Disability and Rehabilitation

ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20

Effects of supervised slackline training on postural

instability, freezing of gait, and falls efficacy in
people with Parkinson’s disease

Luis Santos, Javier Fernandez-Rio, Kristian Winge, Beatriz Barragán-Pérez,

Vicente Rodríguez-Pérez, Vicente González-Díez, Miguel Blanco-Traba, Oscar
E. Suman, Charles Philip Gabel & Javier Rodríguez-Gómez

To cite this article: Luis Santos, Javier Fernandez-Rio, Kristian Winge, Beatriz Barragán-Pérez,
Vicente Rodríguez-Pérez, Vicente González-Díez, Miguel Blanco-Traba, Oscar E. Suman, Charles
Philip Gabel & Javier Rodríguez-Gómez (2016): Effects of supervised slackline training on
postural instability, freezing of gait, and falls efficacy in people with Parkinson’s disease,
Disability and Rehabilitation, DOI: 10.1080/09638288.2016.1207104

To link to this article: http://dx.doi.org/10.1080/09638288.2016.1207104

Published online: 14 Jul 2016.

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 DISABILITY AND REHABILITATION, 2016
http://dx.doi.org/10.1080/09638288.2016.1207104

REVIEW ARTICLE

Effects of supervised slackline training on postural instability, freezing of gait, and

falls efficacy in people with Parkinson’s disease
Luis Santosa,b, Javier Fernandez-Rioa , Kristian Wingec, Beatriz Barragan-Perezd, Vicente Rodrıguez-Perezd,
Vicente Gonzalez-Dıeza, Miguel Blanco-Trabae, Oscar E. Sumanf,g, Charles Philip Gabelh and
Javier Rodrıguez-Gomezi
a
University School of Sports Medicine, University of Oviedo, Oviedo, Spain; bPerformance and Health Group, Department of Physical Education
and Sport, Faculty of Sports Sciences and Physical Education, University of A Coruna, Spain; cDepartment of Neurology, Bispebjerg Movement
Disorders Biobank, Bispebjerg University Hospital, Copenhagen, Denmark; dFaculty of Physiotherapy, University of Le on, Leon, Spain; eCatholic
University of Valencia, Valencia, Spain; fDepartment of Surgery, University of Texas Medical Branch, Galveston, TX, USA; gShriners Hospitals for
Children, Galveston, TX, USA; hUniversity of the Sunshine Coast, Coolum Beach, Australia; iDepartment of Neurology, Hospital of the Bierzo,
Ponferrada, Spain
Downloaded by [RMIT University Library] at 06:37 18 July 2016

ABSTRACT ARTICLE HISTORY

Purpose: The aim of this study was to assess whether supervised slackline training reduces the risk of falls Received 25 January 2016
in people with Parkinson’s disease (PD). Revised 23 June 2016
Methods: Twenty-two patients with idiopathic PD were randomized into experimental (EG, N ¼ 11) and Accepted 25 June 2016
control (CG, N ¼ 11) groups. Center of Pressure (CoP), Freezing of Gait (FOG), and Falls Efficacy Scale (FES) Published online 8 July 2016
were assessed at pre-test, post-test and re-test. Rate perceived exertion (RPE, Borg’s 6–20 scale) and local KEYWORDS
muscle perceived exertion (LRPE) were also assessed at the end of the training sessions. Motor control; balance;
Results: The EG group showed significant improvements in FOG and FES scores from pre-test to post-test. physical activity; health;
Both decreased at re-test, though they did not return to pre-test levels. No significant differences were rehabilitation; self-
detected in CoP parameters. Analysis of RPE and LRPE scores revealed that slackline was associated with confidence
minimal fatigue and involved the major lower limb and lumbar muscles.
Conclusions: These findings suggest that slacklining is a simple, safe, and challenging training and rehabili-
tation tool for PD patients. It could be introduced into their physical activity routine to reduce the risk of
falls and improve confidence related to fear of falling.

ä IMPLICATIONS FOR REHABILITATION

 Individuals with Parkinson’s disease (PD) are twice as likely to have falls compared to patients with
other neurological conditions.
 This study support slackline as a simple, safe, and challenging training and rehabilitation tool for peo-
ple with PD, which reduce their risk of falls and improve confidence related to fear of falling.
 Slackline in people with PD yields a low tiredness or fatigue impact and involves the major lower limb
and lumbar muscles.

Introduction integrate vestibular, visual, and propioceptive inputs at the central

Individuals suffering from Parkinsons’ disease (PD) are twice as
likely to fall compared to patients with other neurological condi-
tions.[1] These falls can have significant and far-reaching conse-
quences, not only leading to immediate injuries,[2,3] but also
having psychological ramifications such as basiphobia or fear of
falling.[4] This, in turn, can lead to reduced activity levels,[2] poor
quality of life,[2,5] and caregiver stress.[6,7] Several risk factors are
known to be associated with falls in people with PD. These include
previous falls, postural instability, freezing of gait (FOG), leg muscle
weakness, and cognitive impairment.[8–10]
Postural stability is a significant contributor to the maintenance
of upright posture and balance in daily movements and activities.
Moreover, postural instability can increase the risk of a fall and
subsequent injury, particularly in the elderly.[11] The postural con-
trol system relies upon the unimpaired ability to correctly perceive
the environment through peripheral sensory systems as well as to
nervous system level.[11]
FOG is a condition in which an individual is unable to walk.
That is, an individual’s feet seem to be frozen, while their upper
body continues to move. The forward progression of the feet is
markedly reduced despite the individual’s intention to walk.[12]
For this reason, it is considered a locomotor disorder. The fact that
FOG is also characterized by falls has led to the suggestion that it
is also a postural stability disorder.[12] Nevertheless, more evi-
dence supports the idea that this phenomenon results from motor,
cognitive, and affective deficits, which reinforce one another.[13]
Slacklining is a recreational activity that has gained popularity
in recent years. During slacklining, one walks and/or maintains bal-
ance on a polyester band placed between two anchor points. It
allows very high movement variability, provides only a small non-
fixed base of support, and produces very fast medio-lateral pertur-
bations to the body.[14] The highly movable base of support can
be considered the main difference between slacklining and

CONTACT Luis Santos luis.santos.ef@gmail.com University School of Sports Medicine, University of Oviedo, Catedratico Gimenez, 7, 33007, Oviedo, Spain
ß 2016 Informa UK Limited, trading as Taylor & Francis Group
 2 L. SANTOS ET AL.
‘‘classical balance training,’’ since the latter uses a more or station-
ary base of support.[15] Previous studies on slacklining have
shown that it improves postural stability in young healthy adults
[14] and athletes [16,17] and that it benefits rehabilitation of the
lower limbs and possibly the core.[18] Current therapies for FOG in
individuals with PD, including deep brain stimulation and levo-
dopa, have proven unsuccessful.[19] Given that slacklining has
been shown to improve postural stability and that FOG has been
considered a postural stability disorder, the potential of slacklining
to improve FOG in individuals with PD deserves attention. The aim
of the present study was to assess whether supervised slackline
training could reduce the risk of falling in people with PD; improve
their postural instability, FOG, perceptions of balance, and stability
during daily living activities; and diminish the fear of falling. We
hypothesize that (1) supervised slackline training would generate
benefits in the participants’ postural stability/control system
parameters and in FOG; (2) the program would produce positive
effects on participants’ balance and stability perception; (3) the
program would be perceived as ‘‘hard’’ by the patients (assessed
by the Borg’s 6–20 scale [20]); and (4) that patients would rate the
Downloaded by [RMIT University Library] at 06:37 18 July 2016
Soleus, Gastrocnemius, and Quadriceps as being the most exerted
muscles on a muscular ‘‘local perceived exertion scale’’ (LRPE).[21]
Methods
Participants
A group of 22 patients with idiopathic PD agreed to participate
(Table 1). The study was designed and conducted in accordance
with the guidelines contained within the Declaration of Helsinki,
and it was approved by the Regional Clinical Research Ethics
Committee of the Principality of Asturias, Spain (No. 38/15).
Informed written consent was obtained from all participants. None
had previously used a slackline. Participants were recruited through
advertisements placed in public places and worksites. Inclusion cri-
teria were as follows: idiopathic PD diagnosis (Hoehn and Yahr
Scale 1–3, H&Y [22]); absence of dementia (Mini-Mental State
Examination, the mean score of the present study population was
>27 [23]); ability to stand on two feet for at least 2 min; and ability
to walk at least 10 meters without assistance. Exclusion criteria
included the following: previous history of neurological disease;
severe dyskinesias or ‘‘ON OFF’’ phenomenon; and any alteration in
the Parkinson’s medication regimen. Participants were randomized
into two groups using a random number generator: experimental
group (EG, N ¼ 11) and control group (CG, N ¼ 11). Two drop-outs
occurred during the training period (one from each group) because
these patients moved to another city. Participants were questioned
about their activity level: number of days per week that they par-
ticipated in more than 30 min of physical activity such as walking,
running, biking, stair climbing, sports, rhythmic movement, and
gardening.[24] All participants answered 2–3 days per week.
Protocol
A randomized controlled design was used to investigate the
effects of supervised slackline training on postural instability, FOG,
and scores from the Tinetti Falls Efficacy Scale (FES, [25]) in individ-
uals with PD. Participants underwent antrophometrical assess-
ments and Center of Pressure (CoP) measurements. In addition,
participants were asked to provide ratings for an ad hoc Spanish
version of the FES and a Spanish version of the Movement
Disorders Society-Unified Parkinson’s Disease Rating Scale (MDS-
UPDRS, motor part [26]). They were also asked to complete a
Spanish version of the Freezing of Gait Questionnaire (FOG-Q, 6-
item version,[27]). Tests were conducted by the same researcher at
three times: pre-test (before the training program), post-test
(6 weeks after pre-tests, at the end of the training period), and 4
weeks after the post-test (re-test). Tests and training sessions were
carried out while the patients were on medication (1–2 h after tak-
ing their morning or evening dose) and under the supervision of
their neurologists. Additionally, rate perceived exertion (RPE, Borg’s
>6–20 scale [20]) and LRPE [21] were assessed at the end of each
training session to plan workouts and to identify the major pos-
tural muscles that were being used during slacklining.
Slackline training program
The training program was designed so that it would be safe, sim-
ple, useful, and realistic for people with PD (stages 1–3).
Consequently, the slackline training program focused solely on
static body posture. While both groups followed their usual weekly
physical activity routine, the EG also performed 12 balance training
sessions using a slackline over 6 weeks (two training sessions per
week on nonconsecutive days). The same therapist, blinded for the
purposes of the study, conducted all training sessions. Slackline
sessions lasted approximately 23 min. The sessions were performed
in a gym and conducted on a GibbonTM Slackrack 300 (ID Sports,
Stuttgart, Germany), using a slackrack weight of 29 kg, a line
height of 30 cm, a line length of 3 m, and a line width of 5 cm).
Gymnastic mats were placed under the slackrack to provide a safe
training environment. Each training session was identical. A warm-
up was first performed on the floor and consisted of walking for-
ward, backward, and laterally; walking forward and making shoul-
der movements (forward and backward); and passive stretching of
the main muscle groups (approximately 10 min). Slackline tasks
were then performed (approximately 8 min) and followed by a
cool down (approximately 5 min), which consisted of passive
stretching of the main muscle groups. The slackline training pro-
gram was divided into four blocks, and participants used the fol-
lowing sequence in each session.
Block 1:
 Stand on the band using the right leg as support for 20 s
(with arms and the other leg free). A therapist supplied
help (they placed one of their hands over the participants’
lumbar area of the back and the other at the elbow).
 Repeat task 1, but with the right arm held akimbo (left
arm free).
 Repeat task 1, but with the left arm held akimbo (right
arm free).
 Repeat task 1 with both arms held akimbo.
After this first block, which lasted 80 s, participants took a 40-s
break.
Block 2:
 Stand using the left leg as support for 20 s (with arms and
the other leg free). A therapist supplied help as described
for Block 1.
 Repeat task 1, but the right arm was held akimbo (the left
arm was free).
 Repeat task 1, but the left arm was held akimbo (the right
arm was free).
 Repeat task 1 with both arms held akimbo.
After the second block, participants took a break (80 s work/40 s
rest).
Block 3:
 Tandem stance for 20 s. Participants set the right leg as
the rear leg (arms were free). A therapist supplied help as
already described.
 Repeat task 1, but with the right arm held akimbo.
 Downloaded by [RMIT University Library] at 06:37 18 July 2016

Table 1. Patients’ profile (EG and CG).

Age Age Disease Disease BMI BMI H&Y MDS-UPDRS MDS-UPDRS
(EG) (CG) Sex Sex duration duration (EG) (CG) H&Y (EG) (CG) (EG) (CG) Medication per day Medication per day
(years) (years) (EG) (CG) (EG) (years) (CG) (years) (kg/m2) (kg/m2) (score) (score) (motor part) (motor part) (EG) (mg) (CG) (mg)
64 67 F F 15 14 23.76 35.84 2 2 7 2 Sinemet Plus 25/100 mg, Sinemet Plus Retard
Sinemet Retard 25/100 mg, Rolpryna
50/200 mg, Azilect 8 mg, Azilect 1 mg,
1 mg, Ropimirol 8 mg Amantadine Level
100 mg, Stalevo 75 mg
54 74 F F 4 15 20.19 33.15 2 1 5 4 Sinemet 25/250 mg, Mirapexin 0.7 mg,
Sinemet Retard 50/ Madopar 50/200 mg
200 mg, Amantadine
100 mg, Ropimirol
Prolif 8 mg, Madopar
50/200 mg
76 75 M M 14 15 33.64 31.77 2 2 7 10 Sinemet Retard Sinemet Plus Retard
50/200 mg, Azilect 25/100 mg, Sinemet
1mg, Pramipexol Retard 50/200 mg,
Normon 0.7 mg Azilect 1 mg, Requip
5 mg
82 78 M M 13 7 29.90 26.21 2 3 12 27 Sinemet 25/250 mg, Sinemet 50/200 mg,
Neupro (patch) 6 mg Azilect 1 mg, Stalevo
200 mg,
80 77 M M 15 9 21 28.57 3 2 8 3 Sinemet 25/250 mg Sinemet Plus 25/100 mg,
Neupro (patch) 8 mg
67 84 M F 9 12 26.66 24.03 3 1 7 6 Azilect 1 mg, Sinemet Plus Sinemet Plus 25/100 mg
25/100 mg
81 77 F F 14 8 27.11 32.88 2 2 13 19 Madopar 50/200 mg Sinemet 25/250 mg
63 79 F F 4 7 21.90 26.44 1 2 4 5 Sinemet Plus Retard 25/ Sinemet 25/250 mg
100 mg
75 79 M F 9 8 26.05 24.91 2 2 8 1 Sinemet Plus Retard Rolpryna 8 mg
25/100 mg, Sinemet
25/250 mg, Rolpryna
8 mg
86 86 M M 13 14 28.02 27.43 2 2 17 12 Sinemet Retard 50/100 mg Sinemet 100/250 mg,
Azilect 1 mg,
76 83 F M 8 11 24.91 26.82 3 2 19 12 Sinemet Retard 50/100 mg Sinemet Retard
50/250 mg, Sinemet
Plus 25/100 mg
73.09 ± 9.81* 78.09 ± 5.24* 10.72 ± 4.14* 10.90 ± 3.23* 25.74 ± 4* 28.91 ± 3.87* 2.18 ± 0.60 1.9 ± 0.53* 9.72 ± 4.88* 9.18 ± 8.01*
EG: experimental group; CG: control group; M: male; F: female; BMI: body mass index; kg/m2: kilograms divided by square meters; H&Y: Hoehn and Yarh; MDS-UPDRS: Movement Disorder Society-Unified Parkinson’s
Disease Rating Scale; mg: milligrams.
*Mean and standard deviation.
PARKINSON’S DISEASE & SLACKLINE
3
 4 L. SANTOS ET AL.
 Repeat task 1, but with the left arm held akimbo.
 Repeat task 1, with both arms held akimbo.
After this third block, participants had a break (80/40 s).
Block 4:
 Tandem stance for 20 s. Participants set the left leg as the
rear leg (arms were free). A therapist supplied help as
before.
 Repeat task 1, but the right arm held akimbo.
 Repeat task 1, but the left arm held akimbo.
 Repeat task 1, with both arms held akimbo.
The total duration of the slackline workout was approximately
8 min (including break time). Tasks were performed barefooted to
maximize the effect of the balance workout.
Data collection
Center of pressure
A footscan baropodometric platform (Medicapteurs, Balma, France)
was used to assess postural instability. Data were registered and
analyzed with T-Plate software (3.0 version, Medicapteurs, Balma,
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France). A sampling frequency of 100 Hz with a cutoff frequency of
10 Hz was used for data collection.[11] A bipedal standing support
test with open eyes on a firm surface was used. Stance was at
17 cm, since different studies have shown that the magnitude of
body sway decreases with increased stance width.[28,29] Tests were
performed barefooted.[11] Regarding CoP data acquisition duration,
a minimum of 90 s is required to reach acceptable reliability for all
traditional CoP parameters in healthy subjects.[11] However, the lit-
erature does not provide recommendations for CoP measurements
in individuals with PD. In the present study, CoP data acquisition
time was 30 s. Preliminary practice trials ensured participants were
comfortable with testing conditions and understood instructions.[30]
Participants were told to rest their gaze on a target (10 cm2 circle)
that was elevated 1.65 m and situated 2.5 m from the platform.
During testing, hands were held akimbo.[31] Prior to recording, par-
ticipants were asked to ‘‘stand as still as possible.’’ This procedure
minimizes the effect of intrinsic physical differences among partici-
pants on CoP measurement reliability.[32] Three attempts were
recorded, and data were averaged for statistical analysis.[11]
Participants were given a 1-min resting time after each trial. An
attempt was considered invalid and repeated if participants grasped
the tests assistants. Two test assistants were available to prevent
falls. Three types of CoP parameters were assessed: (1) positioning,
