The effect of auditory cues on gait variability in people with Parkinson's disease and older adults: a systematic review

Amplifying walking activity in Parkinson's disease through autonomous music-based rhythmic auditory stimulation: randomized controlled trial

Habitual moderate intensity walking has disease-modifying benefits in Parkinson's disease (PD). However, the lack of sustainable gait interventions that collectively promote sufficient intensity, daily amount, and quality of walking marks a critical gap in PD rehabilitation. In this randomized controlled trial (clinicaltrials.gov#: NCT05421624, registered on June 6, 2022), we demonstrate the effectiveness of a real-world walking intervention delivered using an autonomous music-based digital rhythmic auditory stimulation (RAS) system. In comparison to an active-control arm (N = 20) of moderately intense brisk walking, the autonomous RAS system used in the experimental arm (N = 21) amplified moderate-to-vigorous walking intensities, increased daily steps, and improved (reduced) gait variability. While regular engagement in real-world walking with or without RAS each cultivated habits for walking, only the RAS intervention yielded a combination of strengthened habits and improved gait outcomes. Findings from this study supported the use of a personalized, autonomous RAS gait intervention that is effective, habit-forming and translatable to real-world walking in individuals with PD.

Personalized Auditory Rhythmic Cues to Optimize Gait in Older Adults and People With Parkinson Disease

BACKGROUND AND PURPOSE

Gait dysfunction in people with Parkinson disease (PwPD) is common and debilitating. Internal cues (ie, mental singing) may provide a useful alternative to external cueing (ie, listening to music) to improve walking for PwPD. In this study, we individually tailored cues to each participant by allowing them to choose their own cue song and by selecting the cue rate that elicited the longest strides.

METHODS

Fifty-six participants (28 controls and 28 PwPD) performed walking trials in a single-session, cross-sectional study. Initially, uncued trials were compared with cued conditions in which participants walked to music or while they mentally sang at 4 randomized cue rates (90%, 100%, 110%, and 120% of uncued walking cadence). Participants chose their songs from a curated catalog. Cues were optimized according to longest stride lengths as measured by APDM wearable sensors. Repeated measures Analysis of Variance assessed differences between gait characteristics (velocity, cadence, and stride length) and gait variabilities (coefficients of variations) across conditions and groups.

RESULTS

Both cue types improved velocity, cadence, and stride length as compared to uncued walking. Internal cues were most beneficial to gait variability. The majority of participants exhibited the longest strides and fastest velocities at the highest cue rate of 120%, though a cue rate of 110% was most beneficial to gait variability.

DISCUSSION AND CONCLUSIONS

This study shows how internal and external cues personalized by song choice and cue rate may be tailored to individuals. The information gained may help tailor cues to optimize gait performance for older adults and PwPD.

VIDEO ABSTRACT AVAILABLE

for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A518 ).

Rhythmic auditory cues improve gait asymmetry during unobstructed walking in people with Parkinson's disease but have no effect on obstacle avoidance - AsymmGait-Parkinson study

Introduction

This study investigated the influence of rhythmic auditory cues (RAC) on gait asymmetry (GA) during unobstructed and obstacle avoidance walking in people with Parkinson's disease (PD) and neurologically healthy individuals.

Methods

Thirteen individuals with PD (70.33 ± 6.02 years) and 13 healthy controls (CG) (70.77 ± 7.56 years) participated in this study. They performed a total of five trials during unobstructed walking and 10 trials during obstacle walking under each auditory cue condition (without and with RAC). For obstacle walking, five trials were performed with each limb as leading during obstacle avoidance. First, the volunteers performed the trials without RAC. The trial order, unobstructed or obstacle walking, was randomly defined, and the cues (controlled by a metronome) were personalized according to participants' cadence. The symmetric index of gait parameters was analyzed using 2 × 2 factorial analysis of variance (group and RAC as factors) separately for each gait type (unobstructed and obstructed walking).

Results

A group-by-auditory cue interaction for step velocity (p = 0.027) showed that the PD group exhibited 57.6% reduced asymmetry with RAC during unobstructed walking, with no significant effects observed for the CG. However, RAC had no effect on GA during obstacle avoidance walking in people with PD. Conversely, the CG exhibited 10.5% greater step length asymmetry, 7.1% greater step duration asymmetry, 7.0% greater step velocity asymmetry, and 10.6% greater double support duration asymmetry during obstacle avoidance with RAC (p < 0.001).

Conclusion

We conclude that RAC can reduce GA in people with PD during unobstructed walking, but appear to have no effect and negative effects on GA during obstacle walking in people with PD and neurologically healthy individuals, respectively.

Coupling neurologic music therapy with immersive virtual reality to improve executive functions in individuals with Parkinson's disease: A Quasi-Randomized Clinical Trial

Introduction

Parkinson's disease (PD) is one the most common neurodegenerative movement disorder, leading to motor and non-motor symptoms, including deficits in executive functions (EF), memory, visuospatial abilities, and psychomotor speed. Current treatments are primarily symptomatic, involving pharmacological, surgical strategies. Neurologic Music Therapy (NMT) has gained recognition for its effectiveness in neurorehabilitation of PD patients and improving motor and cognitive domains, such as EF. This study combines NMT with the virtual reality (VR) platform Computer-Assisted Rehabilitation Environment (CAREN), offering customizable environments for rhythmic cue practice to provide an innovative approach to Parkinson's rehabilitation.

Methods

In our single-blind quasi-randomized controlled trial, forty patients were assigned to either an experimental group (EG = 20) or a control group (CG = 20). Both groups underwent two months of training with CAREN scenarios (three times a week for 24 sessions). The experimental group additionally received NMT applied to the selected scenarios. Participants were evaluated by a neuropsychologist at baseline and immediately after training.

Results

Intra-group analysis showed significant improvements in the EG for MOCA (p = 0.007), FAB (p = 0.008), Stroop Error (p = 0.003), Stroop Time (p < 0.001), and Visual Search (p < 0.001). The CG showed a significant difference only in Stroop Error (p = 0.02).

Conclusions

This pilot study is the first to combine NMT with CAREN in PD patients. Our findings suggest that NMT, within an immersive VR environment, effectively improves cognitive and EF in PD. Music structured within NMT techniques, coupled with advanced audio-visual feedback from VR, offers an innovative and potentially more effective approach for managing cognitive and executive deficits associated with PD.

Harnessing Mirror Neurons: A New Frontier in Parkinson's Disease Rehabilitation-A Scoping Review of the Literature

Background: Parkinson's disease (PD) is a neurodegenerative disorder characterized by motor symptoms such as tremors, rigidity, and bradykinesia. Rehabilitation utilizing mirror neurons leverages the brain's capacity for action observation (AO) and motor imagery (MI) to enhance motor function. This approach involves patients imitating movements observed in therapists or videos, aiming to improve gait, coordination, and overall quality of life. Mirror neuron activation facilitates motor learning and may decelerate disease progression, thus enhancing patient mobility and independence. Methods: This scoping review aimed to map current evidence on PD therapies employing mirror neuron-based rehabilitation. Databases searched included PubMed, PEDro, and Cochrane. The review included randomized controlled trials (RCTs) and systematic reviews that examined the effects of AO and MI in PD rehabilitation. Results: Five studies met the inclusion criteria, encompassing various rehabilitation techniques focusing on AO and MI. These studies consistently demonstrated positive outcomes, such as reduced disease severity and improved quality of life, gait, and balance in PD patients. The activation of mirror neurons through AO and MI was shown to facilitate motor learning and contribute to improved functional mobility. Conclusions: Although the included studies support the beneficial impact of AO and MI techniques in PD rehabilitation, numerous questions remain unresolved. Further research is necessary to evaluate the potential integration of these techniques into standard physiotherapy routines for PD patients. This review highlights the promise of AO and MI in enhancing motor rehabilitation for PD, suggesting the need for more comprehensive studies to validate and refine these therapeutic approaches.

Protocol for a randomised controlled unblinded feasibility trial of HD-DRUM: a rhythmic movement training application for cognitive and motor symptoms in people with Huntington's disease

INTRODUCTION

Huntington's disease (HD) is an inherited neurodegenerative disease causing progressive cognitive and motor decline, largely due to basal ganglia (BG) atrophy. Rhythmic training offers promise as therapy to counteract BG-regulated deficits. We have developed HD-DRUM, a tablet-based app to enhance movement synchronisation skills and improve cognitive and motor abilities in people with HD. This paper outlines a randomised controlled unblinded trial protocol to determine the feasibility of a larger effectiveness trial for HD-DRUM. Additionally, the trial investigates cognitive and motor function measures, along with brain microstructure, aiming to advance our understanding of the neural mechanisms underlying training effects.

