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

Vibrotactile Foot Device for Freezing of Gait in Parkinson's Disease: A Pilot Study

BACKGROUND

Vibrotactile stimulation has been studied in its efficacy of reducing freezing of gait (FOG) in patients with Parkinson's disease (PD). However, the results are still controversial. We evaluated the efficacy of a newly developed vibrotactile foot device on freezing severity and gait measures in PD patients with FOG.

OBJECTIVE

To evaluate the efficacy of vibrotactile foot device on PD patients with FOG.

METHODS

Thirty-three PD patients with FOG were examined during their "off" medication state. The efficacy of the vibrotactile foot device was evaluated using a gait protocol comprising walking trials with vibrotactile stimulation "off" and "on." Walking trials were videotaped for the offline rating by two movement disorder specialists. The Opal inertial sensor unit (128 Hz; Mobility Lab; APDM Inc., Portland, OR, USA) was used for quantitative gait analysis.

RESULTS

The results demonstrated 33.1% reduction in number of FOG episodes (P < 0.001) and 32.6% reduction of freezing episodes (P < 0.001). Quantitative gait analysis showed a significant increase in step length (P = 0.033). A moderate negative correlation was observed between the change of percent time frozen and age (r = -0.415, P = 0.016). 73% of participants reported minimal to substantial improvement in walking with this vibrating stimulation delivered by the vibrotactile foot device.

CONCLUSIONS

The vibrotactile foot device is an efficient device that could significantly reduce freezing severity and provide gait regulation to patients with PD experiencing frequent freezing. It could potentially be used in the home environment for improving the quality of life.

The effects of laser cane cues on the freezing of gait of Parkinson's disease patients: can increasing the laser light beam width play a role?

INTRODUCTION

Freezing of gait can be seen in a significant number of people with Parkinson's disease. Disappointingly, the classic standard treatment of Parkinson's disease with dopamine replacement has not shown promising results in improving the freezing of gait. Hence the approach have shifted towards using non-invasive methods to address this problem.

OBJECTIVES

To assess the effect of laser cane as a visual cue on the freezing of gait of people with Parkinson's disease and further determine the effect of laser light beam width and color on the freezing of gait.

METHODS

7 known Parkinson's Disease patients were enrolled in this study, all of whom had at least one episode of freezing at at least one clinical visit. These patients underwent gait analysis in 4 stages: walking without a cane, walking with a thin red light laser cane, a thick red light laser cane, and a green light laser cane.

RESULTS

Using laser canes effectively improved nearly all parameters of walking, including right and left stride length, step length, the velocity of movement, and rotation time, compared to walking without a stick. Using different colors of laser cane didn't make any significant difference in improving the freezing of gait of our patients. Nevertheless, increasing the laser light beam width significantly improved almost all walking parameters.

CONCLUSION

This is the first study assessing the effect of laser light beam width on freezing of gait in Parkinson's disease patients and shows promising results in regards to increasing the thickness of laser lights in order to improve walking parameters in Parkinson's disease patients more effectively. Furthermore, this is the second study to evaluate the effect of laser light color, contradicting the previous results by showing no significant correlation between the color of laser light and improvements in walking parameters.

Insights into Parkinson's Disease-Related Freezing of Gait Detection and Prediction Approaches: A Meta Analysis

Parkinson's Disease (PD) is a complex neurodegenerative disorder characterized by a spectrum of motor and non-motor symptoms, prominently featuring the freezing of gait (FOG), which significantly impairs patients' quality of life. Despite extensive research, the precise mechanisms underlying FOG remain elusive, posing challenges for effective management and treatment. This paper presents a comprehensive meta-analysis of FOG prediction and detection methodologies, with a focus on the integration of wearable sensor technology and machine learning (ML) approaches. Through an exhaustive review of the literature, this study identifies key trends, datasets, preprocessing techniques, feature extraction methods, evaluation metrics, and comparative analyses between ML and non-ML approaches. The analysis also explores the utilization of cueing devices. The limited adoption of explainable AI (XAI) approaches in FOG prediction research represents a significant gap. Improving user acceptance and comprehension requires an understanding of the logic underlying algorithm predictions. Current FOG detection and prediction research has a number of limitations, which are identified in the discussion. These include issues with cueing devices, dataset constraints, ethical and privacy concerns, financial and accessibility restrictions, and the requirement for multidisciplinary collaboration. Future research avenues center on refining explainability, expanding and diversifying datasets, adhering to user requirements, and increasing detection and prediction accuracy. The findings contribute to advancing the understanding of FOG and offer valuable guidance for the development of more effective detection and prediction methodologies, ultimately benefiting individuals affected by PD.

A recent update on drugs and alternative approaches for parkinsonism

Parkinson's disease, often known as PD, is a more common age-related neurological disorder that affects a huge number of older adults worldwide. Parkinson's disease is predominantly a movement-related pathosis and is distinguished by the deposition of intra-neuronal aggregates, as the alpha-synuclein gene is expressed as Lewy bodies (LB) causing dopaminergic neurons to die. Stress in early life may contribute to the development of depression, and depression in patients may result in the development of Parkinson's disease as they mature. Depression is a non-motor condition that leads to motor symptoms, such as Parkinson's disease. PD Patients are currently utilizing a variety of other therapies like utilizing nutritional supplements, herbal remedies, vitamins, and massage. When a patient's functional ability is impaired, drug treatment is usually initiated according to the individual's condition and the severity of signs and symptoms. The current marketed anti-Parkinson drugs, has low brain distribution and failing to repair dopaminergic neurons or delaying the progression of the disease these negative effects were unavoidable. To overcome these disadvantages, this review considers the inclusion of drugs used in Parkinson's disease, focusing on strategies to reuse existing compounds to speed up drug development, their capacity to traverse the BBB, and drug dispersion in the brain. We look at cellular therapies and repurposed drugs. We also investigate the mechanisms, effectiveness, as well as safety of several new medications that are being repositioned for Parkinson's disease pharmacotherapy. In this study, we focus on global trends in Parkinson's disease research. We hope to raise awareness about the present state of major factors for disability worldwide, including yearly prevalence's from international and national statistics. The pathophysiology of Parkinsonism and also analyze existing therapies for Parkinson's disease, moreover new and innovative drug therapies, and to assess the prospects for disease modification.

