Feasibility of virtual therapy in rehabilitation of Parkinson ’ s disease patients : pilot study

Introduction: Among Parkinson’s disease (PD) motor disabilities, postural and balance alterations are important parameters to physical therapists who need to choose speci ic, targeted therapies for their patients. Among many therapy options, virtual therapy is studied as to whether it can be a viable rehabilitation method. Objective: To verify the applicability of virtual rehabilitation in PD patients for the improvement of their balance and quality of life. Material and methods: Six volunteers, diagnosed to be in Stages II and III of PD (Hoehn and Yahr Scale), were recruited for this study. Patients (65 ± 13 years old) participated in activities involving Wii Fit, for a total of twelve interventions, twice per week. Clinical and qualitative methods were used for the data collection for the initial and inal evaluations: Borg’s Scale, Berg Functional Balance Scale, Time Up and Go, anterior and lateral functional reach and Nottingham’s Scale were performed during the study. Penguin Slide, Ski Slalom, Soccer Heading and Table Tilt were the Wii games selected as a form of

virtual therapy.Results: The collected data were analyzed using the Wilcoxon test.Motor skill, functional capacities and quality of life were analyzed as variables of the patients' balance.Statistically signi icant differences were found in the following tests: Borg's Scale (p = 0.0464), Berg Functional Balance Scale (p = 0.0277), lateral functional reach to the right (p = 0.0431*) and lateral functional reach to the left (p = 0.0277).Conclusion: It is believed that exercises with virtual reality therapy can be a useful tool to improve the balance in PD patients.
axis (4).The loss of postural re lexes and also a slow gait velocity have been associated with an increased risk of falls and postural instability, which can have a variety of impacts in the patients' lives, such as morbidity, functional deterioration, hospitalization, institutionalization, and social problems due to the loss of trust in their capacity to undertake daily life activities, leading to social isolation and a greater state of dependence (5,6).
Physical therapy can be an important tool that can help in the treatment of these patients.The therapeutic program can be administered individually or in a group, and its duration and frequency will depend on the phase and dysfunction found in the patient.The therapeutic exercises can maintain physical conditioning, preserve muscular activity and lexibility, and improve balance.They have also been found to decrease depression and lack of Introduction Parkinson's disease is considered a progressive and chronic disease of the nervous system, involving the basal ganglia and resulting in motor damage, consequently disturbing balance and posture (1).As the disease evolves, the head and the trunk remain ventrally lexed, with the superior members in front of the body and the knees bent.Gait disorder includes a slow, short-stepped shuf ling and a forward-stooped gait with an asymmetrical arm swing (2).Another important manifestation is a postural re lex, where the reactions of straightening, balancing, and protective extension are decreased by the alteration of sensorial processing (3).Postural responses may also be injured due to the rigidity of the trunk, which doesn't allow an adequate movement of rotation in the longitudinal As part of the selection procedures, the volunteers were asked to sign the informed consent to participate in the experimental procedure, as required by the Declaration of Helsinki and the Institutional Research Ethics Committee of PUCPR, approved under number 0002940/09.These patients were not involved in any other form of physical activity throughout the duration of the study.

Assessments
The following evaluations were performed at the beginning and at the end of interventions under the same conditions throughout the whole program, and their brief descriptions are the following: a) Borg's Scale: To establish relationships between perceived exertion and objective data of external load, or physiological stress.b) Berg Functional Balance Scale (BFS): To determine risk factors for loss of independence and falls in the elderly.Evaluates the performance of functional balance of fourteen common items in daily life.c) Notthingham's Scale: To assess quality of life.d) Time Up and Go (TUG): Quick monitoring to detect balance problems that affect activities of daily living in elderly.e) Functional Reach: Developed as a quick monitoring of balance problems in the elderly.The test determines how well the individual is able to move with stability.

