The effect of real and virtual visual cues on walking in Parkinson’s disease

A wearable system for visual cueing gait rehabilitation in Parkinson's disease: a randomized non-inferiority trial

BACKGROUND

Gait disturbances represent one of the most disabling features of Parkinson's disease (PD).

AIM

The aim of this study was to evaluate the non-inferiority of a new wearable visual cueing system (Q-Walk) for gait rehabilitation in PD subjects, compared to traditional visual cues (stripes on the floor).

DESIGN

Open-label, monocentric, randomized controlled non-inferiority trial.

SETTING

Outpatients.

POPULATION

Patients affected by idiopathic PD without cognitive impairment, Hoehn and Yahr stage II-IV, Unified Parkinson's Disease Rating Scale motor section III ≥2, stable drug usage since at least 3 weeks.

METHODS

At the enrollment (T0), all subjects underwent a clinical/functional evaluation and the instrumental gait and postural analysis; then they were randomly assigned to the Study Group (SG) or Control Group (CG). Rehabilitation program consisted in 10 consecutive individual sessions (5 sessions/week for 2 consecutive weeks). Each session included 60 minutes of conventional physiotherapy plus 30 minutes of gait training by Q-Walk (SG) or by traditional visual cues (CG). Follow-up visits were scheduled at the end of the treatment (T1) and after 3 months (T2).

RESULTS

Fifty-two subjects were enrolled in the study, 26 in each group. The within-groups analysis showed a significant improvement in clinical scales and instrumental data at T1 and at T2, compared to baseline, in both groups. According to the between-group analysis, Q-Walk cueing system was not-inferior to the traditional cues for gait rehabilitation. The satisfaction questionnaire revealed that most subjects described the Q-Walk cueing system as simple, motivating and easily usable, possibly suitable for home use.

CONCLUSIONS

Data showed that motor rehabilitation of PD subjects performed by means of the new wearable Q-Walk cueing system was feasible and as effective as traditional cues in improving gait parameters and balance.

CLINICAL REHABILITATION IMPACT

Wearable devices can act as an additional rehabilitation strategy for long-term and continuous care, allowing patients to train intensively and extensively in household settings, favoring a tailor-made and personalized approach as well as remote monitoring.

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.

A Review of Artificial Intelligence-Based Gait Evaluation and Rehabilitation in Parkinson's Disease

Parkinson's disease (PD) is a long-term degenerative disease of the central nervous system that affects both motor and non-motor functions. In most cases, symptoms develop gradually, with non-motor symptoms increasing in frequency as the condition progresses. Tremors, stiffness, slow movements, and difficulty walking are some of the early symptoms. There may be problems with cognition, behavior, sleep, and thinking. Dementia caused by PD becomes more common as the disease progresses. The development of PD is linked to certain sequences of motion that eventually contribute to diminished function. Patients with Parkinson's disease (PWPD) have a sluggish, scattered gait that is accompanied by intermittent freezing of gait (FOG), in which efficient heading briefly pauses. In individuals with severe PD, FOG is a neurological deficit that is related to falls and has an unfavorable impact on the patient's standard of living. Artificial intelligence (AI) and ambient intelligence (AmI) are inextricably linked as intelligence is the ability to gain new information and employ it in novel contexts. The ambience is what accompanies us, while artificial represents something developed by humans. Wearable technologies are being designed to recognize FOG and support patients in the beginning to walk again via periodic cueing. The article proposes a unique automated approach for action description that utilizes AI to carry out a non-intrusive, markerless evaluation in real-time and with full robotics. This computerized method accelerates detection and safeguards from human error. Despite significant improvements brought about by the advent of novel technologies, the available assessment platforms still fail to strike the ideal equilibrium among expenditure, diagnostic precision, velocity, and simplicity. The value of the recommended approach can be seen through a comparison of the gait parameters collected by each of the motion-tracking gadgets.

The effect of backpack weight on the performance of basic short-term/working memory tasks while walking along a pre-determined route

This study investigated possible backpack weight effects on the performance of three basic short-term/working memory (STM/WM) tasks conducted concurrently with the physical task of route walking. The STM/WM tasks were the Corsi block-tapping, digit span, and 3-back tasks, and, were employed to examine the visuo-spatial sketchpad, phonological loop and central executive components of the WM system. Four backpack weight levels (0%, 15%, 25% and 40% of body mass) were considered. Thirty participants conducted the three experimental tasks requiring physical-cognitive multitasking. Data analyses revealed that: (1) increased backpack weight resulted in decreases in the performance of the Corsi block-tapping and the 3-back task, but (2) backpack weight did not significantly affect the digit span task performance. The study results suggest that reducing backpack weight could benefit the performance of various cognitive tasks during route walking. The study findings may be useful for the ergonomics design of body-worn equipment and human-system interfaces.Practitioner summary: This study examined the backpack weight effects on the performance of three basic short-term/working memory tasks conducted concurrently with the physical task of route walking. The study revealed that reducing backpack weight could benefit various cognitive tasks during physical-cognitive multitasking, especially cognitive tasks that require visuospatial processing and executive control.

[Features of visual, cognitive and neuroimaging changes in Parkinson's disease patients with freezing of gait]

OBJECTIVE

To determine visual and cognitive impairments in relation to MRI changes in patients with freezing of Gait (FOG) in Parkinson's disease (PD).

MATERIAL AND METHODS

We examined 78 patients with PD without dementia, who were divided into groups according to the presence (FOG«+» group) or absence (FOG«-» group) of «freezing» episodes.

RESULTS

A decrease in contrast sensitivity (CS) and retinal photosensitivity was determined in all subjects with PD, but in patients with FOG, the decrease in CS was more pronounced. There was a significant decrease in the volume of the cuneus, lingual gyrus, posterior cingulate gyrus, superior parietal lobe and middle frontal gyrus in the FOG«+» group. It was revealed that patients with FOG had cognitive impairments of both the frontal and posterior cortical subtypes, while in the FOG«-» group, only visuospatial deficit prevailed. A direct correlation was determined between the severity of FOG and part I of the UPDRS scale, between a decrease in CS and cortical areas related to the dorsal and ventral visual information processing systems. The presence of a negative relationship between the scores of the FOG-Q, Timed Up and Go test and the volume of cortical areas of the frontal lobe responsible for planning and programming of movements indicates their role in the development of FOG in PD.

CONCLUSION

Thus, visual impairments associated with PD, along with a heterogeneous profile of cognitive impairment, make a significant contribution to the development of FOG.

Recent trends in wearable device used to detect freezing of gait and falls in people with Parkinson's disease: A systematic review

Background

The occurrence of freezing of gait (FOG) is often observed in moderate to last-stage Parkinson's disease (PD), leading to a high risk of falls. The emergence of the wearable device has offered the possibility of FOG detection and falls of patients with PD allowing high validation in a low-cost way.

Objective

This systematic review seeks to provide a comprehensive overview of existing literature to establish the forefront of sensors type, placement and algorithm to detect FOG and falls among patients with PD.

Methods

Two electronic databases were screened by title and abstract to summarize the state of art on FOG and fall detection with any wearable technology among patients with PD. To be eligible for inclusion, papers were required to be full-text articles published in English, and the last search was completed on September 26, 2022. Studies were excluded if they; (i) only examined cueing function for FOG, (ii) only used non-wearable devices to detect or predict FOG or falls, and (iii) did not provide sufficient details about the study design and results. A total of 1,748 articles were retrieved from two databases. However, only 75 articles were deemed to meet the inclusion criteria according to the title, abstract and full-text reviewed. Variable was extracted from chosen research, including authorship, details of the experimental object, type of sensor, device location, activities, year of publication, evaluation in real-time, the algorithm and detection performance.

