BETA-PD: Balance Elderly Training and Activity in Parkinson’s disease.

The BETA-PD project aims to translate knowledge from basic neuroscience into applied research and clinical understanding and implement the evaluation methods and highly-challenging balance training program into clinical practice. Our main hypothesis is that highly challenging exercise will lead to greater gait and balance ability, increased levels of physical activity and an improved health related quality of life.

Project description

The BETA-PD study consists of several steps: method development and laboratory studies, an efficacy study, an effectiveness/implementation study and neuroplasticity studies.

Beta PD study

Method development (Step 1)

We have tested the validity and reliability of the measurement methods that we use. We have also conducted kinematic and kinetic studies in movement laboratories (at KI and at Sunnaas rehabilitation hospital) in which we have investigated straight walking, variability and turning strategies as well as the effect of levodopa on these strategies in individuals with PD (ON and OFF their medication) compared to controls.

Efficacy (Step 2)

We have developed the HiBalance program and showed the program to be feasible and effective to improve balance performance, gait velocity, step length, cognitive performance while dual-tasking, as well as beneficial transfer effects to everyday living, seen as increased physical activity and improved activities of daily living. Analysis of the long-term effects showed that effects on gait, balance and physical activity attenuated after the training period and at 6 months no group effects were evident.

Findings from a qualitative study, suggest that being pushed to the limits of balance capacity provoked people with mild-moderate PD to re-think their individual motor and cognitive resources, a process that was further enabled by the PD-specific group setting.

The implementation/effectiveness (Step 3)

The implementation/effectiveness consists of a clinical effectiveness trial together with implementation research. We are here using a type-1 hybrid design by testing effects of the HiBalance program delivered in clinical setting on relevant patient outcome measures while observing and gathering information on barriers and facilitators to the implementation process We have performed a pilot study in primary care facilities in Stockholm. During spring 2016, we started the full implementation and effectiveness trial. Training and data collection concerning the outcome evaluation of the trial was completed at all clinics in February 2018. Analysis is ongoing. Additionally, we have performed a series of longitudinal focus-group interviews with the trainers in which we have followed their perceptions of implementing the program over two years.

Neuroplasticity study (Step 4)

In this study we compare the HiBalance program with an active control group (HiCommunication) with the aim to characterise and link the effects on physical and cognitive symptoms to structural and functional changes in the brain as well as wet biomarkers after the training. During fall 2017 we performed a feasibility/pilot study of the RCT and during spring 2018 the larger trial started. The aim is also to determine which biomarkers in the central nervous system may explain these changes.

Primary investigator

Erika Franzén

H1 Department of Neurobiology, Care Sciences and Society

Project members/Collaborators

Martin Benka Wallén, postdoc

David Conradsson, PhD

Espen Dietrich, professor

Urban Ekman, PhD/postdoc

Malin Freidle, PhD student

Maria Hagströmer, docent

Staffan Holmin, professor

Hanna Johansson, PhD student

Conran Joseph, postdoc

Petra Koski, research assistant

Breiffni Leavy, postdoc

Alexander Lebedev, postdoc

Niklas Löfgren, postdoc

Johan Lökk, professor

Martin Lövdén, professor

Håkan Nero, PhD

Arve Opheim, PhD

Caroline Paquette, docent

Linda Rennie, PhD student

Ellika Schalling, docent

Kirsti Skavberg-Roaldsen, PhD

Agneta Ståhle, professor

Per Svenningsson, professor

Master students

Bachelor students

Trainers and assesors (physioterapists/speech therapists)

Financial support

The Swedish research council




National School in Health Care Sciences

NEURO Sweden

Stockholm County Council research funds

StratNeuro, Karolinska Institutet

Swedish Parkinson foundation

Parkinsons Research Foundation

Extrastiftelsen, Helse & Rehabilitering

Selected publications

Evaluation and implementation of highly challenging balance training in clinical practice for people with Parkinson's disease: protocol for the HiBalance effectiveness-implementation trial.
Leavy B, Kwak L, Hagströmer M, Franzén E
BMC Neurol 2017 Feb;17(1):27

Monitoring training activity during gait-related balance exercise in individuals with Parkinson's disease: a proof-of-concept-study.
Conradsson D, Nero H, Löfgren N, Hagströmer M, Franzén E
BMC Neurol 2017 Jan;17(1):19

Pre- and unplanned walking turns in Parkinson's disease - Effects of dopaminergic medication.
Conradsson D, Paquette C, Lökk J, Franzén E
Neuroscience 2017 01;341():18-26

Objectively Assessed Physical Activity and its Association with Balance, Physical Function and Dyskinesia in Parkinson's Disease.
Nero H, Benka Wallén M, Franzén E, Conradsson D, Ståhle A, Hagströmer M
J Parkinsons Dis 2016 10;6(4):833-840

"Pushing the Limits": Rethinking Motor and Cognitive Resources After a Highly Challenging Balance Training Program for Parkinson Disease.
Leavy B, Roaldsen KS, Nylund K, Hagströmer M, Franzén E
Phys Ther 2017 01;97(1):81-89

Investigating the Mini-BESTest's construct validity in elderly with Parkinson's disease.
Löfgren N, Benka Wallén M, Sorjonen K, Conradsson D, Franzén E
Acta Neurol. Scand. 2017 Jun;135(6):614-621

Depressive symptoms associated with concerns about falling in Parkinson's disease.
Franzén E, Conradsson D, Hagströmer M, Nilsson MH
Brain Behav 2016 10;6(10):e00524

Structural Validity of the Mini-Balance Evaluation Systems Test (Mini-BESTest) in People With Mild to Moderate Parkinson Disease.
Benka Wallén M, Sorjonen K, Löfgren N, Franzén E
Phys Ther 2016 Nov;96(11):1799-1806

Accelerometer Cut Points for Physical Activity Assessment of Older Adults with Parkinson's Disease.
Nero H, Benka Wallén M, Franzén E, Ståhle A, Hagströmer M
PLoS ONE 2015 ;10(9):e0135899

The Effects of Highly Challenging Balance Training in Elderly With Parkinson's Disease: A Randomized Controlled Trial.
Conradsson D, Löfgren N, Nero H, Hagströmer M, Ståhle A, Lökk J, et al
Neurorehabil Neural Repair 2015 Oct;29(9):827-36

Levels and Patterns of Physical Activity and Sedentary Behavior in Elderly People With Mild to Moderate Parkinson Disease.
Benka Wallén M, Franzén E, Nero H, Hagströmer M
Phys Ther 2015 Aug;95(8):1135-41

The Mini-BESTest--a clinically reproducible tool for balance evaluations in mild to moderate Parkinson's disease?
Löfgren N, Lenholm E, Conradsson D, Ståhle A, Franzén E
BMC Neurol 2014 Dec;14():235

A novel conceptual framework for balance training in Parkinson's disease-study protocol for a randomised controlled trial.
Conradsson D, Löfgren N, Ståhle A, Hagströmer M, Franzén E
BMC Neurol 2012 Sep;12():111

Is highly challenging and progressive balance training feasible in older adults with Parkinson's disease?
Conradsson D, Löfgren N, Ståhle A, Franzén E
Arch Phys Med Rehabil 2014 May;95(5):1000-3

Comparison of pedometer and accelerometer derived steps in older individuals with Parkinson's disease or osteoporosis under free-living conditions.
Wallén MB, Dohrn IM, Ståhle A, Franzén E, Hagströmer M
J Aging Phys Act 2014 Oct;22(4):550-6

Content reviewer: