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Park JM, Moon CW, Lee BC, Oh E, Lee J, Jang WJ, Cho KH, Lee SH. Detection of freezing of gait in Parkinson's disease from foot-pressure sensing insoles using a temporal convolutional neural network. Front Aging Neurosci 2024; 16:1437707. [PMID: 39092074 PMCID: PMC11291202 DOI: 10.3389/fnagi.2024.1437707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 07/01/2024] [Indexed: 08/04/2024] Open
Abstract
Backgrounds Freezing of gait (FoG) is a common and debilitating symptom of Parkinson's disease (PD) that can lead to falls and reduced quality of life. Wearable sensors have been used to detect FoG, but current methods have limitations in accuracy and practicality. In this paper, we aimed to develop a deep learning model using pressure sensor data from wearable insoles to accurately detect FoG in PD patients. Methods We recruited 14 PD patients and collected data from multiple trials of a standardized walking test using the Pedar insole system. We proposed temporal convolutional neural network (TCNN) and applied rigorous data filtering and selective participant inclusion criteria to ensure the integrity of the dataset. We mapped the sensor data to a structured matrix and normalized it for input into our TCNN. We used a train-test split to evaluate the performance of the model. Results We found that TCNN model achieved the highest accuracy, precision, sensitivity, specificity, and F1 score for FoG detection compared to other models. The TCNN model also showed good performance in detecting FoG episodes, even in various types of sensor noise situations. Conclusions We demonstrated the potential of using wearable pressure sensors and machine learning models for FoG detection in PD patients. The TCNN model showed promising results and could be used in future studies to develop a real-time FoG detection system to improve PD patients' safety and quality of life. Additionally, our noise impact analysis identifies critical sensor locations, suggesting potential for reducing sensor numbers.
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Affiliation(s)
- Jae-Min Park
- School of Electrical Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea
| | - Chang-Won Moon
- Department of Rehabilitation Medicine, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Department of Biomedical Institute, Chungnam National University, Daejeon, Republic of Korea
| | - Byung Chan Lee
- Department of Physical Medicine and Rehabilitation, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Eungseok Oh
- Department of Neurology, College of Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Juhyun Lee
- Department of Biomedical Institute, Chungnam National University, Daejeon, Republic of Korea
| | - Won-Jun Jang
- School of Electrical Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea
| | - Kang Hee Cho
- Department of Rehabilitation Medicine, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Department of Biomedical Institute, Chungnam National University, Daejeon, Republic of Korea
| | - Si-Hyeon Lee
- School of Electrical Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea
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Seuthe J, Hermanns H, Hulzinga F, D'Cruz N, Deuschl G, Ginis P, Nieuwboer A, Schlenstedt C. Gait asymmetry and symptom laterality in Parkinson's disease: two of a kind? J Neurol 2024; 271:4373-4382. [PMID: 38652262 PMCID: PMC11233399 DOI: 10.1007/s00415-024-12379-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND The laterality of motor symptoms is considered a key feature of Parkinson's disease (PD). Here, we investigated whether gait and turning asymmetry coincided with symptom laterality as determined by the MDS-UPRDS part III and whether it was increased compared to healthy controls (HC). METHODS We analyzed the asymmetry of gait and turning with and without a cognitive dual task (DT) using motion capture systems and wearable sensors in 97 PD patients mostly from Hoehn & Yahr stage II and III and 36 age-matched HC. We also assessed motor symptom asymmetry using the bilateral sub-items of the MDS-UPDRS-III. Finally, we examined the strength of the association between gait asymmetry and symptom laterality. RESULTS Participants with PD had increased gait but not more turning asymmetry compared to HC (p < 0.05). Only 53.7% of patients had a shorter step length on the more affected body side as determined by the MDS-UPDRS-III. Also, 54% took more time and 29% more steps during turns toward the more affected side. The degree of asymmetry in the different domains did not correlate with each other and was not influenced by DT-load. CONCLUSIONS We found a striking mismatch between the side and the degree of asymmetry in different motor domains, i.e., in gait, turning, and distal symptom severity in individuals with PD. We speculate that motor execution in different body parts relies on different neural control mechanisms. Our findings warrant further investigation to understand the complexity of gait asymmetry in PD.
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Affiliation(s)
- Jana Seuthe
- Institute of Interdisciplinary Exercise Science and Sports Medicine, Medical School Hamburg, Hamburg, Germany.
- Department of Neurology, Christian-Albrechts-University Kiel, University Hospital Schleswig-Holstein, Kiel, Germany.
| | - Helen Hermanns
- Department of Neurology, Christian-Albrechts-University Kiel, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Femke Hulzinga
- Neuromotor Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven, Louvain, Belgium
| | - Nicholas D'Cruz
- Neuromotor Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven, Louvain, Belgium
| | - Günther Deuschl
- Department of Neurology, Christian-Albrechts-University Kiel, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Pieter Ginis
- Neuromotor Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven, Louvain, Belgium
| | - Alice Nieuwboer
- Neuromotor Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven, Louvain, Belgium
| | - Christian Schlenstedt
- Institute of Interdisciplinary Exercise Science and Sports Medicine, Medical School Hamburg, Hamburg, Germany
- Department of Neurology, Christian-Albrechts-University Kiel, University Hospital Schleswig-Holstein, Kiel, Germany
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3
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Abraham A, Hart A, Bozzorg A, Pothineni S, Wolf SL, Schuh K, Caughlan M, Parker J, Blackwell A, Tharp Cianflona M, Asker C, Prusin T, Hackney ME. Comparison of externally and internally guided dance movement to address mobility, cognition, and psychosocial function in people with Parkinson's disease and freezing of gait: a case series. Front Aging Neurosci 2024; 16:1372894. [PMID: 38813534 PMCID: PMC11135342 DOI: 10.3389/fnagi.2024.1372894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/20/2024] [Indexed: 05/31/2024] Open
Abstract
Objective The aim of this study is to explore the impact of internally guided (IG) versus externally guided (EG) adapted tango (AT) dance training (i.e., dancing the IG "Leader" role or the EG "Follower" role), on motor and non-motor functions in individuals with Parkinson's disease and freezing of gait (PD-FOG). The "Leader" role, a proxy for IG movements, conveys direction, timing, and amplitude of steps with tactile cues. The "Follower" role, a proxy for EG movements, detects and responds to the leader's tactile cues. Case description Six participants were randomly assigned to the IG ("Leader") or EG ("Follower") roles for 20, 90-min AT lessons over 12 weeks. Participants were assessed for PD-specific and non-PD-specific functions before and twice after the end of the 12-week intervention, at 1-week and 1-month post-intervention. Results EG participants improved and/or maintained performance on more outcomes across all domains than IG participants. Five participants improved in PD motor symptoms, dynamic gait, global cognitive function, and the FOG Questionnaire immediately or 1 month after intervention. All participants expressed positive attitudes toward the intervention, including improvements in walking, balance, and endurance. Conclusion AT training in the follower role may benefit individuals with PD-FOG to a greater extent compared to the leader role. Impact This case series study could inform additional research with the goal of enhancing physical therapy or music-based therapy approaches for addressing PD-FOG.
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Affiliation(s)
- Amit Abraham
- Department of Physical Therapy, Faculty of Health Sciences, Ariel University, Ariel, Israel
- Navigation and Accessibility Research Center of Ariel University (NARCA), Ariel University, Ariel, Israel
| | - Ariel Hart
- Emory University School of Medicine, Department of Medicine, Division of Geriatrics and Gerontology, Atlanta, GA, United States
- University of Georgia, Athens, GA, United States
| | - Ariyana Bozzorg
- Atlanta Veterans Affairs Center for Visual & Neurocognitive Rehabilitation, Decatur, GA, United States
| | - Suraj Pothineni
- Emory University School of Medicine, Department of Medicine, Division of Geriatrics and Gerontology, Atlanta, GA, United States
| | - Steven L. Wolf
- Emory University School of Medicine, Department of Medicine, Division of Geriatrics and Gerontology, Atlanta, GA, United States
- Atlanta Veterans Affairs Center for Visual & Neurocognitive Rehabilitation, Decatur, GA, United States
- Emory University School of Medicine Department of Rehabilitation Medicine, Atlanta, GA, United States
| | - Kersey Schuh
- Emory University School of Medicine Department of Rehabilitation Medicine, Atlanta, GA, United States
| | - Molly Caughlan
- Emory University School of Medicine Department of Rehabilitation Medicine, Atlanta, GA, United States
| | - Jelani Parker
- Emory University School of Medicine Department of Rehabilitation Medicine, Atlanta, GA, United States
| | - Amanda Blackwell
- Emory University School of Medicine Department of Rehabilitation Medicine, Atlanta, GA, United States
| | - Megan Tharp Cianflona
- Emory University School of Medicine Department of Rehabilitation Medicine, Atlanta, GA, United States
| | - Courtney Asker
- Emory University School of Medicine Department of Rehabilitation Medicine, Atlanta, GA, United States
| | - Todd Prusin
- Emory University School of Medicine, Department of Medicine, Division of Geriatrics and Gerontology, Atlanta, GA, United States
| | - Madeleine E. Hackney
- Emory University School of Medicine, Department of Medicine, Division of Geriatrics and Gerontology, Atlanta, GA, United States
- Atlanta Veterans Affairs Center for Visual & Neurocognitive Rehabilitation, Decatur, GA, United States
- Emory University School of Medicine Department of Rehabilitation Medicine, Atlanta, GA, United States
- Birmingham/Atlanta VA Geriatric Research Education Clinical Center, Decatur, GA, United States
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Cosentino C, Putzolu M, Mezzarobba S, Cecchella M, Innocenti T, Bonassi G, Botta A, Lagravinese G, Avanzino L, Pelosin E. 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. Neurosci Biobehav Rev 2023; 150:105189. [PMID: 37086934 DOI: 10.1016/j.neubiorev.2023.105189] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 04/03/2023] [Accepted: 04/17/2023] [Indexed: 04/24/2023]
Abstract
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.
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Affiliation(s)
- Carola Cosentino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Genoa, Italy
| | - Martina Putzolu
- Department of Experimental Medicine (DIMES), Section of Human Physiology, University of Genoa, Genoa, Italy
| | - Susanna Mezzarobba
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Genoa, Italy; IRCCS, Ospedale Policlinico San Martino, Genoa, Italy
| | - Margherita Cecchella
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Genoa, Italy
| | - Tiziano Innocenti
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands; GIMBE Foundation, Bologna, Italy
| | - Gaia Bonassi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Genoa, Italy
| | | | - Giovanna Lagravinese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Genoa, Italy; IRCCS, Ospedale Policlinico San Martino, Genoa, Italy
| | - Laura Avanzino
- Department of Experimental Medicine (DIMES), Section of Human Physiology, University of Genoa, Genoa, Italy; IRCCS, Ospedale Policlinico San Martino, Genoa, Italy.
| | - Elisa Pelosin
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Genoa, Italy; IRCCS, Ospedale Policlinico San Martino, Genoa, Italy
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Yogev-Seligmann G, Josman N, Bitterman N, Rosenblum S, Naaman S, Gilboa Y. The development of a home-based technology to improve gait in people with Parkinson's disease: a feasibility study. Biomed Eng Online 2023; 22:2. [PMID: 36658571 PMCID: PMC9851591 DOI: 10.1186/s12938-023-01066-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/09/2023] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
- Galit Yogev-Seligmann
- grid.18098.380000 0004 1937 0562Department of Occupational Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, 3498838 Haifa, Israel
| | - Naomi Josman
- grid.18098.380000 0004 1937 0562Department of Occupational Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, 3498838 Haifa, Israel
| | - Noemi Bitterman
- grid.6451.60000000121102151Technion, Israel Institute of Technology, Haifa, Israel
| | - Sara Rosenblum
- grid.18098.380000 0004 1937 0562Department of Occupational Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, 3498838 Haifa, Israel
| | - Sitar Naaman
- grid.18098.380000 0004 1937 0562Department of Physical Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, Haifa, Israel
| | - Yafit Gilboa
- grid.9619.70000 0004 1937 0538School of Occupational Therapy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
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Choi H, Youm C, Park H, Kim B, Cheon SM, Lee M. Association between Severity of Freezing of Gait and Turning Characteristics in People with Parkinson's Disease. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12131. [PMID: 36231432 PMCID: PMC9564463 DOI: 10.3390/ijerph191912131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 06/16/2023]
Abstract
For people with Parkinson's disease (PD) with freezing of gait (FOG) (freezers), symptoms mainly exhibit as unilateral motor impairments that may cause difficulty during postural transitions such as turning during daily activities. We investigated the turning characteristics that distinguished freezers among people with PD and analyzed the association between the New Freezing of Gait Questionnaire (NFOGQ) scores and the gait characteristics according to the turning direction for the affected limbs of freezers. The study recruited 57 people with PD (27 freezers, 30 non-freezers). All experiments measured the maximum 180° turning task with the "Off" medication state. Results revealed that the outer ankle range of motion in the direction of the inner step of the more affected limb (IMA) was identified to distinguish freezers and non-freezers (RN2 = 0.735). In addition, higher NFOGQ scores were associated with a more significant anteroposterior root mean square distance of the center of mass in the IMA direction and a greater inner stance phase in the outer step of the more affected limb (OMA) direction; explanatory power was 50.1%. Assessing the maximum speed and turning direction is useful for evaluating the differences in turning characteristics between freezers and non-freezers, which can help define freezers more accurately.
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Affiliation(s)
- Hyejin Choi
- Department of Health Sciences, The Graduate School, Dong-A University, Saha-gu, Busan 49315, Korea
| | - Changhong Youm
- Department of Health Sciences, The Graduate School, Dong-A University, Saha-gu, Busan 49315, Korea
- Department of Health Care and Science, Dong-A University, Saha-gu, Busan 49315, Korea
| | - Hwayoung Park
- Department of Health Sciences, The Graduate School, Dong-A University, Saha-gu, Busan 49315, Korea
| | - Bohyun Kim
- Department of Health Sciences, The Graduate School, Dong-A University, Saha-gu, Busan 49315, Korea
| | - Sang-Myung Cheon
- Department of Neurology, School of Medicine, Dong-A University, Seo-gu, Busan 49201, Korea
| | - Myeounggon Lee
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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Das J, Vitorio R, Butterfield A, Morris R, Graham L, Barry G, McDonald C, Walker R, Mancini M, Stuart S. Visual Cues for Turning in Parkinson's Disease. SENSORS (BASEL, SWITZERLAND) 2022; 22:s22186746. [PMID: 36146096 PMCID: PMC9502260 DOI: 10.3390/s22186746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/22/2022] [Accepted: 08/31/2022] [Indexed: 05/07/2023]
Abstract
Turning is a common impairment of mobility in people with Parkinson’s disease (PD), which increases freezing of gait (FoG) episodes and has implications for falls risk. Visual cues have been shown to improve general gait characteristics in PD. However, the effects of visual cues on turning deficits in PD remains unclear. We aimed to (i) compare the response of turning performance while walking (180° and 360° turns) to visual cues in people with PD with and without FoG; and (ii) examine the relationship between FoG severity and response to visual cues during turning. This exploratory interventional study measured turning while walking in 43 participants with PD (22 with self-reported FoG) and 20 controls using an inertial sensor placed at the fifth lumbar vertebrae region. Participants walked straight and performed 180° and 360° turns midway through a 10 m walk, which was done with and without visual cues (starred pattern). The turn duration and velocity response to visual cues were assessed using linear mixed effects models. People with FoG turned slower and longer than people with PD without FoG and controls (group effect: p < 0.001). Visual cues reduced the velocity of turning 180° across all groups and reduced the velocity of turning 360° in people with PD without FoG and controls. FoG severity was not significantly associated with response to visual cues during turning. Findings suggest that visual cueing can modify turning during walking in PD, with response influenced by FoG status and turn amplitude. Slower turning in response to visual cueing may indicate a more cautious and/or attention-driven turning pattern. This study contributes to our understanding of the influence that cues can have on turning performance in PD, particularly in freezers, and will aid in their therapeutic application.
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Affiliation(s)
- Julia Das
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle NE1 8ST, UK
- Northumbria Healthcare NHS Foundation Trust, North Shields NE29 8NH, UK
| | - Rodrigo Vitorio
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle NE1 8ST, UK
| | - Allissa Butterfield
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle NE1 8ST, UK
- Northumbria Healthcare NHS Foundation Trust, North Shields NE29 8NH, UK
| | - Rosie Morris
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle NE1 8ST, UK
- Northumbria Healthcare NHS Foundation Trust, North Shields NE29 8NH, UK
| | - Lisa Graham
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle NE1 8ST, UK
| | - Gill Barry
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle NE1 8ST, UK
| | - Claire McDonald
- Gateshead Health NHS Foundation Trust, Gateshead NE8 2PJ, UK
| | - Richard Walker
- Northumbria Healthcare NHS Foundation Trust, North Shields NE29 8NH, UK
| | - Martina Mancini
- Department of Neurology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Samuel Stuart
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle NE1 8ST, UK
- Northumbria Healthcare NHS Foundation Trust, North Shields NE29 8NH, UK
- Correspondence: ; Tel.: +44-(0)-1912273343
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A study of turn bias in people with idiopathic Parkinson's disease. Exp Brain Res 2022; 240:1673-1685. [PMID: 35551430 DOI: 10.1007/s00221-022-06378-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/19/2022] [Indexed: 11/04/2022]
Abstract
The objective of the study is to explore whether people with Parkinson's disease (PwPD) display a preferential turn bias dependent upon disease asymmetry, and whether specific disease features predict turn bias. PwPD and age-matched controls were instructed to walk on an instrumented gait mat making "normal" turns. Trials were analyzed using Proto Kinetics Movement Analysis Software (PKMAS) and time-locked video recordings to obtain turn directionality and spatiotemporal turn measures. Turn bias was estimated using previously defined formulas. Seventy-two PwPD and 28 controls were included. One hundred percent of controls and 85% of PwPD had left turn bias. Turn bias was not significantly associated with age, gender, handedness, disease asymmetry, cognition, or disease severity. The Freezing of Gait Questionnaire (FOGQ) questions 5 and 6 showed linear-by-linear association with turn bias. In binary logistic and ordinal regression models, FOGQ question 6 (average duration of turn freezing) and turn width were predictive of turn bias. Rightward turns had greater frequency of freezing episodes. Turn bias in our PwPD cohort does not appear related to disease asymmetry or other disease features, except gait freezing. Whether freezing severity on turning leads to non-left turn bias or vice versa requires more focused studies. Physical therapy interventions targeting turning direction in PwPD could reduce freezing severity.
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Fujikawa J, Morigaki R, Yamamoto N, Oda T, Nakanishi H, Izumi Y, Takagi Y. Therapeutic Devices for Motor Symptoms in Parkinson’s Disease: Current Progress and a Systematic Review of Recent Randomized Controlled Trials. Front Aging Neurosci 2022; 14:807909. [PMID: 35462692 PMCID: PMC9020378 DOI: 10.3389/fnagi.2022.807909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/14/2022] [Indexed: 11/29/2022] Open
Abstract
Background Pharmacotherapy is the first-line treatment option for Parkinson’s disease, and levodopa is considered the most effective drug for managing motor symptoms. However, side effects such as motor fluctuation and dyskinesia have been associated with levodopa treatment. For these conditions, alternative therapies, including invasive and non-invasive medical devices, may be helpful. This review sheds light on current progress in the development of devices to alleviate motor symptoms in Parkinson’s disease. Methods We first conducted a narrative literature review to obtain an overview of current invasive and non-invasive medical devices and thereafter performed a systematic review of recent randomized controlled trials (RCTs) of these devices. Results Our review revealed different characteristics of each device and their effectiveness for motor symptoms. Although invasive medical devices are usually highly effective, surgical procedures can be burdensome for patients and have serious side effects. In contrast, non-pharmacological/non-surgical devices have fewer complications. RCTs of non-invasive devices, especially non-invasive brain stimulation and mechanical peripheral stimulation devices, have proven effectiveness on motor symptoms. Nearly no non-invasive devices have yet received Food and Drug Administration certification or a CE mark. Conclusion Invasive and non-invasive medical devices have unique characteristics, and several RCTs have been conducted for each device. Invasive devices are more effective, while non-invasive devices are less effective and have lower hurdles and risks. It is important to understand the characteristics of each device and capitalize on these.
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Affiliation(s)
- Joji Fujikawa
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
| | - Ryoma Morigaki
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
- Department of Neurosurgery, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
- *Correspondence: Ryoma Morigaki,
| | - Nobuaki Yamamoto
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
- Department of Neurology, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
| | - Teruo Oda
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
| | - Hiroshi Nakanishi
- Department of Neurosurgery, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
| | - Yuishin Izumi
- Department of Neurology, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
| | - Yasushi Takagi
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
- Department of Neurosurgery, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
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Geerse DJ, Coolen B, van Hilten JJ, Roerdink M. Holocue: A Wearable Holographic Cueing Application for Alleviating Freezing of Gait in Parkinson's Disease. Front Neurol 2022; 12:628388. [PMID: 35082741 PMCID: PMC8784874 DOI: 10.3389/fneur.2021.628388] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/17/2021] [Indexed: 11/22/2022] Open
Abstract
External visual cueing is a well-known means to target freezing of gait (FOG) in Parkinson's disease patients. Holocue is a wearable visual cueing application that allows the HoloLens 1 mixed-reality headset to present on-demand patient-tailored action-relevant 2D and 3D holographic visual cues in free-living environments. The aim of this study involving 24 Parkinson's disease patients with dopaminergic “ON state” FOG was two-fold. First, to explore unfamiliarity and habituation effects associated with wearing the HoloLens on FOG. Second, to evaluate the potential immediate effect of Holocue on alleviating FOG in the home environment. Three sessions were conducted to examine (1) the effect of wearing the unfamiliar HoloLens on FOG by comparing walking with and without the HoloLens, (2) habituation effects to wearing the HoloLens by comparing FOG while walking with HoloLens over sessions, and (3) the potential immediate effect of Holocue on FOG by comparing walking with HoloLens with and without Holocue. Wearing the HoloLens (without Holocue) did significantly increase the number and duration of FOG episodes, but this unfamiliarity effect disappeared with habituation over sessions. This not only emphasizes the need for sufficient habituation to unfamiliar devices, but also testifies to the need for research designs with appropriate control conditions when examining effects of unfamiliar wearable cueing devices. Holocue had overall no immediate effect on FOG, although objective and subjective benefits were observed for some individuals, most notably those with long and/or many FOG episodes. Our participants raised valuable opportunities to improve Holocue and confirmed our assumptions about current and anticipated future design choices, which supports ongoing Holocue development for and with end users.
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Affiliation(s)
- Daphne J Geerse
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Bert Coolen
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
| | | | - Melvyn Roerdink
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
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11
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D'Cruz N, Seuthe J, De Somer C, Hulzinga F, Ginis P, Schlenstedt C, Nieuwboer A. Dual Task Turning in Place: A Reliable, Valid, and Responsive Outcome Measure of Freezing of Gait. Mov Disord 2021; 37:269-278. [PMID: 34939224 DOI: 10.1002/mds.28887] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/31/2021] [Accepted: 11/24/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Freezing of gait (FOG) is a complex symptom in Parkinson's disease (PD) that is both elusive to elicit and varied in its presentation. These complexities present a challenge to measuring FOG in a sensitive and reliable way, precluding therapeutic advancement. OBJECTIVE We investigated the reliability, validity, and responsiveness of manual video annotations of the turning-in-place task and compared it to the sensor-based FOG ratio. METHODS Forty-five optimally medicated people with PD and FOG performed rapid alternating 360° turns without and with an auditory stroop dual task, thrice over two consecutive days. The tasks were video recorded, and inertial sensors were placed on the lower back and shins. Interrater reliability between three raters, criterion validity with self-reported FOG, and responsiveness to single-session split-belt treadmill (SBT) training were investigated and contrasted with the sensor-based FOG ratio. RESULTS Visual ratings showed excellent agreement between raters for the percentage time frozen (%TF) (ICC [intra-class correlation coefficient] = 0.99), the median duration of a FOG episode (ICC = 0.90), and the number of FOG episodes (ICC = 0.86). Dual tasking improved the sensitivity and validity of visual FOG ratings resulting in increased FOG detection, criterion validity with self-reported FOG ratings, and responsiveness to a short SBT intervention. The sensor-based FOG ratio, on the contrary, showed complex FOG presentation-contingent relationships with visual and self-reported FOG ratings and limited responsiveness to SBT training. CONCLUSIONS Manual video annotations of FOG during dual task turning in place generate reliable, valid, and sensitive outcomes for investigating therapeutic effects on FOG. © 2021 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Nicholas D'Cruz
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group, Leuven, Belgium
| | - Jana Seuthe
- Department of Neurology, Christian-Albrechts-University (CAU) Kiel, University Hospital Schleswig-Holstein, Kiel, Germany.,Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Clara De Somer
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group, Leuven, Belgium
| | - Femke Hulzinga
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group, Leuven, Belgium
| | - Pieter Ginis
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group, Leuven, Belgium
| | - Christian Schlenstedt
- Department of Neurology, Christian-Albrechts-University (CAU) Kiel, University Hospital Schleswig-Holstein, Kiel, Germany.,Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Alice Nieuwboer
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group, Leuven, Belgium
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12
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Park H, Shin S, Youm C, Cheon SM, Lee M, Noh B. Classification of Parkinson's disease with freezing of gait based on 360° turning analysis using 36 kinematic features. J Neuroeng Rehabil 2021; 18:177. [PMID: 34930373 PMCID: PMC8686361 DOI: 10.1186/s12984-021-00975-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Freezing of gait (FOG) is a sensitive problem, which is caused by motor control deficits and requires greater attention during postural transitions such as turning in people with Parkinson's disease (PD). However, the turning characteristics have not yet been extensively investigated to distinguish between people with PD with and without FOG (freezers and non-freezers) based on full-body kinematic analysis during the turning task. The objectives of this study were to identify the machine learning model that best classifies people with PD and freezers and reveal the associations between clinical characteristics and turning features based on feature selection through stepwise regression. METHODS The study recruited 77 people with PD (31 freezers and 46 non-freezers) and 34 age-matched older adults. The 360° turning task was performed at the preferred speed for the inner step of the more affected limb. All experiments on the people with PD were performed in the "Off" state of medication. The full-body kinematic features during the turning task were extracted using the three-dimensional motion capture system. These features were selected via stepwise regression. RESULTS In feature selection through stepwise regression, five and six features were identified to distinguish between people with PD and controls and between freezers and non-freezers (PD and FOG classification problem), respectively. The machine learning model accuracies revealed that the random forest (RF) model had 98.1% accuracy when using all turning features and 98.0% accuracy when using the five features selected for PD classification. In addition, RF and logistic regression showed accuracies of 79.4% when using all turning features and 72.9% when using the six selected features for FOG classification. CONCLUSION We suggest that our study leads to understanding of the turning characteristics of people with PD and freezers during the 360° turning task for the inner step of the more affected limb and may help improve the objective classification and clinical assessment by disease progression using turning features.
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Affiliation(s)
- Hwayoung Park
- Department of Health Sciences, The Graduate School of Dong-A University, Saha-gu, Busan, Republic of Korea
| | - Sungtae Shin
- Department of Mechanical Engineering, College of Engineering, Dong-A University, Saha-gu, Busan, Republic of Korea
| | - Changhong Youm
- Department of Health Sciences, The Graduate School of Dong-A University, Saha-gu, Busan, Republic of Korea.
- Department of Healthcare and Science, College of Health Sciences, Dong-A University, 37 Nakdong‑Daero, 550 Beon‑gil, Hadan 2-dong, Saha-gu, Busan, 49315, Republic of Korea.
| | - Sang-Myung Cheon
- Department of Neurology, School of Medicine, Dong-A University, 26, Daesingongwon-ro, Seo-gu, Busan, 49201, Republic of Korea.
| | - Myeounggon Lee
- Department of Health and Human Performance, Center for Neuromotor and Biomechanics Research, University of Houston, Houston, TX, USA
| | - Byungjoo Noh
- Department of Kinesiology, Jeju National University, Jeju-si, Jeju-do, Republic of Korea
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13
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Filtjens B, Ginis P, Nieuwboer A, Afzal MR, Spildooren J, Vanrumste B, Slaets P. Modelling and identification of characteristic kinematic features preceding freezing of gait with convolutional neural networks and layer-wise relevance propagation. BMC Med Inform Decis Mak 2021; 21:341. [PMID: 34876110 PMCID: PMC8650332 DOI: 10.1186/s12911-021-01699-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/23/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although deep neural networks (DNNs) are showing state of the art performance in clinical gait analysis, they are considered to be black-box algorithms. In other words, there is a lack of direct understanding of a DNN's ability to identify relevant features, hindering clinical acceptance. Interpretability methods have been developed to ameliorate this concern by providing a way to explain DNN predictions. METHODS This paper proposes the use of an interpretability method to explain DNN decisions for classifying the movement that precedes freezing of gait (FOG), one of the most debilitating symptoms of Parkinson's disease (PD). The proposed two-stage pipeline consists of (1) a convolutional neural network (CNN) to model the reduction of movement present before a FOG episode, and (2) layer-wise relevance propagation (LRP) to visualize the underlying features that the CNN perceives as important to model the pathology. The CNN was trained with the sagittal plane kinematics from a motion capture dataset of fourteen PD patients with FOG. The robustness of the model predictions and learned features was further assessed on fourteen PD patients without FOG and fourteen age-matched healthy controls. RESULTS The CNN proved highly accurate in modelling the movement that precedes FOG, with 86.8% of the strides being correctly identified. However, the CNN model was unable to model the movement for one of the seven patients that froze during the protocol. The LRP interpretability case study shows that (1) the kinematic features perceived as most relevant by the CNN are the reduced peak knee flexion and the fixed ankle dorsiflexion during the swing phase, (2) very little relevance for FOG is observed in the PD patients without FOG and the healthy control subjects, and (3) the poor predictive performance of one subject is attributed to the patient's unique and severely flexed gait signature. CONCLUSIONS The proposed pipeline can aid clinicians in explaining DNN decisions in clinical gait analysis and aid machine learning practitioners in assessing the generalization of their models by ensuring that the predictions are based on meaningful kinematic features.
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Affiliation(s)
- Benjamin Filtjens
- Intelligent Mobile Platform Research Group, Department of Mechanical Engineering, KU Leuven, Andreas Vesaliusstraat 13, 3000, Leuven, Belgium.
- eMedia Research Lab/STADIUS, Department of Electrical Engineering (ESAT), KU Leuven, Andreas Vesaliusstraat 13, 3000, Leuven, Belgium.
| | - Pieter Ginis
- Research Group for Neurorehabilitation (eNRGy), Department of Rehabilitation Sciences, KU Leuven, Tervuursevest 101, 3001, Heverlee, Belgium
| | - Alice Nieuwboer
- Research Group for Neurorehabilitation (eNRGy), Department of Rehabilitation Sciences, KU Leuven, Tervuursevest 101, 3001, Heverlee, Belgium
| | - Muhammad Raheel Afzal
- Intelligent Mobile Platform Research Group, Department of Mechanical Engineering, KU Leuven, Andreas Vesaliusstraat 13, 3000, Leuven, Belgium
| | - Joke Spildooren
- Faculty of Rehabilitation Sciences, REVAL - Rehabilitation Research Center, Hasselt University, Agoralaan Building A, 3590, Diepenbeek, Belgium
| | - Bart Vanrumste
- eMedia Research Lab/STADIUS, Department of Electrical Engineering (ESAT), KU Leuven, Andreas Vesaliusstraat 13, 3000, Leuven, Belgium
| | - Peter Slaets
- Intelligent Mobile Platform Research Group, Department of Mechanical Engineering, KU Leuven, Andreas Vesaliusstraat 13, 3000, Leuven, Belgium
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14
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Shalin G, Pardoel S, Lemaire ED, Nantel J, Kofman J. Prediction and detection of freezing of gait in Parkinson's disease from plantar pressure data using long short-term memory neural-networks. J Neuroeng Rehabil 2021; 18:167. [PMID: 34838066 PMCID: PMC8626900 DOI: 10.1186/s12984-021-00958-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 11/10/2021] [Indexed: 11/10/2022] Open
Abstract
Background Freezing of gait (FOG) is a walking disturbance in advanced stage Parkinson’s disease (PD) that has been associated with increased fall risk and decreased quality of life. Freezing episodes can be mitigated or prevented with external intervention such as visual or auditory cues, activated by FOG prediction and detection systems. While most research on FOG detection and prediction has been based on inertial measurement unit (IMU) and accelerometer data, plantar-pressure data may capture subtle weight shifts unique to FOG episodes. Different machine learning algorithms have been used for FOG detection and prediction; however, long short-term memory (LSTM) deep learning methods hold an advantage when dealing with time-series data, such as sensor data. This research aimed to determine if LSTM can be used to detect and predict FOG from plantar pressure data alone, specifically for use in a real-time wearable system. Methods Plantar pressure data were collected from pressure-sensing insole sensors worn by 11 participants with PD as they walked a predefined freeze-provoking path. FOG instances were labelled, 16 features were extracted, and the dataset was balanced and normalized (z-score). The resulting datasets were classified using long short-term memory neural-network models. Separate models were trained for detection and prediction. For prediction models, data before FOG were included in the target class. Leave-one-freezer-out cross validation was used for model evaluation. In addition, the models were tested on all non-freezer data to determine model specificity. Results The best FOG detection model had 82.1% (SD 6.2%) mean sensitivity and 89.5% (SD 3.6%) mean specificity for one-freezer-held-out cross validation. Specificity improved to 93.3% (SD 4.0%) when ignoring inactive state data (standing) and analyzing the model only on active states (turning and walking). The model correctly detected 95% of freeze episodes. The best FOG prediction method achieved 72.5% (SD 13.6%) mean sensitivity and 81.2% (SD 6.8%) mean specificity for one-freezer-held-out cross validation. Conclusions Based on FOG data collected in a laboratory, the results suggest that plantar pressure data can be used for FOG detection and prediction. However, further research is required to improve FOG prediction performance, including training with a larger sample of people who experience FOG.
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Affiliation(s)
- Gaurav Shalin
- Department of Systems Design Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Scott Pardoel
- Department of Systems Design Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Edward D Lemaire
- Faculty of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Julie Nantel
- School of Human Kinetics, University of Ottawa, Ottawa, ON, Canada
| | - Jonathan Kofman
- Department of Systems Design Engineering, University of Waterloo, Waterloo, ON, Canada.
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15
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Zoetewei D, Herman T, Brozgol M, Ginis P, Thumm PC, Ceulemans E, Decaluwé E, Palmerini L, Ferrari A, Nieuwboer A, Hausdorff JM. Protocol for the DeFOG trial: A randomized controlled trial on the effects of smartphone-based, on-demand cueing for freezing of gait in Parkinson's disease. Contemp Clin Trials Commun 2021; 24:100817. [PMID: 34816053 PMCID: PMC8591418 DOI: 10.1016/j.conctc.2021.100817] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/22/2021] [Accepted: 06/27/2021] [Indexed: 12/16/2022] Open
Abstract
Background Freezing of gait (FOG) is a highly incapacitating symptom that affects many people with Parkinson's disease (PD). Cueing triggered upon real-time FOG detection (on-demand cueing) shows promise for FOG treatment. Yet, the feasibility of implementation and efficacy in daily life is still unknown. Therefore, this study aims to investigate the effectiveness of DeFOG: a smartphone and sensor-based on-demand cueing solution for FOG. Methods Sixty-two PD patients with FOG will be recruited for this single-blind, multi-center, randomized controlled phase II trial. Patients will be randomized into either the intervention group or the active control group. For four weeks, both groups will receive feedback about their physical activity using the wearable DeFOG system in daily life. In addition, the intervention group will also receive on-demand auditory cueing and instructions. Before and after the intervention, home-based assessments will be performed to evaluate the primary outcome, i.e., “percentage time frozen” during a FOG-provoking protocol. Secondary outcomes include the training effects on physical activity monitored over 7 days and the user-friendliness of the technology. Discussion The DeFOG trial will investigate the effectiveness of personalized on-demand cueing in a controlled design, delivered for 4 weeks in the patient's home environment. We anticipate that DeFOG will reduce FOG to a greater degree than in the control group and we will explore the impact of the intervention on physical activity levels. We expect to gain in-depth insight into whether and how patients control FOG using cueing methods in their daily lives. Trial registration Clinicaltrials.gov NCT03978507.
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Affiliation(s)
- Demi Zoetewei
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), Leuven, Belgium
| | - Talia Herman
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Marina Brozgol
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Pieter Ginis
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), Leuven, Belgium
| | - Pablo Cornejo Thumm
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Eva Ceulemans
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), Leuven, Belgium
| | - Eva Decaluwé
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), Leuven, Belgium
| | - Luca Palmerini
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, 40136, Bologna, Italy.,Health Sciences and Technologies-Interdepartmental Center for Industrial Research (CIRI-SDV), University of Bologna, 40126, Bologna, Italy
| | - Alberto Ferrari
- Department of Engineering "Enzo Ferrari" University of Modena and Reggio Emilia, Modena, Italy.,Science & Technology Park for Medicine, TPM, Democenter Foundation, Mirandola, Modena, Italy
| | - Alice Nieuwboer
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), Leuven, Belgium
| | - Jeffrey M Hausdorff
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sagol School of Neuroscience, Tel Aviv University, Israel.,Department of Physical Therapy, Sackler Faculty of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel.,Rush Alzheimer's Disease Center and Department of Orthopedic Surgery, Rush University, Chicago, IL, USA
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16
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Sweeney D, Quinlan LR, Richardson M, Meskell P, Cunnington AL, Rosenthal L, Luo L, ÓLaighin G. Multifaceted Sensory Electrical Stimulation cueing for Freezing of Gait in Parkinson's disease. Parkinsonism Relat Disord 2020; 82:106-108. [PMID: 33278753 DOI: 10.1016/j.parkreldis.2020.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Dean Sweeney
- Electrical & Electronic Engineering, School of Engineering, NUI Galway, University Road, Galway, H91 TK33, Ireland; Human Movement Laboratory, CÚRAM Centre for Research in Medical Devices, NUI Galway, University Road, Galway, H91 TK33, Ireland.
| | - Leo R Quinlan
- Human Movement Laboratory, CÚRAM Centre for Research in Medical Devices, NUI Galway, University Road, Galway, H91 TK33, Ireland; Physiology, School of Medicine, NUI Galway, University Road, Galway, H91 TK33, Ireland.
| | - Margaret Richardson
- Neurology Department, University Hospital Limerick, Dooradoyle, Limerick, V94 F858, Ireland.
| | - Pauline Meskell
- Department of Nursing and Midwifery, University of Limerick, Castletroy, Limerick, V94 T9PX, Ireland.
| | - Anne-Louise Cunnington
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, G12 8TA, United Kingdom.
| | - Lois Rosenthal
- Physiotherapy Department, Day Hospital, Queen Elizabeth University Hospital, Glasgow, Scotland, G51 4TF, United Kingdom.
| | - Lan Luo
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Gearóid ÓLaighin
- Electrical & Electronic Engineering, School of Engineering, NUI Galway, University Road, Galway, H91 TK33, Ireland; Human Movement Laboratory, CÚRAM Centre for Research in Medical Devices, NUI Galway, University Road, Galway, H91 TK33, Ireland.
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17
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Hardeman LES, Kal EC, Young WR, van der Kamp J, Ellmers TJ. Visuomotor control of walking in Parkinson's disease: Exploring possible links between conscious movement processing and freezing of gait. Behav Brain Res 2020; 395:112837. [PMID: 32739286 DOI: 10.1016/j.bbr.2020.112837] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/10/2020] [Accepted: 07/24/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Changes in visual attention have been argued to influence freezing of gait (FOG) in people with Parkinson's Disease (PD). However, the specific visual search patterns of people with FOG pathology (PD + FOG) and potential underlying mechanisms are not well understood. The current study explored visual search behavior in PD + FOG while walking on a pathway featuring environmental features known to exacerbate FOG (e.g., narrow doorway and tripping hazards). Potential underpinning attentional mechanisms were also assessed, such as conscious movement processing. METHODS Visual search behavior of twelve people with PD + FOG tested in ON-state (Mage = 74.3) and twelve age-matched healthy controls (Mage = 72.5) were analyzed during a complex walking task. The task required participants to step over an obstacle and navigate through a narrow doorway, surrounded by clutter. RESULTS People with PD + FOG more frequently directed visual attention to ongoing and imminent steps compared to healthy controls (Mdn = 26% vs Mdn = 14%, respectively; p = 0.042). Self-reported conscious movement processing was also significantly higher in people with PD + FOG. The one participant who froze during the walking task fixated the future trip hazard (obstacle, approximately 6 steps ahead) almost exclusively during freezing trials (i.e., 60-100% of the trial). In contrast, during 'non-freeze' trials, this participant increased the duration of fixations towards ongoing and imminent steps. CONCLUSION Results suggest that people with PD + FOG strongly monitor/control ongoing and immediately upcoming stepping movements. However, prolonged fixations towards threats to future movements might prevent people with PD + FOG from processing the visual information needed to do this, thereby provoke freezing episodes.
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Affiliation(s)
- L E S Hardeman
- Faculty of Behavioral and Movement Sciences, VU University Amsterdam, Netherlands; College of Health, Medicine and Life Sciences, Brunel University London, UK
| | - E C Kal
- College of Health, Medicine and Life Sciences, Brunel University London, UK; Centre for Cognitive Neuroscience, Brunel University London, UK
| | - W R Young
- College of Health, Medicine and Life Sciences, Brunel University London, UK; School of Sport and Health Sciences, University of Exeter, UK
| | - J van der Kamp
- Faculty of Behavioral and Movement Sciences, VU University Amsterdam, Netherlands
| | - T J Ellmers
- College of Health, Medicine and Life Sciences, Brunel University London, UK; Centre for Cognitive Neuroscience, Brunel University London, UK.
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18
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Filtjens B, Nieuwboer A, D'cruz N, Spildooren J, Slaets P, Vanrumste B. A data-driven approach for detecting gait events during turning in people with Parkinson's disease and freezing of gait. Gait Posture 2020; 80:130-136. [PMID: 32504940 DOI: 10.1016/j.gaitpost.2020.05.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 05/01/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Manual annotation of initial contact (IC) and end contact (EC) is a time consuming process. There are currently no robust techniques available to automate this process for Parkinson's disease (PD) patients with freezing of gait (FOG). OBJECTIVE To determine the validity of a data-driven approach for automated gait event detection. METHODS 15 freezers were asked to complete several straight-line and 360 degree turning trials in a 3D gait laboratory during the off-period of their medication cycle. Trials that contained a freezing episode were indicated as freezing trials (FOG) and trials without a freezing episode were termed as functional gait (FG). Furthermore, the highly varied gait data between onset and termination of a FOG episode was excluded. A Temporal Convolutional Neural network (TCN) was trained end-to-end with lower extremity kinematics. A Bland-Altman analysis was performed to evaluate the agreement between the results of the proposed model and the manual annotations. RESULTS For FOG-trials, F1 scores of 0.995 and 0.992 were obtained for IC and EC, respectively. For FG-trials, F1 scores of 0.997 and 0.999 were obtained for IC and EC, respectively. The Bland-Altman plots indicated excellent timing agreement, with on average 39% and 47% of the model predictions occurring within 10 ms from the manual annotations for FOG-trials and FG-trials, respectively. SIGNIFICANCE These results indicate that our data-driven approach for detecting gait events in PD patients with FOG is sufficiently accurate and reliable for clinical applications.
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Affiliation(s)
- Benjamin Filtjens
- eMedia Research Lab/STADIUS, Department of Electrical Engineering (ESAT), KU Leuven, Andreas Vesaliusstraat 13, 3000 Leuven, Belgium; Intelligent Mobile Platform Research Group, Department of Mechanical Engineering, KU Leuven, Andreas Vesaliusstraat 13, 3000 Leuven, Belgium.
| | - Alice Nieuwboer
- Research Group for Neurorehabilitation (eNRGy), Department of Rehabilitation Sciences, KU Leuven, Tervuursevest 101, 3001 Heverlee, Belgium
| | - Nicholas D'cruz
- Research Group for Neurorehabilitation (eNRGy), Department of Rehabilitation Sciences, KU Leuven, Tervuursevest 101, 3001 Heverlee, Belgium
| | - Joke Spildooren
- Rehabilitation Research Center (REVAL), Department of Rehabilitation Sciences, Hasselt University, Agoralaan Gebouw A, 3590 Diepenbeek, Belgium
| | - Peter Slaets
- Intelligent Mobile Platform Research Group, Department of Mechanical Engineering, KU Leuven, Andreas Vesaliusstraat 13, 3000 Leuven, Belgium
| | - Bart Vanrumste
- eMedia Research Lab/STADIUS, Department of Electrical Engineering (ESAT), KU Leuven, Andreas Vesaliusstraat 13, 3000 Leuven, Belgium
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19
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Sweeney D, ÓLaighin G, Richardson M, Meskell P, Rosenthal L, McGeough A, Cunnington AL, Quinlan LR. Effect of auditory, visual and somatosensory cueing strategies on On-State Freezing of Gait in Parkinson's disease. Parkinsonism Relat Disord 2020; 77:1-4. [PMID: 32563079 DOI: 10.1016/j.parkreldis.2020.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Dean Sweeney
- Electrical & Electronic Engineering, School of Engineering, NUI Galway, University Road, Galway, H91 TK33, Ireland; Human Movement Laboratory, CÚRAM Centre for Research in Medical Devices, NUI Galway, University Road, Galway, H91 TK33, Ireland.
| | - Gearóid ÓLaighin
- Electrical & Electronic Engineering, School of Engineering, NUI Galway, University Road, Galway, H91 TK33, Ireland; Human Movement Laboratory, CÚRAM Centre for Research in Medical Devices, NUI Galway, University Road, Galway, H91 TK33, Ireland.
| | - Margaret Richardson
- Neurology Department University Hospital Limerick, Dooradoyle, Limerick, V94 F858, Ireland.
| | - Pauline Meskell
- Department of Nursing and Midwifery, University of Limerick, Castletroy, Limerick, V94 T9PX, Ireland.
| | - Lois Rosenthal
- Physiotherapy Department, Day Hospital, Queen Elizabeth University Hospital, Glasgow, Scotland, G51 4TF, UK.
| | - Aimi McGeough
- Physiotherapy Department, Day Hospital, Stobhill Hospital, Glasgow, Scotland, G21 3UW, UK.
| | - Anne-Louise Cunnington
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, G12 8TA, UK.
| | - Leo R Quinlan
- Human Movement Laboratory, CÚRAM Centre for Research in Medical Devices, NUI Galway, University Road, Galway, H91 TK33, Ireland; Physiology, School of Medicine, NUI Galway, University Road, Galway, H91 TK33, Ireland.
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20
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Park H, Youm C, Lee M, Noh B, Cheon SM. Turning Characteristics of the More-Affected Side in Parkinson's Disease Patients with Freezing of Gait. SENSORS 2020; 20:s20113098. [PMID: 32486303 PMCID: PMC7309092 DOI: 10.3390/s20113098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 11/16/2022]
Abstract
This study investigated the turning characteristics of the more-affected limbs in Parkinson's disease (PD) patients in comparison with that of a control group, and in PD patients with freezing of gait (FOG; freezers) in comparison with those without FOG (non-freezers) for 360° and 540° turning tasks at the maximum speed. A total of 12 freezers, 12 non-freezers, and 12 controls participated in this study. The PD patients showed significantly longer total durations, shorter inner and outer step lengths, and greater anterior-posterior (AP) root mean square (RMS) center of mass (COM) distances compared to those for the controls. The freezers showed significantly greater AP and medial-lateral (ML) RMS COM distances compared to those of non-freezers. The turning task toward the inner step of the more-affected side (IMA) in PD patients showed significantly greater step width, total steps, and AP and ML RMS COM distances than that toward the outer step of the more-affected side (OMA). The corresponding results for freezers revealed significantly higher total steps and shorter inner step length during the 540° turn toward the IMA than that toward the OMA. Therefore, PD patients and freezers exhibited greater turning difficulty in performing challenging turning tasks such as turning with an increased angle and speed and toward the more-affected side.
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Affiliation(s)
- Hwayoung Park
- Biomechanics Laboratory, College of Health Sciences, Dong-A University, Busan 49315, Korea; (H.P.); (M.L.)
| | - Changhong Youm
- Biomechanics Laboratory, College of Health Sciences, Dong-A University, Busan 49315, Korea; (H.P.); (M.L.)
- Department of Healthcare and Science, College of Health Sciences, Dong-A University, Busan 49315, Korea;
- Correspondence: ; Tel.: +82-51-200-7830; Fax: +82-51-200-7505
| | - Myeounggon Lee
- Biomechanics Laboratory, College of Health Sciences, Dong-A University, Busan 49315, Korea; (H.P.); (M.L.)
| | - Byungjoo Noh
- Department of Healthcare and Science, College of Health Sciences, Dong-A University, Busan 49315, Korea;
| | - Sang-Myung Cheon
- Department of Neurology, School of Medicine, Dong-A University, Dongdaesin-dong 3-ga, Seo-gu, Busan 49315, Korea;
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21
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Janssen S, de Ruyter van Steveninck J, Salim HS, Cockx HM, Bloem BR, Heida T, van Wezel RJA. The Effects of Augmented Reality Visual Cues on Turning in Place in Parkinson's Disease Patients With Freezing of Gait. Front Neurol 2020; 11:185. [PMID: 32265826 PMCID: PMC7105859 DOI: 10.3389/fneur.2020.00185] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/25/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Turning in place is particularly bothersome for patients with Parkinson's disease (PD) experiencing freezing of gait (FOG). Cues designed to enforce goal-directed turning are not yet available. Objectives: Assess whether augmented reality (AR) visual cues improve FOG and turning in place in PD patients with FOG. Methods: Sixteen PD patients with FOG performed a series of 180° turns under an experimental condition with AR visual cues displayed through a HoloLens and two control conditions (one consisting of auditory cues and one without any cues). FOG episodes were annotated by two independent raters from video recordings. Motion data were measured with 17 inertial measurement units for calculating axial kinematics, scaling, and timing of turning. Results: AR visual cues did not reduce the percent time frozen (p = 0.73) or the number (p = 0.73) and duration (p = 0.78) of FOG episodes compared to the control condition without cues. All FOG parameters were higher with AR visual cues than with auditory cues [percent time frozen (p = 0.01), number (p = 0.02), and duration (p = 0.007) of FOG episodes]. The AR visual cues did reduce the peak angular velocity (visual vs. uncued p = 0.03; visual vs. auditory p = 0.02) and step height (visual vs. uncued p = 0.02; visual vs. auditory p = 0.007), and increased the step height coefficient of variation (visual vs. uncued p = 0.04; visual vs. auditory p = 0.01) and time to maximum head–pelvis separation (visual vs. uncued p = 0.02; visual vs. auditory p = 0.005), compared to both control conditions. Conclusions: The AR visual cues in this study did not reduce FOG, and worsened some measures of axial kinematics, and turn scaling and timing. Stimulating goal-directed turning might, by itself, be insufficient to reduce FOG and improve turning performance. Trial Registration: This study was registered in the Dutch trial registry (NTR6409; 2017-02-16).
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Affiliation(s)
- Sabine Janssen
- Biomedical Signals and Systems Group, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands.,Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, Netherlands
| | - Jaap de Ruyter van Steveninck
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Hizirwan S Salim
- Biomedical Signals and Systems Group, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands
| | - Helena M Cockx
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Bastiaan R Bloem
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, Netherlands
| | - Tjitske Heida
- Biomedical Signals and Systems Group, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands
| | - Richard J A van Wezel
- Biomedical Signals and Systems Group, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands.,Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
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22
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Prefrontal Cortical Activation With Open and Closed-Loop Tactile Cueing When Walking and Turning in Parkinson Disease: A Pilot Study. J Neurol Phys Ther 2020; 44:121-131. [DOI: 10.1097/npt.0000000000000286] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Ramos JB, Duarte GS, Bouça-Machado R, Fabbri M, Mestre TA, Costa J, Ramos TB, Ferreira JJ. The Role of Architecture and Design in the Management of Parkinson's Disease: A Systematic Review. JOURNAL OF PARKINSON'S DISEASE 2020; 10:1301-1314. [PMID: 32804100 PMCID: PMC7683074 DOI: 10.3233/jpd-202035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/06/2020] [Indexed: 12/04/2022]
Abstract
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.
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Affiliation(s)
- Joana Beisl Ramos
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Serviço de Anestesiologia, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Gonçalo S. Duarte
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa.
Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal
| | - Raquel Bouça-Machado
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa.
Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal
- CNS –Campus Neurológico Sénior, Torres Vedras, Portugal
| | - Margherita Fabbri
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa.
Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal
- Department of Neuroscience Rita Levi Montalcini, University of Torino, Turin, Italy
| | - Tiago A. Mestre
- Department of Medicine, Parkinson’s Disease and Movement Disorders Center, Division of Neurology, The Ottawa Hospital Research Institute, University of Ottawa Brain and Mind Institute, Ottawa, Ontario, Canada
| | - João Costa
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa.
Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal
| | - Tânia Beisl Ramos
- Centro de Investigação em Arquitetura, Urbanismo e Design (CIAUD), Faculdade de Arquitetura, Universidade de Lisboa, Lisbon, Portugal
| | - Joaquim J. Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa.
Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal
- CNS –Campus Neurológico Sénior, Torres Vedras, Portugal
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24
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A turn for the worse: Turning performance in Parkinson's disease and Essential tremor. Clin Biomech (Bristol, Avon) 2019; 70:245-248. [PMID: 31669958 DOI: 10.1016/j.clinbiomech.2019.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/24/2019] [Accepted: 09/22/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Turning is an activity of daily living known to elicit falls in older adults and particularly in persons with movement disorders. Specifically, those with Parkinson's disease have marked impairments in forward walking and turning. Although recent work has identified gait impairment in those with Essential tremor, turning has not been extensively evaluated. As the cerebellum is key in the pathophysiology of Essential tremor, complex tasks like turning, may be impaired for this population. The purpose of this study was to investigate turning behavior and falls in those with Essential tremor and Parkinson's disease. METHODS 15 persons with Essential tremor and 15 persons with Parkinson's disease performed forward walking and turns on an instrumented walkway. t-tests compared groups and a regression was performed to predict fall frequency. FINDINGS During turning, those with Essential tremor had lower cadence (p = .042) and took more time (p = .05). No other variables, including forward walking variables, differed between groups. When pooling groups, the significant fall frequency predictor model (p = .003) included decreased forward cadence, increased turning cadence, and female sex. Overall, the model explained 40.7% of the variance. INTERPRETATION While forward gait performance was similar between groups, those with Essential tremor had increased turn time, a measure often associated with turning impairment. Together, these results suggest overall gait impairment in Essential tremor is more prevalent than recognized. Walking performance, both turning and forward, and sex were predictive of fall frequency. Therapeutic interventions in these populations should include both forward walking and turns to mitigate fall risk.
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25
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Corzani M, Ferrari A, Ginis P, Nieuwboer A, Chiari L. Motor Adaptation in Parkinson's Disease During Prolonged Walking in Response to Corrective Acoustic Messages. Front Aging Neurosci 2019; 11:265. [PMID: 31607899 PMCID: PMC6769108 DOI: 10.3389/fnagi.2019.00265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 09/10/2019] [Indexed: 11/13/2022] Open
Abstract
Wearable sensing technology is a new way to deliver corrective feedback. It is highly applicable to gait rehabilitation for persons with Parkinson’s disease (PD) because feedback potentially engages spared neural function. Our study characterizes participants’ motor adaptation to feedback signaling a deviation from their normal cadence during prolonged walking, providing insight into possible novel therapeutic devices for gait re-training. Twenty-eight persons with PD (15 with freezing, 13 without) and 13 age-matched healthy elderly (HE) walked for two 30-minute sessions. When their cadence varied, they heard either intelligent cueing (IntCue: bouts of ten beats indicating normal cadence) or intelligent feedback (IntFB: verbal instruction to increase or decrease cadence). We created a model that compares the effectiveness of the two conditions by quantifying the number of steps needed to return to the target cadence for every deviation. The model fits the short-term motor responses to the external step inputs (collected with wearable sensors). We found some significant difference in motor adaptation among groups and subgroups for the IntCue condition only. Both conditions were instead able to identify different types of responders among persons with PD, although showing opposite trends in their speed of adaptation. Increasing rather than decreasing the pace appeared to be more difficult for both groups. In fact, under IntFB the PD group required about seven steps to increase their cadence, whereas they only needed about three steps to decrease their cadence. However, it is important to note that this difference was not significant; perhaps future work could include more participants and/or more sessions, increasing the total number of deviations for analysis. Notably, a significant negative correlation, r = −0.57 (p-value = 0.008), was found between speed of adaptation and number of deviations during IntCue, but not during IntFB, suggesting that, for people who struggle with gait, such as those with PD, verbal instructions rather than metronome beats might be more effective at restoring normal cadence. Clinicians and biofeedback developers designing novel therapeutic devices could apply our findings to determine the optimal timing for corrective feedback, optimizing gait rehabilitation while minimizing the risk of cue-dependency.
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Affiliation(s)
- Mattia Corzani
- Department of Electrical, Electronic, and Information Engineering, University of Bologna, Bologna, Italy
| | - Alberto Ferrari
- Department of Electrical, Electronic, and Information Engineering, University of Bologna, Bologna, Italy
| | - Pieter Ginis
- Department of Rehabilitation Sciences, Neurorehabilitation Research Group, KU Leuven, Leuven, Belgium
| | - Alice Nieuwboer
- Department of Rehabilitation Sciences, Neurorehabilitation Research Group, KU Leuven, Leuven, Belgium
| | - Lorenzo Chiari
- Department of Electrical, Electronic, and Information Engineering, University of Bologna, Bologna, Italy
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26
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Müller MLTM, Marusic U, van Emde Boas M, Weiss D, Bohnen NI. Treatment options for postural instability and gait difficulties in Parkinson's disease. Expert Rev Neurother 2019; 19:1229-1251. [PMID: 31418599 DOI: 10.1080/14737175.2019.1656067] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Introduction: Gait and balance disorders in Parkinson's disease (PD) represent a major therapeutic challenge as frequent falls and freezing of gait impair quality of life and predict mortality. Limited dopaminergic therapy responses implicate non-dopaminergic mechanisms calling for alternative therapies.Areas covered: The authors provide a review that encompasses pathophysiological changes involved in axial motor impairments in PD, pharmacological approaches, exercise, and physical therapy, improving physical activity levels, invasive and non-invasive neurostimulation, cueing interventions and wearable technology, and cognitive interventions.Expert opinion: There are many promising therapies available that, to a variable degree, affect gait and balance disorders in PD. However, not one therapy is the 'silver bullet' that provides full relief and ultimately meaningfully improves the patient's quality of life. Sedentariness, apathy, and emergence of frailty in advancing PD, especially in the setting of medical comorbidities, are perhaps the biggest threats to experience sustained benefits with any of the available therapeutic options and therefore need to be aggressively treated as early as possible. Multimodal or combination therapies may provide complementary benefits to manage axial motor features in PD, but selection of treatment modalities should be tailored to the individual patient's needs.
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Affiliation(s)
- Martijn L T M Müller
- Functional Neuroimaging, Cognitive and Mobility Laboratory, Department of Radiology, University of Michigan, Ann Arbor, MI, USA.,Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI, USA
| | - Uros Marusic
- Institute for Kinesiology Research, Science and Research Centre of Koper, Koper, Slovenia.,Department of Health Sciences, Alma Mater Europaea - ECM, Maribor, Slovenia
| | - Miriam van Emde Boas
- Functional Neuroimaging, Cognitive and Mobility Laboratory, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Daniel Weiss
- Centre for Neurology, Department for Neurodegenerative Diseases and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Nicolaas I Bohnen
- Functional Neuroimaging, Cognitive and Mobility Laboratory, Department of Radiology, University of Michigan, Ann Arbor, MI, USA.,Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI, USA.,Geriatric Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Neurology, University of Michigan, Ann Arbor, USA
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27
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Serrao M, Pierelli F, Sinibaldi E, Chini G, Castiglia SF, Priori M, Gimma D, Sellitto G, Ranavolo A, Conte C, Bartolo M, Monari G. Progressive Modular Rebalancing System and Visual Cueing for Gait Rehabilitation in Parkinson's Disease: A Pilot, Randomized, Controlled Trial With Crossover. Front Neurol 2019; 10:902. [PMID: 31543859 PMCID: PMC6730596 DOI: 10.3389/fneur.2019.00902] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 08/05/2019] [Indexed: 12/11/2022] Open
Abstract
Introduction: The progressive modular rebalancing (PMR) system is a comprehensive rehabilitation approach derived from proprioceptive neuromuscular facilitation principles. PMR training encourages focus on trunk and proximal muscle function through direct perception, strength, and stretching exercises and emphasizes bi-articular muscle function in the improvement of gait performance. Sensory cueing, such as visual cues (VC), is one of the more established techniques for gait rehabilitation in PD. In this study, we propose PMR combined with VC for improving gait performance, balance, and trunk control during gait in patients with PD. Our assumption herein was that the effect of VC may add to improved motor performance induced by the PMR treatment. The primary aim of this study was to evaluate whether the PMR system plus VC was a more effective treatment option than standard physiotherapy in improving gait function in patients with PD. The secondary aim of the study was to evaluate the effect of this treatment on motor function severity. Design: Two-center, randomized, controlled, observer-blind, crossover study with a 4-month washout period. Participants: Forty individuals with idiopathic PD in Hoehn and Yahr stages 1–4. Intervention: Eight-week rehabilitation programs consisting of PMR plus VC (treatment A) and conventional physiotherapy (treatment B). Primary outcome measures: Spatiotemporal gait parameters, joint kinematics, and trunk kinematics. Secondary outcome measures: UPDRS-III scale scores. Results: The rehabilitation program was well-tolerated by individuals with PD and most participants showed improvements in gait variables and UPDRS-III scores with both treatments. However, patients who received PMR with VC showed better results in gait function with regard to gait performance (increased step length, gait speed, and joint kinematics), gait balance (increased step width and double support duration), and trunk control (increased trunk motion) than those receiving conventional physiotherapy. While crossover results revealed some differences in primary outcomes, only 37.5% of patients crossed over between the groups. As a result, our findings should be interpreted cautiously. Conclusions: The PMR plus VC program could be used to improve gait function and severity motor of motor deficit in individuals with PD. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03346265.
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Affiliation(s)
- Mariano Serrao
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy.,Movement Analysis Laboratory, Policlinico Italia, Rome, Italy
| | - Francesco Pierelli
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli, Italy
| | - Elisabetta Sinibaldi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Giorgia Chini
- Movement Analysis Laboratory, Policlinico Italia, Rome, Italy
| | - Stefano Filippo Castiglia
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Marina Priori
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy.,Movement Analysis Laboratory, Policlinico Italia, Rome, Italy
| | - Dario Gimma
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Giovanni Sellitto
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Alberto Ranavolo
- Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, INAIL, Rome, Italy
| | | | - Michelangelo Bartolo
- Neurorehabilitation Unit, Department of Rehabilitation, HABILITA Zingonia, Bergamo, Italy
| | - Giuseppe Monari
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
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28
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Gómez-González J, Martín-Casas P, Cano-de-la-Cuerda R. Effects of auditory cues on gait initiation and turning in patients with Parkinson's disease. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2018.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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29
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Gómez-González J, Martín-Casas P, Cano-de-la-Cuerda R. Efectos de los estímulos auditivos en la fase de iniciación de la marcha y de giro en pacientes con enfermedad de Parkinson. Neurologia 2019; 34:396-407. [DOI: 10.1016/j.nrl.2016.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/05/2016] [Accepted: 10/13/2016] [Indexed: 10/20/2022] Open
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30
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Godi M, Giardini M, Schieppati M. Walking Along Curved Trajectories. Changes With Age and Parkinson's Disease. Hints to Rehabilitation. Front Neurol 2019; 10:532. [PMID: 31178816 PMCID: PMC6543918 DOI: 10.3389/fneur.2019.00532] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/03/2019] [Indexed: 01/11/2023] Open
Abstract
In this review, we briefly recall the fundamental processes allowing us to change locomotion trajectory and keep walking along a curved path and provide a review of contemporary literature on turning in older adults and people with Parkinson's Disease (PD). The first part briefly summarizes the way the body exploits the physical laws to produce a curved walking trajectory. Then, the changes in muscle and brain activation underpinning this task, and the promoting role of proprioception, are briefly considered. Another section is devoted to the gait changes occurring in curved walking and steering with aging. Further, freezing during turning and rehabilitation of curved walking in patients with PD is mentioned in the last part. Obviously, as the research on body steering while walking or turning has boomed in the last 10 years, the relevant critical issues have been tackled and ways to improve this locomotor task proposed. Rationale and evidences for successful training procedures are available, to potentially reduce the risk of falling in both older adults and patients with PD. A better understanding of the pathophysiology of steering, of the subtle but vital interaction between posture, balance, and progression along non-linear trajectories, and of the residual motor learning capacities in these cohorts may provide solid bases for new rehabilitative approaches.
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Affiliation(s)
- Marco Godi
- Division of Physical Medicine and Rehabilitation, ICS Maugeri SPA SB, Pavia, Italy
| | - Marica Giardini
- Division of Physical Medicine and Rehabilitation, ICS Maugeri SPA SB, Pavia, Italy
| | - Marco Schieppati
- Department of Exercise and Sport Science, International University of Health, Exercise and Sports, LUNEX University, Differdange, Luxembourg
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31
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Which Gait Parameters and Walking Patterns Show the Significant Differences Between Parkinson's Disease and Healthy Participants? BIOSENSORS-BASEL 2019; 9:bios9020059. [PMID: 31027153 PMCID: PMC6627461 DOI: 10.3390/bios9020059] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 04/16/2019] [Accepted: 04/22/2019] [Indexed: 02/08/2023]
Abstract
This study investigated the difference in the gait of patients with Parkinson’s disease (PD), age-matched controls and young controls during three walking patterns. Experiments were conducted with 24 PD, 24 age-matched controls and 24 young controls, and four gait intervals were measured using inertial measurement units (IMU). Group differences between the mean and variance of the gait parameters (stride interval, stance interval, swing interval and double support interval) for the three groups were calculated and statistical significance was tested. The results showed that the variance in each of the four gait parameters of PD patients was significantly higher compared with the controls, irrespective of the three walking patterns. This study showed that the variance of any of the gait interval parameters obtained using IMU during any of the walking patterns could be used to differentiate between the gait of PD and control people.
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32
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Sweeney D, Quinlan LR, Browne P, Richardson M, Meskell P, ÓLaighin G. A Technological Review of Wearable Cueing Devices Addressing Freezing of Gait in Parkinson's Disease. SENSORS 2019; 19:s19061277. [PMID: 30871253 PMCID: PMC6470562 DOI: 10.3390/s19061277] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/01/2019] [Accepted: 03/03/2019] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Dean Sweeney
- Electrical & Electronic Engineering, School of Engineering and Informatics, NUI Galway, University Road, H91 TK33 Galway, Ireland.
- Human Movement Laboratory, CÚRAM Centre for Research in Medical Devices, NUI Galway, University Road, H91 TK33 Galway, Ireland.
| | - Leo R Quinlan
- Human Movement Laboratory, CÚRAM Centre for Research in Medical Devices, NUI Galway, University Road, H91 TK33 Galway, Ireland.
- Physiology, School of Medicine, NUI Galway, University Road, H91 TK33 Galway, Ireland.
| | - Patrick Browne
- Neurology Department, University Hospital Galway, H91 YR71 Galway, Ireland.
- School of Nursing and Midwifery, NUI Galway, University Road, H91 TK33 Galway, Ireland.
- School of Medicine, NUI Galway, University Road, H91 TK33 Galway, Ireland.
| | - Margaret Richardson
- Neurology Department University Hospital Limerick, Dooradoyle, V94 F858 Limerick, Ireland.
| | - Pauline Meskell
- Department of Nursing and Midwifery University of Limerick, Castletroy, V94 T9PX Limerick, Ireland.
| | - Gearóid ÓLaighin
- Electrical & Electronic Engineering, School of Engineering and Informatics, NUI Galway, University Road, H91 TK33 Galway, Ireland.
- Human Movement Laboratory, CÚRAM Centre for Research in Medical Devices, NUI Galway, University Road, H91 TK33 Galway, Ireland.
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Fernandez L, Huys R, Issartel J, Azulay JP, Eusebio A. Movement Speed-Accuracy Trade-Off in Parkinson's Disease. Front Neurol 2018; 9:897. [PMID: 30405521 PMCID: PMC6208126 DOI: 10.3389/fneur.2018.00897] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/03/2018] [Indexed: 11/24/2022] Open
Abstract
Patients with Parkinson's disease (PD) often have difficulties generating rhythmic movements, and also difficulties on movement adjustments to accuracy constraints. In the reciprocal aiming task, maintaining a high accuracy comes with the cost of diminished movement speed, whereas increasing movement speed disrupts end-point accuracy, a phenomenon well known as the speed-accuracy trade-off. The aim of this study was to examine how PD impacts speed-accuracy trade-off during rhythmic aiming movements by studying the structural kinematic movement organization and to determine the influence of dopamine replacement therapy on continuous movement speed and accuracy. Eighteen patients with advanced idiopathic Parkinson's disease performed a reciprocal aiming task, where the difficulty of the task was manipulated through target width. All patients were tested in two different sessions: ON-medication and OFF-medication state. A control group composed of healthy age-matched participants was also included in the study. The following variables were used for the analyses: Movement time, Error rate, effective target width, and Performance Index. Percentage of acceleration time and percentage of non-linearity were completed with kinematics patterns description using Rayleigh-Duffing model. Both groups traded off speed against accuracy as the constraints pertaining to the latter increased. The trade-off was more pronounced with the PD patients. Dopamine therapy allowed the PD patients to move faster, but at the cost of movement accuracy. Surprisingly, the structural kinematic organization did not differ across group nor across medication condition. These results suggest that PD patients, when involved in a reciprocal aiming task, are able to produce rhythmic movements. PD patients' overall slowing down seems to reflect a global adaptation to the disease in the absence of a structurally altered kinematic organization.
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Affiliation(s)
| | - Raoul Huys
- Université de Toulouse, UMR 5549 CERCO (Centre de Recherche Cerveau et Cognition), UPS, CNRS, Toulouse, France
| | - Johann Issartel
- Multisensory Motor Learning Lab, School of Health and Human Performance, Dublin City University, Dublin, Ireland
| | - Jean-Philippe Azulay
- Aix-Marseille Université, APHM, CHU Timone, Department of Neurology and Movement Disorders, Marseille, France
| | - Alexandre Eusebio
- Aix-Marseille Université, APHM, CHU Timone, Department of Neurology and Movement Disorders, Marseille, France.,Aix-Marseille Université, CNRS, UMR 7289, Institut de Neurosciences de la Timone, Marseille, France
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Mancini M, Smulders K, Harker G, Stuart S, Nutt JG. Assessment of the ability of open- and closed-loop cueing to improve turning and freezing in people with Parkinson's disease. Sci Rep 2018; 8:12773. [PMID: 30143726 PMCID: PMC6109152 DOI: 10.1038/s41598-018-31156-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 08/13/2018] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Martina Mancini
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, OP-32, 97239, Portland, OR, USA.
| | - Katrijn Smulders
- Sint Maartenskliniek, Research Department, PO Box 9011, 6500 GM, Nijmegen, The Netherlands
| | - Graham Harker
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, OP-32, 97239, Portland, OR, USA
| | - Samuel Stuart
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, OP-32, 97239, Portland, OR, USA
| | - John G Nutt
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, OP-32, 97239, Portland, OR, USA
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Sensory Electrical Stimulation Cueing May Reduce Freezing of Gait Episodes in Parkinson's Disease. JOURNAL OF HEALTHCARE ENGINEERING 2018; 2018:4684925. [PMID: 30154990 PMCID: PMC6092973 DOI: 10.1155/2018/4684925] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 05/25/2018] [Accepted: 06/26/2018] [Indexed: 11/18/2022]
Abstract
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.
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Spildooren J, Vinken C, Van Baekel L, Nieuwboer A. Turning problems and freezing of gait in Parkinson’s disease: a systematic review and meta-analysis. Disabil Rehabil 2018; 41:2994-3004. [DOI: 10.1080/09638288.2018.1483429] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Joke Spildooren
- REVAL – Rehabilitation Research Center, BIOMED – Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Cathérine Vinken
- REVAL – Rehabilitation Research Center, BIOMED – Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Laura Van Baekel
- REVAL – Rehabilitation Research Center, BIOMED – Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Alice Nieuwboer
- Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation, KU Leuven, Leuven, Belgium
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Dantas IV, Leal JC, Hilgert LS, Allegretti ALC, Dos Santos Mendes FA. Training healthy persons and individuals with Parkinson's disease to use Xbox Kinect games: a preliminary study. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2018. [DOI: 10.12968/ijtr.2018.25.6.280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Bekkers EMJ, Dockx K, Devan S, Van Rossom S, Verschueren SMP, Bloem BR, Nieuwboer A. The Impact of Dual-Tasking on Postural Stability in People With Parkinson’s Disease With and Without Freezing of Gait. Neurorehabil Neural Repair 2018; 32:166-174. [DOI: 10.1177/1545968318761121] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Esther M. J. Bekkers
- KU Leuven, Leuven, Belgium
- Radboud University Medical Center, Nijmegen, the Netherlands
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Son M, Cheon SM, Youm C, Kim Y, Kim JW. Impacts of freezing of gait on forward and backward gait in Parkinson's disease. Gait Posture 2018; 61:320-324. [PMID: 29413804 DOI: 10.1016/j.gaitpost.2018.01.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 11/14/2017] [Accepted: 01/28/2018] [Indexed: 02/02/2023]
Abstract
Freezing of gait (FOG) is a major risk factor for falls and fall-related injuries in patients with Parkinson's disease (PD). The characteristics of gait in PD patients with FOG have been studied but remain controversial. To investigate gait characteristics of FOG in PD, this study analyzed the forward and backward walking of patients with PD. Twenty-six patients with PD were recruited [age: 71.0 ± 6.2 years, Hoehn and Yahr stage: 2-3 (median 2.5)]. Based on responses to the New Freezing of Gait Questionnaire, we classified patients into either the "freezer" or "non-freezer" group. Spatiotemporal and kinematic analyses of forward and backward walking were completed using a three-dimensional motion analysis system over an 8 m walkway in the defined "off" state. There was no difference in demographic and clinical characteristics between the freezers (n = 10) and non-freezers (n = 16). Analysis of forward walking revealed no between-group differences, except for faster walking speed among the non-freezers. During backward walking, the freezers exhibited slower walking speed, shorter stride length, and increased asymmetry of step length. Kinematic analysis of backward walking revealed smaller range of motion in hip and ankle joints and lower step height in freezers. Further investigations of backward walking might expand our understanding of the pathophysiology of FOG in patients with PD.
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Affiliation(s)
- Minji Son
- Biomechanics Laboratory, College of Health Sciences, Dong-A University, Busan, Republic of Korea
| | - Sang-Myung Cheon
- Department of Neurology, School of Medicine, Dong-A University, Busan, Republic of Korea.
| | - Changhong Youm
- Department of Health Care and Science, College of Health Sciences, Dong-A University, Busan, Republic of Korea
| | - Youkyung Kim
- Biomechanics Laboratory, College of Health Sciences, Dong-A University, Busan, Republic of Korea
| | - Jae Woo Kim
- Department of Neurology, School of Medicine, Dong-A University, Busan, Republic of Korea
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Altered effective connectivity contributes to micrographia in patients with Parkinson’s disease and freezing of gait. J Neurol 2017; 265:336-347. [DOI: 10.1007/s00415-017-8709-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/08/2017] [Accepted: 12/09/2017] [Indexed: 02/06/2023]
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Son M, Youm C, Cheon S, Kim J, Lee M, Kim Y, Kim J, Sung H. Evaluation of the turning characteristics according to the severity of Parkinson disease during the timed up and go test. Aging Clin Exp Res 2017; 29:1191-1199. [PMID: 28220396 DOI: 10.1007/s40520-016-0719-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 12/22/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Patients with Parkinson disease (PD) experience problems such as falls and freezing of gait during walking and turning in daily activities. However, few studies have examined the relationship between simultaneous turning tasks and the severity of PD. AIM To investigate turning characteristics in patients with PD using three-dimensional (3D) analysis during the timed up and go (TUG) test. METHODS Thirty individuals performed the TUG test under 3D motion analysis: 10 patients with Hoehn and Yahr (H&Y) stages 2.5 and 3.0 PD (group I), 10 patients with H&Y stage 2.0 PD (group II), and 10 healthy older adult controls. Spatiotemporal and kinematic variables were analyzed during the TUG test with a Vicon 3-D motion analysis system. RESULTS The walking speed, step length, step length asymmetry index, range of motion of the hip, knee, and shoulder joints, and foot clearance height significantly differed between patients with PD and the controls. The step length and foot clearance height were significantly different between groups I and II. DISCUSSION The step length and foot clearance are different between the severity levels of PD, and the TUG test may be useful for identifying turning characteristics in patients with PD. CONCLUSIONS Patients with PD exhibited significant differences in all variables of interest compared to the controls. The step length and foot clearance height as well as the TUG test during the turning phase may be helpful for measuring turning in patients with different severity levels of PD.
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A Mechanical Sensor Designed for Dynamic Joint Angle Measurement. JOURNAL OF HEALTHCARE ENGINEERING 2017; 2017:8465212. [PMID: 29065653 PMCID: PMC5390652 DOI: 10.1155/2017/8465212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 01/14/2017] [Accepted: 01/30/2017] [Indexed: 11/18/2022]
Abstract
Background. The measurement of the functional range of motion (FROM) of lower limb joints is an essential parameter for gait analysis especially in evaluating rehabilitation programs. Aim. To develop a simple, reliable, and affordable mechanical goniometer (MGR) for gait analysis, with six-degree freedom to dynamically assess lower limb joint angles. Design. Randomized control trials, in which a new MGR was developed for the measurements of FROM of lower limb joints. Setting. Reliability of the designed MGR was evaluated and validated by a motion analysis system (MAS). Population. Thirty healthy subjects participated in this study. Methods. Reliability and validity of the new MGR were tested by intraclass correlation coefficient (ICC), Bland-Altman plots, and linear correlation analysis. Results. The MGR has good inter- and intrarater reliability and validity with ICC ≥ 0.93 (for both). Moreover, measurements made by MGR and MAS were comparable and repeatable with each other, as confirmed by Bland-Altman plots. Furthermore, a very high degree of linear correlation (R ≥ 0.92 for all joint angle measurements) was found between the lower limb joint angles measured by MGR and MAS. Conclusion. A simple, reliable, and affordable MGR has been designed and developed to aid clinical assessment and treatment evaluation of gait disorders.
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Cueing for people with Parkinson's disease with freezing of gait: A narrative review of the state-of-the-art and novel perspectives. Ann Phys Rehabil Med 2017; 61:407-413. [PMID: 28890341 DOI: 10.1016/j.rehab.2017.08.002] [Citation(s) in RCA: 163] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 08/17/2017] [Accepted: 08/17/2017] [Indexed: 11/20/2022]
Abstract
Freezing, which manifests during gait and other movements, is an incapacitating motor symptom experienced by many patients with Parkinson's disease (PD). In rehabilitation, auditory and visual cueing methods are commonly applied to evoke a more goal-directed type of motor control and, as such, reduce freezing severity in patients with PD. In this narrative review, we summarize the current evidence regarding the effects of external cueing in patients with PD with freezing of gait (FOG) and provide suggestions on how to further improve cueing effectiveness with emerging technological developments. For this paper, we reviewed 24 articles describing the assessment of the effects of cues in patients with FOG (n=354). Because these studies mostly involved quasi-experimental designs, no methodological analysis was undertaken. In general, the evidence suggests that cue-augmented training can reduce FOG severity, improve gait parameters and improve upper-limb movements immediately after training. However, findings were not univocal, and long-term consolidation and transfer of the effects appear to be hampered specifically in this subgroup. With the increasing use of wearable technology, new possibilities are allowing for adapting the cue type, cue content and dose of cues to the needs of individual patients, which may boost the clinical use and efficiency of cued training in PD patients with FOG.
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Claesson IM, Ståhle A, Lökk J, Grooten WJA. Somatosensory Focused Balance Training without cues can improve balance and gait in early Parkinson’s disease – a randomised pilot study. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2017. [DOI: 10.1080/21679169.2017.1363284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Ingrid M. Claesson
- Functional Area Occupational therapy and Physiotherapy, Allied Health Professionals Function, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Agneta Ståhle
- Functional Area Occupational therapy and Physiotherapy, Allied Health Professionals Function, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Johan Lökk
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Department of Geriatric Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Wilhelmus J. A. Grooten
- Functional Area Occupational therapy and Physiotherapy, Allied Health Professionals Function, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
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External input for gait in people with Parkinson’s disease with and without freezing of gait: One size does not fit all. J Neurol 2017; 264:1488-1496. [DOI: 10.1007/s00415-017-8552-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/15/2017] [Accepted: 06/19/2017] [Indexed: 10/19/2022]
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Janssen S, Bolte B, Nonnekes J, Bittner M, Bloem BR, Heida T, Zhao Y, van Wezel RJA. Usability of Three-dimensional Augmented Visual Cues Delivered by Smart Glasses on (Freezing of) Gait in Parkinson's Disease. Front Neurol 2017; 8:279. [PMID: 28659862 PMCID: PMC5468397 DOI: 10.3389/fneur.2017.00279] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 05/29/2017] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Sabine Janssen
- Biomedical Signal and Systems Group, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands.,Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Benjamin Bolte
- Biomedical Signal and Systems Group, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands
| | - Jorik Nonnekes
- Biomedical Signal and Systems Group, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands.,Department of Rehabilitation, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marian Bittner
- Biomedical Signal and Systems Group, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands
| | - Bastiaan R Bloem
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Tjitske Heida
- Biomedical Signal and Systems Group, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands
| | - Yan Zhao
- Biomedical Signal and Systems Group, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands
| | - Richard J A van Wezel
- Biomedical Signal and Systems Group, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands.,Department of Biophysics, Donders Institute of Brain, Cognition and Behavior, Radboud University, Nijmegen, Netherlands
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Ginis P, Heremans E, Ferrari A, Dockx K, Canning CG, Nieuwboer A. Prolonged Walking with a Wearable System Providing Intelligent Auditory Input in People with Parkinson's Disease. Front Neurol 2017; 8:128. [PMID: 28428770 PMCID: PMC5382170 DOI: 10.3389/fneur.2017.00128] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 03/20/2017] [Indexed: 11/13/2022] Open
Abstract
Rhythmic auditory cueing is a well-accepted tool for gait rehabilitation in Parkinson's disease (PD), which can now be applied in a performance-adapted fashion due to technological advance. This study investigated the immediate differences on gait during a prolonged, 30 min, walk with performance-adapted (intelligent) auditory cueing and verbal feedback provided by a wearable sensor-based system as alternatives for traditional cueing. Additionally, potential effects on self-perceived fatigue were assessed. Twenty-eight people with PD and 13 age-matched healthy elderly (HE) performed four 30 min walks with a wearable cue and feedback system. In randomized order, participants received: (1) continuous auditory cueing; (2) intelligent cueing (10 metronome beats triggered by a deviating walking rhythm); (3) intelligent feedback (verbal instructions triggered by a deviating walking rhythm); and (4) no external input. Fatigue was self-scored at rest and after walking during each session. The results showed that while HE were able to maintain cadence for 30 min during all conditions, cadence in PD significantly declined without input. With continuous cueing and intelligent feedback people with PD were able to maintain cadence (p = 0.04), although they were more physically fatigued than HE. Furthermore, cadence deviated significantly more in people with PD than in HE without input and particularly with intelligent feedback (both: p = 0.04). In PD, continuous and intelligent cueing induced significantly less deviations of cadence (p = 0.006). Altogether, this suggests that intelligent cueing is a suitable alternative for the continuous mode during prolonged walking in PD, as it induced similar effects on gait without generating levels of fatigue beyond that of HE.
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Affiliation(s)
- Pieter Ginis
- Neuromotor Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Elke Heremans
- Neuromotor Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Alberto Ferrari
- Department of Electrical, Electronic and Information Engineering - Guglielmo Marconi, University of Bologna, Bologna, Italy
| | - Kim Dockx
- Neuromotor Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Colleen G Canning
- Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Alice Nieuwboer
- Neuromotor Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
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Influence of Cueing and an Attentional Strategy on Freezing of Gait in Parkinson Disease During Turning. J Neurol Phys Ther 2017; 41:129-135. [DOI: 10.1097/npt.0000000000000178] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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49
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Young WR, Shreve L, Quinn EJ, Craig C, Bronte-Stewart H. Auditory cueing in Parkinson's patients with freezing of gait. What matters most: Action-relevance or cue-continuity? Neuropsychologia 2016; 87:54-62. [DOI: 10.1016/j.neuropsychologia.2016.04.034] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 04/22/2016] [Accepted: 04/28/2016] [Indexed: 11/27/2022]
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50
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Walking Turns in Parkinson's Disease Patients with Freezing of Gait: The Short-term Effects of Different Cueing Strategies. INT J GERONTOL 2016. [DOI: 10.1016/j.ijge.2014.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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