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.

Effects of rhythmic visual cues on cortical activation and functional connectivity features during stepping: an fNIRS study

Introduction

Rhythmic visual cues (RVCs) may influence gait initiation by modulating cognition resources. However, it is unknown how RVCs modulate cognitive resources allocation during gait movements. This study focused on investigating the effects of RVCs on cortical hemodynamic response features during stepping to evaluate the changes of cognitive resources.

Methods

We recorded cerebral hemoglobin concentration changes of 14 channels in 17 healthy subjects using functional near-infrared spectroscopy (fNIRS) during stepping tasks under exposure to RVCs and non-rhythmic visual cues (NRVCs). We reported mean oxygenated hemoglobin (HbO) concentration changes, β-values, and functional connectivity (FC) between channels.

Results

The results showed that, the RVC conditions revealed lower HbO responses compared to the NRVC conditions during the preparation and early stepping. Correspondingly, the β-values reflected that RVCs elicited lower hemodynamic responses than NRVCs, and there was a decreasing trend in stimulus-evoked cortical activation as the task progressed. However, the FC between channels were stronger under RVCs than under NRVCs during the stepping progress, and there were more significant differences in FC during the early stepping.

Discussion

In conclusion, there were lower cognitive demand and stronger FC under RVC conditions than NRVC conditions, which indicated higher efficiency of cognitive resources allocation during stepping tasks. This study may provide a new insight for further understanding the mechanism on how RVCs alleviate freezing of gait.

Grid cells: the missing link in understanding Parkinson's disease?

The mechanisms underlying Parkinson's disease (PD) are complex and not fully understood, and the box-and-arrow model among other current models present significant challenges. This paper explores the potential role of the allocentric brain and especially its grid cells in several PD motor symptoms, including bradykinesia, kinesia paradoxa, freezing of gait, the bottleneck phenomenon, and their dependency on cueing. It is argued that central hubs, like the locus coeruleus and the pedunculopontine nucleus, often narrowly interpreted in the context of PD, play an equally important role in governing the allocentric brain as the basal ganglia. Consequently, the motor and secondary motor (e.g., spatially related) symptoms of PD linked with dopamine depletion may be more closely tied to erroneous computation by grid cells than to the basal ganglia alone. Because grid cells and their associated central hubs introduce both spatial and temporal information to the brain influencing velocity perception they may cause bradykinesia or hyperkinesia as well. In summary, PD motor symptoms may primarily be an allocentric disturbance resulting from virtual faulty computation by grid cells revealed by dopamine depletion in PD.

Investigating gait-responsive somatosensory cueing from a wearable device to improve walking in Parkinson's disease

Freezing-of-gait (FOG) and impaired walking are common features of Parkinson's disease (PD). Provision of external stimuli (cueing) can improve gait, however, many cueing methods are simplistic, increase task loading or have limited utility in a real-world setting. Closed-loop (automated) somatosensory cueing systems have the potential to deliver personalised, discrete cues at the appropriate time, without requiring user input. Further development of cue delivery methods and FOG-detection are required to achieve this. In this feasibility study, we aimed to test if FOG-initiated vibration cues applied to the lower-leg via wearable devices can improve gait in PD, and to develop real-time FOG-detection algorithms. 17 participants with Parkinson's disease and daily FOG were recruited. During 1 h study sessions, participants undertook 4 complex walking circuits, each with a different intervention: continuous rhythmic vibration cueing (CC), responsive cueing (RC; cues initiated by the research team in response to FOG), device worn with no cueing (NC), or no device (ND). Study sessions were grouped into 3 stages/blocks (A-C), separated by a gap of several weeks, enabling improvements to circuit design and the cueing device to be implemented. Video and onboard inertial measurement unit (IMU) data were analyzed for FOG events and gait metrics. RC significantly improved circuit completion times demonstrating improved overall performance across a range of walking activities. Step frequency was significantly enhanced by RC during stages B and C. During stage C, > 10 FOG events were recorded in 45% of participants without cueing (NC), which was significantly reduced by RC. A machine learning framework achieved 83% sensitivity and 80% specificity for FOG detection using IMU data. Together, these data support the feasibility of closed-loop cueing approaches coupling real-time FOG detection with responsive somatosensory lower-leg cueing to improve gait in PD.

Paradoxical kinesia may no longer be a paradox waiting for 100 years to be unraveled

Parkinson's disease (PD) is a progressive neurodegenerative disorder mainly characterized by bradykinesia and akinesia. Interestingly, these motor disabilities can depend on the patient emotional state. Disabled PD patients remain able to produce normal motor responses in the context of urgent or externally driven situations or even when exposed to appetitive cues such as music. To describe this phenomenon Souques coined the term "paradoxical kinesia" a century ago. Since then, the mechanisms underlying paradoxical kinesia are still unknown due to a paucity of valid animal models that replicate this phenomenon. To overcome this limitation, we established two animal models of paradoxical kinesia. Using these models, we investigated the neural mechanisms of paradoxical kinesia, with the results pointing to the inferior colliculus (IC) as a key structure. Intracollicular electrical deep brain stimulation, glutamatergic and GABAergic mechanisms may be involved in the elaboration of paradoxical kinesia. Since paradoxical kinesia might work by activation of some alternative pathway bypassing basal ganglia, we suggest the IC as a candidate to be part of this pathway.