Intervention programs
The treatment plan consisted of two visits per week lasting 20 minutes each, over a period of ive weeks of interventions during ON-periods (in presence of the effect of medication).The patients' blood pressure was measured before and after the intervention with the purpose of monitoring the vascular response to the exercises in order to prevent a cardiovascular overload.
The dynamic therapy with the Wii Fit exercises consisted of three planes of motion (sagittal, frontal and transversal) at lower dif iculty levels of the game, targeting stretching exercises and balance training using the balance board.Among various initiative which often occur in Parkinson's disease (7).Various resources and tactics can be used, such as it balls (8), resistance exercises (9, 10), treadmill with partial weight support (11,12), aerobic exercises (13), acupuncture (14), and hidrotherapy (15,16).In recent years, virtual reality technologies have been studied as tools for the evaluation and treatment in neurorehabilitation (17,18).
Virtual reality works in a multisensory and multidimensional environment.The main objectives in rehabilitation by virtual reality through different software, exercises and rehabilitation techniques, would be the increase of functional ability and the raise in the participation of the patient in daily life, which can be reached through the improvement of sensory, motor, and cognitive functions, in a way that can stimulate and motivate the individual to his or her own recovery (19).
One of the new resources available for virtual reality is Nintendo's Wii videogame and its derived products, such as Wii Fit.Its interactive games can help in the recovery of motor skills, working on one's coordination skills, strength, and reasoning, which enable it to interact lucidly and rehabilitate at the same time (20).
This research had the objective of verifying the applicability of virtual rehabilitation in PD patients for the improvement of their balance and quality of life.

Participants
We conducted the study with six patients of both sexes (65 ± 13 years old), belonging to the Parkinson Association of Curitiba.All patients were at intermediate level (Hoen & Yahr Stage II-III) (21), with a dif iculty in walking (de ined by Uni ied Parkinson's Disease Rating Scale -UPDRS, motor part), but able to walk without assistance for at least ive minutes.To be included in the study, patients had to be in PD stages II or III, according to the Hoen and Yahr Scale while in the OFF-medication phase (in absence of the effect of medication) and lack of dementia (Mini-Mental State Examination score ≥ 24).The exclusion criteria were the following: existence of a serious chronic disease (orthopedic, neurological or psychiatric); severe visual impairment; unable to walk independently; had undergone treatment for PD.
The Berg Functional Balance Scale results were statistically signi icant when comparing the initial and the inal assessments (Figure 1B).
The Time Up and Go test was not statistically signi icant when comparing the initial and inal values (Figure 1C).
The following values show the evaluation of the functional range: anterior, lateral right and left side (Figure 2).
The assessment of quality of life by the Nottingham Scale showed no statistical signi icance between the initial and the inal evaluations (Figure 3).

Discussion
The virtualization technology is an emerging reality with a variety of bene its for the recovery aspects of the assessment, treatment and research (22).Research and understanding of this technology will be crucial for effective integration into rehabilitation.This requires a period of adaptation of new technological resources, especially in individuals who do not have the practice of virtual technology (23,24).
Virtual reality systems are new and potentially useful technologies that allow users to interact in three dimensions with a computer generated scenario.It is known that the conventional treatment of neurological patients is based on repetition of movements for the acquisition or retrieval of motor patterns.Therapy with virtual technology can also work with the repetition of movements and allows the user to interact with the system and receive feedback on their performance in real time (24).It therefore incorporates the principles of motor learning and at the same time offers engaging and challenging training in complex environments (25).
Although the use of virtual rehabilitation activities have grown in recent years, little research has been reported in the therapeutic management of people with Parkinson's disease.This pilot study used interactive games in the hopes of stimulating specific movements and benefits related to balance control and quality of life.People affected by Parkinson's disease have a higher propensity for falls and postural instability.In a study by Scandale et al. (9), they used two groups of 32 individuals, a group affected by PD and another group of healthy people.It was found that the PD group had a slower types of games, the following six were selected for the study: -Stretching Exercises: -Half Moon: the patient performs the inclination of the trunk stretching the muscles of the lateral regions of the upper, lower limbs, and the trunk.This is repeated on the opposite side.-Balance Training Exercises: -Penguin Slide: the patient simulates a catching of the ish jumping in the water for points.The game consists of latero-lateral displacements.
-Ski Slalom: the patient tries to zig-zag between red and blue lags without missing any lag.The more the patient leans the trunk forward, the faster he is able to weave through the lags.
-Soccer Heading: just like heading of the ball in soccer, the patient has to head the ball which comes toward him and de lect the ball away from the heads of pandas.If the ball lands on the pandas, it results in reduction of points.
-Tightrope Walk: the patient must traverse a tightrope without falling off or without disturbing various barriers along the way.
-Table Tilt: the patient is presented with a table with various holes in it.Then, he must try to direct the balls into the holes by tilting the table.
Throughout all the balance training exercises, strengthening exercises were performed in parallel.

