The role of sensory cues in the rehabilitation of parkinsonian patients: a comparison of two physical therapy protocols

Robotics-Based Characterization of Sensorimotor Integration in Parkinson's Disease and the Effect of Medication

Integration of multi-modal sensory inputs and modulation of motor outputs based on perceptual estimates is called Sensorimotor Integration (SMI). Optimal functioning of SMI is essential for perceiving the environment, modulating the motor outputs, and learning or modifying motor skills to suit the demands of the environment. Growing evidence suggests that patients diagnosed with Parkinson's Disease (PD) may suffer from an impairment in SMI that contributes to perceptual deficits, leading to motor abnormalities. However, the exact nature of the SMI impairment is still unclear. This study uses a robot-assisted assessment tool to quantitatively characterize SMI impairments in PD patients and how they affect voluntary movements. A set of assessment tasks was developed using a robotic manipulandum equipped with a virtual-reality system. The sensory conditions of the virtual environment were varied to facilitate the assessment of SMI. A hundred PD patients (before and after medication) and forty-three control subjects completed the tasks under varying sensory conditions. The kinematic measures obtained from the robotic device were used to evaluate SMI. The findings reveal that across all sensory conditions, PD patients had 36% higher endpoint error, 38% higher direction error in reaching tasks, and 43% higher number of violations in tracing tasks than control subjects due to impairment in integrating sensory inputs. However, they still retained motor learning ability and the ability to modulate motor outputs. The medication worsened the SMI deficits as PD patients, after medication, performed worse than before medication when encountering dynamic sensory environments and exhibited impaired motor learning ability.

The Effects of Vibratory and Acoustic Stimulations on Postural Control in Healthy People: A Systematic Review

Research on human posture and balance control has grown in recent years, leading to continued advances in their understanding. The ability to maintain balance is attributed to the interplay of the visual, vestibular, and somatosensory systems, although an important role is also played by the auditory system. The lack or deficit in any of these systems leads to a reduced stability that may be counterbalanced by the integration of all the remaining sensory information. Auditory and vibratory stimulation have been found to be useful to enhance balance alongside daily activities either in healthy or pathological subjects; nevertheless, while widely investigated, the literature relating to these approaches is still fragmented. This review aims at addressing this by collecting, organising, and discussing all the literature to date on the effects of the various acoustic and vibratory stimulation techniques available on static upright posture in healthy subjects. In addition, this review intends to provide a solid and comprehensive starting point for all the researchers interested in these research areas. A systematic search of the literature was performed and a total of 33 articles (24 on vibratory stimulation and 9 on acoustic stimulation) were included in our analysis. For all articles, several elements were highlighted including: the study sample, the characteristics of the stimulations, the recording instruments, the experimental protocols, and outcomes. Overall, both stimulations analysed were found to have a positive effect on balance but more research is needed to align those alternative approaches to the traditional ones.

An Overview of the Available Intervention Strategies for Postural Balance Control in Individuals with Autism Spectrum Disorder

BACKGROUND

Postural instability is a prevalent issue among individuals with autism spectrum disorder (ASD) that affects the development of their perceptual-motor skills and social functioning. Visual and somatosensory processing deficits, hypotonia, basal ganglia dysfunction, and anxiety are some of the concurrent disorders in individuals with ASD. Nevertheless, a definite management protocol for postural instability in ASD has not been introduced yet. Hence, we aim to shed light on the available intervention strategies for postural instability in individuals with ASD.

METHODS

Even though several studies have been conducted on the effects of various interventions for balance control in individuals with ASD, no study has compared their efficacy, limitations, and clinical implications.

RESULTS

This review discusses diverse proposed interventions contributing to ASD postural instability, including martial arts, water-based interventions, animal-assisted therapies, trampoline, balance training, vestibular therapy, transcranial direct current stimulation, sports, play, and active recreation for kids (SPARK), and square-stepping exercise (SSE).

CONCLUSION

Enhancing motor skills, cerebellum function, and sensory input integration were some of the main mechanisms of these interventions to improve balance control in ASD. Some interventions, such as water-based exercises and video games, were enjoyable for children with ASD and could raise their treatment adherence. In most studies, small sample sizes and the lack of a control group represented their major limitations. Therefore, future well-designed randomized controlled trials are required to assess the effects of available interventions on postural control in ASD.

The power of instruction on retropulsion: A pilot randomized controlled trial of therapeutic exercise focused on ankle joint movement in Parkinson’s disease

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Retropulsion in PD may involve the lack of push-off for a backward step.

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Exercise with ankle-movement instruction can improve backward response.

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Toe-landing instruction may facilitate treatment of retropulsion in PD.

Introduction

Although retropulsion is a serious complication of Parkinson’s disease (PD), it is unknown whether ankle joint movement patterns can be targeted to treat retropulsion. The primary aim of this study was to investigate the effectiveness of therapeutic exercise focused on instructions regarding ankle joint movement on retropulsion in PD.

Methods

Twenty patients with moderate PD were randomly allocated to the experimental intervention (INSTR) or control groups. The INSTR group received a 2-week therapeutic exercise program (40 min/day, five times/week) that involved repeated backward pulls on the shoulders with instructions to land on the toes as a response, and the control group received the same intervention without the instructions. The primary outcome was the difference in changes from baseline in the Movement Disorder Society-sponsored revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS part III) score between the study groups at weeks 1 and 2.

Results

The improvement in the MDS-UPDRS part III scores was significantly greater for the INSTR group in the week 1 (p = 0.033, _pη² = 0.241) and week 2 (p = 0.004, _pη² = 0.401) assessments. However, the provision of instructions to land on the toes as a backward response induced improvement in the only scores related to the backward response, and no significant between-group differences were observed in the other outcomes.

Conclusion

The 2-week therapeutic exercise program with instructions to treat retropulsion improved the backward response.

Trial registration

UMIN-CTR, UMIN000042722.

Table tennis for patients with Parkinson's disease: A single-center, prospective pilot study

INTRODUCTION

Table tennis is a popular sport worldwide. However, no study has examined whether it is an effective exercise for patients with Parkinson's disease (PD). The efficacy and safety of table tennis exercise for PD patients was examined.

METHODS

This 6-month prospective study investigated if our table tennis exercise program could improve parkinsonian motor symptoms, cognition and psychiatric symptoms. Twelve PD patients with Hoehn & Yahr stage ≤4 were recruited. Patients participated in a 6-hour exercise session once weekly. All patients were assessed with the Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) parts I-IV, Montreal Cognitive Assessment (MoCA), Frontal Assessment Battery (FAB), Self-Rating Depression Scale (SDS), and Starkstein Apathy Scale (SAS) at baseline, 3 months, and 6 months.

RESULTS

Nine of 12 PD patients were analyzed, except for three patients for which data was missing. MDS-UPDRS parts II and III were improved at 3 months (median -4.0, p = 0.012 and median -10.0, p = 0.012) and 6 months (median -7.0, p = 0.015 and median -12.0, p = 0.008), whereas MDS-UPDRS total parts I scores and total IV scores, MoCA, FAB, SDS, and SAS were unchanged. Adverse events included fall and backache in one patient each.