Results

A total of 72 on FOG detection and 3 on fall detection were selected for data extraction. There were wide varieties of the studied population (from 1 to 131), type of sensor, placement and algorithm. The thigh and ankle were the most popular device location, and the combination of accelerometer and gyroscope was the most frequently used inertial measurement unit (IMU). Furthermore, 41.3% of the studies used the dataset as a resource to examine the validity of their algorithm. The results also showed that increasingly complex machine-learning algorithms had become the trend in FOG and fall detection.

Conclusion

These data support the application of the wearable device to access FOG and falls among patients with PD and controls. Machine learning algorithms and multiple types of sensors have become the recent trend in this field. Future work should consider an adequate sample size, and the experiment should be performed in a free-living environment. Moreover, a consensus on provoking FOG/fall, methods of assessing validity and algorithm are necessary.Systematic Review Registration: PROSPERO, identifier CRD42022370911.

Phenomenology of Atypical Anxiety Disorders in Parkinson's Disease: A Systematic Review

OBJECTIVE

Anxiety is a prominent concern in Parkinson's disease (PD) that negatively impacts quality of life, increases functional disability, and complicates clinical management. Atypical presentations of anxiety are under-recognized and inadequately treated in patients with PD, compromising global PD care.

METHODS

This systematic review focuses on the prevalence, symptomology and clinical correlates of atypical presentations of PD-related anxiety following PRISMA guidelines.

RESULTS

Of the 60 studies meeting inclusion criteria, 14 focused on 'Anxiety Not Otherwise Specified (NOS)' or equivalent, 31 reported on fluctuating anxiety symptoms, and 22 reported on 'Fear of Falling (FOF)'. Anxiety NOS accounted for a weighted mean prevalence of 14.9%, fluctuating anxiety for 34.19%, and FOF for 51.5%. These latter two exceeded the average reported overall prevalence rate of 31% for anxiety disorders in PD. We identified a diverse array of anxiety symptoms related to motor and non-motor symptoms of PD, to complications of PD medication (such as "on" and "off" fluctuations, or both), and, to a lesser extent, to cognitive symptoms.

CONCLUSION

Atypical anxiety is common, clinically relevant, and heterogeneous in nature. A better understanding of the phenomenology, clinical course, and pathophysiology of varied forms of atypical anxiety in PD is needed to improve recognition, advance therapeutic development and ultimately optimize quality of life in PD.

Benefits of Virtual Reality Balance Training for Patients With Parkinson Disease: Systematic Review, Meta-analysis, and Meta-Regression of a Randomized Controlled Trial

BACKGROUND

Virtual reality (VR) balance training is increasingly being pursued in biomedical research, specifically with respect to investigating balance ability with VR. However, existing systematic reviews have found inconsistent conclusions about the efficacy of VR in improving balance in Parkinson disease (PD) patients.

OBJECTIVE

The goal of the research was to evaluate the impact of VR balance training on the balance ability of patients with PD.

METHODS

All major databases, including Web of Science, PubMed, Scopus, China National Knowledge Infrastructure, and Wanfang, were searched to identify all relevant studies published in English or Chinese since September 15, 2010. Two researchers independently conducted document retrieval, study selection, data extraction, and methodological quality evaluation.

RESULTS

A total of 16 randomized controlled trials were analyzed (n=583 patients with PD), with the methodological quality evaluation score ranging from 5 to 8 points. A random effects model was selected to combine effect sizes. Meta-analysis showed that the balance ability of PD was significantly improved after VR training compared with the control group (standardized mean difference [SMD] 2.127, 95% CI 1.202 to 3.052, P<.001, I²=95.1, df=15). It is worth noting that the intervention platform may be the main reason for heterogeneity. Meta regression analysis showed that no training program could predict the impact of VR training (P=.57 to .94) on PD balance ability. Subgroup result showed that a single training time of 0 to 20 minutes (SMD 6.446), 4 to 6 times per week (SMD 4.067), training for 3 to 5 weeks (SMD 62.478), training course reached more than 30 times (SMD 4.405), and 201 to 300 minutes per week (SMD 4.059) maybe have more benefit.

CONCLUSIONS

A systematic review and meta-analysis confirmed that VR balance training is a highly effective means to improve balance performance with large effects in PD. In addition, we preliminarily extracted dose-effect relationships for training volume, informing clinicians and practitioners to design effective VR balance training for balance ability. Further research is needed to reveal optimal dose-response relationships following VR balance training.

Designing Virtual Reality Assisted Psychotherapy for Anxiety in Older Adults Living with Parkinson's Disease: Integrating Literature for Scoping

Objective: This review integrates literature to discuss the potential use of virtual reality (VR) in treatment of anxiety in Parkinson's disease (PD) and inform next steps.Methods: A systematic search was performed to identify studies of VR use in PD, using four databases. Data were reported in accordance to the Preferred Reporting Items for Systematic reviews and Meta-Analyzes extension for Scoping Reviews (PRISMA-ScR).Results: Thirty-two studies met the inclusion criteria with four VR studies from the same study group directly assessing the effects of anxiety on motor symptoms in PD. Primary studies implementing a VR protocol in PD identified focus areas of understanding and alleviating freezing of gait (FOG), balance training, and cognitive and motor rehabilitation, and informed design considerations.Conclusion: VR in PD studies suggested established feasibility. With appropriate design considerations, a VR based protocol could improve anxiety outcomes in PD.Clinical implications: VR in PD provides control of a patient's field of view, which can be exploited to induce specific responses, provide visual feedback, analysis of patient actions, and introduce safe challenges in the context of training. VR assisted Cognitive Behavioral Therapy (CBT) tailored to suit subtypes of anxiety disorders in PD have the potential to improve the efficacy and effectiveness of psychotherapy in PD.

Virtual Reality in the Neurosciences: Current Practice and Future Directions

Virtual reality has made numerous advancements in recent years and is used with increasing frequency for education, diversion, and distraction. Beginning several years ago as a device that produced an image with only a few pixels, virtual reality is now able to generate detailed, three-dimensional, and interactive images. Furthermore, these images can be used to provide quantitative data when acting as a simulator or a rehabilitation device. In this article, we aim to draw attention to these areas, as well as highlight the current settings in which virtual reality (VR) is being actively studied and implemented within the field of neurosurgery and the neurosciences. Additionally, we discuss the current limitations of the applications of virtual reality within various settings. This article includes areas in which virtual reality has been used in applications both inside and outside of the operating room, such as pain control, patient education and counseling, and rehabilitation. Virtual reality's utility in neurosurgery and the neurosciences is widely growing, and its use is quickly becoming an integral part of patient care, surgical training, operative planning, navigation, and rehabilitation.

Slow Breathing Exercise with Multimodal Virtual Reality: A Feasibility Study

Many studies have shown that slow breathing training is beneficial for human health. However, several factors might discourage beginners from continuing their training. For example, a long training period is generally required for benefit realization, and there is no real-time feedback to trainees to adjust their breathing control strategy. To raise the user’s interest in breathing exercise training, a virtual reality system with multimodal biofeedback is proposed in this work. In our system, a realistic human model of the trainee is provided in virtual reality (VR). At the same time, abdominal movements are sensed, and the breathing rate can be visualized. Being aware of the breathing rate, the trainee can regulate his or her breathing to achieve a slower breathing rate. An additional source of tactile feedback is combined with visual feedback to provide a more immersive experience for the trainees. Finally, the user’s satisfaction with the proposed system is reported through questionnaires. Most of the users find it enjoyable to use such a system for mediation training.

Systemic Literature Review of the Use of Virtual Reality for Rehabilitation in Parkinson Disease

Background

Functional rehabilitation is important when managing Parkinson disease (PD). Virtual reality (VR) therapy is a noninvasive, potential alternative or adjunct to conventional therapies used during rehabilitation.

Observations

The authors searched for articles in Google Scholar, PubMed, Physiotherapy Evidence Database Score (PEDro), and Cochrane after setting specific requirements starting in July 2019. Methodologic quality was assessed by PEDro for randomized controlled trials. Among 89 studies identified, 28 included in this review evaluated VR therapy for use during rehabilitation for PD: 7 used immersive VR and 21 used nonimmersive VR. Among the immersive VR studies, 6 showed improvement in primary outcomes after adding VR therapy. Among the nonimmersive VR studies, 5 showed improvement with VR therapy when compared with conventional therapy, 9 showed improvement with VR and conventional therapy with no between group difference, and the remaining 7 showed improvement in primary outcomes after adding VR intervention. The quality and diversity of studies was a major limitation.

Conclusion

VR therapy is a promising rehabilitation modality for PD but more studies are needed. Additional investigations of VR therapy and PD should include direct comparisons between immersive and nonimmersive VR therapies.

Head-Mounted Display-Based Therapies for Adults Post-Stroke: A Systematic Review and Meta-Analysis

Immersive virtual reality techniques have been applied to the rehabilitation of patients after stroke, but evidence of its clinical effectiveness is scarce. The present review aims to find studies that evaluate the effects of immersive virtual reality (VR) therapies intended for motor function rehabilitation compared to conventional rehabilitation in people after stroke and make recommendations for future studies. Data from different databases were searched from inception until October 2020. Studies that investigated the effects of immersive VR interventions on post-stroke adult subjects via a head-mounted display (HMD) were included. These studies included a control group that received conventional therapy or another non-immersive VR intervention. The studies reported statistical data for the groups involved in at least the posttest as well as relevant outcomes measuring functional or motor recovery of either lower or upper limbs. Most of the studies found significant improvements in some outcomes after the intervention in favor of the virtual rehabilitation group. Although evidence is limited, immersive VR therapies constitute an interesting tool to improve motor learning when used in conjunction with traditional rehabilitation therapies, providing a non-pharmacological therapeutic pathway for people after stroke.

Transverse Strips Instead of Wearable Laser Lights Alleviate the Sequence Effect Toward a Destination in Parkinson's Disease Patients With Freezing of Gait

Background: The sequence effect (SE), referring to step-to-step reduction in amplitude, is considered to lead to freezing of gait (FOG) in Parkinson's disease (PD). Visual cues may alleviate SE and help reduce freezing episodes. FOG patients show significant SE prior to turning or toward a doorway, but the SE toward a destination has not been clearly studied. Objectives: To examine the SE when approaching a destination in PD patients with FOG, and to further explore the effects of different types of visual cues on destination SE. Methods: Thirty-five PD patients were divided into a freezing (PD+FOG, n = 15) group and a non-freezing (PD-FOG, n = 20) group. Walking trials were tested under three conditions, including without cues (no-cue condition), with wearable laser lights (laser condition), and with transverse strips placed on the floor (strip condition). Kinematic data was recorded by a portable Inertial Measurement Unit (IMU) system. The destination SE and some key gait parameters were evaluated. Results: The PD+FOG group showed greater destination SE in the no-cue and laser conditions when compared to the PD-FOG group. There were no significant differences in the strip condition when comparing destination SE of the two groups. The destination SE was alleviated only by using the transverse strips on the floor. In contrast, transverse strips and wearable laser lights could increase the step length. Conclusions: The significant destination SE may explain why FOG patients are prone to freezing when heading toward their destination. Visual cues using transverse strips on the floor may be a more effective strategy for FOG rehabilitation in PD patients.

The benefits and mechanisms of exercise training for Parkinson's disease

Parkinson's disease (PD) is a significantly progressive neurodegenerative disease characterised by both motor and nonmotor disorders. The main pathological characteristics of PD consist of the loss of dopaminergic neurons and the formation of alpha-synuclein-containing Lewy bodies in the substantia nigra. Currently, the main therapeutic method for PD is anti-Parkinson medications, including levodopa, madopar, sirelin, and so on. However, the effect of pharmacological treatment has its own limitations, the most significant of which is that the therapeutic effect of dopaminergic treatments gradually diminishes with time. Exercise training, as an adjunctive treatment and complementary therapy, can improve the plasticity of cortical striatum and increase the release of dopamine. Exercise training has been proven to effectively improve motor disorders (including balance, gait, risk of falls and physical function) and nonmotor disorders (such as sleep impairments, cognitive function and quality of life) in PD patients. In recent years, various types of exercise training have been used to treat PD. In this review, we summarise the exercise therapy mechanisms and the protective effects of different types of exercise training on PD patients.

The Role of Architecture and Design in the Management of Parkinson's Disease: A Systematic Review

BACKGROUND

Parkinson's disease (PD) is a neurological condition characterized by the development of daily disabling symptoms. Although the architecture and design of a PD patient's environment can hinder or facilitate full participation in daily activities, their putative role in the management of these patients has received little attention to date.

OBJECTIVE

We conducted a systematic review to evaluate the evidence of architectural and design features in the management of people with PD.

METHODS

An electronic database search of observational and experimental studies was conducted in MEDLINE and Embase from inception to May 2020, with two independent reviewers identifying the studies. Falls, fear of falling, postural instability, gait impairment/disability, and functional mobility were our outcomes of interest.

RESULTS

Thirty-six studies were included, among which nineteen were observational and seventeen were experimental studies (overall participants = 2,965). Pavement characteristics, notably unstable surfaces and level differences, were found to be a major cause of falling. Ground-based obstacles and confined/narrowed spaces were found to disturb gait, increase postural instability, and decrease functional mobility. Housing type did not appear to increase risk of falling, nor to significantly explain concerns about falling.

CONCLUSION

Findings suggest a need to adjust architectural features of the surrounding space to ensure appropriate care and provide a safe environment to PD patients. More evidence about the impact of such modifications on PD outcomes is needed.

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.

Pavement patterns can be designed to improve gait in Parkinson's disease patients

BACKGROUND

Public spaces are usually designed with respect to various patient populations, but not Parkinson's disease. The objective of this study was to explore what type of easily applicable visual cueing might be used in public spaces and some interiors to improve gait in people with Parkinson's disease.

METHODS

Thirty-two patients with freezing of gait walked an 8-meter track on 6 different floor patterns in single- and dual-task conditions in random sequence. The reference pattern was a virtual large transverse chessboard, and the other patterns differed either in size (small floor stones), orientation (diagonal), nature (real paving), regularity (irregular), or no pattern. Time, number of steps, velocity, step length, cadence, and dual-task effect were calculated. The number and total duration of freezing episodes were analyzed.

RESULTS

Virtual, large, transverse floor stones improve time (P = 0.0101), velocity (P = 0.0029), number of steps (P = 0.0291), and step length (P = 0.0254) in Parkinson's disease patients compared with walking on no pattern. Virtual floor stones were superior in time and velocity to the real ones. Transverse floor stones were better than diagonal, whereas regular pattern stones were superior to irregular in some gait parameters. Subjectively, the reference pattern was preferred to the irregular one and to no pattern. No direct effect on freezing of gait was observed.

CONCLUSIONS

Parkinson's disease patients may benefit from floor patterns incorporating transverse oriented large rectangular visual cues. Because public space can be regulated with respect to people with medical conditions, the relevant legislative documents should be extended to allow for parkinsonian gait disorder. © 2019 International Parkinson and Movement Disorder Society.

Using Kinect v2 to Control a Laser Visual Cue System to Improve the Mobility during Freezing of Gait in Parkinson's Disease

Different auditory and visual cues have been proven to be very effective in improving the mobility of people with Parkinson's (PwP). Nonetheless, many of the available methods require user intervention and so on to activate the cues. Moreover, once activated, these systems would provide cues continuously regardless of the patient's needs. This research proposes a new indoor method for casting dynamic/automatic visual cues for PwP based on their head direction and location in a room. The proposed system controls the behavior of a set of pan/tilt servo motors and laser pointers, based on the real-time skeletal information acquired from a Kinect v2 sensor. This produces an automatically adjusting set of laser lines that can always be in front of the patient as a guideline for where the next footstep would be placed. A user interface was also created that enables users to control and adjust the settings based on the preferences. The aim of this research was to provide PwP with an unobtrusive/automatic indoor system for improving their mobility during a Freezing of gait (FOG) incident. The results showed the possibility of employing such system, which does not rely on the subject's input nor does it introduce any additional complexities to operate.

A Non-Invasive Medical Device for Parkinson's Patients with Episodes of Freezing of Gait

A critical symptom of Parkinson’s disease (PD) is the occurrence of Freezing of Gait (FOG), an episodic disorder that causes frequent falls and consequential injuries in PD patients. There are various auditory, visual, tactile, and other types of stimulation interventions that can be used to induce PD patients to escape FOG episodes. In this article, we describe a low cost wearable system for non-invasive gait monitoring and external delivery of superficial vibratory stimulation to the lower extremities triggered by FOG episodes. The intended purpose is to reduce the duration of the FOG episode, thus allowing prompt resumption of gait to prevent major injuries. The system, based on an Android mobile application, uses a tri-axial accelerometer device for gait data acquisition. Gathered data is processed via a discrete wavelet transform-based algorithm that precisely detects FOG episodes in real time. Detection activates external vibratory stimulation of the legs to reduce FOG time. The integration of detection and stimulation in one low cost device is the chief novel contribution of this work. We present analyses of sensitivity, specificity and effectiveness of the proposed system to validate its usefulness.

Chronic Subthalamic Nucleus Stimulation in Parkinson's Disease: Optimal Frequency for Gait Depends on Stimulation Site and Axial Symptoms

Axial symptoms emerge in a significant proportion of patients with Parkinson's disease (PD) within 5 years of deep brain stimulation (STN-DBS). Lowering the stimulation frequency may reduce these symptoms. The objectives of the current study were to establish the relationship between gait performance and STN-DBS frequency in chronically stimulated patients with PD, and to identify factors underlying variability in this relationship. Twenty-four patients treated chronically with STN-DBS (>4 years) were studied off-medication. The effect of stimulation frequency (40–140 Hz, 20 Hz-steps, constant energy) on gait was assessed in 6 sessions spread over 1 day. Half of the trials/session involved walking through a narrow doorway. The influence of stimulation voltage was investigated separately in 10 patients. Gait was measured using 3D motion capture and axial symptoms severity was assessed clinically. A novel statistical method established the optimal frequency(ies) for each patient by operating on frequency-tuning curves for multiple gait parameters. Narrowly-tuned optimal frequencies (20 Hz bandwidth) were found in 79% of patients. Frequency change produced a larger effect on gait performance than voltage change. Optimal frequency varied between patients (between 60 and 140 Hz). Contact site in the right STN and severity of axial symptoms were independent predictors of optimal frequency (P = 0.009), with lower frequencies associated with more dorsal contacts and worse axial symptoms. We conclude that gait performance is sensitive to small changes in STN-DBS frequency. The optimal frequency varies considerably between patients and is associated with electrode contact site and severity of axial symptoms. Between-subject variability of optimal frequency may stem from variable pathology outside the basal ganglia.

Crossing Virtual Doors: A New Method to Study Gait Impairments and Freezing of Gait in Parkinson's Disease

Studying freezing of gait (FOG) in the lab has proven problematic. This has primarily been due to the difficulty in designing experimental setups that maintain high levels of ecological validity whilst also permitting sufficient levels of experimental control. To help overcome these challenges, we have developed a virtual reality (VR) environment with virtual doorways, a situation known to illicit FOG in real life. To examine the validity of this VR environment, an experiment was conducted, and the results were compared to a previous "real-world" experiment. A group of healthy controls (N = 10) and a group of idiopathic Parkinson disease (PD) patients without any FOG episodes (N = 6) and with a history of freezing (PD-f, N = 4) walked under three different virtual conditions (no door, narrow doorway (100% of shoulder width) and standard doorway (125% of shoulder width)). The results were similar to those obtained in the real-world setting. Virtual doorways reduced step length and velocity while increasing general gait variability. The PD-f group always walked slower, with a smaller step length, and showed the largest increases in gait variability. The narrow doorway induced FOG in 66% of the trials, while the standard doorway caused FOG in 29% of the trials. Our results closely mirrored those obtained with real doors. In short, this methodology provides a safe, personalized yet adequately controlled means to examine FOG in Parkinson's patients, along with possible interventions.

Multifractality, Interactivity, and the Adaptive Capacity of the Human Movement System: A Perspective for Advancing the Conceptual Basis of Neurologic Physical Therapy

BACKGROUND AND PURPOSE

Physical therapists seek to optimize movement as a means of reducing disability and improving health. The short-term effects of interventions designed to optimize movement ultimately are intended to be adapted for use across various future patterns of behavior, in potentially unpredictable ways, with varying frequency, and in the context of multiple tasks and environmental conditions. In this perspective article, we review and discuss the implications of recent evidence that optimal movement variability, which previously had been associated with adaptable motor behavior, contains a specific complex nonlinear feature known as "multifractality."

SUMMARY OF KEY POINTS

Multifractal movement fluctuation patterns reflect robust physiologic interactivity occurring within the movement system across multiple time scales. Such patterns provide conceptual support for the idea that patterns of motor behavior occurring in the moment are inextricably linked in complex, physiologic ways to patterns of motor behavior occurring over much longer periods. The human movement system appears to be particularly tuned to multifractal fluctuation patterns and exhibits the ability to reorganize its output in response to external stimulation embedded with multifractal features.

RECOMMENDATIONS FOR CLINICAL PRACTICE

As a fundamental feature of human movement, multifractality opens new avenues for conceptualizing the link between physiologic interactivity and adaptive capacity. Preliminary evidence supporting the positive influence of multifractal rhythmic auditory stimulation on the gait patterns of individuals with Parkinson disease is used to illustrate how physical therapy interventions might be devised to specifically target the adaptive capacity of the human movement system.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A183).

