cholinergic system helping to control attentional orienting and stimuli discrimination may contribute to increased fall risk. Research demonstrated that VR with treadmill training increased inhibition of short-latency afferent inhibition (SAI), a measure of cholinergic activity, resulting in a higher SAI. Improved obstacle negotiation performance, and reduced injury rates compared with treadmill training alone was shown.
4. Modifies prefrontal plasticity during walking. Further research also aimed to understand how VR with treadmill training may be exerting its beneficial effects. Research has shown that patients performing treadmill training with VR had altered prefrontal activation during normal and more challenging walking conditions. The addition of a cognitive training component to a treadmill exercise program apparently modifies the effects of the training on the magnitude and lateralization of prefrontal activation and on falls, extending the understanding of the plasticity of the brain in PD.
5. Improves brain efficiency in frontal regions and promotes functional connectivity. A further paper also demonstrated GaitBetter system’s effects on brain activation with PD patients demonstrating motor-cognitive training using VR with treadmill training decreased the reliance on frontal regions. This resulted in improved function, reflecting increased brain efficiency. Further research aiming to extend these earlier findings also indicated that VR and treadmill training alone specifically highlighted distinct effects on resting-state functional networks of the brain, which are associated with improved dual-task walking performance.