Smart ankle bracelet-laser device to improve gait and detect freezing of gait in Parkinsonism patients: a case series

Freezing of gait (FOG) is one of the most disabling symptoms of Parkinsonism. Moreover, it does not respond well to medication. Visual cues have been shown to alleviate FOG in Parkinsonism; however, their efficacy is inconsistent. Currently, most mobile cueing devices are used as an open-loop cueing system, which requires manual control to enable constant visual cues. Thus, such devices may not be suitable for some people, especially those who have attention deficits. In addition, objective measurements of FOG in real-life situations remain challenging. Therefore, we developed a smart-ankle laser as a closed-loop cueing system that can detect the patient's walking pattern and automatically project a laser line that follows each walking step, thus requires less attention. Real-time motion was also recorded within the device for FOG measurement. We studied the efficacy of the device in three Parkinsonism patients with FOG (one man and two women, aged 58-76 years) immediately after use and two patients at 1-week follow-up. Gait speed, Timed Up and Go test performance, stride length, and % FOG improved with the use of the laser, without adverse effects.

One cue does not fit all: a systematic review with meta-analysis of the effectiveness of cueing on freezing of gait in Parkinson's disease

The difficulty in assessing FOG and the variety of existing cues, hamper to determine which cueing modality should be applied and which FOG-related aspect should be targeted to reach personalized treatments for FOG. This systematic review aimed to highlight: i) whether cues could reduce FOG and improve FOG-related gait parameters, ii) which cues are the most effective, iii) whether medication state (ON-OFF) affects cues-related results. Thirty-three repeated measure design studies assessing cueing effectiveness were included and subdivided according to gait tasks (gait initiation, walking, turning) and to the medication state. Main results reveal that: preparatory phase of gait initiation benefit from visual and auditory cues; spatio-temporal parameters (e.g., step and stride length) and are improved by visual cues during walking; turning time and step time variability are reduced by applying auditory and visual cues. Some findings on the potential benefits of cueing on FOG and FOG gait-related parameters were found. Questions remain about which are the best behavioral strategies according to FOG features and PD clinical characteristics.

Evidence for the Efficacy of Commercially Available Wearable Biofeedback Gait Devices: Consumer-Centered Review

BACKGROUND

The number of wearable technological devices or sensors that are commercially available for gait training is increasing. These devices can fill a gap by extending therapy outside the clinical setting. This was shown to be important during the COVID-19 pandemic when people could not access one-on-one treatment. These devices vary widely in terms of mechanisms of therapeutic effect, as well as targeted gait parameters, availability, and strength of the evidence supporting the claims.

OBJECTIVE

This study aimed to create an inventory of devices targeting improvement in gait pattern and walking behavior and identify the strength of the evidence underlying the claims of effectiveness for devices that are commercially available to the public.

METHODS

As there is no systematic or reproducible way to identify gait training technologies available to the public, we used a pragmatic, iterative approach using both the gray and published literature. Four approaches were used: simple words, including some suggested by laypersons; devices endorsed by condition-specific organizations or charities; impairment-specific search terms; and systematic reviews. A findable list of technological devices targeting walking was extracted separately by 3 authors. For each device identified, the evidence for efficacy was extracted from material displayed on the websites, and full-text articles were obtained from the scientific databases PubMed, Ovid MEDLINE, Scopus, or Google Scholar. Additional information on the target population, mechanism of feedback, evidence for efficacy or effectiveness, and commercial availability was obtained from the published material or websites. A level of evidence was assigned to each study involving the device using the Oxford Centre for Evidence-Based Medicine classification. We also proposed reporting guidelines for the clinical appraisal of devices targeting movement and mobility.

RESULTS

The search strategy for this consumer-centered review yielded 17 biofeedback devices that claim to target gait quality improvement through various sensory feedback mechanisms. Of these 17 devices, 11 (65%) are commercially available, and 6 (35%) are at various stages of research and development. Of the 11 commercially available devices, 4 (36%) had findable evidence for efficacy potential supporting the claims. Most of these devices were targeted to people living with Parkinson disease. The reporting of key information about the devices was inconsistent; in addition, there was no summary of research findings in layperson's language.

CONCLUSIONS

The amount of information that is currently available to the general public to help them make an informed choice is insufficient, and, at times, the information presented is misleading. The evidence supporting the effectiveness does not cover all aspects of technology uptake. Commercially available technologies help to provide continuity of therapy outside the clinical setting, but there is a need to demonstrate effectiveness to support claims made by the technologies.

Good vibrations: tactile cueing for freezing of gait in Parkinson's disease

BACKGROUND

Cueing strategies can alleviate freezing of gait (FOG) in people with Parkinson's disease (PD). We evaluated tactile cueing delivered via vibrating socks, which has the benefit of not being noticeable to bystanders.

OBJECTIVE

To evaluate the effect of tactile cueing compared to auditory cueing on FOG.

METHODS

Thirty-one persons with PD with FOG performed gait tasks during both ON and OFF state. The effect of open loop and closed loop tactile cueing, as delivered by vibrating socks, was compared to an active control group (auditory cueing) and to a baseline condition (uncued gait). These four conditions were balanced between subjects. Gait tasks were videotaped and annotated for FOG by two experienced raters. Motion data were collected to analyze spatiotemporal gait parameters. Responders were defined as manifesting a relative reduction of > 10% in the percent time frozen compared to uncued gait.

RESULTS

The average percent time frozen during uncued gait was 11.2% in ON and 21.5% in OFF state. None of the three tested cueing modalities affected the percentage of time frozen in either the ON (p = 0.20) or OFF state (p = 0.12). The number of FOG episodes and spatiotemporal gait parameters were also not affected. We found that 22 out of 31 subjects responded to cueing, the response to the three types of cueing was highly individual.

CONCLUSIONS

Cueing did not improve FOG at the group level; however, tactile as well as auditory cueing improved FOG in many individuals. This highlights the need for a personalized approach when using cueing to treat FOG.