CONCLUSION

A table tennis exercise program is relatively safe and may improve activities of daily living and motor symptoms in patients with PD.

Cueing Paradigms to Improve Gait and Posture in Parkinson's Disease: A Narrative Review

Progressive gait dysfunction is one of the primary motor symptoms in people with Parkinson’s disease (PD). It is generally expressed as reduced step length and gait speed and as increased variability in step time and step length. People with PD also exhibit stooped posture which disrupts gait and impedes social interaction. The gait and posture impairments are usually resistant to the pharmacological treatment, worsen as the disease progresses, increase the likelihood of falls, and result in higher rates of hospitalization and mortality. These impairments may be caused by perceptual deficiencies (poor spatial awareness and loss of temporal rhythmicity) due to the disruptions in processing intrinsic information related to movement initiation and execution which can result in misperceptions of the actual effort required to perform a desired movement and maintain a stable posture. Consequently, people with PD often depend on external cues during execution of motor tasks. Numerous studies involving open-loop cues have shown improvements in gait and freezing of gait (FoG) in people with PD. However, the benefits of cueing may be limited, since cues are provided in a consistent/rhythmic manner irrespective of how well a person follows them. This limitation can be addressed by providing feedback in real-time to the user about performance (closed-loop cueing) which may help to improve movement patterns. Some studies that used closed-loop cueing observed improvements in gait and posture in PD, but the treadmill-based setup in a laboratory would not be accessible outside of a research setting, and the skills learned may not readily and completely transfer to overground locomotion in the community. Technologies suitable for cueing outside of laboratory environments could facilitate movement practice during daily activities at home or in the community and could strongly reinforce movement patterns and improve clinical outcomes. This narrative review presents an overview of cueing paradigms that have been utilized to improve gait and posture in people with PD and recommends development of closed-loop wearable systems that can be used at home or in the community to improve gait and posture in PD.

Combined Transcranial Direct Current Stimulation and Selective Motor Training Enhances Balance in Children With Autism Spectrum Disorder

Previous studies have shown that transcranial direct current stimulation (tDCS) over the primary motor cortex (M1) can facilitate the consolidation of motor skills in people who are typically developed, especially when tDCS is combined with goal-oriented exercises. Yet, the effect of tDCS on the motor skills of children with autism spectrum disorder is unknown. This study sought to investigate the effects of combined anodal tDCS and selective motor training on balance among 18 children with autism spectrum disorder (aged 6–14 years) who we randomly assigned to equal-sized experimental and control groups. The experimental group practiced motor training to improve balance after receiving 1.5 mA anodal tDCS over the left M1 for 20 minutes before each of 10 motor training sessions. The control (sham) group underwent a similar protocol with identical motor training, but tDCS was only artificially administered to them. We evaluated participants’ balance at baseline and after training. Data analysis showed that both anodal tDCS plus motor skill training and motor skill training with sham tDCS had significant positive impacts on balance, but tDCS participants who received both actual tDCS and motor skill training performed significantly better than those who received SHAM tDCS and motor skill training. These preliminary findings suggest that tDCS may enhance motor skill training for children with autism spectrum disorder, but replications with larger samples involving participants with varying levels of autistic symptoms and varied tDCS stimulation polarity are needed to affirm the practical use of this noninvasive brain stimulation.

Sensorimotor integration training in Parkinson`s disease

OBJECTIVE

To determine the effects of sensorimotor integration training on postural control in Parkinson`s disease.

METHODS

This prospective, randomized controlled trial was conducted at Hacettepe University (Ankara, Turkey). The study was carried out from August 2012 until March 2015 and included 24 Parkinson`s patients with stage 2-3 according to the Modified Hoehn&Yahr Rating Scale. The patients were divided into 2 groups (control and study). The control group received conventional physiotherapy; the study group received sensorimotor integration training combined with conventional physiotherapy, 2 times per week for 6 weeks. We assessed the patients with clinical balance tests and computerized dynamic posturography. Assessments were performed at baseline, 7- and 12-weeks follow-up.

RESULTS

Computerized dynamic posturography posturography values (5th and 6th positions, composite balance, and vestibular system scores) were higher in the study group than in the control group. The improvements were maintained at the 12-week follow up except 6th positions scores (p<0.05).

CONCLUSION

Sensorimotor integration training combined with conventional physiotherapy approach ameliorated postural control by improving vestibular system in patients with Parkinson`s disease by improving sensory processes.

Music and movement: Towards a translational approach

Rhythmic abilities are highly widespread in the general population. Most people can extract the regular beat of music, and align their movements with it. The aim of a translational approach for music and movement is to build on current fundamental research and theories of beat perception and synchronization to devise music-based interventions, which are informed by theory. To illustrate this approach, Parkinson's disease is taken as a model, with a focus on the positive effects of rhythmic auditory cueing on walking. In Parkinson's disease, a relation is found between the success of this music-based intervention and individual differences in rhythmic abilities. Patients with relatively spared rhythmic abilities are the most likely to benefit from cueing. Moreover, rhythmic auditory cueing can be optimized by using mobile technologies (tablets and smartphones), in the form of dedicated apps or serious games. A similar translational approach to the study of music, rhythm, and movement can be extended to remediation of cognitive, speech and language functions in other patient populations, such as children and adults with neurodevelopemental disorders.

The Use of Footstep Sounds as Rhythmic Auditory Stimulation for Gait Rehabilitation in Parkinson's Disease: A Randomized Controlled Trial

Background

The use of rhythmic auditory stimulation (RAS) has been proven useful in the management of gait disturbances associated with Parkinson’s disease (PD). Typically, the RAS consists of metronome or music-based sounds (artificial RAS), while ecological footstep sounds (ecological RAS) have never been used for rehabilitation programs.

Objective

The aim of this study was to compare the effects of a rehabilitation program integrated either with ecological or with artificial RAS.

Methods

An observer-blind, randomized controlled trial was conducted to investigate the effects of 5 weeks of supervised rehabilitation integrated with RAS. Thirty-eight individuals affected by PD were randomly assigned to one of the two conditions (ecological vs. artificial RAS); thirty-two of them (age 68.2 ± 10.5, Hoehn and Yahr 1.5–3) concluded all phases of the study. Spatio-temporal parameters of gait and clinical variables were assessed before the rehabilitation period, at its end, and after a 3-month follow-up.

Results

Thirty-two participants were analyzed. The results revealed that both groups improved in the majority of biomechanical and clinical measures, independently of the type of sound. Moreover, exploratory analyses for separate groups were conducted, revealing improvements on spatio-temporal parameters only in the ecological RAS group.

Conclusion

Overall, our results suggest that ecological RAS is equally effective compared to artificial RAS. Future studies should further investigate the role of ecological RAS, on the basis of information revealed by our exploratory analyses. Theoretical, methodological, and practical issues concerning the implementation of ecological sounds in the rehabilitation of PD patients are discussed.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier NCT03228888.

