improvement in motor disorders in parkinson s disease ( pd ) involves drug and rehabilitation therapy , in which physiotherapy activities are of major importance . according to this premise , physical therapy for people with pd prioritizes the execution of isolated motor tasks at all stages of the disease , especially when patients are in the moderate and advanced stages . from this perspective , the use of virtual reality through nintendo wii has been considered a good alternative in the motor rehabilitation of individuals with pd , requiring simultaneous interaction to develop physical , visual , auditory , cognitive , psychological and social strategies in carrying out activities , and improving functional performance and gait .
the aim of this study was to analyze the effect of virtual sensorimotor activity on gait disorders in people with pd .
the study included 15 individuals diagnosed with pd , presenting gait disturbance that had been observed and examined in the movement disorders section of the neurology department at the pedro ernesto university hospital , rio de janeiro state university ( hupe / uerj ) .
gender and disease duration were not taken into consideration and participants were aged 45 - 85 years .
those with dementia , mental disorders or the need for changes in medication were excluded .
participants were selected according to anamnesis , functional motor assessment , mini mental state examination , and disease staging by the modified hoehn and yahr scale with scores 2 - 4 .
selected participants were submitted to the motor subscale of the unified rating scale for pd ( updrs iii ) , schwab and england daily living activities scale ( se ) , functional independence measure questionnaire ( fim ) , and biomechanical analysis of gait using images taken by digital video camera , always during the on phase of the disease , and repeated at the end of the program .
images were acquired with a sony digital camera with 5.1 megapixels of resolution ( super steadyshot dsc - t70 ) .
the number of steps and walking speed to cover the 18 meters were evaluated by means of the images using windows media player . after these assessments , participants started playing with the nintendo wii platform .
sessions lasted 40 min and were performed twice a week for a total of 14 sessions , with two min between each exercise . for this program , three categories with different virtual exercises
step free step involves stepping on and off the platform with each leg ( l ) , before progressing to rhythmic step and rhythmic boxing , performed by standing on one leg ( mi ) while the other leg moves in a rhythmic sequence , alternating the foot and arm movement ( a ) .
it consists of : ski slalom , advanced skiing , ski jumping , followed by header and jump rope ( three series for each exercise ) .
ski slalom is performed standing on both feet while the body moves side to side ( as if moving forward in a zigzag movement ) to change direction .
ski jump involves standing with the feet slightly apart , bending the knees , leaning the upper body forward , and holding the arms straight back in a straight line .
the participant straightens up the body position at the end of the jump , arms by the side .
the same position is used to perform header and jump rope , but with specific sensorimotor stimulations .
when the participant leans forward he or she goes faster , and upper body movement enables the player to move the handlebars and change direction .
upper body movements , and moving the hands up and down as if beating a drum , enable the participant to change direction .
step free step involves stepping on and off the platform with each leg ( l ) , before progressing to rhythmic step and rhythmic boxing , performed by standing on one leg ( mi ) while the other leg moves in a rhythmic sequence , alternating the foot and arm movement ( a ) .
it consists of : ski slalom , advanced skiing , ski jumping , followed by header and jump rope ( three series for each exercise ) .
ski slalom is performed standing on both feet while the body moves side to side ( as if moving forward in a zigzag movement ) to change direction .
ski jump involves standing with the feet slightly apart , bending the knees , leaning the upper body forward , and holding the arms straight back in a straight line .
the participant straightens up the body position at the end of the jump , arms by the side .
the same position is used to perform header and jump rope , but with specific sensorimotor stimulations .
when the participant leans forward he or she goes faster , and upper body movement enables the player to move the handlebars and change direction .
upper body movements , and moving the hands up and down as if beating a drum , enable the participant to change direction .
the study included 8 women and 7 men , mean age 68.7010.2 years , mean disease duration 7.33.7 years , and hoehn and yahr average of 2.10.3 . to check whether the differences found between pre- and post - treatment were statistically significant at a 95% confidence level ( tp ) we used the paired means test for student s t - test distribution . in the initial analysis with updrs iii
the average score was 28.5 points , while a second evaluation gave an average of 15.8 .
the schwab and england activities of daily living scale indicates mean values of 79.33% and 90% , pre - and post - treatment , respectively .
evaluation of the functional independence gave 114.3 points for the initial mean ; mean score after treatment was 121.3 .
evaluation of the gait motor behavior gave average number of steps as 54.23 , whereas in a second evaluation this was 46.92 .
mean values of average linear speed ranged from 0.48 m / s in initial assessment to 0.53 m / s in second evaluation .
the implementation of a program developed through sensory - motor exercises specific to wii fit plus improved gait performance in pd patients , with an increase in stride length and gait speed , demonstrated through an analysis of images , when comparing the results obtained before and after the selected program .
