Aquatic Physical Therapy in the balance and gait of people with Parkinson’s Disease: a pilot study

Background . Parkinson’s disease (PD) is a neurodegenerative, chronic, progressive disease, resulting mainly from the depletion of dopaminergic neurons in the substantia nigra. It is characterized by four cardinal signs, namely: bradykinesia, stiffness, tremor, and postural instability, which contribute to body balance and gait functional deficits. Among the possibilities of intervention, the Aquatic Physical Therapy (APT) stands out in the prevention and rehabilitation of motor and functional alterations, using water physical and thermal properties. Objective . To verify the effects of APT on body balance and gait. Method . This pilot study is part of quasi-experimental research involving a group with a clinical diagnosis of PD. They participated in an APT program for 12 weeks, twice a week. They were assessed with the MiniBESTest for body balance and the Dynamic Gait Index (DGI) for gait balance. The statistical analysis was made in the Statistical Package for the Social Sciences (SPSS). Results . A total of 11 people – mean age of 70.73±3.2 years – participated in the study. After the APT program, no difference was verified in the Mini-BESTest (p=0.41) or the DGI (p=0.105). Conclusions . The APT program proposed was unable to present significant improvement regarding the balance and gait in the group of people with PD in question. cuasi-experimental, que involucró a un grupo con diagnóstico clínico de EP, que participó en un programa de FA, de 12 semanas de duración, dos veces por semana. Para la evaluación, se utilizó lo siguiente: Mini BESTest para el equilibrio corporal y la Escala de índice de marcha dinámica (DGI) para el equilibrio durante la marcha. El análisis estadístico se realizó mediante el paquete estadístico para las ciencias sociales (SPSS). Resultados . Participaron del estudio 11 participantes, con una edad media de 70,73±3,2 años. Después del programa de AF, se encontró que no hubo diferencia significante en Mini BESTest (p=0.41) y en DGI (p=0.105). Conclusiones . Se concluyó que el programa de FA propuesto no pudo presentar datos significativos para el equilibrio y la marcha en el grupo de personas con EP en cuestión. clave. Enfermedad de Parkinson; Equilibrio postural; Marzo; Hidroterapia;


INTRODUCTION
Parkinson's disease (PD) is one of the movement disorders that most affect older adults. It is caused by progressive degeneration of the central nervous system With time, the person presents functional alterations in postural balance and, consequently, in gait 5 . The deficits in balance appear because of the motor impairments correlated with a certain inefficiency in processing vestibular, visual, and proprioceptive signs to perform the activities of daily living 6 . Hence, with the alteration in postural control and balance reactions, there is an increased risk of falls. Such a decline in motor capacity also contributes to a decrease in functional performance, including difficulties to perform daily tasks, besides negatively changing these individuals' quality of life 7,8 .
Gait is cortically and subcortically controlled in healthy people -the subcortical control is automatic and quick, whereas the cortical one is slow and sensitive to any other stimulus. In PD, the automatic control processes are dysfunctional due to the deficits in the functioning of the basal ganglia in the dopamine-dependent pathways 9 .
Other factors interfere with gait and postural balance, such as the stooped and inclined posture 5 and frozen gaitcharacterized as the incapacity to take the first step, or efficiently take steps in sequence 10 . Another alteration is the festinating gait, defined as rapid small steps with increasing pace which, in association with the alteration in the center of gravity, triggers such a pattern 11 .
There are no indicators that drug treatment alone is the most efficient. Therefore, multiprofessional attention must focus on PD 12 . Thus, the ideal is that the strategies involving a physical therapy approach be aligned with adequate clinical prescription of therapeutic and functional exercises, which bring good results to the performance in physical aptitudes, body balance, and gait 5,13 .
The Aquatic Physical Therapy (APT) is one of the possibilities in the field of physical therapy, especially because it has physiological and thermal effects, such as muscle relaxation and decreased muscle spasms, which in turn influence the PD patients' stiffness and physical/motor Hence, several motor features can be positively modified using APT on PD persons 5,13 . The aquatic environment is safe and has physiological and thermal effects for exercises on PD population. However, is not clear how much this affects gait and balance when assessed by usual evaluation scales. Therefore, this study aimed to verify the effects of APT on body balance and gait in people with PD.

Sample
This is a single-blinded (blind assessor) pilot study in quasi-experimental research, convenience sampling, in The exclusion criteria, in their turn, were participants confined to a wheelchair (either due to PD or not), without independent gait, with another pathology that could cause vestibular or balance alterations, or with some deficit that impaired them from following instructions (such as visual or auditory deficits, keeping them from understanding verbal or visual commands), and that had either absolute or relative contraindications to attend a heated pool. Also, participants whose dosage of Levodopa changed during the research, who did not agree with or sign the informed consent form (ICF), or who gave up during the research were excluded from it.

Procedures
The static and dynamic body balance was assessed balance training (e.g., sit and stand); relaxation; cooling down (these last ones using Ai Chi movements -in each session, three of the movements in the method were used, with increasing difficulty). The intervention was designed and applied by a physical therapist, who did not participate in the assessments on land.

Statistical Analysis
Descriptive statistics were used to present the   Shapiro-Wilk test.

DISCUSSION
The absence of significant results in body balance is the opposite of what was found in studies cited in a literature review 19 . In it, this variable was assessed with the Berg Balance Scale (BBS), Tinetti, and Mini-BESTest, revealing improvements 19 .
Other study also had a significant improvement in balance (assessed with BBS) after APT intervention 20  In the study conducted with older adults, it is proposed that 2.9 points be increased in the DGI to represent a 95% confidence that there was an actual change in the person's function 24 . Regarding the people with PD, the authors of the The therapeutic physical exercises and the physical and thermal properties of water influence and help the gait, giving the person confidence to perform activities in the pool.
Likewise, buoyancy offers support, making the person even more confident and easing their fear of falling 27 . A study analyzed subaquatic gait and revealed that in water the step is shortened, the pace is reduced, and the speed is slowed down. Also, these decreased gait parameters were associated with the increased angular displacements of the hip and shoulder joints 28 .
This study was limited by low number of participants as well as the absence of a control group. It is suggested, then, that future studies analyze the effects of aquatic physical therapy exercises approaching a larger sample size.

CONCLUSIONS
It is concluded that the proposed Aquatic Physical Therapy program did not produce significant gains in this group of people with Parkinson's disease.