Measuring gait and gait-related activities in Parkinson's patients own home environment: a reliability, responsiveness and feasibility study

The effect of a home-based exercise program on gait characteristics in an individual with Parkinson's disease over a one-year period: A case study

BACKGROUND

The COVID-19 pandemic has placed a restriction on physiotherapy clinical visits for supervised exercise. It is important that individuals with Parkinson's Disease (PD) continue an exercise regime at home during the pandemic and also in normal situations.

OBJECTIVE

The purpose of this study was to explore the case history of an individual with PD who used a developed home-based exercise programme for one year during the COVID-19 pandemic.

METHODS

A 67 year-old married woman was diagnosed with PD stage 2.5 on the modified Hoehn and Yahr (HY) scale. Gait characteristics and the Movement Disorders Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor scores were assessed at baseline, 10 weeks, and 12 months. The home-based exercise program included breathing exercises, posture correction, stretching exercises, rotation of the axial segments, balance training, and task-specific gait training.

RESULTS

After 12 months, her MDS-UPDRS motor scores decreased when compared to baseline and 10 weeks, and gait characteristics at 12 months showed an increase in the degree of foot rotation, step length, cadence, and gait speed when compared to baseline and 10 weeks.

CONCLUSION

This case study showed that improvements in MDS-UPDRS and gait characteristics can continue over a 12 month period as a result of a home-based exercise programme. Therefore, home-based exercise programs should be encouraged with weekly monitoring, especially in individuals with gait disorders which show deterioration.

Probabilistic Estimation of Cadence and Walking Speed From Floor Vibrations

OBJECTIVE

This research aims to extract human gait parameters from floor vibrations. The proposed approach provides an innovative methodology on occupant activity, contributing to a broader understanding of how human movements interact within their built environment.

METHODS AND PROCEDURES

A multilevel probabilistic model was developed to estimate cadence and walking speed through the analysis of floor vibrations induced by walking. The model addresses challenges related to missing or incomplete information in the floor acceleration signals. Following the Bayesian Analysis Reporting Guidelines (BARG) for reproducibility, the model was evaluated through twenty-seven walking experiments, capturing floor vibration and data from Ambulatory Parkinson's Disease Monitoring (APDM) wearable sensors. The model was tested in a real-time implementation where ten individuals were recorded walking at their own selected pace.

RESULTS

Using a rigorous combined decision criteria of 95% high posterior density (HPD) and the Range of Practical Equivalence (ROPE) following BARG, the results demonstrate satisfactory alignment between estimations and target values for practical purposes. Notably, with over 90% of the 95% HPD falling within the region of practical equivalence, there is a solid basis for accepting the estimations as probabilistically aligned with the estimations using the APDM sensors and video recordings.

CONCLUSION

This research validates the probabilistic multilevel model in estimating cadence and walking speed by analyzing floor vibrations, demonstrating its satisfactory comparability with established technologies such as APDM sensors and video recordings. The close alignment between the estimations and target values emphasizes the approach's efficacy. The proposed model effectively tackles prevalent challenges associated with missing or incomplete data in real-world scenarios, enhancing the accuracy of gait parameter estimations derived from floor vibrations.

CLINICAL IMPACT

Extracting gait parameters from floor vibrations could provide a non-intrusive and continuous means of monitoring an individual's gait, offering valuable insights into mobility and potential indicators of neurological conditions. The implications of this research extend to the development of advanced gait analysis tools, offering new perspectives on assessing and understanding walking patterns for improved diagnostics and personalized healthcare.Clinical and Translational Impact Statement: This manuscript introduces an innovative approach for unattended gait assessments with potentially significant implications for clinical decision-making. By utilizing floor vibrations to estimate cadence and walking speed, the technology can provide clinicians with valuable insights into their patients' mobility and functional abilities in real-life settings. The strategic installation of accelerometers beneath the flooring of homes or care facilities allows for uninterrupted daily activities during these assessments, reducing the reliance on specialized clinical environments. This technology enables continuous monitoring of gait patterns over time and has the potential for integration into healthcare platforms. Such integration can enhance remote monitoring, leading to timely interventions and personalized care plans, ultimately improving clinical outcomes. The probabilistic nature of our model enables uncertainty quantification in the estimated parameters, providing clinicians with a nuanced understanding of data reliability.