Effectiveness of external cues to facilitate task performance in people with neurological disorders: a systematic review and meta-analysis

Purpose: To examine in people with neurological disorders, which method/s of providing external cues to improve task performance are most effective. Methods: Medline, EMBASE, and PsycINFO were systematically searched. Two reviewers independently screened, extracted data, and assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: Twenty six studies were included. Studies examined a wide-range of cues including visual, tactile, auditory, verbal, and multi-component cues. Cueing (any type) improved walking speed when comparing cues to no cues (mean difference (95% confidence interval): 0.08 m/s (0.06-0.10), I² = 68%, low quality of evidence). Remaining evidence was analysed narratively; evidence that cueing improves activity-related outcomes was inconsistent and rated as very low quality. It was not possible to determine which form of cueing may be more effective than others. Conclusion: Providing cues to encourage successful task performance is a core component of rehabilitation, however there is limited evidence on the type of cueing or which tasks benefit most from external cueing. Low-quality evidence suggests there may be a beneficial effect of cueing (any type) on walking speed. Sufficiently powered randomised controlled trials are needed to inform therapists of the most effective cueing strategies to improve activity performance in populations with a neurological disorder. Implications for rehabilitation Providing cues is a core component of rehabilitation and may improve successful task performance and activities in people with neurological conditions including stroke, Parkinson's disease, Alzheimer's disease, traumatic brain injury, and multiple sclerosis, but evidence is limited for most neurological conditions with much research focusing on stroke and Parkinson's disease. Therapists should consider using a range of different types of cues depending on the aims of treatment and the neurological condition. There is currently insufficient evidence to suggest one form of cueing is superior to other forms. Therapists should appreciate that responding optimally to cues may take many sessions to have an effect on activities such as walking. Further studies should be conducted over a longer timeframe to examine the effects of different types of cues towards task performance and activities in people with neurological conditions.

Walking to a multisensory beat

Living in a complex and multisensory environment demands constant interaction between perception and action. In everyday life it is common to combine efficiently simultaneous signals coming from different modalities. There is evidence of a multisensory benefit in a variety of laboratory tasks (temporal judgement, reaction time tasks). It is less clear if this effect extends to ecological tasks, such as walking. Furthermore, benefits of multimodal stimulation are linked to temporal properties such as the temporal window of integration and temporal recalibration. These properties have been examined in tasks involving single, non-repeating stimulus presentations. Here we investigate the same temporal properties in the context of a rhythmic task, namely audio-tactile stimulation during walking. The effect of audio-tactile rhythmic cues on gait variability and the ability to synchronize to the cues was studied in young adults. Participants walked with rhythmic cues presented at different stimulus-onset asynchronies. We observed a multisensory benefit by comparing audio-tactile to unimodal stimulation. Moreover, both the temporal window of integration and temporal recalibration mediated the response to multimodal stimulation. In sum, rhythmic behaviours obey the same principles as temporal discrimination and detection behaviours and thus can also benefit from multimodal stimulation.

Temporary Nerve Block at Selected Digits Revealed Hand Motor Deficits in Grasping Tasks

Peripheral sensory feedback plays a crucial role in ensuring correct motor execution throughout hand grasp control. Previous studies utilized local anesthesia to deprive somatosensory feedback in the digits or hand, observations included sensorimotor deficits at both corticospinal and peripheral levels. However, the questions of how the disturbed and intact sensory input integrate and interact with each other to assist the motor program execution, and whether the motor coordination based on motor output variability between affected and non-affected elements (e.g., digits) becomes interfered by the local sensory deficiency, have not been answered. The current study aims to investigate the effect of peripheral deafferentation through digital nerve blocks at selective digits on motor performance and motor coordination in grasp control. Our results suggested that the absence of somatosensory information induced motor deficits in hand grasp control, as evidenced by reduced maximal force production ability in both local and non-local digits, impairment of force and moment control during object lift and hold, and attenuated motor synergies in stabilizing task performance variables, namely the tangential force and moment of force. These findings implied that individual sensory input is shared across all the digits and the disturbed signal from local sensory channel(s) has a more comprehensive impact on the process of the motor output execution in the sensorimotor integration process. Additionally, a feedback control mechanism with a sensation-based component resides in the formation process for the motor covariation structure.

Integration of Motor Imagery and Physical Practice in Group Treatment Applied to Subjects With Parkinson’s Disease

Background and Purpose. The application of motor imagery practice in the treatment of Parkinson’s disease (PD) is a novel treatment approach for improving motor function. The purpose of this study was to compare group treatment using a combination of physical and motor imagery practice with group treatment using only physical practice in subjects with PD.

Methods. Of 23 patients with idiopathic PD, 12 received combined therapy, whereas 11 received physical therapy alone. Exercises for both groups were applied during 1-h sessions held twice a week for 12 weeks. Comparable motor tasks provided to both groups included callisthenic exercises, functional tasks, and relaxation exercises. However, the experimental group was treated with both imagery and real practice, whereas the control group received only physical exercises. Outcome measures included the time required to complete sequences of movements, the performance of balance tasks, impairment and functional scores on the Unified Parkinson’s Disease Rating Scale (UPDRS), and specific cognitive abilities (Stroop and clock drawing tests).

Results. Following the intervention, the combined treatment group exhibited significantly faster performance of movement sequences than the control group. In addition, the experimental subjects demonstrated higher gains in the mental and motor subsets of the UPDRS and in the cognitive tests. Both groups improved on the activities of daily living scale.

Conclusions. The combination of motor imagery and real practice may be effective in the treatment of PD, especially for reducing bradykinesia. The implementation of this treatment regimen allows for the extension of practice time with negligible risk and low cost.

Effects of Physical Rehabilitation Integrated with Rhythmic Auditory Stimulation on Spatio-Temporal and Kinematic Parameters of Gait in Parkinson's Disease

Movement rehabilitation by means of physical therapy represents an essential tool in the management of gait disturbances induced by Parkinson’s disease (PD). In this context, the use of rhythmic auditory stimulation (RAS) has been proven useful in improving several spatio-temporal parameters, but concerning its effect on gait patterns, scarce information is available from a kinematic viewpoint. In this study, we used three-dimensional gait analysis based on optoelectronic stereophotogrammetry to investigate the effects of 5 weeks of supervised rehabilitation, which included gait training integrated with RAS on 26 individuals affected by PD (age 70.4 ± 11.1, Hoehn and Yahr 1–3). Gait kinematics was assessed before and at the end of the rehabilitation period and after a 3-month follow-up, using concise measures (Gait Profile Score and Gait Variable Score, GPS and GVS, respectively), which are able to describe the deviation from a physiologic gait pattern. The results confirm the effectiveness of gait training assisted by RAS in increasing speed and stride length, in regularizing cadence and correctly reweighting swing/stance phase duration. Moreover, an overall improvement of gait quality was observed, as demonstrated by the significant reduction of the GPS value, which was created mainly through significant decreases in the GVS score associated with the hip flexion–extension movement. Future research should focus on investigating kinematic details to better understand the mechanisms underlying gait disturbances in people with PD and the effects of RAS, with the aim of finding new or improving current rehabilitative treatments.

