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A Single-Blinded Randomised Controlled Trial CRE0010.1177/0269215517721593Clinical RehabilitationSong et al. 721593research-article2017 CLINICAL Article REHABILITATION Clinical Rehabilitation 2018, Vol. 32(3) 299 –311 Home-based step training © The Author(s) 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav using videogame technology DOI:https://doi.org/10.1177/0269215517721593 10.1177/0269215517721593 in people with Parkinson’s journals.sagepub.com/home/cre disease: a single-blinded randomised controlled trial Jooeun Song1,2, Serene S Paul1,3, Maria Joana D Caetano4, Stuart Smith5, Leland E Dibble6, Rachelle Love1, Daniel Schoene7, Jasmine C Menant4, Cathie Sherrington3, Stephen R Lord4, Colleen G Canning1 and Natalie E Allen1 Abstract Objectives: To determine whether 12-week home-based exergame step training can improve stepping performance, gait and complementary physical and neuropsychological measures associated with falls in Parkinson’s disease. Design: A single-blinded randomised controlled trial. Setting: Community (experimental intervention), university laboratory (outcome measures). Subjects: Sixty community-dwelling people with Parkinson’s disease. Interventions: Home-based step training using videogame technology. Main measures: The primary outcomes were the choice stepping reaction time test and Functional Gait Assessment. Secondary outcomes included physical and neuropsychological measures associated with falls in Parkinson’s disease, number of falls over six months and self-reported mobility and balance. Results: Post intervention, there were no differences between the intervention (n = 28) and control (n = 25) groups in the primary or secondary outcomes except for the Timed Up and Go test, where there was a significant difference in favour of the control group (P = 0.02). Intervention participants reported mobility improvement, whereas control participants reported mobility deterioration—between-group difference on an 11-point scale = 0.9 (95% confidence interval: −1.8 to −0.1, P = 0.03). Interaction effects between intervention and disease severity on physical function measures were observed (P = 0.01 to 1 Faculty of Health Sciences, The University of Sydney, Sydney, 5 Southern Cross University, Coffs Harbour, NSW, Australia NSW, Australia 6 Department of Physical Therapy, University of Utah, Salt 2 Graduate School of Health, University of Technology Sydney, Lake City, UT, USA Sydney, NSW, Australia 7 Institute for Biomedicine of Ageing, Friedrich-Alexander 3 Musculoskeletal Health Sydney, School of Public Health, The University Erlangen-Nürnberg, Erlangen, Germany University of Sydney, Sydney, NSW, Australia 4 Falls, Balance and Injury Research Centre, Neuroscience Corresponding author: Research Australia, The University of New South Wales, Natalie E Allen, Faculty of Health Sciences, The University of Sydney, NSW, Australia Sydney, P.O. Box 170, Lidcombe, NSW 1825, Australia. Email: [email protected] 300 Clinical Rehabilitation 32(3) P = 0.08) with seemingly positive effects for the low-severity group and potentially negative effects for the high-severity group. Conclusion: Overall, home-based exergame step training was not effective in improving the outcomes assessed. However, the improved physical function in the lower disease severity intervention participants as well as the self-reported improved mobility in the intervention group suggest home-based exergame step training may have benefits for some people with Parkinson’s disease. Keywords Parkinson’s disease, exergames, stepping performance, home-based training Received: 14 February 2017; accepted: 28 June 2017 Introduction Most people with Parkinson’s disease suffer falls difficulty in maintaining motivation and the as the disease progresses1 and this debilitating desire for feedback on performance as key fac- problem responds poorly to Parkinson’s disease tors influencing exercise participation in people medications.2 Due to the common motor impair- with Parkinson’s disease.8 Furthermore, a feasi- ments associated with Parkinson’s disease, these bility study where people with Parkinson’s dis- individuals have reduced ability to make quick and ease were supervised while using a commercially appropriately timed steps, a critical skill for main- available stepping exergame reported that par- taining balance and preventing falls.3 ticipants could play the game safely without Research has shown that supervised step physical assistance and found the game to be fun training is feasible and efficacious in people and easy to use.9 This form of step training there- with Parkinson’s disease.4–6 A recent large fore has the potential to provide engaging and (n = 282) trial of supervised treadmill walking in relatively inexpensive exercise that people with