The development of a home-based technology to improve gait in people with Parkinson's disease: a feasibility study

BACKGROUND

People with Parkinson's disease (PwP) may experience gait impairment and freezing of gait (FOG), a major cause of falls. External cueing, including visual (e.g., spaced lines on the floor) and auditory (e.g., rhythmic metronome beats) stimuli, are considered effective in alleviating mobility deficits and FOG. Currently, there is a need for a technology that delivers automatic, individually adjusted cues in the homes of PwP. The aims of this feasibility study were to describe the first step toward the development of a home-based technology that delivers external cues, test its effect on gait, and assess user experience.

METHODS

Iterative system development was performed by our multidisciplinary team. The system was designed to deliver visual and auditory cues: light stripes projected on the floor and metronome beats, separately. Initial testing was performed using the feedback of five healthy elderly individuals on the cues' clarity (clear visibility of the light stripes and the sound of metronome beats) and discomfort experienced. A pilot study was subsequently conducted in the homes of 15 PwP with daily FOG. We measured participants' walking under three conditions: baseline (with no cues), walking with light stripes, and walking to metronome beats. Outcome measures included step length and step time. User experience was also captured in semi-structured interviews.

RESULTS

Repeated-measures ANOVA of gait assessment in PwP revealed that light stripes significantly improved step length (p = 0.009) and step time (p = 0.019) of PwP. No significant changes were measured in the metronome condition. PwP reported that both cueing modalities improved their gait, confidence, and stability. Most PwP did not report any discomfort in either modality and expressed a desire to have such a technology in their homes. The metronome was preferred by the majority of participants.

CONCLUSIONS

This feasibility study demonstrated the usability and potential effect of a novel cueing technology on gait, and represents an important first step toward the development of a technology aimed to prevent FOG by delivering individually adjusted cues automatically. A further full-scale study is needed. Trial registration This study was registered in ClinicalTrials.gov at 1/2/2022 NCT05211687.

Adaptive cueing strategy for gait modification: A case study using auditory cues

People with Parkinson's (PwP) experience gait impairments that can be improved through cue training, where visual, auditory, or haptic cues are provided to guide the walker's cadence or step length. There are two types of cueing strategies: open and closed-loop. Closed-loop cueing may be more effective in addressing habituation and cue dependency, but has to date been rarely validated with PwP. In this study, we adapt a human-in-the-loop framework to conduct preliminary analysis with four PwP. The closed-loop framework learns an individualized model of the walker's responsiveness to cues and generates an optimized cue based on the model. In this feasibility study, we determine whether participants in early stages of Parkinson's can respond to the novel cueing framework, and compare the performance of the framework to two alternative cueing strategies (fixed/proportional approaches) in changing the participant's cadence to two target cadences (speed up/slow down). The preliminary results show that the selection of the target cadence has an impact on the participant's gait performance. With the appropriate target, the framework and the fixed approaches perform similarly in slowing the participants' cadence. However, the proposed framework demonstrates better efficiency, explainability, and robustness across participants. Participants also have the highest retention rate in the absence of cues with the proposed framework. Finally, there is no clear benefit of using the proportional approach.

A Systematic Survey of Research Trends in Technology Usage for Parkinson's Disease

Parkinson's disease (PD) is a neurological disorder with complicated and disabling motor and non-motor symptoms. The complexity of PD pathology is amplified due to its dependency on patient diaries and the neurologist's subjective assessment of clinical scales. A significant amount of recent research has explored new cost-effective and subjective assessment methods pertaining to PD symptoms to address this challenge. This article analyzes the application areas and use of mobile and wearable technology in PD research using the PRISMA methodology. Based on the published papers, we identify four significant fields of research: diagnosis, prognosis and monitoring, predicting response to treatment, and rehabilitation. Between January 2008 and December 2021, 31,718 articles were published in four databases: PubMed Central, Science Direct, IEEE Xplore, and MDPI. After removing unrelated articles, duplicate entries, non-English publications, and other articles that did not fulfill the selection criteria, we manually investigated 1559 articles in this review. Most of the articles (45%) were published during a recent four-year stretch (2018-2021), and 19% of the articles were published in 2021 alone. This trend reflects the research community's growing interest in assessing PD with wearable devices, particularly in the last four years of the period under study. We conclude that there is a substantial and steady growth in the use of mobile technology in the PD contexts. We share our automated script and the detailed results with the public, making the review reproducible for future publications.

Intelligent wearable system with accurate detection of abnormal gait and timely cueing for mobility enhancement of people with Parkinson's disease

Previously reported wearable systems for people with Parkinson's disease (PD) have been focused on the detection of abnormal gait. They suffered from limited accuracy, large latency, poor durability, comfort, and convenience for daily use. Herewith we report an intelligent wearable system (IWS) that can accurately detect abnormal gait in real-time and provide timely cueing for PD patients. The system features novel sensitive, comfortable and durable plantar pressure sensing insoles with a highly compressed data set, an accurate and fast gait algorithm, and wirelessly controlled timely sensory cueing devices. A total of 29 PD patients participated in the first phase without cueing for developing processes of the algorithm, which achieved an accuracy of over 97% for off-line detection of freezing of gait (FoG). In the second phase with cueing, the evaluation of the whole system was conducted with 16 PD subjects via trial and a questionnaire survey. This system demonstrated an accuracy of 94% for real-time detection of FoG and a mean latency of 0.37 s between the onset of FoG and cueing activation. In questionnaire survey, 88% of the PD participants confirmed that this wearable system could effectively enhance walking, 81% thought that the system was comfortable and convenient, and 70% overcame the FoG. Therefore, the IWS makes it an effective, powerful, and convenient tool for enhancing the mobility of people with PD.