which expresses postural stability from a global point of view
(Length: CoP displacement; Area: postural stability precision area;
Speed: postural reactions to maintain balance); (2) medial position-
ing, which was determined from the CoP dispersion in the antero-
posterior and medio-lateral axis (Xmean: CoP position in the
medio-lateral direction; Ymean: CoP position in the antero-posterior
direction; Xspeed: postural reactions to maintain balance in the
medio-lateral direction; Yspeed: postural reactions to maintain bal-
ance in the antero-posterior direction); and (3) dispersion, which
reflects CoP deviation from the positioning parameters (Xdeviation:
CoP deviation from Xmean in the medio-lateral direction; Ydeviation:
CoP deviation from Ymean in the antero-posterior direction).
Freezing of Gait Questionnaire
The 6-item version of the FOG-Q [27] was used. It is a patient-
reported rating scale [33,34] that consists of 6 items scored from 0
to 4, with a total score ranging from 0 to 24. Higher scores denote
more severe FOG.[33,34]
Falls Efficacy Scale
This 10-item questionnaire was designed to assess confidence
in the patients’ ability to perform 10 daily tasks without
falling, as an indicator of fear of falling.[25] The total score
ranges from 10 (best possible) to 100 (worst possible). Since
there is no validated Spanish version, we translated the ori-
ginal version according to the recommendations of Hambleton
et al. [35] The original questionnaire was translated and back-
translated by a language specialist. In addition, two experts
assessed all items in the Spanish version, and verified that
they adequately captured all information on fall efficacy (face
validity).
Rate perceived exertion
The rate of change of RPE during prolonged work is used as a pre-
dictor of self-imposed exhaustion.[36] The Borg’s 6–20 scale
assumes a linear function between perceptual and physiological
(oxygen uptake, VO2, and heart rate [HR]) or physical (work–rate)
parameters.[20] The scale was explained to participants prior to
the program, and they rated perceived exertion at the end of each
training session.
Local muscle rate perceived exertion
A variation of Borg’s scale was used to estimate perceived exertion
in specific muscles during the program.[21] At the end of each ses-
sion, participants indicated the muscle groups they felt were
involved via an anatomical diagram.
Data analysis
Descriptive statistics were used summarize all dependent varia-
bles, which are presented as mean ± standard deviation (SD)
unless otherwise noted. A two-way fixed-effects analysis of vari-
ance (ANOVA) was performed to assess changes in dependent
variables across time utilizing tests (pre-test, post-test, and re-
test) and group (EG and CG) as factors. When interactions were
detected, data were analyzed using Bonferroni post-hoc correc-
tions (significance, p < 0.05). The Tukey HSD post-hoc test was
used to determine differences for all dependent variables.
Normality and homocedasticity of the data were verified
through the Shapiro–Wilk’s test and Levene’s test, respectively
(p > 0.05 for both tests). Reliability of CoP measurements was
calculated using an Intraclass Correlation Coefficient model 3,1
(ICC3,1 ¼ MSS-MSE/MSSþ (k-1)MSE [37]), since a two-way fixed-
effects ANOVA was performed to assess dependent variables.[37]
For the ICC3,1, reliability values were defined as follows:
poor ¼ <0.00, slight ¼ 0.00–0.20, fair ¼ 0.21–0.40, moderate
¼ 0.41–0.60, substantial ¼ 0.61–0.80, and almost perfect
¼ 0.81–1.00.[38] The minimal detectable change (MDC ¼ 1.96 
冑2  SEM; SEM ¼ SD  冑(1  R) [39]) is used to assess the min-
imal change that falls outside the measurement error in the
score of an instrument used to measure a symptom. It was
used here when significant differences were detected in the
dependent variables. Effect size was also used to determine the
magnitude of change when significant differences were detected
(Cohen’s f; f ¼ MEGMCG/SU [40]). Effect size was defined as fol-
lows: small ¼ f > 0.10, medium ¼ f > 0.25, and large ¼ f > 0.40.[40]
All data were analyzed using the R statistical computer program
(version 3.2.1., 2015.06.18).
Results
The CoP reliability test showed that, in both groups (EG and CG),
the data were almost perfectly reliable for all CoP parameters in all
tests (pre-test, post-test, and re-test), with one exception. For the
CG, Ymean was considered substantially reliable in the post-test
and re-test (Table 2).
 PARKINSON’S DISEASE & SLACKLINE 5