Effects of rhythmic auditory stimulation on gait speed in older adult inpatients in a convalescent rehabilitation ward: a pilot randomized controlled trial

PURPOSE

To assess the impact of gait training with rhythmic auditory stimulation (RAS) on enhancing gait speed in older people admitted to a convalescent rehabilitation ward (CRW), compared to conventional gait training methods.

METHODS

The study was designed as a single-center, open-label, pilot, randomized, parallel-group study. Thirty older people admitted to CRW were divided into two groups: the experimental group, which received gait training with RAS (n = 15, females = 53.3%, mean age = 83.9, SD = 6.5), and the control group, which underwent usual gait training (n = 15, females = 60.0%, mean age = 81.3, SD = 8.4). Regardless of their assigned group, all participants underwent 30 min training sessions, five times a week, for 3 weeks. The primary outcome was the 10 m walk test (10mWT), and the secondary outcomes included the Medical Outcome Study 8-Item Short-Form Health Survey and the Japanese version of the modified Gait Efficacy Scale. All measurements were taken at baseline and again at week 3.

RESULTS

Results indicated that older people in CRWs in the experimental group showed significant improvements in their 10mWT (effect size - 1.02) compared to the control group. None of the secondary outcomes were significant.

CONCLUSIONS

This study suggests the preliminary effectiveness and feasibility of a gait practice intervention using RAS in a CRW.

TRIAL REGISTRATION

The University Hospital Medical Information Network (UMIN) Registered 1 October 2022 (UMIN000049089).

Remotely prescribed, monitored, and tailored home-based gait-and-balance exergaming using augmented reality glasses: a clinical feasibility study in people with Parkinson's disease

Background

Exergaming has the potential to increase adherence to exercise through play, individually tailored training, and (online) remote monitoring. Reality Digital Therapeutics (Reality DTx®) is a digital therapeutic software platform for augmented reality (AR) glasses that enables a home-based gait-and-balance exergaming intervention specifically designed for people with Parkinson's disease (pwPD).

Objective

The primary objective was to evaluate the feasibility and potential efficacy of Reality DTx® AR exergaming intervention for improving gait, balance, and walking-adaptability fall-risk indicators. The secondary objective was to evaluate the potential superiority of AR glasses [Magic Leap 2 (ML2) vs. HoloLens 2 (HL2)].

Methods

This waitlist-controlled clinical feasibility study comprised three laboratory visits (baseline; pre-intervention; and post-intervention), a home visit, and a 6-week AR exergaming intervention. Five complementary gait-and-balance exergames were remotely prescribed (default five sessions/week of 30 active minutes/session), monitored, and tailored. Feasibility was assessed in terms of safety, adherence, and user experience. During laboratory visits, gait-and-balance capacity was assessed using standard clinical gait-and-balance tests and advanced walking-adaptability fall-risk assessments.

Results

In total, 24 pwPD participated. No falls and four near falls were reported. Session adherence was 104%. The User Experience Questionnaire scores for Reality DTx® ranged from above average to excellent, with superior scores for HL2 over ML2 for Perspicuity and Dependability. Intervention effects were observed for the Timed Up and Go test (albeit small), the Five Times Sit to Stand test, and walking speed. Walking-adaptability fall-risk indicators all improved post-intervention.

Conclusion

Reality DTx® is a safe, adherable, usable, well-accepted, and potentially effective intervention in pwPD. These promising results warrant future randomized controlled trials on the (cost-)effectiveness of home-based AR exergaming interventions for improving gait, balance, and fall risk.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05605249.

