The feasibility and positive effects of a customised videogame rehabilitation programme for freezing of gait and falls in Parkinson's disease patients: a pilot study

Abstract

Background: Freezing of gait and falls represent a major burden in patients with advanced forms of Parkinson's disease (PD). These axial motor signs are not fully alleviated by drug treatment or deep-brain stimulation. Recently, virtual reality has emerged as a rehabilitation option for these patients. In this pilot study, we aim to determine the feasibility and acceptability of rehabilitation with a customised videogame to treat gait and balance disorders in PD patients, and assess its effects on these disabling motor signs.

Methods: We developed a customised videogame displayed on a screen using the Kinect system. To play, the patient had to perform large amplitude and fast movements of all four limbs, pelvis and trunk, in response to visual and auditory cueing, to displace an avatar to collect coins and avoid obstacles to gain points. We tested ten patients with advanced forms of PD (median disease duration = 16.5 years) suffering from freezing of gait and/or falls (Hoehn&Yahr score ≥ 3) resistant to antiparkinsonian treatment and deep brain stimulation. Patients performed 18 training sessions during a 6-9 week period. We measured the feasibility and acceptability of our rehabilitation programme and its effects on parkinsonian disability, gait and balance disorders (with clinical scales and kinematics recordings), positive and negative affects, and quality of life, after the 9th and 18th training sessions and 3 months later.

Results: All patients completed the 18 training sessions with high feasibility, acceptability and satisfaction scores. After training, the freezing-of-gait questionnaire, gait-and-balance scale and axial score significantly decreased by 39, 38 and 41%, respectively, and the activity-balance confidence scale increased by 35%. Kinematic gait parameters also significantly improved with increased step length and gait velocity and decreased double-stance time. Three months after the final session, no significant change persisted except decreased axial score and increased step length and velocity.

Conclusions: This study suggests that rehabilitation with a customised videogame to treat gait and balance disorders is feasible, well accepted, and effective in parkinsonian patients. These data serve as preliminary evidence for further larger and controlled studies to propose this customised videogame rehabilitation programme at home.

Trial registration: ClinicalTrials.gov NCT02469350 .

Keywords: Falls; Freezing of gait; Parkinson’s disease; Rehabilitation; Videogame.

Fig. 1

The ‘Toap Run’ videogame training. The images show screen shots of one patient during videogame training with ‘Toap Run’ in the three different scenarios. From Top to Bottom: ‘The Garden’, ‘The Mine’, and ‘The River’. The movements are schematically represented to the side of the images, from top to bottom: arm extension, lateral shift, trunk lateral displacement with knee flexion, knee flexion/extension, trunk rotation with arm movements, and anteroposterior trunk movement

Fig. 2

Kinematic parameter recordings of gait initiation. Kinematic parameters of gait initiation in an individual patient. From top to bottom, curves represent the smoothed mean of ten trials and show the vertical centre of mass velocity (CoM-Vz), mediolateral (CoP x) and anteroposterior (CoP y) displacements and anteroposterior centre of foot pressure (CoP) velocity (CoP-Vy). APAs: anticipatory postural adjustments, DS: double-stance, CoP: centre of foot pressure, CoM: centre of mass, FC: foot contact of the swing leg, FO1: foot-off of the swing leg, FO2: foot-off of the stance leg, L: step length, t0: time of the first biomechanical event, V1: negative peak of the CoM vertical velocity, V2: CoM vertical velocity at the time of foot contact, W: step width

Fig. 3

Game duration, difficulty and performance in PD patients. The graphs represent the mean and standard deviation, from top to bottom, in game duration, difficulty (number of movements) and performance after the 1st (S1), 3rd (S3), 6th (S6), 9th (S9), 12th (S12), 15th (S15) and 18th (S18) training sessions. * p < 0.05 repeated measures ANOVAs

Fig. 4

Acceptability and feasibility of the ‘Toap Run’ videogame training in PD patients. The graphs represent the mean and standard deviation, from left to right and top to bottom, in perceived interest, perceived competence, perceived difficulty, perceived fatigue, acceptability and positive affects after the 1st session (W1) and once a week from the 2nd to the 6th week (W2 to W6). * p < 0.05 repeated measures ANOVAs

Fig. 5

Effects of the ‘Toap Run’ videogame training on gait and balance disorders, parkinsonian disability and quality of life in PD patients. The graphs represent the mean and standard deviation, from left to right and top to bottom, in the Freezing Of Gait Questionnaire (FOG-Q), Activities and Balance Confidence (ABC) scale, Gait And Balance scale part B (GABS-B), Axial score (UPDRS items 18 + 27 + 28 + 29 + 30), parkinsonian motor disability (UPDRS part III) and activities of daily living (ADL, UPDRS part II) scores. Results were obtained before the first (Pre), after the 9th (Post-9) and 18th (Post-18) training sessions, and 3 months later (Post-M3). * p < 0.05 as compared to the first (baseline) assessment

Fig. 6

Effects of the ‘Toap Run’ videogame training on gait initiation kinematic parameters. Each graph represents the mean and standard deviation from left to right and top to bottom of the APAs phase and double-stance durations, and anteroposterior CoP displacements during APAs and step length. Results were obtained before (Pre), after the 9th (Post-9) and 18th (Post-18) sessions, and 3 months later (Post-M3). * p < 0.05 as compared to the first (Pre) assessment