Statistical analysis
We assessed the relationship between motor learning, functional capacity and the balance of patients by looking at the following: Borg' Scale, Berg Functional Balance Scale, Time Up and Go, Anterior Functional Reach, Right and Left Functional Reach and Quality of Life for Nottigham Scale.For this purpose, we performed the Wilcoxon test, values were considered signi icant when p ≤ 0.05.

Results
The Borg Scale (Figure 1A) results show a signi icant relevance between the baseline and the inal groups (p = 0.0464).
At the end of intervention with Wii Fit, there were no significant differences in relation to the Time Up an Go test, however it was found that participants traveled more distance in the same interval of time in the initial assessment, as measured by the Borg Scale (Figure 1).This result was significant.The gains made by the participants show a drop in stress levels and fatigue to perform these daily activities.gait, stride length and cadence in a 6-minute walk test.Furthermore, Shenkman et al., in their 2001 (10) study, found a deficit in functional mobility in PD patients while performing the 6-minute walk test, which is a test for functional capacity in PD patients.these studies examined.Therefore, there needs to be further research in this endeavor.

Conclusion
The Virtual Reality therapy using Wii Fit showed statistically signi icant improvements in the patients' balance and provides the basis for future research in larger trials.It is believed that exercises with virtual reality therapy can be a useful tool for the following reasons: stimulation of voluntary muscles; sensitization of initial system through constant oscillations of the body on the platform and during the basic movements; activation of somatosensory system by various positions of body segments during different amplitudes of movements; and engaging set of tasks and real-time feedback.All this leads to the potentialization of the system of balance adjustments.Moreover, the playful, dynamic and fun aspects of the virtual therapy may also contribute to improved motivation and willingness for therapy and at the same time may lead to reduction of apathy among patients.
This pilot study suggests that the virtual reality represents a potentially effective alternative to facilitate physical therapy that should emphasize the relationship between balance control improvements and external sensory stimuli.
Rehabilitation with Wii Fit features favorable results with respect to fatigue, suggesting that it takes less effort to perform daily activities (24)(25)(26).The use of this technology for treatment of cerebral palsy was ef icient in terms of improved itness for walking (26).The effects of virtual reality on the level of effort for everyday tasks, is also reported in patients with cerebrovascular accident (CVA), and despite the reduction of fatigue in these patients, no signi icant results were indicated in a study that compared the stress levels of patients in Group Wii Fit with Recreation Therapy Group (24).
It can be observed that the participants in this study had a statistically signi icant increase in points in the initial evaluation and inal Berg Functional Balance Scale.It is believed that this may be related to the balance exercises with Wii Fit.The improvements observed in our study are in line with the Schiaviato study (27).Recent work with hemiparetic stroke complications by performing physical therapy with Wii Fit showed greater control of static and dynamic balance in accordance with the Berg Balance Scale, and reduced mediolateral sway in the stabilometry test (22).By using Wii Fit in a patient with cerebellar dysfunction to determine the in luence of virtual reality on the balance, it was found that the patient had an increase of 23.21% in the BFS, as well as greater independence to perform daily tasks (27).
The participants in this study showed signi icant improvements in functional right and left lateral movements (Figure 2) despite some signs of muscular stiffness, impaired postural reactions, decreased range of motion for straightening of the trunk, reduced balance and protective extension.
A study of elderly patients undergoing balance training using Wii Fit showed improved balance, which was veri ied by analysis of center of pressure (28).
In addition to these clinical parameters, we must consider the social, mental and emotional factors that re lect the quality of life (29)(30)(31).It is critical that the treatment of PD try to promote social interaction and improve the quality of life of these patients.Although the Wii Fit therapy has brought improved results as reported by the participants of this study, they were not suf icient for statistical signi icance for conclusive evidence in evaluating the quality of life.Despite the growing number of studies using Wii Fit balance training, very few in the literature target the patients

Figure 1 -Figure 2 Figure 3
Figure 1 -Borg Scale, Berg Functional Balance Scale and Time Up and GO A) The results of the Borg scale are expressed as mean ± standard deviation.* Statistically signifi cant when compared to the Borg Scale Initial and Final (Wilcoxon).B) The results for the Berg Functional Balance Scale are expressed as mean ± standard deviation.* Statistically signifi cant when compared to the Borg Scale Initial and Final (Wilcoxon).C) The results are expressed as mean ± standard deviation, related to initial assessment and fi nal Test Time Up and GO.Source: Research data.