Long-term impact of a community-based adapted boxing program on physical functioning and quality of life of individuals with Parkinson's disease

BACKGROUND

Adapted boxing can help improve the physical functioning and health-related quality of life (HRQoL) of individuals with Parkinson's disease (PD). Whether these benefits persist longitudinally is unclear.

OBJECTIVE

The purpose of this retrospective study was to evaluate the impact of a community-based adapted boxing program on the physical functioning and HRQoL of individuals with PD over 1-1.5 years.

METHODS

Twenty-six individuals with PD agreed to share their results on tests administered upon enrollment in the program (PRE) and ∼431 days later (POST). The tests included the Fullerton Advanced Balance scale, (FAB), the Timed Up-and-Go test (TUG), the 30-second Sit-to-Stand test (30-STS), and the PD questionnaire-39 (PDQ-39).

RESULTS

From PRE to POST, performance significantly improved on the TUG and 30-STS tests (both p < 0.001), but not on the FAB (p = 0.79). Over the same period, PDQ-39 scores significantly increased (p = 0.05). No PRE to POST changes surpassed the minimal detectable change threshold.

CONCLUSION

The results of this study suggest that adapted boxing is at worst non-detrimental and at best potentially beneficial for muscle strength, endurance, and functional mobility in individuals with PD. However, adapted boxing probably cannot fully counteract the HRQoL decrements that accompany PD progression.

Effect of gait training using rhythmic auditory stimulation on gait speed in older adults admitted to convalescent rehabilitation wards: A study protocol for a pilot randomized controlled clinical trial

Background

Decreased walking speed in older patients admitted to convalescent rehabilitation wards (CRWs) is one of the factors that inhibit home discharge. Therefore, interventions to improve gait speed in older patients admitted to CRWs are important, and rhythmic auditory stimulation (RAS) may be an effective intervention strategy. However, the effect of RAS on gait speed in older patients admitted to CRWs is not well known. Therefore, this study protocol aims to determine the feasibility of the RAS-based gait practice for older patients admitted to the CRW.

Methods

The study is designed as a single-center, open-label, pilot, randomized, parallel-group study. Participants will be 30 patients aged ≥65 years admitted to the CRW and randomly assigned to the experimental group (RAS-based gait practice; n = 15) or the control group (normal gait practice; n = 15). In both groups, interventions will be conducted for 30 min per session, 5 times per week for 3 weeks. The primary outcome is the change in the 10-m walk test 3 weeks after the baseline assessment. Secondary outcome is the change in the score of the Medical Outcome Study 8-Item Short-Form Health Survey and the Japanese version of the modified Gait Efficacy Scale from baseline assessment to 3 weeks later.

Discussion

This exploratory RCT was developed using strict scientific standards and is based on defined protocols. Thus, this study will be used to assess the viability of a larger investigation into RAS-based gait practice. If our theory is accurate, this study could serve as a foundation for establishing RAS-based gait practice in CRWs as a common rehabilitation strategy.

Trial registration

This study was registered in the University Hospital Medical Information Network (UMIN) clinical trials registry in Japan (UMIN000049089).

Determinants of 6-minute walk test in people with Parkinson's disease

BACKGROUND

Most of the previous studies, investigating determinants of 6-minute walk test (6MWT), were conducted on small sample sizes and/or have not explored different aspects such as freezing of gait, physical activity, gender, dual-task cost, and/or have not been able to explain large portion of variation in 6MWT in people with Parkinson's disease.

AIMS

This study aimed to investigate the determinants of 6MWT, including aspects that previous studies have not explored.

METHODS

In this descriptive cross-sectional study, 6MWT determinants were investigated upon 42 people with Parkinson's disease. After recording participants' demographic data, walking capacity, disease stage, severity of motor symptoms, freezing of gait, balance, physical activity, fear of falling, functional balance, and dual-task cost values were evaluated and grouped into modifiable and unmodifiable variables to investigate possible therapeutic benefits aiming improvement in walking capacity.

