Volume 21, Issue 1 (Spring 2020)                   jrehab 2020, 21(1): 40-53 | Back to browse issues page


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Jamebozorgy A, Bolghanabadi Z, Mahdizadeh A, Irani A. Effect of Neurofeedback on Postural Balance and Attention of Women With Knee Osteoarthritis After Bilateral Total Knee Replacement. jrehab 2020; 21 (1) :40-53
URL: http://rehabilitationj.uswr.ac.ir/article-1-2567-en.html
1- Department of Occupational Therapy,‎‏ ‏University of Social Welfare and Rehabilitation Sciences‏, ‏Tehran‏, ‏Iran.‎
2- MSc, Department of Occopational Therapy, School of Rehabilitation, Shahid Beheshti University of Medical Sciences, Tehran, Iran. , bolghanabadi70@sbmu.ac.ir
3- Ph.D Student of Occupational Therapy, Department of Occopational Therapy, University of Social Welfare and Rehabilitation Sciencess, Tehran, Iran.
4- MSc, Department of Occopational Therapy, School of Rehabilitation, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Extended Abstract
Introduction

As life expectancy increased to 77.5 years in 2016, a rise in the rate of degenerative diseases such as knee osteoarthritis occurred [1]. The prevalence of knee osteoarthritis is higher in developed countries compared to the developing countries [2, 3]. However, in certain countries such as Iran, according to the Community Oriented Program for the Control of Rheumatic Disease (COPCORD) data, its prevalence is relatively high, 19.3% in rural areas [3]. Total knee replacement surgery is the most effective treatment in the last stage of symptomatic knee osteoarthritis, which significantly reduces joint pain and dryness. However, about 37%-55% of patients do not experience significant improvement in functional mobility even 6 months after surgery, and about 50% of patients are not satisfied with the outcome [4, 5]. Maintaining balance is a fundamental predictor of postoperative improvement after knee joint placement [6]. Studies have shown that postoperative balance training improves balance in patients with osteoarthritis who have had a total knee replacement [7, 8].
Postoperative rehabilitation now focuses on increasing the range of motion and strengthening, endurance, and functional exercises, such as going up and down the stairs, walking, etc. However, the use of such exercises to improve balance is not always possible because balance impairment is obvious in the first four months after surgery [9]. Also, there are movement limitations, especially in older adults prone to osteoporosis [10, 11] and consequently fractures caused by falling. Therefore, we need a non-invasive method instead. One of these methods that improve balance at the level of the central nervous system is neurofeedback. It is one of the neurotherapeutic techniques that can improve the abnormal pattern of cortical brain waves [12] and correct abnormal Electroencephalogram (EEG) by affecting neurological physiology and active conditioning [13]. 
It thus improves behavioral, cognitive, and sports functions [14]. Since there is a link between specific patterns of cerebral cortex activity and specific levels of function, the use of neurofeedback in patients with motor impairments to restore normal patterns of brain activity can lead to improved performance and cognition. Hammond is one of the pioneers in using the neurofeedback protocol to improve balance. He reported successful clinical treatment of balance problems caused by stroke and traumatic brain injury in 4 patients [15]. Moshref-Razavi et al., after examining the effect of 8 sessions of Hammond’s neurofeedback protocol and mental imaging on the balance of aged people, reported its positive and significant effects [16]. Safari, after evaluating the impact of physical activity and neurofeedback on the balance of stroke patients, also confirmed its positive effect [17]. Because of few studies on the impact of neurofeedback on the balance of patients with osteoporosis in Iran, the present study aimed to test the effect of Hammond’s neurofeedback protocol on the balance and attention of patients with Bilateral Total Knee Replacement (BTKR).
Materials and Methods
This is a quasi-experimental study with a pretest/posttest design. The study population consisted of all female patients with BTKR referred to the occupational therapy clinic of Shahid Beheshti University of Medical Sciences in 2017 (3 months after surgery). Considering the inclusion criteria, we selected 8 patients using a convenience sampling method. The inclusion criteria were being over 55 years old, having a history of BTKR surgery in the last 2 to 4 months, using a cement prosthesis; being able to walk independently; lacking cognitive problems (MMSE>20), acute cardiovascular disease, uncontrolled high blood pressure and visual impairment, use of neuroleptics and sedatives, not receiving neurofeedback before this study, and lacking any record of surgery in other joints of lower limbs such as ankle or hip. The exclusion criteria were absence from the intervention for more than two sessions and unwillingness to continue participation. After obtaining ethical approval from the university and necessary permissions from the clinic, measurements were performed by the examiner in the laboratory of the faculty once before the intervention, and then at the 4th and 8th sessions. 
To assess the balance in patients, we used the Biodex balance system, which tests the dynamics stability level 6. To evaluate the sustained attention, the vigilance subscale of the Vienna test system was used. For neurofeedback, the SA7525 ProComp Infiniti system and BioGraph Infiniti Software (Thought Technology Co., Canada) were used. The neurofeedback training program was applied for each patient three days a week, in eight 30-min sessions. The subject is placed in front of the computer. After adjusting the seat, installing the electrodes, and checking the accuracy of their positions based on the International System 10/20 standard, the base brain signal was recorded with both eyes open and closed for two minutes. In the end, the recording was repeated for two minutes. Based on Hammond’s neurofeedback protocol, the frequency of 4-7 Hz (Theta wave) was decreased, and the frequency of 15-15 Hz (Beta 1 wave) increased.
The Shapiro-Wilk test was used to test the normality of data distribution. Because of their normality, the paired t test was used to perform a pairwise comparison of the test scores at three different measurement phases. Also, we used repeated-measures ANOVA for evaluating the beta wave changes during the intervention. Data analysis was carried out in SPSS.
Results
Study participants were 8 women with BTKR having a Mean±SD age of 67.5±6.61 years (range: 56–75 years) and mean body mass index of 30.7±2.65 kg/m2 (ranged 28–35.38). Results of balance and attention tests at three different measurement phases are presented in Table 1. Regarding the attention scores, the repeated measures ANOVA results showed no significant difference in correct and wrong responses at different measurement phases. Still, in terms of reaction time, a significant difference was observed (P=0.001). Moreover, the results of the pairwise comparison showed a significant difference in the reaction time scores between baseline and the third phase (P=0.001); however, there was no significant difference in the scores between the baseline and the second phase (P=0.053) and between the second and third phases (P=0.076).
Regarding the balance scores, the ANOVA results showed a significant difference in the mean scores between the three phases (P=0.004). Moreover, the pairwise comparison showed a significant difference between the baseline and the second phase (P=0.002) and between baseline and the third phase (P=0.004). But there was no significant difference in its scores between the second and third phases (P=0.998).
Table 2 presents the mean and standard deviation of the beta wave changes during the intervention. According to Figure 1, a gradual increase in the beta wave is seen, but this increase was not statistically significant (P=0.192).
Discussion
This study aimed to investigate the effect of neurofeedback on postural stability and the attention of women with BTKR after surgery. Patients were assessed at three times (before the intervention, at the fourth session of treatment, and after the intervention) by using the vigilance subscale of the Vienna test system and the Biodex balance system. Findings related to postural balance in this study showed that neurofeedback training had a significant and positive effect on patients’ postoperative balance. These findings are consistent with the results of Hammond [15] and Azarpaikan et al. [18] who conducted their studies on patients with stroke and Parkinson disease, respectively. 
But these findings are against the findings of Nan et al. [19] who examined the effect of neurofeedback on healthy individuals. Healthy people already have higher performance and scores than patients, so patients with balance problems can be improved more than healthy people. Moreover, the effect of neurofeedback on improving the balance of healthy individuals is difficult due to their normal functional level. Besides, the method of assessing balance in healthy people and patients is very different. Almost all patient evaluation methods have a ceiling effect when used for healthy individuals, or healthy people may need a longer training process for better balance.
The study results showed a significant difference in the postural balance scores between the first and second phases of assessment. Still, no significant difference was observed between the second and third phases. This result indicates a rapid improvement in postural balance and nervous system function in receiving proprioception information by only four sessions of neurofeedback therapy. However, neurofeedback training had no significant effect on patients’ attention after BTKR surgery. This finding is in agreement with the results of Vernon et al. [20] but is against the findings of Kristi [21]. Vernon et al. reported that the protocol had little effect on cognitive performance. Kristi showed an increase in the sensorimotor rhythm wave in the Cz area could affect cognitive performance in stroke patients. 
Each brain wave has a specific function depending on the frequency. Therefore, the type of the used protocol is also very important, and special attention should be paid in choosing the right protocol. In this study, neurofeedback was presented in 8 sessions. It is possible that with more training sessions, better results be achieved.
Regarding the attention score of patients, our results indicated an increase in the reaction speed and a decrease in the reaction time of patients. The results of this study with the findings of Nabavi Aleagha et al. [22] who showed that neurofeedback training could improve executive performance and reaction time of participants, Doppelmayr and Weber [23] who reported that neurofeedback training improves simple and selective reaction time as well as spatial ability and creativity, and Parsaei et al. [24] who found out that neurofeedback can significantly improve the reaction time of the older adults. 
By increasing age, the sensitivity of transmitters and sensory receptors decreases. Body reactions are impaired because of ambiguity in receiving signals due to the lower intensity and accuracy of sensory inputs and outputs [25]. Regarding the amplitude of the beta wave, there were few positive changes over time, but this increase was not statistically significant. According to Keller [26], the amplitude may not be the most critical factor in therapeutic changes [26]. Maybe more therapeutic sessions are needed to make significant changes in brain waves.
One of the limitations of this research was its sample size due to the time and financial constraints, and lack of a control group due to the low number of samples. Moreover, this study was performed in only one health care center, with no access to male patients. Given these limitations and the nature of this study, it is not possible to generalize the results to all patients with BTKR, especially male patients. Still, the results indicate the possibility of using neurofeedback therapy in orthopedic rehabilitation. It is recommended that further studies be performed with larger sample size and a stronger design (randomized controlled trial) to obtain stronger evidence. More clinical trials should be designed to evaluate the long-term effects of neurofeedback intervention in these patients.
Conclusion
Neurofeedback may improve postural stability in women with knee osteoarthritis in four months after BTKR surgery, but it has limited effects on sustained attention. Therefore, this non-invasive and uncomplicated program can be used as a complementary treatment method for the rehabilitation of these patients.
Ethical Considerations
Compliance with ethical guidelines
All ethical principles were considered in this article. The participants were informed about the purpose of the research and its implementation stages; they were also assured about the confidentiality of their information; Moreover, They were allowed to leave the study whenever they wish
Funding
This study was extracted from the MSc thesis of the second author, Department of Occopational Therapy, School of Rehabilitation, Shahid Beheshti University of Medical Sciences.
Authors' contributions
All authors contributed in preparing this article.
Conflicts of interest
The authors declared no conflict of interest.
Acknowledgements
The authors would like to thank the Department of Occupational Therapy and laboratory staff of the School of Rehabilitation at Shahid Beheshti University of Medical Sciences for their cooperation, and Drs Bayanfar and Sazgari (Experts in orthopedic surgery) for referring the study patients.
Type of Study: Original | Subject: Occupational Therapy
Received: 7/01/2019 | Accepted: 10/07/2019 | Published: 1/04/2020

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