Dynamic High-Cadence Cycling Improves Motor Symptoms in Parkinson's Disease

RATIONALE

Individuals with Parkinson's disease (PD) often have deficits in kinesthesia. There is a need for rehabilitation interventions that improve these kinesthetic deficits. Forced (tandem) cycling at a high cadence improves motor function. However, tandem cycling is difficult to implement in a rehabilitation setting.

OBJECTIVE

To construct an instrumented, motored cycle and to examine if high cadence dynamic cycling promotes improvements in motor function.

METHOD

This motored cycle had two different modes: dynamic and static cycling. In dynamic mode, the motor maintained 75-85 rpm. In static mode, the rider determined the pedaling cadence. UPDRS Motor III and Timed Up and Go (TUG) were used to assess changes in motor function after three cycling sessions.

RESULTS

Individuals in the static group showed a lower cadence but a higher power, torque and heart rate than the dynamic group. UPDRS score showed a significant 13.9% improvement in the dynamic group and only a 0.9% improvement in the static group. There was also a 16.5% improvement in TUG time in the dynamic group but only an 8% improvement in the static group.

CONCLUSION

These findings show that dynamic cycling can improve PD motor function and that activation of proprioceptors with a high cadence but variable pattern may be important for motor improvements in PD.

A Kinect-Based System for Lower Limb Rehabilitation in Parkinson's Disease Patients: a Pilot Study

This work brings together the emerging virtual reality techniques and the natural user interfaces to offer new possibilities in the field of rehabilitation. We have designed a rehabilitation game based on a low cost device (Microsoft Kinect(TM)) connected to a personal computer. It provides patients having Parkinson's Disease (PD) with a motivating way to perform several motor rehabilitation exercises to improve their rehabilitation. The experiment was tested on seven Parkinson's Disease patients and results demonstrated significant improvements in completion time score and in the 10 Meters Walk Test score. Nevertheless, additional research is needed to determine if this type of training has a long-term impact. Both the device and protocol were well accepted by subjects, being safe and easy to use. We conclude that our work provides a simple and suitable tool resulting in a more enriching rehabilitation process where motivation is highly encouraged in PD patients. Feedback coming from participants corroborate the hypothesis that the system can be applied not only in clinical rehabilitation centers but at home.

Group Education with Personal Rehabilitation for Idiopathic Parkinson's Disease

Objective:

To evaluate the effect of a group education program with personal rehabilitation for idiopathic Parkinson's disease (IPD).

Methods:

A single-blind, randomized, controlled clinical trial, with a pre-test/post-test quasi-experimental design. Fortyfour stable, non-demented patients with IPD were randomly assigned to an intervention group (n=23) and control group (n=21). Three group lectures on health education specific to IPD were delivered to the intervention group. The theme of lectures was “Not a lonely journey, as your friend, we—experts specializing in IPD— would love to join with you.” Three domains of the management of IPD were mentioned: “How to manage your routine Meal, Moving and Mood after suffering from IPD” Each lecture was scheduled for 45 minutes (excluding breaks), and designed as an interactive dialogue rather than a traditional lecture. To strengthen the impact of the lectures, relevant information was published on a website: http://www.parkinsonism.cn/. Following the group lecture, individualized and tailored rehabilitation made up of 24 half-hour sessions over eight weeks were provided for the intervention group.

Results:

The program ran smoothly and IPD patients were satisfied with this program. After only eight weeks, the health-related quality of life (HR-QOL) in the intervention group improved significantly (p<0.001). Patients and their caregivers in this group also reported their mood elevations following the program.

Conclusion:

Group education combined with personal rehabilitation program appears to be a beneficial and practical intervention, not only complementing the medical treatment for IPD patients but also meeting the growing demand for long-term care.

Listenmee and Listenmee smartphone application: synchronizing walking to rhythmic auditory cues to improve gait in Parkinson's disease

Evidence supports the use of rhythmic external auditory signals to improve gait in PD patients (Arias & Cudeiro, 2008; Kenyon & Thaut, 2000; McIntosh, Rice & Thaut, 1994; McIntosh et al., 1997; Morris, Iansek, & Matyas, 1994; Thaut, McIntosh, & Rice, 1997; Suteerawattananon, Morris, Etnyre, Jankovic, & Protas , 2004; Willems, Nieuwboer, Chavert, & Desloovere, 2006). However, few prototypes are available for daily use, and to our knowledge, none utilize a smartphone application allowing individualized sounds and cadence. Therefore, we analyzed the effects on gait of Listenmee®, an intelligent glasses system with a portable auditory device, and present its smartphone application, the Listenmee app®, offering over 100 different sounds and an adjustable metronome to individualize the cueing rate as well as its smartwatch with accelerometer to detect magnitude and direction of the proper acceleration, track calorie count, sleep patterns, steps count and daily distances. The present study included patients with idiopathic PD presented gait disturbances including freezing. Auditory rhythmic cues were delivered through Listenmee®. Performance was analyzed in a motion and gait analysis laboratory. The results revealed significant improvements in gait performance over three major dependent variables: walking speed in 38.1%, cadence in 28.1% and stride length in 44.5%. Our findings suggest that auditory cueing through Listenmee® may significantly enhance gait performance. Further studies are needed to elucidate the potential role and maximize the benefits of these portable devices.

Effect of transcranial direct-current stimulation combined with treadmill training on balance and functional performance in children with cerebral palsy: a double-blind randomized controlled trial

Background

Cerebral palsy refers to permanent, mutable motor development disorders stemming from a primary brain lesion, causing secondary musculoskeletal problems and limitations in activities of daily living. The aim of the present study was to determine the effects of gait training combined with transcranial direct-current stimulation over the primary motor cortex on balance and functional performance in children with cerebral palsy.

Methods

A double-blind randomized controlled study was carried out with 24 children aged five to 12 years with cerebral palsy randomly allocated to two intervention groups (blocks of six and stratified based on GMFCS level (levels I-II or level III).The experimental group (12 children) was submitted to treadmill training and anodal stimulation of the primary motor cortex. The control group (12 children) was submitted to treadmill training and placebo transcranial direct-current stimulation. Training was performed in five weekly sessions for 2 weeks. Evaluations consisted of stabilometric analysis as well as the administration of the Pediatric Balance Scale and Pediatric Evaluation of Disability Inventory one week before the intervention, one week after the completion of the intervention and one month after the completion of the intervention. All patients and two examiners were blinded to the allocation of the children to the different groups.

Results

The experimental group exhibited better results in comparison to the control group with regard to anteroposterior sway (eyes open and closed; p<0.05), mediolateral sway (eyes closed; p<0.05) and the Pediatric Balance Scale both one week and one month after the completion of the protocol.

Conclusion

Gait training on a treadmill combined with anodal stimulation of the primary motor cortex led to improvements in static balance and functional performance in children with cerebral palsy.