Training healthy persons and individuals with Parkinson's disease to use Xbox Kinect games: a preliminary study

Background/Aims:

Individuals with Parkinson's disease, besides the motor and cognitive symptoms may even present deficits in the motor learning. A recent therapeutic approach involves virtual reality that offers elements that can minimize the difficulties in the learning process. Recently, the therapeutic potential of Nintendo Wii® gaming device for rehabilitation of patients with Parkinson's disease has been showing positive results, but studies related to the use of the Kinect for XboxTM are still scarce. The present study aimed to investigate the effects of motor and cognitive demands of six Kinect for Xbox 360TM games on the learning of patients with Parkinson's disease, comparing it with healthy individuals.

Methods:

A total of 19 adults, 8 with idiopathic Parkinson's disease and 11 healthy adults participated in a program which included 10 training sessions and had their scores registered three times.

Findings:

The results showed that in four of those games, patients with Parkinson's disease showed an ability to improve and keep their performance, but not in the other two games, similar to healthy adults.

Conclusions:

It was concluded that motor and cognitive abilities affected by Parkinson's disease may be improved with the use of virtual training proposed in this study. Some of the games and gaming devices features can influence the learning process, even in healthy adults.

Kinect4FOG: monitoring and improving mobility in people with Parkinson's using a novel system incorporating the Microsoft Kinect v2

Parkinson's is a neurodegenerative condition associated with several motor symptoms including tremors and slowness of movement. Freezing of gait (FOG); the sensation of one's feet being "glued" to the floor, is one of the most debilitating symptoms associated with advanced Parkinson's. FOG not only contributes to falls and related injuries, but also compromises quality of life as people often avoid engaging in functional daily activities both inside and outside the home. In the current study, we describe a novel system designed to detect FOG and falling in people with Parkinson's (PwP) as well as monitoring and improving their mobility using laser-based visual cues cast by an automated laser system. The system utilizes a RGB-D sensor based on Microsoft Kinect v2 and a laser casting system consisting of two servo motors and an Arduino microcontroller. This system was evaluated by 15 PwP with FOG. Here, we present details of the system along with a summary of feedback provided by PwP. Despite limitations regarding its outdoor use, feedback was very positive in terms of domestic usability and convenience, where 12/15 PwP showed interest in installing and using the system at their homes. Implications for Rehabilitation Providing an automatic and remotely manageable monitoring system for PwP gait analysis and fall detection. Providing an automatic, unobtrusive and dynamic visual cue system for PwP based on laser line projection. Gathering feedback from PwP about the practical usage of the implemented system through focus group events.

The laser shoes: A new ambulatory device to alleviate freezing of gait in Parkinson disease

OBJECTIVE

To assess, in a cross-sectional study, the feasibility and immediate efficacy of laser shoes, a new ambulatory visual cueing device with practical applicability for use in daily life, on freezing of gait (FOG) and gait measures in Parkinson disease (PD).

METHODS

We tested 21 patients with PD and FOG, both "off" and "on" medication. In a controlled gait laboratory, we measured the number of FOG episodes and the percent time frozen occurring during a standardized walking protocol that included FOG provoking circumstances. Participants performed 10 trials with and 10 trials without cueing. FOG was assessed using offline video analysis by an independent rater. Gait measures were recorded in between FOG episodes with the use of accelerometry.

RESULTS

Cueing using laser shoes was associated with a significant reduction in the number of FOG episodes, both "off" (45.9%) and "on" (37.7%) medication. Moreover, laser shoes significantly reduced the percent time frozen by 56.5% (95% confidence interval [CI] 32.5-85.8; p = 0.004) when "off" medication. The reduction while "on" medication was slightly smaller (51.4%, 95% CI -41.8 to 91.5; p = 0.075). These effects were paralleled by patients' positive subjective experience on laser shoes' efficacy. There were no clinically meaningful changes in the gait measures.

CONCLUSIONS

These findings demonstrate the immediate efficacy of laser shoes in a controlled gait laboratory, and offer a promising intervention with potential to deliver in-home cueing for patients with FOG.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for patients with PD, laser shoes significantly reduce FOG severity (both number and duration of FOG episodes).

Usability of Three-dimensional Augmented Visual Cues Delivered by Smart Glasses on (Freezing of) Gait in Parkinson's Disease

External cueing is a potentially effective strategy to reduce freezing of gait (FOG) in persons with Parkinson's disease (PD). Case reports suggest that three-dimensional (3D) cues might be more effective in reducing FOG than two-dimensional cues. We investigate the usability of 3D augmented reality visual cues delivered by smart glasses in comparison to conventional 3D transverse bars on the floor and auditory cueing via a metronome in reducing FOG and improving gait parameters. In laboratory experiments, 25 persons with PD and FOG performed walking tasks while wearing custom-made smart glasses under five conditions, at the end-of-dose. For two conditions, augmented visual cues (bars/staircase) were displayed via the smart glasses. The control conditions involved conventional 3D transverse bars on the floor, auditory cueing via a metronome, and no cueing. The number of FOG episodes and percentage of time spent on FOG were rated from video recordings. The stride length and its variability, cycle time and its variability, cadence, and speed were calculated from motion data collected with a motion capture suit equipped with 17 inertial measurement units. A total of 300 FOG episodes occurred in 19 out of 25 participants. There were no statistically significant differences in number of FOG episodes and percentage of time spent on FOG across the five conditions. The conventional bars increased stride length, cycle time, and stride length variability, while decreasing cadence and speed. No effects for the other conditions were found. Participants preferred the metronome most, and the augmented staircase least. They suggested to improve the comfort, esthetics, usability, field of view, and stability of the smart glasses on the head and to reduce their weight and size. In their current form, augmented visual cues delivered by smart glasses are not beneficial for persons with PD and FOG. This could be attributable to distraction, blockage of visual feedback, insufficient familiarization with the smart glasses, or display of the visual cues in the central rather than peripheral visual field. Future smart glasses are required to be more lightweight, comfortable, and user friendly to avoid distraction and blockage of sensory feedback, thus increasing usability.

The Parkinson's Active Living (PAL) Program

BACKGROUND

Apathy, one of the most common neuropsychiatric symptoms in Parkinson's disease (PD), has been associated with reduced daily functioning, cognition, treatment compliance, quality of life, and increased caregiver burden and distress, among other outcomes.

OBJECTIVES

The purpose of the present study was to develop and gather pilot data on the feasibility, acceptability, and efficacy of the Parkinson's Active Living (PAL) program, to our knowledge, the first behavioral treatment specifically designed to target apathy in patients with PD. The Parkinson's Active Living is a primarily telephone-based, 6-week activity scheduling and monitoring intervention that incorporates external cueing to target disease-related self-generational deficits to reduce levels of apathy in nondemented, highly apathetic patients with PD.

METHODS

Participants aged 44 to 86 years (mean = 66, SD [standard deviation] = 10.7) ranging in disease duration from <1 to 23 years with elevated apathy (Apathy Evaluation Scale >35) were enrolled in a 1-arm trial and tested at 3 time points (baseline, posttest, and 1-month follow-up).

RESULTS

Feasibility aspects (ie, acceptability, demand, implementation, practicality, adaptation, integration, and expansion) and efficacy of PAL program are reported. Matched pairs t tests showed a medium to large effect of treatment on patient apathy (52% showing ≥1 SD improvement), depression (33% showing ≥1 SD improvement), and quality of life at posttest, with improvements in apathy and depression maintained at follow-up.

CONCLUSIONS

The program may hold promise as an effective nonpharmacological intervention for apathy in PD. Implications and future directions are discussed. Randomized controlled trials are needed.

Loss of visual feedback revealing motor impairment - an early symptom of Parkinson's disease in two Irish farmers

Background

In the absence of visual feedback, humans depend upon proprioceptive information for reaching movements and coordination. Use of sensory information in order to assist movement is impaired in patients with early Parkinson’s disease (PD). It has been postulated that patients with PD compensate for this kinaesthetic deficit by relying on visual information.

Case presentation

We report two farmers who first noticed symptoms of PD when working on the farm in situations requiring processing of the proprioceptive/kinaesthetic information in order to execute motor output in the absence of visual cues. A 68-year-old right-handed farmer had a 5-year history of left hand awkwardness. He first noticed the problem while performing artificial insemination in cattle using the recto-vaginal technique. He was diagnosed with PD 15 months after his initial symptoms and responded well to a combination of carbidopa-levodopa and ropinirole but has not returned to performing artificial insemination since. Clinical examination revealed asymmetric parkinsonism with normal sensation on gross neurological examination (including proprioception). A 60-year-old right-handed farmer had a 6-year history of difficulty manoeuvring his right hand whilst turning the calf during calving only when he did not have direct sight of his hand. 18 months later he developed right hand tremor and bradykinesia. He was diagnosed with PD 2 years following these initial symptoms. He had a good response to a combination of carbidopa-levodopa, rasagiline and ropinirole. He switched to using his left hand during calf delivery but is not as dextrous as previously. Clinical examination revealed parkinsonism, more marked in the right hand and normal sensation in all modalities.

Conclusions

Although task-specific motor impairment could explain the symptoms of these patients, it is noteworthy that loss of visual feedback was central to both of these presentations. Given that early kinaesthetic deficits are known to be present in patients with PD, we postulate that removing visual feedback can expose such deficits in early PD, even when not detectable on routine examination. These two patients suggest that sensorimotor control can be impaired early in PD and may be the first symptom. Once the visual compensatory mechanism is not available, it becomes difficult or impossible to perform complex hand movements.

Movement visualisation in virtual reality rehabilitation of the lower limb: a systematic review

BACKGROUND

Virtual reality (VR) based applications play an increasing role in motor rehabilitation. They provide an interactive and individualized environment in addition to increased motivation during motor tasks as well as facilitating motor learning through multimodal sensory information. Several previous studies have shown positive effect of VR-based treatments for lower extremity motor rehabilitation in neurological conditions, but the characteristics of these VR applications have not been systematically investigated. The visual information on the user's movement in the virtual environment, also called movement visualisation (MV), is a key element of VR-based rehabilitation interventions. The present review proposes categorization of Movement Visualisations of VR-based rehabilitation therapy for neurological conditions and also summarises current research in lower limb application.

METHODS

A systematic search of literature on VR-based intervention for gait and balance rehabilitation in neurological conditions was performed in the databases namely; MEDLINE (Ovid), AMED, EMBASE, CINAHL, and PsycInfo. Studies using non-virtual environments or applications to improve cognitive function, activities of daily living, or psychotherapy were excluded. The VR interventions of the included studies were analysed on their MV.

RESULTS

In total 43 publications were selected based on the inclusion criteria. Seven distinct MV groups could be differentiated: indirect MV (N = 13), abstract MV (N = 11), augmented reality MV (N = 9), avatar MV (N = 5), tracking MV (N = 4), combined MV (N = 1), and no MV (N = 2). In two included articles the visualisation conditions included different MV groups within the same study. Additionally, differences in motor performance could not be analysed because of the differences in the study design. Three studies investigated different visualisations within the same MV group and hence limited information can be extracted from one study.

CONCLUSIONS

The review demonstrates that individuals' movements during VR-based motor training can be displayed in different ways. Future studies are necessary to fundamentally explore the nature of this VR information and its effect on motor outcome.

Auditory and visual cueing modulate cycling speed of older adults and persons with Parkinson's disease in a Virtual Cycling (V-Cycle) system

BACKGROUND

Evidence based virtual environments (VEs) that incorporate compensatory strategies such as cueing may change motor behavior and increase exercise intensity while also being engaging and motivating. The purpose of this study was to determine if persons with Parkinson's disease and aged matched healthy adults responded to auditory and visual cueing embedded in a bicycling VE as a method to increase exercise intensity.

METHODS

We tested two groups of participants, persons with Parkinson's disease (PD) (n = 15) and age-matched healthy adults (n = 13) as they cycled on a stationary bicycle while interacting with a VE. Participants cycled under two conditions: auditory cueing (provided by a metronome) and visual cueing (represented as central road markers in the VE). The auditory condition had four trials in which auditory cues or the VE were presented alone or in combination. The visual condition had five trials in which the VE and visual cue rate presentation was manipulated. Data were analyzed by condition using factorial RMANOVAs with planned t-tests corrected for multiple comparisons.

RESULTS

There were no differences in pedaling rates between groups for both the auditory and visual cueing conditions. Persons with PD increased their pedaling rate in the auditory (F 4.78, p = 0.029) and visual cueing (F 26.48, p < 0.000) conditions. Age-matched healthy adults also increased their pedaling rate in the auditory (F = 24.72, p < 0.000) and visual cueing (F = 40.69, p < 0.000) conditions. Trial-to-trial comparisons in the visual condition in age-matched healthy adults showed a step-wise increase in pedaling rate (p = 0.003 to p < 0.000). In contrast, persons with PD increased their pedaling rate only when explicitly instructed to attend to the visual cues (p < 0.000).

CONCLUSIONS

An evidenced based cycling VE can modify pedaling rate in persons with PD and age-matched healthy adults. Persons with PD required attention directed to the visual cues in order to obtain an increase in cycling intensity. The combination of the VE and auditory cues was neither additive nor interfering. These data serve as preliminary evidence that embedding auditory and visual cues to alter cycling speed in a VE as method to increase exercise intensity that may promote fitness.

Immediate effects of adding mental practice to physical practice on the gait of individuals with Parkinson's disease: Randomized clinical trial

BACKGROUND

Mental practice has shown benefits in the rehabilitation of neurological patients, however, there is no evidence of immediate effects on gait of individuals with Parkinson's disease.

OBJECTIVE

Determine the effects of mental practice activity added to physical practice on the gait of individuals with Idiopathic Parkinson's Disease (IPD).

METHODS

20 patients classified with stage 2 and 3, according to the Hoehn and Yahr scale were randomized into 2 groups. The experimental group (N = 10) was submitted to a single session of mental practice and physical practice gait protocol and the control group (N = 10) only to physical practice. The primary outcomes were stride length and total stance and swing time. Secondary outcomes were hip range of motion, velocity and mobility. Subjects were reassessed 10 minutes, 1 day and 7 days after the end of the session.

RESULTS

There was no statistically significant difference between the groups. An intragroup difference was observed in velocity, stride length, hip range of motion, and mobility, as well as total stance and swing time. These results were also observed on follow-ups.

CONCLUSIONS

Mental practice did not have a greater effect on the gait of individuals with IPD than physical practice, after a single session.

[Paradoxical kinesia in Parkinson's disease: theories and practical application]

This literature review addresses the phenomenon of paradoxical kinesia (PK) in patients with Parkinson's disease (PD). PK is the sudden ability of the patient wit hPD to perform movements that were previously disturbed. This ability can be caused by different internal or environmental stressors. Different theories explaining the mechanism of paradoxical kinesia were proposed. In recent years, in the context of a search for new effective methods of treatment of akinesia I PD, methods of correction of motor impairment based on the phenomenon of PK are being developed.

Effect of three cueing devices for people with Parkinson's disease with gait initiation difficulties

BACKGROUND

Freezing of gait (FOG) remains one of the most common debilitating aspects of Parkinson's disease and has been linked to injuries, falls and reduced quality of life. Although commercially available portable cueing devices exist claiming to assist with overcoming freezing; their immediate effectiveness in overcoming gait initiation failure is currently unknown. This study investigated the effects of three different types of cueing device in people with Parkinson's disease who experience freezing.

METHODS

Twenty participants with idiopathic Parkinson's disease who experienced freezing during gait but who were able to walk short distances indoors independently were recruited. At least three attempts at gait initiation were recorded using a 10 camera Qualisys motion analysis system and four force platforms. Test conditions were; Laser Cane, sound metronome, vibrating metronome, walking stick and no intervention.

RESULTS

During testing 12 of the 20 participants had freezing episodes, from these participants 100 freezing and 91 non-freezing trials were recorded. Clear differences in the movement patterns were seen between freezing and non-freezing episodes. The Laser Cane was most effective cueing device at improving the forwards/backwards and side to side movement and had the least number of freezing episodes. The walking stick also showed significant improvements compared to the other conditions. The vibration metronome appeared to disrupt movement compared to the sound metronome at the same beat frequency.

CONCLUSION

This study identified differences in the movement patterns between freezing episodes and non-freezing episodes, and identified immediate improvements during gait initiation when using the Laser Cane over the other interventions.

Effects of sensory cueing in virtual motor rehabilitation. A review

OBJECTIVES

To critically identify studies that evaluate the effects of cueing in virtual motor rehabilitation in patients having different neurological disorders and to make recommendations for future studies.

METHODS

Data from MEDLINE®, IEEExplore, Science Direct, Cochrane library and Web of Science was searched until February 2015. We included studies that investigate the effects of cueing in virtual motor rehabilitation related to interventions for upper or lower extremities using auditory, visual, and tactile cues on motor performance in non-immersive, semi-immersive, or fully immersive virtual environments. These studies compared virtual cueing with an alternative or no intervention.

RESULTS

Ten studies with a total number of 153 patients were included in the review. All of them refer to the impact of cueing in virtual motor rehabilitation, regardless of the pathological condition. After selecting the articles, the following variables were extracted: year of publication, sample size, study design, type of cueing, intervention procedures, outcome measures, and main findings. The outcome evaluation was done at baseline and end of the treatment in most of the studies. All of studies except one showed improvements in some or all outcomes after intervention, or, in some cases, in favor of the virtual rehabilitation group compared to the control group.

CONCLUSIONS

Virtual cueing seems to be a promising approach to improve motor learning, providing a channel for non-pharmacological therapeutic intervention in different neurological disorders. However, further studies using larger and more homogeneous groups of patients are required to confirm these findings.

Acute and Chronic Effect of Acoustic and Visual Cues on Gait Training in Parkinson's Disease: A Randomized, Controlled Study

In this randomized controlled study we analyse and compare the acute and chronic effects of visual and acoustic cues on gait performance in Parkinson's Disease (PD). We enrolled 46 patients with idiopathic PD who were assigned to 3 different modalities of gait training: (1) use of acoustic cues, (2) use of visual cues, or (3) overground training without cues. All patients were tested with kinematic analysis of gait at baseline (T0), at the end of the 4-week rehabilitation programme (T1), and 3 months later (T2). Regarding the acute effect, acoustic cues increased stride length and stride duration, while visual cues reduced the number of strides and normalized the stride/stance distribution but also reduced gait speed. As regards the chronic effect of cues, we recorded an improvement in some gait parameters in all 3 groups of patients: all 3 types of training improved gait speed; visual cues also normalized the stance/swing ratio, acoustic cues reduced the number of strides and increased stride length, and overground training improved stride length. The changes were not retained at T2 in any of the experimental groups. Our findings support and characterize the usefulness of cueing strategies in the rehabilitation of gait in PD.

Randomized controlled trial protocol: balance training with rhythmical cues to improve and maintain balance control in Parkinson's disease

Background

Postural instability is a particularly incapacitating disorder, whose loss of motor independence by Parkinson´s Disease (PD) patients marks a significant stage of disease onset. Evidence suggests that deficits in automatic motor control, sensory integration and attention are associated with the lack of balance in PD. Physiotherapy together with medication play an important role in the treatment of this state, although no consensus has been reached on the best treatment modality. The aim of this randomized controlled trial protocol is to evaluate the effects of balance training with rhythmical (BRT), which is a motor program to improve balance associated with rhythmical auditory cues (RACs). This study is ongoing in the stage 1.

Methods and design

A total of 150 PD patients at H&Y stages II–III and asymptomatic for depression and dementia are enrolled in a single-blind randomized study. Randomization is achieved via a computer-generated random-sequence table. All patients should also present a fall history. They will be assigned into one of three groups, and their balance and gait will be assessed before and after 10 training sessions, and after 4 and 30 weeks subsequent to the end of the training. The BRT group will receive a motor program to improve balance associated with RACs, the MT group will perform motor training with the same aims as those in the BRT group but without RACs, and the control group (CG) will be trained only in orientations. The exercise program specific to balance is of 5 weeks’ duration with two sessions per week, 45 min each, and consists of general physiotherapy exercises. Each session will be divided into five warm-up minutes—30 min for the main part and 10 min for the cool down. The training progresses and intensifies each week depending on the individual’s performance. The subjects should be able to execute 10 repetitions of the exercise sequences correctly to progress to the next movement.

Discussion

This randomized study protocol will evaluate the effects of a motor program designed to improve balance associated with RACs, and will also assess whether balance training leads to activation of balance reactions at the appropriate time. We hypothesize that if this motor program is maintained long-term, it will prevent falls.

Trial registration

Clinicaltrials.gov NCT02488265; Ethics Committee of the University of São Paulo Faculty of Medicine Clinics Hospital 1.102.464.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-015-0418-x) contains supplementary material, which is available to authorized users.

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.

Visual cues combined with treadmill training to improve gait performance in Parkinson’s disease: a pilot randomized controlled trial

Objective:

To evaluate the effects of visual cues combined with treadmill training on gait performance in patients with Parkinson’s disease and to compare the strategy with pure treadmill training.

Design:

Pilot, exploratory, non-blinded, randomized controlled trial.

Setting:

University Hospital of Munich, Germany.

Subjects:

Twenty-three outpatients with Parkinson’s disease (Hoehn and Yahr stage II–IV).

Interventions:

Patients received 12 training sessions within five weeks of either visual cues combined with treadmill training ( n = 12) or pure treadmill training ( n = 11).