Wearable Walking Assistant for Freezing of Gait With Environmental IoT Monitoring: A Contribution to the Discussion

Parkinson's disease (PD) is the second most common neurodegenerative disease, significantly increasing in the last three decades. Worldwide, seven to ten million people are affected by PD. In people living with PD, freezing of gait (FoG) significantly impacts activities of daily living, potentially leading to falls, injuries, and loss of autonomy. FoG prevalence rates vary widely, reaching at least 50% of patients with PD. Current therapeutic options have limited effectiveness, and their complement with innovative technology-based solutions in the real world is demanded to enhance daily functioning for people living with PD. This article provides a narrative review of current technological developments for people living with PD and, derived from that evidence, presents a perspective on integrating wearable technology and IoT to support telemonitoring and self-management of people living with PD in their daily living environment. Complementing current therapeutic options with technology-based solutions in PD patients' real-world environment is crucial to enhancing the quality of life of people living with PD. In that way, wearable technology and IoT might constitute resources of excellence in seamless monitoring and self-management in people's home environments.

The Efficacy of a Newly Developed Cueing Device for Gait Mobility in Parkinson’s Disease

Background. External cues are effective in improving gait in people with Parkinson’s disease (PD). However, the most effective cueing method has yet to be determined. Objective. The aim of this study was to compare the immediate effects of using visual, auditory, or somatosensory cues on their own or in combination during walking compared to no cues in people with PD. Methods. This was a single blinded, randomly selected, controlled study. Twenty people with PD with an age range of 46–79 years and Hoehn and Yahr scores of 1–3 were recruited. Participants were studied under 4 cueing conditions; no cue, visual, auditory, or somatosensory cues, which were randomly selected individually or in a combination. Results. A repeated measures ANOVA with pairwise comparisons using Bonferroni correction showed that any single or combination of the cues resulted in an improvement in gait velocity and stride length compared to no cue. Some significant differences were also seen when comparing different combinations of cues, specifically stride length showed significant improvements when additional cues were added to the light cue. The statistically significant difference was set at $p<0.05$ . Conclusions. Walking using visual, auditory, or somatosensory cues can immediately improve gait mobility in people with PD. Any or a combination of the cues tested could be chosen depending on the ability of the individual to use that cue.

Efficacy of a novel walking assist device with auxiliary laser illuminator in stroke Patients~ a randomized control trial

BACKGROUND/PURPOSE

Task-oriented functional walking is important in stroke patients. We aimed to investigate effects of a quad-cane with auxiliary laser illuminator (laser-cane) among stroke patients.

METHODS

This was a randomized-prospective study. Patients in the experimental group (EG) received 15-min of walking training with laser-cane and 15-min of traditional physical therapy. Patients in the control group (CG) received the same rehabilitation without laser-cane. The rehabilitation lasted for 4 weeks, twice per week. Primary outcome were gait parameters. Secondary outcomes were Berg Balance Scale (BBS), Timed Up and Go Test (TUG), and Barthel index (BI). Outcomes were measured at baseline, at the end of the rehabilitation (visit-1), and 4 weeks later (visit-2).

RESULTS

Both the groups (both n = 15) showed improvement of cadence, relative stance and swing phase duration of non-paretic side, BBS, and TUG at both visits. In the intragroup comparison, the EG additionally improved at stride length, relative stance and swing phase duration of paretic side, and gait speed at both visits; temporal swing symmetry, and toe-off angle of non-paretic side at the visit-2. Intergroup comparing for changing of outcomes with the CG, stride length and gait speed increased, relative stance phase duration of the non-paretic site decreased, and the temporal swing symmetry improved at the visit-1; relative stance phase duration of the paretic side decreased and the temporal stance symmetry improved at the visit-2 in the EG.

CONCLUSION

Rehabilitation with laser-cane improved the balance, activity of daily living, gait symmetry and gait parameters of stroke patients.

An Update on Medical and Surgical Treatments of Parkinson's Disease

Parkinson’s disease (PD) is characterized by degeneration of dopaminergic neurons in the substantia nigra pars compacta and other neuronal populations. The worldwide prevalence of PD is over 7 million and has been increasing more rapidly than many other neurodegenerative disorders. PD symptoms can be broadly divided into motor (slowness, stiffness, tremor) and non-motor symptoms (such as depression, dementia, psychosis, orthostatic hypotension). Patients can also have prodromal symptoms of rapid eye movement sleep behavior disorder, hyposmia, and constipation. The diagnosis of PD is mainly clinical, but dopamine transporter single-photon emission computed tomography can improve the accuracy of the diagnosis. Dopamine based therapies are used for the treatment of motor symptoms. Non-motor symptoms are treated with other medications such as selective serotonin reuptake inhibitors (depression/anxiety), acetylcholinesterase inhibitors (dementia), and atypical antipsychotics (psychosis). Patients with motor fluctuations or uncontrolled tremor, benefit from deep brain stimulation. Levodopa-carbidopa intestinal gel is an alternative to deep brain stimulation for uncontrolled motor fluctuations. Rehabilitative therapies such as physical, occupational, and speech therapy are important during all stages of the disease. Management of PD is complex but there have been significant advancements in the treatment of motor and non-motor symptoms over the past few years. This review discusses the updates in the medical and surgical management of PD.