METHODS, DESIGN AND ANALYSIS

50 individuals with HD, confirmed by genetic testing, and a Total Functional Capacity (TFC) score of 9-13, will be recruited into a two-arm randomised controlled feasibility trial. Consenting individuals with HD will be randomised to the intervention group, which entails 8 weeks of at-home usage of HD-DRUM or a usual-activity control group. All participants will undergo cognitive and motor assessments, alongside ultra-strong gradient (300 mT/m) brain microstructural MRI before and after the 8-week period. The feasibility assessment will encompass recruitment, retention, adherence and acceptability of HD-DRUM following prespecified criteria. The study will also evaluate variations in cognitive and motor performance and brain microstructure changes resulting from the intervention to determine effect size estimates for future sample size calculations.

ETHICS AND DISSEMINATION

The study has received favourable ethical opinion from the Wales Research Ethics Committee 2 (REC reference: 22/WA/0147) and is sponsored by Cardiff University (SPON1895-22) (Research Integrity, Governance and Ethics Team, Research & Innovation Services, Cardiff University, second Floor, Lakeside Building, University Hospital of Wales, Cardiff, CF14 4XW). Findings will be disseminated to researchers and clinicians in peer-reviewed publications and conference presentations, and to participants, carers and the general public via newsletters and public engagement activities. Data will be shared with the research community via the Enroll-HD platform.

TRIAL REGISTRATION NUMBER

ISRCTN11906973.

The Efficacy of Wearable Cueing Devices on Gait and Motor Function in Parkinson Disease: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To summarize the efficacy of wearable cueing devices for improving gait and motor function of patients with Parkinson disease (PWP).

DATA SOURCES

PubMed, Embase, and Cochrane CENTRAL databases were searched for papers published in English, from inception to October 23, 2022.

STUDY SELECTION

Randomized controlled trials focusing on the effects of wearable cueing devices on gait and motor function in PWP were included.

DATA EXTRACTION

Two reviewers independently selected articles and extracted the data. The Cochrane Bias Risk Assessment Tool was used to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation was used to evaluate the quality of evidence.

DATA SYNTHESIS

Seven randomized controlled trials with 167 PWP were included in the meta-analysis. Significant effect of wearable cueing devices on walking speed (mean difference [MD]=0.07 m/s, 95% confidence interval [CI]: [0.05, 0.09], P<.00001) was detected; however, after sensitivity analysis, no significant overall effect on walking speed was noted (MD=0.04 m/s, 95% CI: [-0.03, 0.12], P=.25). No significant improvements were found in stride length (MD=0.06 m, 95% CI: [0.00, 0.13], P=.05), the Unified Parkinson's Disease Rating Scale-III score (MD=-0.61, 95% CI: [-4.10, 2.88], P=.73), Freezing of Gait Questionnaire score (MD=-0.83, 95% CI: [-2.98, 1.33], P=.45), or double support time (MD=-0.91, 95% CI: [-3.09, 1.26], P=.41). Evidence was evaluated as low quality.

CONCLUSIONS

Wearable cueing devices may result in an immediate improvement on walking speed; however, there is no evidence that their use results in a significant improvement in other gait or motor functions.

Laser-light cueing shoes with integrated foot pressure and inertial sensing for investigating the impact of visual cueing on gait characteristics in Parkinson's disease individuals

