Progressive Modular Rebalancing System and Visual Cueing for Gait Rehabilitation in Parkinson's Disease: A Pilot, Randomized, Controlled Trial With Crossover

Abstract

Introduction: The progressive modular rebalancing (PMR) system is a comprehensive rehabilitation approach derived from proprioceptive neuromuscular facilitation principles. PMR training encourages focus on trunk and proximal muscle function through direct perception, strength, and stretching exercises and emphasizes bi-articular muscle function in the improvement of gait performance. Sensory cueing, such as visual cues (VC), is one of the more established techniques for gait rehabilitation in PD. In this study, we propose PMR combined with VC for improving gait performance, balance, and trunk control during gait in patients with PD. Our assumption herein was that the effect of VC may add to improved motor performance induced by the PMR treatment. The primary aim of this study was to evaluate whether the PMR system plus VC was a more effective treatment option than standard physiotherapy in improving gait function in patients with PD. The secondary aim of the study was to evaluate the effect of this treatment on motor function severity. Design: Two-center, randomized, controlled, observer-blind, crossover study with a 4-month washout period. Participants: Forty individuals with idiopathic PD in Hoehn and Yahr stages 1-4. Intervention: Eight-week rehabilitation programs consisting of PMR plus VC (treatment A) and conventional physiotherapy (treatment B). Primary outcome measures: Spatiotemporal gait parameters, joint kinematics, and trunk kinematics. Secondary outcome measures: UPDRS-III scale scores. Results: The rehabilitation program was well-tolerated by individuals with PD and most participants showed improvements in gait variables and UPDRS-III scores with both treatments. However, patients who received PMR with VC showed better results in gait function with regard to gait performance (increased step length, gait speed, and joint kinematics), gait balance (increased step width and double support duration), and trunk control (increased trunk motion) than those receiving conventional physiotherapy. While crossover results revealed some differences in primary outcomes, only 37.5% of patients crossed over between the groups. As a result, our findings should be interpreted cautiously. Conclusions: The PMR plus VC program could be used to improve gait function and severity motor of motor deficit in individuals with PD. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03346265.

Keywords: Parkinson's disease; gait analysis; neurorehabilitation; progressive modular rebalancing system; sensory cues.

Figure 1

Outline of the study design. (A) The flow diagram of the patients enrolled for the study. (B) When both the clinical and the instrumental assessments were performed: at baseline, before rehabilitative treatment (T0), at 4 weeks after the beginning of the rehabilitative treatments (T1), and at 8 weeks (at the end of rehabilitation program) (T2).

Figure 2

The spatio-temporal parameters and trunk and lower limb joint kinematics at the baseline (T0), T1, and T2 evaluations. This figure shows the mean and the standard deviation values of the 21 patients of group A (which performed PMR + sensory treatment) compared to the 19 patients of group B (which performed standard physiotherapy treatment) at the three evaluations (T0, T1, T2). Asterisks (*) denote statistically significant differences.

Figure 3

Trunk and ankle joint kinematic improvements at T1 and T2 evaluations. This figure shows the mean percentage difference and the standard deviation values of the eight patients of group A compared to the seven patients of the group B. Asterisks denote statistically significant differences (*p < 0.05, **p < 0.01).

Figure 4

Trunk kinematics in the three spatial planes. From left to the right: sagittal, frontal, and transverse planes, respectively. This figure shows trunk angles at baseline (T0, light gray line) and at T1 (dark gray line) and T2 (black line) follow-up evaluations in a representative patient. Data were normalized to the cycle duration and represented as a percentage of the gait cycle. In the first, second, and third panels, the vertical segments represent the flexion–extension, bending, and rotation RoM, respectively.