Trial Registration

Ensaiosclinicos.gov.br/RBR-9B5DH7

Musically cued gait-training improves both perceptual and motor timing in Parkinson's disease

It is well established that auditory cueing improves gait in patients with idiopathic Parkinson's disease (IPD). Disease-related reductions in speed and step length can be improved by providing rhythmical auditory cues via a metronome or music. However, effects on cognitive aspects of motor control have yet to be thoroughly investigated. If synchronization of movement to an auditory cue relies on a supramodal timing system involved in perceptual, motor, and sensorimotor integration, auditory cueing can be expected to affect both motor and perceptual timing. Here, we tested this hypothesis by assessing perceptual and motor timing in 15 IPD patients before and after a 4-week music training program with rhythmic auditory cueing. Long-term effects were assessed 1 month after the end of the training. Perceptual and motor timing was evaluated with a battery for the assessment of auditory sensorimotor and timing abilities and compared to that of age-, gender-, and education-matched healthy controls. Prior to training, IPD patients exhibited impaired perceptual and motor timing. Training improved patients' performance in tasks requiring synchronization with isochronous sequences, and enhanced their ability to adapt to durational changes in a sequence in hand tapping tasks. Benefits of cueing extended to time perception (duration discrimination and detection of misaligned beats in musical excerpts). The current results demonstrate that auditory cueing leads to benefits beyond gait and support the idea that coupling gait to rhythmic auditory cues in IPD patients relies on a neuronal network engaged in both perceptual and motor timing.

Physiotherapy for Parkinson's disease: a comparison of techniques

BACKGROUND

Despite medical therapies and surgical interventions for Parkinson's disease (PD), patients develop progressive disability. The role of physiotherapy is to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. The overall aim is to optimise independence, safety and wellbeing, thereby enhancing quality of life. Trials have shown that physiotherapy has short-term benefits in PD. However, which physiotherapy intervention is most effective remains unclear.

OBJECTIVES

To assess the effectiveness of one physiotherapy intervention compared with a second approach in patients with PD.

SEARCH METHODS

Relevant trials were identified by electronic searches of numerous literature databases (for example MEDLINE, EMBASE) and trial registers, plus handsearching of major journals, abstract books, conference proceedings and reference lists of retrieved publications. The literature search included trials published up to the end of January 2012.

SELECTION CRITERIA

Randomised controlled trials of one physiotherapy intervention versus another physiotherapy intervention in patients with PD.

DATA COLLECTION AND ANALYSIS

Data were abstracted independently from each paper by two authors. Trials were classified into the following intervention comparisons: general physiotherapy, exercise, treadmill training, cueing, dance and martial arts.

MAIN RESULTS

A total of 43 trials were identified with 1673 participants. All trials used small patient numbers (average trial size of 39 participants); the methods of randomisation and concealment of allocation were poor or not stated in most trials. Blinded assessors were used in just over half of the trials and only 10 stated that they used intention-to-treat analysis.A wide variety of validated and customised outcome measures were used to assess the effectiveness of physiotherapy interventions. The most frequently reported physiotherapy outcomes were gait speed and timed up and go, in 19 and 15 trials respectively. Only five of the 43 trials reported data on falls (12%). The motor subscales of the Unified Parkinson's Disease Rating Scale and Parkinson's Disease Questionnaire-39 were the most commonly reported clinician-rated disability and patient-rated quality of life outcome measures, used in 22 and 13 trials respectively. The content and delivery of the physiotherapy interventions varied widely in the trials included within this review, so no quantitative meta-analysis could be performed.

AUTHORS' CONCLUSIONS

Considering the small number of participants examined, the methodological flaws in many of the studies, the possibility of publication bias, and the variety of interventions, formal comparison of the different physiotherapy techniques could not be performed. There is insufficient evidence to support or refute the effectiveness of one physiotherapy intervention over another in PD.This review shows that a wide range of physiotherapy interventions to treat PD have been tested . There is a need for more specific trials with improved treatment strategies to underpin the most appropriate choice of physiotherapy intervention and the outcomes measured.

Retraining function in people with Parkinson's disease using the Microsoft kinect: game design and pilot testing

Background

Computer based gaming systems, such as the Microsoft Kinect (Kinect), can facilitate complex task practice, enhance sensory feedback and action observation in novel, relevant and motivating modes of exercise which can be difficult to achieve with standard physiotherapy for people with Parkinson’s disease (PD). However, there is a current need for safe, feasible and effective exercise games that are appropriate for PD rehabilitation. The aims of this study were to i) develop a computer game to rehabilitate dynamic postural control for people with PD using the Kinect; and ii) pilot test the game’s safety and feasibility in a group of people with PD.

Methods

A rehabilitation game aimed at training dynamic postural control was developed through an iterative process with input from a design workshop of people with PD. The game trains dynamic postural control through multi-directional reaching and stepping tasks, with increasing complexity across 12 levels of difficulty. Nine people with PD pilot tested the game for one session. Participant feedback to identify issues relating to safety and feasibility were collected using semi-structured interviews.

Results

Participants reported that they felt safe whilst playing the game. In addition, there were no adverse events whilst playing. In general, the participants stated that they enjoyed the game and seven of the nine participants said they could imagine themselves using the game at home, especially if they felt it would improve their balance. The Flow State Scale indicated participants were immersed in the gameplay and enjoyed the experience. However, some participants reported that they found it difficult to discriminate between different types and orientations of visual objects in the game and some also had difficulty with the stepping tasks, especially when performed at the same time as the reaching tasks.

Conclusion

Computer-based rehabilitation games using the Kinect are safe and feasible for people with PD although intervention trials are needed to test their safety, feasibility and efficacy in the home.

Altered activation in visual cortex: Unusual functional magnetic resonance imaging finding in early Parkinson’s disease

Objective

Movement dysfunction in Parkinson’s disease (PD) is well documented but its cause remains unclear. This study examined whether motor symptoms are caused by sensory impairment, executive dysfunction or other factors.

Methods

We examined the integration of tactile and motor programmes using functional magnetic resonance imaging (fMRI) in early stage PD patients compared with neurologically normal controls, to investigate neural mechanisms underlying movement dysfunction.

Results

Twenty-two control participants exhibited activation in an extensive network of cortical regions involved in tactile–motor integration. Decreased activation in somatosensory and motor regions during performance of passive tactile and movement tasks was found in 21 PD patients. The extrastriate visual cortex exhibited greater activation in controls during performance of the tasks. In contrast, greater activation in bilateral prefrontal regions was found in PD patients.

Conclusions

These results indicate that the extrastriate visual cortex is a multisensory region playing an important role in sensorimotor integration. The findings suggest that PD patients exhibit decreased activation in the extrastriate visual cortex, possibly related to dysfunctional integrative processing, and compensatory activity in the prefrontal cortex.