Gait disorders are a fundamental challenge in Parkinson's disease (PD). The use of laser-light visual cues emitted from shoes has demonstrated effective in improving freezing of gait within less restrictive environments. However, the effectiveness of shoes-based laser-light cueing may vary among individuals with PD who have different types of impairments. We introduced an innovative laser-light visual shoes system capable of producing alternating visual cues for the left and right feet through one-side cueing at a time, while simultaneously recording foot inertial data and foot pressures. The effects of this visual cueing system on gait patterns were assessed in individuals with PD, both those with well-gait and those with worse-gait. Our device successfully quantified gait characteristics, including the asymmetry in the center of pressure trajectory, in individuals with PD. Furthermore, visual cueing prolonged stride times and increased the percentage of stance phase, while concurrently reducing stride length in PD individuals with well-gait. Conversely, in PD individuals with worse-gait, visual cueing resulted in a decreased freeze index and a reduction in the proportion of intervals prone to freezing episodes. The effects of visual cueing varied between PD individuals with well-gait and those with worse-gait. Visual cueing slowed down gait in the well-gait group while it appeared to mitigate freezing episodes in worse-gait group. Future researches, including enhancements to extend the projection distance of visual cues and clinical assessments conducted in real-world settings, will help establish the clinical utility of our proposed visual cueing system.

Effect of musical cues on gait in individuals with Parkinson disease with comorbid dementia

BACKGROUND

Individuals with Parkinson disease and comorbid dementia (PDD) demonstrate gait impairments, but little is known about how these individuals respond to interventions for gait dysfunction. Rhythmic auditory stimulation (RAS), which utilizes music or other auditory cues to alter gait, has been shown to be effective for improving gait in individuals with PD without dementia, but has not been explored in individuals with PDD.

RESEARCH QUESTION

Can individuals with PDD modulate their gait in response to music and mental singing cues?

METHODS

This single center, cross-sectional, interventional study included 17 individuals with PDD. Participants received Music and Mental singing cues at tempos of 90 %, 100 %, 110 %, and 120 % of their uncued walking cadence. Participants were instructed to walk to the beat of the song. Gait variables were collected using APDM Opal sensors. Data were analyzed using mixed effect models to explore the impact of tempo and cue type (Music vs Mental) on selected gait parameters of velocity, cadence, and stride length.

RESULTS

Mixed effects models showed a significant effect of tempo but not for cue type for velocity (F=11.51, p < .001), cadence (F=11.13, p < .001), and stride length (F=5.68, p = .002). When looking at the marginal means, velocity at a cue rate of 90 % was significantly different from 100 %, indicating participants walked slower with a cue rate of 90 %. Participants did not significantly increase their velocity, cadence, or stride length with faster cue rates of 110 % and 120 % SIGNIFICANCE: Individuals with PDD appear to be able to slow their velocity in response to slower cues, but do not appear to be able to increase their velocity, cadence, or stride length in response to faster cue tempos. This is different from what has been reported in individuals with PD without dementia. Further research is necessary to understand the underlying mechanism for these differences.

Holographic Hintways: A systems feasibility and usability study of augmented reality cueing for gait adaptation

BACKGROUND

Through providing on-demand visual and auditory cues while walking,augmented reality (AR) can theoretically cue spatiotemporal gait adaptations in, populations such as those with Parkinson's disease. However, given the novelty of the, technology, the type and extent of gait adaptations in response to such a cueing, system are unknown. Before such systems can be incorporated into rehabilitation, approaches, it is important to understand how people interact with the technology.

RESEARCH QUESTIONS

What are the effects of visual and auditory cues delivered, through AR on spatiotemporal walking patterns and variability in a healthy, young, population? Is there a relationship between system usability and gait variability?

, METHODS

Twenty healthy, young participants walked in four different cueing conditions using an AR headset: No Cues (NC) (i.e., natural gait), Auditory (A), Visual (V), and Auditory + Visual (AV). Inertial measurement units recorded spatiotemporal gait data at 200 Hz, a System Usability Survey was administered afterward, and linear regression models were developed to examine whether gait variability is predictive of system usability.

RESULTS

All cueing conditions exhibited a significantly slower cadence compared to, NC trials. Cadence variability was significantly higher for A trials compared to V and, NC. V trials exhibited significantly decreased stride lengths compared to NC. Increased, reported system usability was significantly correlated with decreased stance phase, time variability across A trials.

SIGNIFICANCE

Our findings support that holographic spatial-visual and auditory cues, are promising to evoke spatiotemporal gait adaptations. Results also support the, notion that the type of system and cue delivery design may impact gait outcomes.,Before an AR cueing system can be applied to a specific population in future, interventions, a more holistic approach towards finding the relationship between this, technology and its users is needed.