Table 2. CoP parameters (mean ± standard deviation) and intra correlation coefficient (ICC3,1) at the different testing times.
ICC3,1 CoP parameters ICC3,1 CoP parameters
CoP parameters (EG) CoP parameters (CG) (EG) (CG)
Pre-test Post-test Re-test Pre-test Post-test Re-test Pre-test Post-test Re-test Pre-test Post-test Re-test
Length (mm) 155.75 ± 53.13 148.59 ± 61.36 173.15 ± 62.97 133.75 ± 55.79 135.84 ± 74.52 214.31 ± 192.99 0.956 0.977 0.941 0.980 0.966 0.992
Area (mm2) 445.99 ± 293.53 520.99 ± 390.88 882.57 ± 728.52 295.37 ± 211.62 301.71 ± 187.03 460.44 ± 232.20 0.962 0.982 0.972 0.989 0.966 0.970
Speed (mm/s) 4.75 ± 1.65 4.69 ± 1.69 5.11 ± 1.55 4.16 ± 1.92 4.18 ± 2.36 4,17 ± 1.20 0.945 0.970 0.917 0.958 0.967 0.975
Xmean (mm) 16.23 ± 20.63 7.46 ± 27.58 8.96 ± 14.59 19 ± 16.64 10.11 ± 13.81 11.33 ± 9.93 0.914 0.986 0.917 0.927 0.936 0.897
Ymean (mm) 51.57 ± 21.94 44.68 ± 19.73 44.49 ± 24.56 63.62 ± 18.25 65.56 ± 8.12 63.95 ± 17 0.929 0.949 0.943 0.865 0.784 0.707
Xspeed (mm/s) 3.19 ± 1.56 3.16 ± 1.55 3.75 ± 2.02 3.05 ± 1.64 3.72 ± 1.53 3.85 ± 4.36 0.924 0.956 0.842 0.975 0.970 0.937
Yspeed (mm/s) 3.47 ± 0.87 3.37 ± 1.37 4.13 ± 1.47 2.93 ± 1.22 3.11 ± 1.74 3.62 ± 1.72 0.810 0.957 0.893 0.877 0.930 0.972
Xdeviation (mm) 3.43 ± 2.57 1.56 ± 7.44 5.01 ± 5.11 .17 ± 8.34 1.96 ± 1.03 2.64 ± 2.49 0.824 0.987 0.951 0.979 0.831 0.976
Ydeviation (mm) 4.79 ± 2.03 4.36 ± 1.61 5.50 ± 2.63 4.25 ± 23.53 3.10 ± 1.27 3.39 ± 1.75 0.856 0.928 0.929 0.999 0.826 0.825
EG: experimental group; CG: control group; mm: millimeters; mm2: square millimeters; mm/s: millimeters divided by seconds.

Table 3. The FOG-Q (6-item version) and the FES at the different testing times (mean ± standard deviation).
EG CG
Pre-test Post-test Re-test Pre-test Post-test Re-test MDC (EG) f (EG)
FOG-Q 3.90 ± 3.60 2.90$± 3.66 3.60 ± 5.03 4.40 ± 6.19 4.80 ± 6.53 4.20 ± 5.67 0.298 0.36
15.00$± 13.71
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FES 19.90 ± 17.84 15.60 ± 12.38 16.30 ± 12.10 15.90 ± 11.70 18.50 ± 14.26 4.93 0.07
FOG-Q (6-item version): Freezing of Gait Questionnaire; FES: Falls Efficacy Scale; EG: experimental group; CG: control group; MDC: minimal detectable change; f: Cohen’s
effect size.
$Indicates p < 0.05.
MDC ¼1.96  冑2  SEM; SEM ¼ SD  冑(1  R).
f ¼ MEG  MCG/SU.

Table 4. RPE and LRPE (%) in slackline training sessions.

Session No. 1 No. 2 No. 3 No. 4 No. 5 No. 6 No. 7 No. 8 No. 9 No. 10 No. 11 No. 12 Average
RPE 8.90 ± 2.7 8.72 ± 2.41 8.63 ± 2.24 8.54 ± 2.8 8.27 ± 2.68 8.27 ± 2.76 8.18 ± 2.82 8.18 ± 2.31 8.27 ± 2.24 8 ± 1.89 8 ± 1.89 8 ± 1.89 8.33 ± 0.36
LRPE
Sternocleidomastoid 1.81 0.15
Trapezius 1.81 0.15
Deltoid 1.36 0.11
Latissimus Dorsi 0.9 0.075
Obliques 4.54 2.27 2.27 1.81 1.81 1.81 1.81 2.27 2.27 2.27 5.9 2.41
Brachioradialis 2.72 2.27 0.37
Lumbars 19 4.54 9.09 15.45 14.09 14.09 14.09 13.18 6.81 6.81 10 10 11.42
Gluteus 1.81 2.27 4.09 4.09 4.09 2.27 2.27 2.27 1.93
Quadriceps 6.81 6.8 19.09 9.54 5.9 11.81 0.9 9.09 25 22.72 9.09 13.18 11.63
Hamstrings 3.18 15 28 20 21.36 19.09 19.09 11.81 13.63 11.36 16.81 18.18 16.45
Adductor Longus 0.9 6.81 6.81 4.54 5.45 2.27 6.81 5.45 4.54 3.64
Gastrocnemius 35 34.54 17.72 20.9 24.09 26.36 25.45 26.36 15.90 15.9 24.09 18.63 26.17
Soleus 24.54 20 9.09 9.09 15.45 11.36 11.36 19.09 6.81 9.09 11.81 13.63 13.44
Tibialis Anterior 8.63 1.81 15.90 4.54 8.18 15 7.72 11.36 6.81 7.72 2.27 7.49
Peroneus Longus 4.54 0.90 3.18 5 8.18 3.18 9.09 4.54 3.18 4.09 3.82