Sensory aspects of movement disorders

Movement disorders, which include disorders such as Parkinson's disease, dystonia, Tourette's syndrome, restless legs syndrome, and akathisia, have traditionally been considered to be disorders of impaired motor control resulting predominantly from dysfunction of the basal ganglia. This notion has been revised largely because of increasing recognition of associated behavioural, psychiatric, autonomic, and other non-motor symptoms. The sensory aspects of movement disorders include intrinsic sensory abnormalities and the effects of external sensory input on the underlying motor abnormality. The basal ganglia, cerebellum, thalamus, and their connections, coupled with altered sensory input, seem to play a key part in abnormal sensorimotor integration. However, more investigation into the phenomenology and physiological basis of sensory abnormalities, and about the role of the basal ganglia, cerebellum, and related structures in somatosensory processing, and its effect on motor control, is needed.

The Efficacy of Exercise Programs for Parkinson's Disease: Tai Chi versus Combined Exercise

Background and Purpose

Exercise is recommended for every patient with Parkinson's disease (PD). The effectiveness of two different forms of exercise for PD, Tai Chi and combined stretching-strengthening exercise, was compared.

Methods

Patients with mild-to-moderate PD were recruited to join either the combined stretching-strengthening exercise group (n=7), the Tai Chi group (n=9), or the control (nonintervention) group (n=7). Exercise was performed three times a week over a period of 8 weeks. The Tai Chi exercise was led by certified instructors based on a Tai-Chi-for-arthritis program. The combined stretching-strengthening exercise comprised folk dancing, stepping, and elastic-band exercises. The subjects' functional fitness, parkinsonian symptoms, quality of life (QoL), and depression were evaluated.

Results

Both exercise groups yielded better results in their overall functional fitness after the intervention. However, no improvement with exercise was found for parkinsonian symptoms, as evaluated using the Unified Parkinson's Disease Rating Scale. With respect to the domains of QoL, the combined stretching-strengthening exercise group fared better in the social domain of QoL, and the Tai Chi group fared better in the emotional domain, while QoL and depression worsened in the control group. The postintervention QoL was improved relative to the control condition only for the Tai Chi group. Although the exercise interventions did not have any effect on depression, the control group was associated with a significant deterioration.

Conclusions

Exercise improved the functional fitness and QoL of PD patients, with Tai Chi yielding better results in QoL and favorable results in functional fitness. These findings suggest that Tai Chi could be a good exercise strategy for patients with PD.

Deep brain stimulation improves movement amplitude but not hastening of repetitive finger movements

External pacing cues, dopaminergic medication, and bilateral subthalamic nucleus deep brain stimulation (STN-DBS) improve repetitive movements performed at low rates. When the pacing rate is increased to frequencies near 2 Hz and above, both external pacing cues and Parkinson's medication were shown to be ineffective at improving repetitive finger movement performance. It remains unclear if STN-DBS improves the performance of repetitive finger movements at high pacing rates. This study examined the effects of STN-DBS on the amplitude and rate of repetitive finger movement across a range of external pacing rates. Nine participants with STN-DBS (OFF and ON stimulation) and nine matched healthy adults performed repetitive index finger flexion movements paced by an acoustic tone that increased from 1.0 to 3.0 Hz. OFF stimulation, most subjects moved at rates that were substantially higher (hastening pattern) or lower (bradykinesia pattern) than the tone rate, particularly at high pacing rates. ON stimulation, movement rate improved in subjects with the bradykinesia pattern, but not in those with the hastening pattern. Overall, STN-DBS did not significantly affect movement rate. In contrast, STN-DBS significantly (p<0.05) improved movement amplitude across all pacing rates. These findings demonstrate that STN-DBS improves movement amplitude, but had no effect on the rate of movement in participants with a hastening pattern. Separately testing movement amplitude and movement rate using both high and low rate externally paced cues in the clinical environment may aid in the diagnosis and treatment of people with Parkinson's disease.

A pilot study to investigate the feasibility of electrical stimulation to assist gait in Parkinson's disease

Objectives.  This study aims to investigate the effect of functional electrical stimulation (FES) on gait in people with Parkinson's disease. Materials and Methods.  Seven subjects with idiopathic Parkinson's disease received single-channel electrical stimulation for eight weeks to the common peroneal nerve to improve heel strike and provide sensory stimulus during the swing phase of gait. Stride length, time, and number of steps to complete a 20-m walk and distance completed in 3 min were assessed. Episodes of freezing and incidence of falls were recorded. Statistical analysis of the walking test data was analyzed using the nonparametric Wilcoxon signed ranks test. Results.  An immediate improvement was demonstrated with FES on distance and average stride length during a 3-min walk during the treatment period but not on number of steps and walking speed during a 20-m walk. A training effect was observed for all parameters of gait measured over the eight-week treatment period, which was mostly maintained four weeks after treatment was stopped. Fewer falls and episodes of freezing occurred during the treatment period. The number of falls returned to pretreatment levels when treatment was stopped. Conclusions.  This study has shown that FES can improve some parameters of gait over an eight-week period of use with a carryover effect that is maintained without stimulation during that time and an immediate reduction in the frequency of falls. An immediate effect of FES was demonstrated over a 3-min walk but not over a 20-m walk. Improvements in gait largely persisted on reassessment four weeks after stopping use of FES although the frequency of falls returned to pretreatment levels. A larger study is required to support these findings, to understand the mechanisms of the effects of electrical stimulation on gait and to identify those most likely to benefit from it.

Postural instability in patients with Parkinson's disease. Epidemiology, pathophysiology and management

Postural instability is one of the cardinal signs in Parkinson's disease (PD). It can be present even at diagnosis, but becomes more prevalent and worsens with disease progression. It represents one of the most disabling symptoms in the advanced stages of the disease, as it is associated with increased falls and loss of independence. Clinical and posturographic studies have contributed to significant advances in unravelling the complex pathophysiology of postural instability in patients with PD, but it still remains yet to be fully clarified, partly due to the difficulty in distinguishing between the disease process and the compensatory mechanisms, but also due to the fact that non-standardized techniques are used to measure balance and postural instability. There is increasing evidence that physical therapy, especially highly challenging balance exercises, can improve postural stability and reduce the risk of falls, although the long-term effects of physical therapy interventions on postural stability need to be explored given the progressive nature of PD. Pharmacotherapy with dopaminergic medications can provide significant improvements in postural instability in early- to mid-stage PD but the effects tend to wane with time consistent with spread of the disease process to non-dopaminergic pathways in advanced PD. Donepezil has been associated with a reduced risk of falls and methylphenidate has shown potential benefit against freezing of gait, but the results are yet to be replicated in large randomized studies. Surgical treatments, including lesioning and deep brain stimulation surgery targeting the subthalamic nucleus and the globus pallidus internus, tend to only provide modest benefit for postural instability. New surgical targets such as the pedunculopontine nucleus have emerged as a potential specific therapy for postural instability and gait disorder but remain experimental.

Exercise for people in early- or mid-stage Parkinson disease: a 16-month randomized controlled trial

BACKGROUND

Exercise confers short-term benefits for individuals with Parkinson disease (PD).

OBJECTIVE

The purpose of the study was to compare short- and long-term responses among 2 supervised exercise programs and a home-based control exercise program.

