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Participant flow diagram for participant inclusion, allocation, follow-up, and analysis.
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Visual training Posture exercises in front of a mirror Locating the body parts according to the straight line that is drawn on the mirror Training in terms of balance and strategy in front of the mirror Following a stable object with one’s eyes while walking to avoid collapsing of the body Somatosensorial training Soft tissue mobilization on the sole Mobilization of big and small joints forming the foot complex Cervical mobilization with the aim of stimulating type 1 proprioceptors in neck Using a small device which vibrates when individuals increase their kyphosis Bandaging with a non-elastic bandage in the shape of 8 whose midpoint is on the apex of the kyphosis on the back and stretching with the bandage towards a belt on the waist to set the back in the correct position. (moving towards elastic bands from non-elastic bands) Kinesiotape application to the trunk extensors and the quadriceps femoris muscle Balance education on hard ground and on an uneven ground Using weights for walking education Vestibular training Anteroposterior and mediolateral rhythmic weight shift in the sitting and standing position Exercises with ball: Moving the ball forwards and backwards while sitting on the ball Similarly, stimulating the otolith organ by little, slight, up and down jumps while sitting on the ball Following with the eye the reference point located half a meter away from to develop vestibulo-ocular activities Stimulating vestibular system by activities like jumping on mini trampoline and education on balance board in sitting position Sensory motor perceptual integration activities The walking trail including different surfaces (hard and soft), objects placed close to each other and different height barrier was designed. Initially, the environment containing less objects and different surfaces was created. Firstly, auditory cues were provided to encourage patients to complete the lap. Then the trail was changed to be difficult to walk. Individuals were asked to complete the trail according to the route. Walking time was determined with a stopwatch. When the time was getting shorter, route or surface changes were made. Dual activities (mental and motor) were added in later times. Characteristics Study Group Control Group P-value Mean±SD n Gender Female/Male 5/7 6/6 0.682b Age 71.83±9.71 72.75±9.23 0.885+ H&Y stage 2.5/3 6/6 8/4 0.408b Duration 6.83±3.78 6.91±5.07 0.704+ Mini Mental Test 28.92±1.17 29.25±1.22 0.383+ UPDRS Motor 20.41±7.30 21.66±8.10 0.728+ UPDRS ADL 13.25±6.92 12.58±4.68 0.772+ CDP-SOT Position 5th 23.99±28.54 37.99±32.17 0.308+ Position 6th 11.64±23.39 39.1±31.09 0.038+ Composite 51.66±13.55 62.33±19.93 0.133+ CDP-Sensory SOM 97.67±2.74 94.25±8.67 0.812+ VIS 65.00±28.56 70.42±28.60 0.488+ VEST 25.66±30.59 41.58±33.89 0.224+ PERF 86.08±16.23 89.50±28.39 0.080+ Clinical Balance Tests BBS 40.91±7.91 42.17±12.26 0.488+ TUG 16.59±8.29 16.75±10.45 0.583+ FRT 12.96±3.21 14.41±6.19 0.623+ N - Number of subject, SD - standard deviation, H&Y Stage - Modified Hoehn & Yahr Scale, UPDRS - Unified Parkinson Disease Rating Scale, ADL - activities of daily living, β - Chi square test, + - Mann Whitney U test, CDP-SOT - Computerized dynamic posturography – Sensory Organization Test, CDP-Sensory - Computerized dynamic posturography – sensory analysis, SOM - Somatosensory system score, VEST - Vestibular system score, VIS - Visual system score, PREF - Visual preference score, BBS - Berg Balance Scale, TUG - Timed Up and Go Test, FRT - Functional Reach Test