No significant within-group or between-group differences were
detected in any of the CoP parameters (Table 2).
In the EG, the FOG-Q score decreased from pre-test to post-test
(3.90 ± 3.60 to 2.90 ± 3.66) and increased at re-test (3.60 ± 5.03). In
the CG, the FOF-Q score increased from pre-test to post-test
(4.40 ± 6.19 to 4.80 ± 6.53) and decreased at re-test (4.20 ± 5.67).
The subsequent ANOVA showed statistically significant differences
only in the EG from pre-test to post-test (p ¼ 0.032). The MDC was
(0).298, and the effect size was (0).36 (‘‘medium’’ effect) (Table 3).
FES scores decrease in the EG from pre-test to post-test
(19.90 ± 17.84 to 15.00 ± 13.71), and a small increase was seen at
re-test (15.60 ± 12.38). In the CG, the FES score decreased pre-test
to post-test (16.30 ± 12.10 to 15.90 ± 11.70) and then increased at
re-test (18.50 ± 14.26). The subsequent ANOVA showed statistically
significant differences only in the EG from pre-test to post-test
(p ¼ 0.010). The MDC was 4.93, and the effect size was (0).07
(‘‘small’’ effect) (Table 3).
The EG reported a mean RPE of 8.33 ± (0).36 for the whole
training program (‘‘very light’’ on the Borg’s 6–20 scale, Table 4).
Analysis of LRPE ratings revealed that the Gastrocnemius (26.17%),
Hamstrings (16.45%), Soleus (13.44%), Quadriceps (11.63%),
Lumbar Extensors (11.42%), and Tibialis Anterior (7.49%) received
the highest ratings (Table 4). The Peroneus Longus (3.82%),
Adductor Longus (3.64%), Obliques (2.41%), and Gluteus (1.93%)
were also mentioned. The Brachioradialis (0.37%),
Sternocleidomastoid (0.15%), Trapezius (0.15%), Deltoid (0.11%),
and Latissimus Dorsi (0.075%) were rarely mentioned.
Discussion
The main goal of this study was to assess whether supervised
slackline training could reduce the risk of falls in patients with PD
and improve postural stability, FOG, PD patients’ perception of bal-
ance and stability during daily living activities, and fear of falling.
The results showed the CoP parameters did not change after 6
weeks of supervised slackline training. Nevertheless, the FOG-Q
and FES scores did significantly change post-intervention.
Participants rated the training program as ‘‘very light,’’ and analysis
 6 L. SANTOS ET AL.
of LRPE revealed that the Gastrocnemius, Hamstrings, Soleus,
Quadriceps, Lumbars, and Tibialis Anterior were the most fre-
quently used muscles.
Regarding our first hypothesis, no CoP parameters significantly
changed after the slackline training. However, trends toward
improvement were seen in all parameters except Area. Previous
studies on postural instability and PD have had different objectives
and have relied on different protocols and assessments. Hirsch
et al. [41] investigated the effect of balance training and high-
intensity resistance training on balance in PD patients. Smania
et al. [42] assessed the effects of balance training on postural
instability in PD patients. Chang-Yi et al. [43] studied the effects of
virtual reality-augmented balance training on the sensory integra-
tion of postural control under varying attentional demands, com-
paring the results with a conventional balance training group and
an untrained CG. Esculier et al. [44] used a Nintendo Wii Fit game
with balance board to test whether a home-based balance training
program with visual feedback affected balance and functional abil-
ities in subjects with moderate PD, comparing the effects with a
group of healthy controls. These studies all demonstrated that
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classic balance training can improve PD patients’ postural instabil-
ity. The absence of significant improvements in the present study
might be due to the training protocol (a low-impact stimulus was
applied). A stimulus of higher intensity might yield significant
enhancements.
Significant improvements were seen in FOG-Q scores after
training, with a medium effect size being seen. The FOG-Q MDC
score showed that there was a true difference between pre-test
and post-test, which is significant in terms of rehabilitation, since
the FOG-Q MDC was 0.298 points and the pre-post FOG-Q differ-
ence was 1 point. These results are in accordance with results of
other PD studies showing satisfactory MDCs in patient out-
comes.[45–47] As in the case of the CoP parameters, the medium
effect size obtained after training might be attributed to the low
stimulus intensity and the participants’ low initial FOG-Q score. The
mechanism underlying this enhancement is unknown. The unusual
environment that the slackline creates (e.g., very small base of sup-
port, compliant surface, a wafting feeling) may force the patients
to focus their attention to prevent a fall, which could produce a
reset of their motor system to avoid or alleviate FOG. This mechan-
ism (resetting of the motor system) is one goal of current PD gait
rehabilitation strategies, which aim to preserve or improve per-
formance and to stimulate walking through the use of alternative
neural circuits.[48] To the best of our knowledge, there are no
studies on balance training, FOG-Q, PD, and postural instability.
Mhatre et al. [49] assessed the effects of three Nintendo Wii bal-
ance board games (marble tracking, skiing, and bubble rafting) on
balance and gait in individuals with PD. They assessed dynamic
gait index (DGI) and postural sway (among other parameters).
Although DGI is not an indicator of FOG, it is a performance-based
tool that allows the study of dynamic balance abilities [50] and the
individual’s ability to modify gait in response to changing
demands.[51] Results showed that DGI and postural sway
improved after Wii training. These results and those of the current
study suggest that balance training enhances individuals’ dynamic
balance abilities, the ability to modify gait in response to changing
gait task demands, and the FOG in individuals with PD.
Consequently, it would be valuable to know whether a classical or
slackline balance training protocol yields stronger and more lasting
improvements. The combined effects of both balance trainings
should also be assessed. In addition, motor novel therapies for
individuals with PD that aim to improve postural stability and FOG
should focus on balance training using demanding training tasks
that require attention and have medium- or high-level intensity
stimuli.
With regard to our second hypothesis, FES scores significantly
improved after slackline training, but the effect size was small. The
FES MDC score also showed that the pre-post FES score difference
was a real; this is meaningful from the rehabilitation point of view,
since the FES MDC was 4.93 points and the pre-post FES difference
was 4.90 points. These results also agree with results of other stud-
ies of PD showing acceptable MDCs in patient abilities.[45–47] The
low training stimulus and participants’ initial FES scores could have
accounted for the small effect size seen after training. Slacklining
has been described as a challenging physical activity.[52]
Outcomes of the current study show that it poses a special chal-
lenge for PD patients, which benefit in terms of their fear of fall-
ing. Nevertheless, the reason that this occurs is unknown. We
hypothesize that, for individuals with PD, being on the slackline is
stressful because of the unusual environment it creates (men-
tioned earlier). However, after several drills, feelings change and
individuals begin to perceive that it is possible to regain control of
their body movements. Hence, PD patients may have felt that they
needed less help from therapists drill by drill (e.g., they were able
to stay upon the line longer, and they felt the therapists used less
strength to support them on the line). At the same time, patients
received positive comments from therapists on their performance.
Thus, they could have received positive internal and external feed-
back and perceived slacklining as a surmountable challenge,
improving their confidence. To our knowledge, there are no stud-
ies on PD, slackline, and FES. Goodwin et al. [53] compared the
effectiveness of a classical balance exercise program with standard
care in individuals with PD who had a history of falls. They saw
significant improvements in FES scores after training. Conradsson
et al. [54] evaluated the short-term effects of the HiBalance pro-
gram, a highly challenging balance-training regimen that incorpo-
rates both dual-tasking and PD-specific balance components. They
compared this approach with standard care in elderly individuals
with mild-to-moderate PD. Post-test results did not show FES score
improvements. The HiBalance program could be too demanding
for patients. It would be useful to know what training protocol
(slackline protocol or that of Goodwin et al.) yields stronger and
more lasting benefits on FES scores. The combined effects of the
both trainings should be assessed as well. Moreover, novel motor
therapies for PD aimed at reducing fear of falling should include
challenging but reachable training tasks in non-conventional
rehabilitation environments.
Our third hypothesis was not confirmed. Nevertheless, the
results were promising since patients perceived slackline workouts
as ‘‘very light’’. This suggests that slackline training (static body
positions) can be matched with other physical activity in the same
training session without an increased risk of fatigue. This further
suggests that slackline intensity can be increased. This is relevant
since therapists can use slacklining as the main focus of a session
and/or as a complementary one. Again, no studies on PD, slackline,
and RPE have been published.
Our fourth hypothesis was partially verified, as patients indi-
cated that the Gastrocnemius, Hamstrings, Soleus, Quadriceps,
Lumbars, and Tibialis Anterior were the most used muscles (LRPE
assessment). This is a notable finding since two of the three major
postural leg muscles are included in this group.[55] Soleus, Tibialis
Anterior, and Peroneus Longus were extensively used during slack-
line training. This is the first study on PD, slacklining, and LRPE,
and more research is necessary. However, this finding suggests
that slackline training is a useful rehabilitation tool for patients
who have deficits in these muscles. Therefore, this information
should be considered when designing slackline training tasks and