DESIGN

The 16-month randomized controlled exercise intervention investigated 3 exercise approaches: flexibility/balance/function exercise (FBF), supervised aerobic exercise (AE), and home-based exercise (control).

SETTING

This study was conducted in outpatient clinics.

PATIENTS

The participants were 121 individuals with PD (Hoehn & Yahr stages 1-3).

INTERVENTIONS

The FBF program (individualized spinal and extremity flexibility exercises followed by group balance/functional training) was supervised by a physical therapist. The AE program (using a treadmill, bike, or elliptical trainer) was supervised by an exercise trainer. Supervision was provided 3 days per week for 4 months, and then monthly (16 months total). The control group participants exercised at home using the National Parkinson Foundation Fitness Counts program, with 1 supervised, clinic-based group session per month.

MEASUREMENTS

Outcomes, obtained by blinded assessors, were determined at 4, 10, and 16 months. The primary outcome measures were overall physical function (Continuous Scale-Physical Functional Performance [CS-PFP]), balance (Functional Reach Test [FRT]), and walking economy (oxygen uptake [mL/kg/min]). Secondary outcome measures were symptom severity (Unified Parkinson's Disease Rating Scale [UPDRS] activities of daily living [ADL] and motor subscales) and quality of life (39-item Parkinson's Disease Quality of Life Scale [PDQ-39]).

RESULTS

Of the 121 participants, 86.8%, 82.6%, and 79.3% completed 4, 10, and 16 months, respectively, of the intervention. At 4 months, improvement in CS-PFP scores was greater in the FBF group than in the control group (mean difference=4.3, 95% confidence interval [CI]=1.2 to 7.3) and the AE group (mean difference=3.1, 95% CI=0.0 to 6.2). Balance was not different among groups at any time point. Walking economy improved in the AE group compared with the FBF group at 4 months (mean difference=-1.2, 95% CI=-1.9 to -0.5), 10 months (mean difference=-1.2, 95% CI=-1.9 to -0.5), and 16 months (mean difference=-1.7, 95% CI=-2.5 to -1.0). The only secondary outcome that showed significant differences was UPDRS ADL subscale scores: the FBF group performed better than the control group at 4 months (mean difference=-1.47, 95% CI=-2.79 to -0.15) and 16 months (mean difference=-1.95, 95% CI=-3.84 to -0.08).

LIMITATIONS

Absence of a non-exercise control group was a limitation of the study.

CONCLUSIONS

Findings demonstrated overall functional benefits at 4 months in the FBF group and improved walking economy (up to 16 months) in the AE group.

Testing the contributions of striatal dopamine loss to the genesis of parkinsonian signs

The diverse and independently-varying signs of Parkinson's disease (PD) are often attributed to one simple mechanism: degeneration of the dopaminergic innervation of the posterolateral striatum. However, growing recognition of the dopamine (DA) loss and other pathology in extra-striatal brain regions has led to uncertainty whether loss of DA in the striatum is sufficient to cause parkinsonian signs. We tested this hypothesis by infusing cis-flupenthixol (cis-flu; a broad-spectrum D1/D2 receptor antagonist) into different regions of the macaque putamen (3 hemispheres of 2 monkeys) while the animal performed a visually-cued choice reaction time task in which visual cues indicated the arm to reach with and the peripheral target to contact to obtain food reward. Following reward delivery, the animal was required to self-initiate release of the peripheral target and return of the chosen hand to its home position (i.e., without the benefit of external sensory cues or immediate rewards). Infusions of cis-flu at 15 of 26 sites induced prolongations of reaction time (9 of 15 cases), movement duration (6 cases), and/or dwell time of the hand at the peripheral target (8 cases). Dwell times were affected more severely (+95%) than visually-triggered reaction times or movement durations (+25% and +15%, respectively). Specifically, the animal's hand often 'froze' at the peripheral target for up to 25-s, similar to the akinetic freezing episodes observed in PD patients. Across injections, slowing of self-initiation did not correlate in severity with prolongations of visually-triggered reaction time or movement duration, although the latter two were correlated with each other. Episodes of slowed self-initiation appeared primarily in the arm contralateral to the injected hemisphere and were not associated with increased muscle co-contraction or global alterations in behavioral state (i.e., inattention or reduced motivation), consistent with the idea that these episodes reflected a fundamental impairment of movement initiation. We found no evidence for an anatomic topography within the putamen for the effects elicited. We conclude that acute focal blockade of DA transmission in the putamen is sufficient to induce marked akinesia-like impairments. Furthermore, different classes of impairments can be induced independently, suggesting that specific parkinsonian signs have unique pathophysiologic substrates.

LSVT LOUD and LSVT BIG: Behavioral Treatment Programs for Speech and Body Movement in Parkinson Disease

Recent advances in neuroscience have suggested that exercise-based behavioral treatments may improve function and possibly slow progression of motor symptoms in individuals with Parkinson disease (PD). The LSVT (Lee Silverman Voice Treatment) Programs for individuals with PD have been developed and researched over the past 20 years beginning with a focus on the speech motor system (LSVT LOUD) and more recently have been extended to address limb motor systems (LSVT BIG). The unique aspects of the LSVT Programs include the combination of (a) an exclusive target on increasing amplitude (loudness in the speech motor system; bigger movements in the limb motor system), (b) a focus on sensory recalibration to help patients recognize that movements with increased amplitude are within normal limits, even if they feel "too loud" or "too big," and (c) training self-cueing and attention to action to facilitate long-term maintenance of treatment outcomes. In addition, the intensive mode of delivery is consistent with principles that drive activity-dependent neuroplasticity and motor learning. The purpose of this paper is to provide an integrative discussion of the LSVT Programs including the rationale for their fundamentals, a summary of efficacy data, and a discussion of limitations and future directions for research.

Effectiveness of an inpatient movement disorders program for patients with atypical parkinsonism

This paper investigated the effectiveness of an inpatient movement disorders program for patients with atypical parkinsonism, who typically respond poorly to pharmacologic intervention and are challenging to rehabilitate as outpatients. Ninety-one patients with atypical parkinsonism participated in an inpatient movement disorders program. Patients received physical, occupational, and speech therapy for 3 hours/day, 5 to 7 days/week, and pharmacologic adjustments based on daily observation and data. Differences between admission and discharge scores were analyzed for the functional independence measure (FIM), timed up and go test (TUG), two-minute walk test (TMW), Berg balance scale (BBS) and finger tapping test (FT), and all showed significant improvement on discharge (P > .001). Clinically significant improvements in total FIM score were evident in 74% of the patients. Results were similar for ten patients whose medications were not adjusted. Patients with atypical parkinsonism benefit from an inpatient interdisciplinary movement disorders program to improve functional status.