zettergren performed a case study on a 69-year - old individual with pd who underwent three exercises ( penguin slide , table tilt and balance bubble ) with nintendo wii fit twice a week for eight weeks , and observed improvement in functional performance and higher gait speed .
analyzed the effect of multi - step training with rhythmic auditory stimulation , step aerobic activity ( similar to that of this study ) , in the functional performance of individuals with pd , showing that the combination of step training with rhythmic auditory stimulation offers benefit for functional improvement of gait and balance in pd patients .
in addition to the activities performed by the nintendo wii fit plus , there are other non - virtual therapeutic strategies for the treatment of motor disorders of gait in pd that resemble the proposed study . among these , there are activities that involve sensorimotor combinations with external auditory rhythm and visual stimulation , as well as coordination physical exercises , dexterity , gait initiation , quick changes in direction , walking with long strides overcoming obstacles and sensorimotor agility . in the present study ,
in addition to the increase in the average linear speed and length of patients steps , there was a reduction in motor impairment , especially in the items of rigidity and flexibility of the lower limbs evaluated by updrs iii , and greater functional independence , as evidenced in the se and fim scales , with improvements in items related to locomotion and stair climbing .
this improvement was observed in the initial months and then progressively decreased , especially in individuals who did not continue the activities ; this underlines the importance of maintaining physical exercise . a randomized study comparing two groups of pd performing different gait training exercises , with visual tracks or physical therapy , showed improvement in both groups .
it showed greater functional independence , increased speed and step length in the gait of those participants undergoing sensorial training than those who underwent conventional physiotherapy .
this led us to conclude that this difference may have been facilitated by the greater visual attention needed to complete the tasks , similar to what happens in virtual exercises .
the use of motion exercises and cognitive abilities in nitendo wii fit showed that , after training , the ability of those with parkinson s disease to learn , retain and transfer performance improvements was totally dependent on the cognitive demands of the games involved , reaffirming the importance for rehabilitation purposes , the need for the selection of the games to be used in activities .
some studies suggest physical exercises as therapeutic strategies in mesencephalic lesions in the substancia nigro ( sn ) .
yoon et al . , in experiments with rats submittted to physical exercise on a treadmill for 14 consecutive days after sn injury , demonstrated improvement in functional activity and found high levels of brain neurotrophic factors in glial cells .
the same was found by tajiri et al . in an experimental parkinsonian model where rats received infusion of 6-hydroxydopamine in the striatum and
these rats showed elevated levels of neurotrophic factor , glial derived , greater proliferation of neuron progenitor cells , and a significant reduction in neuronal death , as well as better performance of animals in a cylinder behavioral test when compared to sedentary animals .
experimental models of pd have been useful to investigate the influence of physical exercises , neurotrophic factors and glial cells as mediators of neuroplasticity in the central nervous system .
such exercises performed later in the sn lesions may improve motor symptoms and preserve striatal dopaminergic terminals , although it is not very clear whether prior physical exercise or its intensity are able to provide protection against 6-hydroxydopamine .
given this , the possible neuroprotection through physical exercises and neurotrophic factors may be important in addressing neurodegenerative diseases and thus improve the response to drug treatment .
the physical exercise proposed in this study using the nintendo wii fit plus may represent a non - invasive practice to achieve neuroprotection .
gait motor training in pd using the nintendo wii fit plus platform was effective and efficient in a short time period .
this activity program was shown to be useful for motor recovery of neurodegenerative diseases , showing improvement in motor performance and functional independence in individuals with pd .
 the use of the nintendo wii has been considered a good alternative in the motor rehabilitation of individuals with parkinson s disease ( pd ) , requiring simultaneous interaction to develop strategies for physical , visual , auditory , cognitive , psychological and social activities in the performing of virtual activities , resulting in improvement in functional performance and gait . 
 the aim of this study was to analyze the effect of virtual sensorimotor activity on gait disorders in people with pd . 
 fifteen subjects with a clinical diagnosis of pd were submitted to the unified parkinson s disease rating scale ( updrs iii ) , schwab and england activities of daily living scale ( se ) , functional independence measure ( fim ) , and biomechanical gait analysis using digital images taken with a video camera before and after the treatment program . 
 the activities with the nintendo wii virtual platform were standardized into three categories : aerobics , balance and wii plus exercises . 
 participants carried out separate virtual exercises for 40 min , twice a week , for a total of 14 sessions . 
 the program improved sensorimotor performance in pd gait , with an increase in stride length and gait speed , in addition to a reduction in motor impairment , especially in items of rigidity and flexibility of the lower limbs evaluated by updrs iii , and greater functional independence , as evidenced in the se and fim scales . 
 improvements in items related to locomotion and stair climbing were also observed . 
 the training was effective in motor recovery in chronic neurodegenerative diseases , showing improvement in motor performance and functional independence in individuals with pd . 
Introduction
Materials and Methods
Aerobics
Balance
Exercise Plus
Results
Discussion
Conclusions