Current Perspectives on the Assessment and Management of Gait Disorders in Parkinson's Disease

Gait dysfunction is a key defining feature of Parkinson's disease (PD), and is associated with symptoms of freezing and an increased risk of falls. In this narrative review, we cover the putative mechanisms of gait dysfunction in PD, the assessment of gait abnormalities, and the management of symptoms caused by the inherent difficulty in walking. Our understanding of the causes of gait problems in PD has progressed in recent times, moving from neurocognitive theory to correlates of affected neuronal pathways. In particular, this can be shown to correspond with abnormalities in responses to dual-task paradigms and dysfunction in cholinergic signaling. Great progress has been made in the sophistication and precision of gait assessment; however, it has firmly remained in the research domain. There is significant momentum behind wearable technologies that can be used by patients in their own environment, acting as digital biomarkers that can not only reflect progression but also independently discriminate PD from non-PD individuals. The treatment of gait dysfunction has historically relied on physical therapies and training combined with a view to mitigating the impact of such consequences as falls. Pharmacological therapies that are the mainstay of treatment in PD have tended to address symptoms like bradykinesia; however, optimization of dopaminergic therapies likely has a positive effect on quality of gait. Other targets have been assessed with the goal of improving gait, of which medications that improve cholinergic signaling appear most promising. Neuromodulation techniques are increasingly used in the form of deep-brain stimulation; however, standard targets, such as the globus pallidus interna, have a modest effect on gait. Considerable benefit has been seen through targeting the pedunculopontine nucleus, and a dual-target approach may be warranted. Stimulation of the spinal cord and brain through direct or magnetic approaches has been assessed, but requires further evidence.

New Sensor and Wearable Technologies to Aid in the Diagnosis and Treatment Monitoring of Parkinson's Disease

Parkinson's disease (PD) is a degenerative disorder of the brain characterized by the impairment of the nigrostriatal system. This impairment leads to specific motor manifestations (i.e., bradykinesia, tremor, and rigidity) that are assessed through clinical examination, scales, and patient-reported outcomes. New sensor-based and wearable technologies are progressively revolutionizing PD care by objectively measuring these manifestations and improving PD diagnosis and treatment monitoring. However, their use is still limited in clinical practice, perhaps because of the absence of external validation and standards for their continuous use at home. In the near future, these systems will progressively complement traditional tools and revolutionize the way we diagnose and monitor patients with PD.

The effect of tactile feedback on gait initiation in people with Parkinson's disease: A pilot study

BACKGROUND

Gait initiation and turning are common triggers for Freezing of Gait (FOG) in people with Parkinson's disease (PD). Recently, it has been shown that closed-loop tactile feedback (CLTF) can be effective to improve turning performance in people with FOG.

RESEARCH QUESTION

Does CLTF change the preparation and execution of the first step during gait initiation?

METHODS

People (n = 36) with PD with FOG (PD + FOG) (n = 18) and without FOG (PD-FOG) (n = 18) were included in the study and performed self-initiated gait with or without CLTF under single and dual task conditions. Anticipatory postural adjustments (APAs) and step kinematics were quantified with inertial measurement units (IMUs). Muscle activity of the right and left tensor fasciae latae (TFL) was measured via EMG recordings.

RESULTS

PD + FOG and PD-FOG did not differ in age, gender and disease duration and severity (p > 0.05). PD + FOG performed smaller APAs (F = 4.559, p = 0.04) with a higher amount of TFL co-contraction (F = 6.034, p = 0.02) compared to PD-FOG. CLTF had no effect on APAs but led to an increase in first step duration (F = 7.921, p = 0.008).

CONCLUSIONS

PD + FOG had smaller APAs and higher left and right TFL co-contraction during gait initiation. CLTF did not impact preparation of the first step but led to a slower execution of the first step. We speculate that, similarly to findings from turning, CLTF might result in the participant attending more closely to the first step compared to without CLTF. Whether increased attention on gait initiation is beneficial in diminishing FOG should be investigated in more detail.

Freezing of gait in Parkinson's disease: pathophysiology, risk factors and treatments

Background

Freezing of gait (FOG) is a common, disabling symptom of Parkinson's disease (PD), but the mechanisms and treatments of FOG remain great challenges for clinicians and researchers. The main focus of this review is to summarize the possible mechanisms underlying FOG, the risk factors for screening and predicting the onset of FOG, and the clinical trials involving various therapeutic strategies. In addition, the limitations and recommendations for future research design are also discussed.

Main body

In the mechanism section, we briefly introduced the physiological process of gait control and hypotheses about the mechanism of FOG. In the risk factor section, gait disorders, PIGD phenotype, lower striatal DAT uptake were found to be independent risk factors of FOG with consistent evidence. In the treatment section, we summarized the clinical trials of pharmacological and non-pharmacological treatments. Despite the limited effectiveness of current medications for FOG, especially levodopa resistant FOG, there were some drugs that showed promise such as istradefylline and rasagiline. Non-pharmacological treatments encompass invasive brain and spinal cord stimulation, noninvasive repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) and vagus nerve stimulation (VNS), and physiotherapeutic approaches including cues and other training strategies. Several novel therapeutic strategies seem to be effective, such as rTMS over supplementary motor area (SMA), dual-site DBS, spinal cord stimulation (SCS) and VNS. Of physiotherapy, wearable cueing devices seem to be generally effective and promising.

Conclusion

FOG model hypotheses are helpful for better understanding and characterizing FOG and they provide clues for further research exploration. Several risk factors of FOG have been identified, but need combinatorial optimization for predicting FOG more precisely. Although firm conclusions cannot be drawn on therapeutic efficacy, the literature suggested that some therapeutic strategies showed promise.

Nonpharmacological, nonsurgical treatments for freezing of gait in Parkinson's disease: A systematic review

Freezing of gait is a disabling phenomenon that appears in a substantial number of Parkinson's disease (PD) patients as the disease evolves. It is considered to be one of the most relevant contributing factors to worsening of quality of life. Current pharmacological or surgical treatment options have limited efficacy. Thus, alternative nonpharmacological/nonsurgical approaches have emerged in recent years in an attempt to improve quality of life in PD. This systematic review summarizes studies of such therapies over the past 5 years. Thirty-five studies were evaluated by use of a qualitative evaluation, while the methodological quality was assessed using validated tools. According to our results, there appear to be two broad categories of nonpharmacological therapies: those that seek a long-lasting benefit and those that aim to achieve a transient effect to overcome the freezing of gait episode. Among the former, it is possible to differentiate between "passive" therapies, which include transcranial magnetic stimulation or transcranial direct current stimulation, and "active" therapies, which are based on different cognitive or physical training programs. Finally, "transient effect" therapies use different types of cues, such as visual, auditory, or proprioceptive stimuli, to attempt to shift the patient's habitual motor control to a goal-directed one. In conclusion, a broad spectrum of nonpharmacological/nonsurgical approaches for freezing of gait has emerged in recent years with promising results. © 2019 International Parkinson and Movement Disorder Society.