Main measures:

Outcome measures were gait speed, stride length and cadence recorded on the treadmill. Functional tests included the Timed Up and Go Test, the Unified Parkinson’s Disease Rating Scale and the Freezing of gait-questionnaire. Assessments were conducted at baseline, after the training period and at two months follow-up.

Results:

After the training period ( n = 20), gait speed and stride length had increased in both groups ( p ⩽ 0.05). Patients receiving the combined training scored better in the Timed Up and Go Test compared with the patients receiving pure treadmill training ( p ⩽ 0.05). At two months follow-up ( n = 13), patients who underwent the combined training sustained better results in gait speed and stride length ( p ⩽ 0.05) and sustained the improvement in the Timed Up and Go Test ( p ⩽ 0.05).

Conclusions:

This pilot study suggests that visual cues combined with treadmill training have more beneficial effects on gait than pure treadmill training in patients with a moderate stage of Parkinson’s disease. A large-scale study with longer follow-up is required.

Parkinson-related changes of activation in visuomotor brain regions during perceived forward self-motion

Radial expanding optic flow is a visual consequence of forward locomotion. Presented on screen, it generates illusionary forward self-motion, pointing at a close vision-gait interrelation. As particularly parkinsonian gait is vulnerable to external stimuli, effects of optic flow on motor-related cerebral circuitry were explored with functional magnetic resonance imaging in healthy controls (HC) and patients with Parkinson’s disease (PD). Fifteen HC and 22 PD patients, of which 7 experienced freezing of gait (FOG), watched wide-field flow, interruptions by narrowing or deceleration and equivalent control conditions with static dots. Statistical parametric mapping revealed that wide-field flow interruption evoked activation of the (pre-)supplementary motor area (SMA) in HC, which was decreased in PD. During wide-field flow, dorsal occipito-parietal activations were reduced in PD relative to HC, with stronger functional connectivity between right visual motion area V5, pre-SMA and cerebellum (in PD without FOG). Non-specific ‘changes’ in stimulus patterns activated dorsolateral fronto-parietal regions and the fusiform gyrus. This attention-associated network was stronger activated in HC than in PD. PD patients thus appeared compromised in recruiting medial frontal regions facilitating internally generated virtual locomotion when visual motion support falls away. Reduced dorsal visual and parietal activations during wide-field optic flow in PD were explained by impaired feedforward visual and visuomotor processing within a magnocellular (visual motion) functional chain. Compensation of impaired feedforward processing by distant fronto-cerebellar circuitry in PD is consistent with motor responses to visual motion stimuli being either too strong or too weak. The ‘change’-related activations pointed at covert (stimulus-driven) attention.

Virtual reality feedback cues for improvement of gait in patients with Parkinson's disease

BACKGROUND

Our aim was to study the effects of visual feedback cues, responding dynamically to patient's self-motion and provided through a portable see-through virtual reality apparatus, on the walking abilities of patients with Parkinson's disease.

METHODS

Twenty patients participated. On-line and residual effects on walking speed and stride length were measured.

RESULTS

Attaching the visual feedback device to the patient with the display turned off showed a negligible effect of about 2%. With the display turned on, 56% of the patients improved either their walking speed, or their stride length, or both, by over 20%. After device removal, and waiting for 15 minutes, the patients were instructed to walk again: 68% of the patients showed over 20% improvement in either walking speed or stride length or both. One week after participating in the first test, 36% of the patients showed over 20% improvement in baseline performance with respect to the previous test. Some of the patients reported that they still walked on the tiles in their minds.

DISCUSSION

Improvements in walking abilities were measured in patients with Parkinson's disease using virtual reality visual feedback cues. Residual effects suggest the examination of this approach in a comprehensive therapy program.

Feasibility, safety and outcomes of playing Kinect Adventures!™ for people with Parkinson's disease: a pilot study

OBJECTIVES

To assess the feasibility, safety and outcomes of playing Microsoft Kinect Adventures™ for people with Parkinson's disease in order to guide the design of a randomised clinical trial.

DESIGN

Single-group, blinded trial.

SETTING

Rehabilitation Center of São Camilo University, Brazil.

PARTICIPANTS

Seven patients (six males, one female) with Parkinson's disease (Hoehn and Yahr Stages 2 and 3).

INTERVENTIONS

Fourteen 60-minute sessions, three times per week, playing four games of Kinect Adventures!

MAIN OUTCOME MEASURES

The feasibility and safety outcomes were patients' game performance and adverse events, respectively. The clinical outcomes were the 6-minute walk test, Balance Evaluation System Test, Dynamic Gait Index and Parkinson's Disease Questionnaire (PDQ-39).

RESULTS

Patients' scores for the four games showed improvement. The mean [standard deviation (SD)] scores in the first and last sessions of the Space Pop game were 151 (36) and 198 (29), respectively [mean (SD) difference 47 (7), 95% confidence interval 15 to 79]. There were no adverse events. Improvements were also seen in the 6-minute walk test, Balance Evaluation System Test, Dynamic Gait Index and PDQ-39 following training.

CONCLUSION

Kinect-based training was safe and feasible for people with Parkinson's disease (Hoehn and Yahr Stages 2 and 3). Patients improved their scores for all four games. No serious adverse events occurred during training with Kinect Adventures!, which promoted improvement in activities (balance and gait), body functions (cardiopulmonary aptitude) and participation (quality of life).

Virtual sensory feedback for gait improvement in neurological patients

We review a treatment modality for movement disorders by sensory feedback. The natural closed-loop sensory-motor feedback system is imitated by a wearable virtual reality apparatus, employing body-mounted inertial sensors and responding dynamically to the patient's own motion. Clinical trials have shown a significant gait improvement in patients with Parkinson's disease using the apparatus. In contrast to open-loop devices, which impose constant-velocity visual cues in a "treadmill" fashion, or rhythmic auditory cues in a "metronome" fashion, requiring constant vigilance and attention strategies, and, in some cases, instigating freezing in Parkinson's patients, the closed-loop device improved gait parameters and eliminated freezing in most patients, without side effects. Patients with multiple sclerosis, previous stroke, senile gait, and cerebral palsy using the device also improved their balance and gait substantially. Training with the device has produced a residual improvement, suggesting virtual sensory feedback for the treatment of neurological movement disorders.

[Visual cues as a therapeutic tool in Parkinson's disease. A systematic review]

Sensory stimuli or sensory cues are being used as a therapeutic tool for improving gait disorders in Parkinson's disease patients, but most studies seem to focus on auditory stimuli. The aim of this study was to conduct a systematic review regarding the use of visual cues over gait disorders, dual tasks during gait, freezing and the incidence of falls in patients with Parkinson to obtain therapeutic implications. We conducted a systematic review in main databases such as Cochrane Database of Systematic Reviews, TripDataBase, PubMed, Ovid MEDLINE, Ovid EMBASE and Physiotherapy Evidence Database, during 2005 to 2012, according to the recommendations of the Consolidated Standards of Reporting Trials, evaluating the quality of the papers included with the Downs & Black Quality Index. 21 articles were finally included in this systematic review (with a total of 892 participants) with variable methodological quality, achieving an average of 17.27 points in the Downs and Black Quality Index (range: 11-21). Visual cues produce improvements over temporal-spatial parameters in gait, turning execution, reducing the appearance of freezing and falls in Parkinson's disease patients. Visual cues appear to benefit dual tasks during gait, reducing the interference of the second task. Further studies are needed to determine the preferred type of stimuli for each stage of the disease.