Exercise and motor training in people with Parkinson's disease: a systematic review of participant characteristics, intervention delivery, retention rates, adherence, and adverse events in clinical trials

There is research evidence that exercise and motor training are beneficial for people with Parkinson's disease (PD), and clinicians seek to implement optimal programs. This paper summarizes important factors about the nature and reporting of randomized controlled trials of exercise and/or motor training for people with PD which are likely to influence the translation of research into clinical practice. Searches identified 53 relevant trials with 90 interventions conducted for an average duration of 8.3 (SD 4.2) weeks. Most interventions were fully supervised (74%) and conducted at a facility (79%). Retention rates were high with 69% of interventions retaining ≥85% of their participants; however adherence was infrequently reported, and 72% of trials did not report adverse events. Overall, the labor-intensive nature of most interventions tested in these trials and the sparse reporting of adherence and adverse events are likely to pose difficulties for therapists attempting to balance benefits and costs when selecting protocols that translate to sustainable clinical practice for people with PD.

Comparison of exercise strategies for motor symptom improvement in Parkinson’s disease

SUMMARY Aims: To evaluate the effectiveness of four exercise interventions on motor symptoms of Parkinson’s disease (PD). Materials and methods: This was a quasi-experimental trial with 89 participants assigned to one of four exercise programs (aquatic, aerobic, strength and sensory attention-focused exercise) or a control group. All groups were assessed by a blinded evaluator with the Unified Parkinson’s Disease Rating Scale (UPDRS III) motor section before exercises began (pre-test), immediately following exercise (post-test) and a subgroup was followed for a 6-week nonexercise washout period (washout). Results: Only sensory attention-focused exercise resulted in significant symptomatic improvement relative to nonexercising control participants. The sensory (6.7 points) and strength training (5.5 points) groups also had significant UPDRS III reductions from pre- to post-exercise. These benefits were not maintained after the washout period. Conclusion: Of the exercise modalities tested, sensory attention-focused exercise and strength training were the most effective strategies for individuals with PD. Future randomized trials are needed to confirm these results and compare other promising strategies aimed at specific pathophysiological deficits of PD.

A Manipulation of Visual Feedback during Gait Training in Parkinson's Disease

Visual cues are known to improve gait in Parkinson's disease (PD); however, the contribution of optic flow continues to be disputed. This study manipulated transverse line cues during two gait training interventions (6 weeks). PD subjects (N = 42) were assigned to one of three groups: treadmill (TG), overground (OG), or control group (CG). Participants walked across lines placed on either treadmills or 16-meter carpets, respectively. The treadmill (TG) offered a reduced dynamic flow from the environment, while lines presented on the ground (OG) emphasized optic flow related to the participant's own displacement. Both interventions significantly improved (and maintained through retention period) step length, thus improving walking velocity. Only the OG improved in the TUG test, while only the TG showed hints of improving (and maintaining) motor symptoms. Since gait improvements were found in both training groups, we conclude that by reducing optic flow, gait benefits associated with visual cueing training can still be achieved.

Rehabilitation interventions in Parkinson disease

OBJECTIVE

This self-directed learning module provides an evidence-based update of exercise-based rehabilitation interventions to treat Parkinson disease (PD). It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This focused review emphasizes treatment of locomotion deficits, upper limb motor control deficits, and hypokinetic dysarthria. New dopaminergic agents and deep brain stimulation are facilitating longer periods of functional stability for patients with PD. Adjunctive exercise-based treatments can therefore be applied over longer periods of time to optimize function before inevitable decline from this neurodegenerative disease. As function deteriorates in patients with PD, the role of caregivers becomes more critical, thus training caregivers is of paramount importance to help maintain a safe environment and limit caregiver anxiety and depression. The overall goal of this article is to enhance the learner's existing practice techniques used to treat PD through exercise-based intervention methods.

Effect of step training and rhythmic auditory stimulation on functional performance in Parkinson patients

BACKGROUND

Rhythmic auditory stimulation (RAS) can influence movement during straight line walking and direction transition in individuals with Parkinson disease (PD).

OBJECTIVE

The authors studied whether multidirectional step training with RAS would generalize to functional gait conditions used in daily activities and balance.

METHODS

In a matched-pairs design, 8 patients practiced externally paced (EP) stepping (RAS group), and 8 patients practiced internally paced (IP) stepping (no RAS group) for 6 weeks. Participants were evaluated on the first and last days of practice, and 1 week, 4 weeks, and 8 weeks after practice termination. Evaluations included a primary measurement--the Dynamic Gait Index (DGI)--and secondary measurements--the Unified Parkinson's Disease Rating Scale (UPDRS), Tinetti-gait and balance tests, Timed-Up-and-Go (TUG), and Freezing of Gait Questionnaire (FOGQ).

RESULTS

The RAS group significantly improved performance on the DGI and several secondary measures, and they maintained improvements for the DGI, Tinetti, FOGQ, and balance and gait items of the UPDRS above pretraining values at least 4 weeks after practice termination. The no RAS group revealed several improvements with training but could not maintain these improvements for as long as the other group.

CONCLUSIONS

Individuals with PD can generalize motor improvements achieved during multidirectional step training to contexts of functional gait and balance. Training with RAS is advantageous for enhancing functional gait improvements and the maintenance of functional gait and balance improvements over 8 weeks.

Physiotherapy for Parkinson’s disease: defining evidence within a framework for intervention

SUMMARY Parkinson’s disease (PD) is a complex multisystem disorder presenting with motor and non-motor deficits in function. Current medical management addresses the symptoms of PD pharmacologically and surgically and targets mainly the dopaminergic system. Symptoms that are not responsive or become resistant to dopamine remain poorly controlled such as gait, postural instability and falls. Management of these problems often falls to the physiotherapist, raising questions as to the nature and evidence for practice. It is clear that evidence to support physiotherapy in the management of PD is accumulating exponentially. However, the heterogenous nature of interventions and trials creates difficulty when applying evidence in the clinical setting. We present a clinical framework to identify and review evidence for the key therapeutic approaches in PD, which we describe as exercise and movement strategy training. Evidence is restricted to that from randomized clinical trials. We argue that physiotherapy efficacy is well established, and the challenge now is to refine its application through the apposite use of selected exercise and movement strategies; consideration of dose intensity; subpopulation; concern for non-motor symptoms; and regard for the course of the disease. We highlight current developments in the evidence that emphasize the potential for motor learning and neuroplasticity. Finally, implications for clinical management, including tools to aid implementation of the evidence and advice for referral, are discussed and recommendations for future work made.

Walking with music is a safe and viable tool for gait training in Parkinson's disease: the effect of a 13-week feasibility study on single and dual task walking

This study explored the viability and efficacy of integrating cadence-matched, salient music into a walking intervention for patients with Parkinson's disease (PD). Twenty-two people with PD were randomised to a control (CTRL, n = 11) or experimental (MUSIC, n = 11) group. MUSIC subjects walked with an individualised music playlist three times a week for the intervention period. Playlists were designed to meet subject's musical preferences. In addition, the tempo of the music closely matched (±10–15 bpm) the subject's preferred cadence. CTRL subjects continued with their regular activities during the intervention. The effects of training accompanied by “walking songs” were evaluated using objective measures of gait score. The MUSIC group improved gait velocity, stride time, cadence, and motor symptom severity following the intervention. This is the first study to demonstrate that music listening can be safely implemented amongst PD patients during home exercise.