a virtual reality environment showed an improve- Parkinson’s disease could undertake at home at ment in balance and gait and a reduction in falls times convenient to them. following the intervention, suggesting that step There is evidence that unsupervised home- training may be an important component of exer- based step training using a modified dance-based cise interventions to reduce falls and improve game (Stepmania) is acceptable to older people mobility in people with Parkinson’s disease. and people with multiple sclerosis. Furthermore, While fully supervised, centre-based step train- in these populations, it was effective in improving ing programmes appear to be feasible and effec- choice stepping reaction time and balance (i.e. tive;4,5 they are difficult to implement broadly postural sway on a compliant surface, alternate and to sustain in the long term. In contrast, exer- step test), thereby reducing fall risk.7,10 The aim of cise-based videogames (exergames) can be set the present trial was to determine whether this up in participants’ homes and delivered unsuper- exergame training programme, which requires vised, after initial supervised training to maxim- participants to make appropriately timed step ise safety while exercising. Such exergames responses to visually displayed targets presented have built-in motivating features and provide on a television screen, is also efficacious in peo- immediate feedback on performance, thereby ple with Parkinson’s disease. Therefore, we enhancing their potential to provide engaging hypothesised that 12 weeks of this exergame step and sustainable exercise.7 This is particularly training would (1) improve stepping performance important as a recent qualitative study identified and gait; (2) improve leg muscle power, mobility, Song et al. 301 simple reaction time, cognition, freezing of gait to the trial manager and the physiotherapist provid- and fear of falling; and (3) reduce falls in people ing the training. with Parkinson’s disease. Participants in the intervention group were taught to perform the exergame in their home by an experi- Methods enced physiotherapist. Participants were instructed to perform the exergame for a minimum of 15 minutes, The study comprised a two-arm, parallel, single- three times a week for 12 weeks, while their usual blinded randomised controlled trial and was Parkinson’s disease medications were working opti- prospectively registered with the Australian mally (i.e. during the “on” phase). The exergame was and New Zealand Clinical Trials Registry a modified version of the open-source Dance Dance (ACTRN12613000688785). Revolution “Stepmania” game (www.stepmania. Community-dwelling people with Parkinson’s com) which has been described in detail elsewhere.7 disease were recruited from metropolitan Sydney, In brief, participants in the intervention group Australia, through Parkinson’s disease support were provided with a small computer to connect to groups and neurology clinics. Participants were their television or monitor and a custom-made step included if they had been diagnosed with idiopathic mat. The step mat had six arrows (right, left, two Parkinson’s disease by a neurologist and were liv- fronts and two backs) as well as two central stance ing in the community, aged 40 years or over, were panels to indicate the position to initiate steps and able to walk unaided for ≥30 m and their Parkinson’s return to after completing them. Participants were disease medication was stable for at least two instructed to stand on the central stance panels and weeks. They were excluded if they had substantial step on the appropriate target arrow (right, left, cognitive impairment (defined as a Mini-Mental right front or back and left front or back) to match State Examination Score < 24)11 or medical condi- the direction and timing (varying stimulus speed) tions which would preclude or interfere with physi- of the arrows that were drifting from the bottom to cal assessment or stepping training. Demographic the top of the television screen. characteristics (age, gender, height, weight, mental To increase the cognitive load, there were three status, Parkinson’s disease duration, Parkinson’s different types of randomly presented targets which disease severity as determined by the Movement sought different responses to get a perfect score: Disorders Society–sponsored version of the (1) an arrow required participants to step on the Unified Parkinson’s Disease Rating Scale Part corresponding arrow on the step pad at the moment III,12 previous falls and freezing of gait) were col- the arrow matched a target on the screen; (2) a lected by trained physiotherapists in order to tailed arrow required the same stepping response, describe the sample. All demographic information
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