The CuePed Trial: How Does Environmental Complexity Impact Cue Effectiveness? A Comparison of Tonic and Phasic Visual Cueing in Simple and Complex Environments in a Parkinson's Disease Population with Freezing of Gait

Background

The optimal prescription of cueing for the treatment of freezing of gait (FoG) in Parkinson's disease (PD) is currently a difficult problem for clinicians due to the heterogeneity of cueing modalities, devices, and the limited comparative trial evidence. There has been a rise in the development of motion-sensitive, wearable cueing devices for the treatment of FoG in PD. These devices generally produce cues after signature gait or electroencephalographic antecedents of FoG episodes are detected (phasic cues). It is not known whether these devices offer benefit over simple (tonic) cueing devices.

Methods

We assembled 20 participants with PD and FoG and familiarized them with a belt-worn, laser-light cueing device (Agilitas™). The device was designed with 2 cueing modalities—gait-dependent or “phasic” cueing and gait-independent or “tonic” cueing. Participants used the device sequentially in the off, phasic, or tonic modes, across 2 tasks—a 2-minute walk and an obstacle course.

Results

A significant improvement in mean distance walked during the 2-minute walk test was observed for the tonic mode (127.3 m) compared with the off (111.4 m) and phasic (116.1 m) conditions. In contrast, there was a nonsignificant trend toward improvement in FoG frequency, duration, and course time when the device was switched from off to tonic and to phasic modes for the obstacle course.

Conclusions

Parkinson's disease patients with FoG demonstrated an improvement in distance walked during the two-minute walk test when a cueing device was switched from off to phasic and to tonic modes of operation. However, this benefit was lost when patients negotiated an obstacle course.

Versatile guideline-based physiotherapy intervention in groups to improve gait speed in Parkinson's disease patients

BACKGROUND:

Gait function is known to be impaired by Parkinson’s disease (PD). The effect of exercise to improve gait has been widely examined, often with special intervention. However, in clinical settings, physiotherapy rarely consists only of gait training.

OBJECTIVE:

To examine whether versatile physiotherapy intervention conducted in accordance with European Physiotherapy Guideline for Parkinson’s Disease (EPGPD) is sufficient to increase gait speed (GS).

METHODS:

Participants (24) with idiopathic PD were randomly enrolled into intervention (IG) and control groups (CG) (n = 12, 7 females and 5 males in each group). Sixteen one-hour therapy sessions (twice per week) were conducted for IG. Each session focused on core areas recommended in EPGPD. Participants were assessed twice with 10 weeks between assessments. GS was calculated based on a gait test of Short Physical Performance Battery. Dominant side hip flexion and abduction range of motion (HFLEX & HABD) were measured and Freezing of Gait questionnaire (FOG) was administered.

RESULTS:

Versatile intervention in groups resulted in increase of GS (ES –0.9 [CI{0.1}–{0.4}] m/s) and HFLEX (ES–0.6 [CI{5.9}–{16.6°}]. FOG was reduced (ES –0.41 [CI {–2.8}{–5.5}]). Re-evaluation HABD differed between groups and indicated large ES (r = –0.5).

CONCLUSIONS:

Versatile physiotherapy is sufficient to improve GS, range of motion and reduce FOG.

A Wearable, Patient-Adaptive Freezing of Gait Detection System for Biofeedback Cueing in Parkinson's Disease

Freezing of Gait (FoG) is a common motor-related impairment among Parkinson's disease patients, which substantially reduces their quality of life and puts them at risk of falls. These patients benefit from wearable FoG detection systems that provide timely biofeedback cues and hence help them regain control over their gait. Unfortunately, the systems proposed thus far are bulky and obtrusive when worn. The objective of this paper is to demonstrate the first integration of an FoG detection system into a single sensor node. To achieve such an integration, features with low computational load are selected and dedicated hardware is designed that limits area and memory utilization. Classification is achieved with a neural network that is capable of learning in real time and thus allows the system to adapt to a patient during run-time. A small form factor FPGA implements the feature extraction and classification, whereas a custom PCB integrates the system into a single node. The system fits into a 4.5 × 3.5 × 1.5 cm ³ housing case, weighs 32 g, and achieves 95.6% sensitivity and 90.2% specificity when adapted to a patient. Biofeedback cues are provided either through auditory or somatosensory means and the system can remain operational for longer than 9 h while providing cues. The proposed system is highly competitive in terms of classification performance and excels with respect to wearability and real-time patient adaptivity.

A Technological Review of Wearable Cueing Devices Addressing Freezing of Gait in Parkinson's Disease

Freezing of gait is one of the most debilitating symptoms of Parkinson’s disease and is an important contributor to falls, leading to it being a major cause of hospitalization and nursing home admissions. When the management of freezing episodes cannot be achieved through medication or surgery, non-pharmacological methods such as cueing have received attention in recent years. Novel cueing systems were developed over the last decade and have been evaluated predominantly in laboratory settings. However, to provide benefit to people with Parkinson’s and improve their quality of life, these systems must have the potential to be used at home as a self-administer intervention. This paper aims to provide a technological review of the literature related to wearable cueing systems and it focuses on current auditory, visual and somatosensory cueing systems, which may provide a suitable intervention for use in home-based environments. The paper describes the technical operation and effectiveness of the different cueing systems in overcoming freezing of gait. The “What Works Clearinghouse (WWC)” tool was used to assess the quality of each study described. The paper findings should prove instructive for further researchers looking to enhance the effectiveness of future cueing systems.