novel motor therapies focusing on balance training to prevent
overloads in patients who have difficulty maintaining their balance
and have lower limb strength, among other deficiencies.
The present study has at least three limitations. First, results
must be considered carefully since this is the first study that has
assessed the effects of slacklining in PD. Second, findings should
be confirmed in a larger group of patients since the sample size is
relatively small. Despite the small sample size, these preliminary
findings still provide valid and relevant data for the fields of
rehabilitation and research. Third, changes in the patients’ postural
instability were assessed through CoP parameters. Including an
analysis of the center of mass would provide deeper insights into
the effects of slacklining on patients’ postural instability.
Conclusion
The findings of the current study support slacklining (static body
positions) as a simple, safe, and challenging training and rehabilita-
tion tool for PD patients. It could be introduced into their physical
Downloaded by [RMIT University Library] at 06:37 18 July 2016
activity routine to reduce the risk of falls and improve confidence
related to fear of falling. Furthermore, RPE and LRPE scores
revealed that static body slackline tasks yielded a low tiredness or
fatigue in the major lower limb and lumbar muscles.
Acknowledgements
The authors would like to express their deepest gratitude to
patients of the Parkinson Association (Ponferrada, Spain) and Mrs.
Marıa Encina Gutierrez Marques (President of the Bierzo Parkinson
Association) for her commitment in participating in this research
project.
Disclosure statement
The authors report no conflicts of interest.
ORCID
Javier Fernandez-Rio http://orcid.org/0000-0002-1368-3723
Charles Philip Gabel http://orcid.org/0000-0001-8354-4545
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