Outcome measurement Study group Control group Statistic T1-T01=12 T2-T0 N2=7 T1-T0 N1=12 T2-T0 Mean± SD Con. Int. N2=8 PT1-T0 dcorr PT2-T0 Mean± SD CI (lower bound – upper bound) UPDRS MOTOR -4.75±3.67* (-7.08) – (-2.42) -2.75 ± 4.97 * (-8.93) – (-1.35) -5.08±2.50* (-67.7) – (-3.49) -5.37±4.65* (-9.27) – (-1.48) 0.930 0.040 0.861 ADL -5.00±2.59* (-6.64) – (-3.35) -4.85 ± 3.71 * (-8.29) – (-1.42) -3.17±2.44* (-1.61) – (-4.71) -2.75±4.97 (-6.91) – (1.41) 0.113 -0.340 0.352 UPDRS Total -11.00±5.49* (-14.49) – (-7.51) -11.14 ± 4.98 * (-15.75) – (-6.54) -8.66±4.40* (-11.46) – (-5.87) -8.13±7.12* (-14.08) – (-2.17) 0.297 -0.169 0.352 CDP-SOT Position 5th 37.89±23.55* 22.92 – 52.85 29.91 ± 24.25 * 7.48 – 52.33 10.05±10.25* 3.54 – 16.56 5.75±15.42 (-7.14) – (18.64) 0.005++ 1.001 0.027++ Position 6th 41.08±24.99* 25.20 – 56.96 41.57 ± 31.83 * 12.13 – 71.01 4.64±10.55 (-2.06) – (11.34) 9.00±13.54 (-2.32) – (20.32) 0.001++ 1.364 0.064 Composite 22.16±10.77* 15.31 – 29.01 17.43 ± 11.18 * 7.09 – 27.77 4.17±5.20* 0.86 – 7.47 4.63±12.94 (-6.19) – (15.44) 0.0001++ 1.214 0.042++ CDP-Sensory SOM -0.83±2.62 (-2.49) – (0.83) -0.14±3.43 (-3.32) – (3.04) 2.58±6.11 (-1.30) – (6.46) 3.14±8.07 (-4.32) – (10.61) 0.089 -0.531 0.330 VIS 12.83±24.92 (-3.00) – (28.67) 5.85±8.76 (-2.25) – (13.96) 8.50±25.43 (-7.46) – (24.65) 6.71±42.85 (-32.98) – (46.35) 0.256 0.130 0.898 VEST 42.08±26.57* 25.20 – 58.96 32.71 ±25.85* 8.80 – 56.63 7.67±14.08 (-1.28) – (16.61) 7.28±20.58 (-11.76) – (26.33) 0.001++ 1.142 0.048++ PREF 6.75±15.77 (-3.27) – (16.77) 14.00±17.73 (-2.41) – (30.41) 7.00±30.13 (-12.15) – (26.15) 15.42±38.08 (-19.80) – (50.65) 0.560 -0.456 0.480 Clinical balance test BBS 10.42±8.48* 5.03 – 15.80 11.71±10.90* 1.63-21.80 4.25±4.31* 1.5 – 6.99 1.37±8.79 (-5.98) – (8.73) 0.027++ 0.609 0.037++ TUG -4.74±2.01* (-6.02) – (-3.47) -4.80±2.34* (-6.97) – (-2.64) -2.36±2.17* (-3.75) – (-0.98) -0.69±1.21 (-1.71) – (0.32) 0.001++ -0.285 0.002++ FRT 6.43±3.00* 4.53 – 8.34 6.14±4.56* 1.92 – 10.36 3.52±2.59 * 1.87 – 5.16 2.62±3.34* (-0.17) – (5.42) 0.024++ 0.600 0.115 N - Number of subject, SD - Standard deviation, CI - Confidence of interval 95%, T1-T0 - post–treatment values - (pre–treatment values), T2-T0 - follow up values - (pre–treatment values), dcorr - Cohen d correction, *p<0.05 according to Wilcoxon test, ++ - p<0.05 according to Mann Whitney U test, UPDRS - Unified Parkinson Disease Rating Scale, ADL - activities of daily living, CDP-SOT - Computerized dynamic posturography–Sensory Organization Test, CDP-Sensory - Computerized dynamic posturography–sensory analysis, SOM - Somatosensory system score, VEST - Vestibular system score, VIS - Visual system score, PREF - Visual preference score, BBS - Berg Balance Scale, TUG - Timed Up and Go Test, FRT - Functional Reach Test
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