Gait Study of Parkinson's Disease Subjects Using Haptic Cues with A Motorized Walker

Gait abnormalities are one of the distinguishing symptoms of patients with Parkinson's disease (PD) that contribute to fall risk. Our study compares the gait parameters of people with PD when they walk through a predefined course under different haptic speed cue conditions (1) without assistance, (2) pushing a conventional rolling walker, and (3) holding onto a self-navigating motorized walker under different speed cues. Six people with PD were recruited at the New York Institute of Technology College of Osteopathic Medicine to participate in this study. Spatial posture and gait data of the test subjects were collected via a VICON motion capture system. We developed a framework to process and extract gait features and applied statistical analysis on these features to examine the significance of the findings. The results showed that the motorized walker providing a robust haptic cue significantly improved gait symmetry of PD subjects. Specifically, the asymmetry index of the gait cycle time was reduced from 6.7% when walking without assistance to 0.56% and below when using a walker. Furthermore, the double support time of a gait cycle was reduced by 4.88% compared to walking without assistance.

Effect of spinal kypho-orthosis to gait and forward flexion in Parkinson disease

[Purpose] The gait characteristics, such as short step, decreased arm swing and stooped posture, in Parkinson disease (PD) are well established. Pharmacological and non-pharmacological treatments have been attempted to improve the gait in patients with PD. Among the non-pharmacological approaches to improve gait, spinal orthosis can be applied for patients with spinal deformity. The purpose of our study was to investigate the effect of spinal kypho-orthosis to gait in PD by using a three-dimensional analysis. [Participants and Methods] Twenty-six patients with PD with gait disturbance with forward bend posture >15°. All participants were instructed to walk along a 6-m track and turn 180° and come back to the starting point under three-dimensional motion capture. The participants performed the test again with spinal kypho-orthosis. Gait parameters during examination is compared with and without spinal kypho-orthosis. The degree of forward flexion after kypho-orthosis in patients with PD was compared. [Results] Wearing the spinal kypho-orthosis significantly improved turning performance but did not affect locomotion. The severity of forward bend posture is mildly improved after the application of spinal kypho-orthosis. [Conclusion] Spinal kypho-orthosis has a short-term effect for gait performance, particularly during turning and erect posture. Spinal kypho-orthosis can be potentially used for management of turning deficits in PD.

Assessment of the ability of open- and closed-loop cueing to improve turning and freezing in people with Parkinson's disease

Turning impairments are common in Parkinson’s disease (PD) and can elicit freezing of gait (FoG). Extensive examination of open-loop cueing interventions has demonstrated that they can ameliorate gait deficits in PD; less is known about efficacy to improve turning. Here, we investigate the immediate effectiveness of open- and closed-loop cueing in improving turning characteristics in people with PD. Twenty-five subjects with and 18 subjects without FoG participated in the study. Subjects turned in place for one minute under single- and dual-task for 3 randomized conditions: (i) Baseline; (ii) Turning to the beat of a metronome (open-loop); and (iii) Turning with phase-dependent tactile biofeedback (closed-loop). Objective measures of freezing, such as % time spent freezing and FoG-ratio, significantly improved when turning with both open-loop and closed-loop cueing compared to baseline. Dual-tasking did not worsen FoG in freezers, but significantly slowed down turns in both groups. Both cueing modalities significantly improved turning smoothness in both groups, but reduced turning velocity and number of turns compared to baseline. Both open and closed-loop cueing markedly improved turning in people with PD. These preliminary observations warrant further exploration of vibrotactile closed-loop cueing to improve mobility in everyday life.

Sensory Electrical Stimulation Cueing May Reduce Freezing of Gait Episodes in Parkinson's Disease

Introduction

Freezing of gait (FoG) is a movement abnormality that presents with advancing Parkinson's disease (PD) and is one of the most debilitating symptoms of the disease. The mainstay of nonpharmacological management of FoG is typically through external cueing techniques designed to relieve or prevent the freezing episode. Previous work shows that electrical stimulation may prove useful as a gait guidance technique, but further evidence is required. The main objective of this study was to determine whether a “fixed” rhythmic sensory electrical stimulation (sES) cueing strategy would significantly (i) reduce the time taken to complete a walking task and (ii) reduce the number of FoG episodes occurring when performing the task.

Methods

9 participants with idiopathic PD performed a self-identified walking task during both control (no cue) and cueing conditions. The self-identified walking task was a home-based daily walking activity, which was known to result in FoG for that person. A trained physiotherapist recorded the time taken to complete the walking task and the number of FoG episodes which occurred during the task. Data were analyzed by paired t-tests for both the time to complete a walking task and the number of FoG episodes occurring.

Results

sES cueing resulted in a reduction in the time taken to complete a walking task and in the number of FoG episodes occurring during performance of this task by 14.23 ± 11.15% (p=0.009) and 58.28 ± 33.89% (p=0.002), respectively.

Conclusions

This study shows a positive effect of “fixed” rhythmic sES on the time taken to complete a walking task and on the number of FoG episodes occurring during the task. Our results provide evidence that sES cueing delivered in a “fixed” rhythmic manner has the potential to be an effective cueing mechanism for FoG prevention.

Gait Disorders

Walking is an extraordinarily complex task requiring integration of the entire nervous system, making gait susceptible to a variety of underlying neurologic abnormalities. Gait disorders are particularly prevalent in the elderly and increase fall risk. In this review we discuss an approach to the examination of gait and highlight key features of common gait disorders and their underlying causes. We review gaits due to lesions of motor systems (spasticity and neuromuscular weakness), the cerebellum and sensory systems (ataxia), parkinsonism, and frontal lobes and discuss the remarkably diverse phenomenology of functional (psychogenic) gait disorders. We offer a pragmatic approach to the diagnosis and management of neurologic gait disorders, because prompt recognition and intervention may improve quality of life in affected individuals.