RESULTS

The mean distance for 6MWT was 401.7 ± 92.7 m. Significant differences between women and men were found for height, walking capacity and speed, fear of falling, and functional balance (p<0.05). Hierarchical regression analysis showed that gender, age, and time since diagnosis significantly explained 52.4% of the variance in 6MWT and disease stage, freezing of gait, dual-task cost, and functional balance added an extra 35.6% to the explained variance.

CONCLUSIONS

These results showed that gender, age, disease stage, freezing of gait, dual-task cost, and functional balance values are significant contributors to the variance in 6MWT. Therefore, while planning rehabilitation strategies to improve walking capacity, one should focus on these aspects in people with Parkinson's disease.

The psychometric properties of the figure-of-eight walk test in people with Parkinson's disease

PURPOSE

To investigate: (1) the interrater, and test-retest reliability of the figure-of-eight walk test (F8WT) in people with Parkinson's disease (PwPD); (2) the minimum detectable change in the F8WT times; (3) the concurrent and known-groups validity of the F8WT times; and (4) the cut-off times that best discriminate PwPD from healthy people and fallers from non-fallers with PD.

METHODS

This was a cross-sectional study. Forty-three PwPD and 34 healthy people were recruited. The F8WT was performed along with the timed up and go test, 10 m walk test, Berg Balance Scale, Activities-Specific Balance Confidence Scale, Unified Parkinson's disease Rating Scale, and Hoehn and Yahr Scale.

RESULTS

The F8WT showed good interrater and test-retest reliability (ICC = 0.964-0.978 and ICC = 0.905-0.920, respectively). The MDC was 2.77 s. The F8WT was correlated with other outcome measures. Significant differences in the F8WT times were found between PwPD and healthy people and between fallers and non-fallers with PD (p < 0.001 and p < 0.001, respectively). The cut-off times of 8.43 s best discriminated PwPD from healthy people, while 11.19 s best discriminated fallers from non-fallers with PD.

CONCLUSIONS

The F8WT is a reliable, valid, and easy-to-administer tool in assessing the walking skill of PwPD.Implications for rehabilitationThe figure-of-eight walk test (F8WT) is a reliable, valid, and clinically available tool for assessing walking skill in Parkinson's disease (PD).The minimal detectable change of the F8WT is 2.77 s, which may help to determine any real change in walking skill after any intervention.The F8WT correlated with functional mobility, gait speed, balance, balance confidence, and severity and stage of PD.The F8WT times may detect impaired walking skill between people with PD and healthy people, and between fallers and non-fallers with PD.

The Clinical Utility of the MOCA in iNPH Assessment

Objectives

We sought to estimate reliable change thresholds for the Montreal Cognitive Assessment (MoCA) for older adults with suspected Idiopathic Normal Pressure Hydrocephalus (iNPH). Furthermore, we aimed to determine the likelihood that shunted patients will demonstrate significant improvement on the MoCA, and to identify possible predictors of this improvement.

Methods

Patients (N = 224) presenting with symptoms of iNPH were given a MoCA assessment at their first clinic visit, and also before and after tap test (TT) or extended lumbar drainage (ELD). Patients who were determined to be good candidates for shunts (N = 71, 31.7%) took another MoCA assessment following shunt insertion. Reliable change thresholds for MoCA were derived using baseline visit to pre-TT/ELD assessment using nine different methodologies. Baseline characteristics of patients whose post-shunt MoCA did and did not exceed the reliable change threshold were compared.

Results

All nine of reliable change methods indicated that a 5-point increase in MoCA would be reliable for patients with a baseline MoCA from 16 to 22 (38.4% of patients). Furthermore, a majority of reliable change methods indicated that a 5-point increase in MoCA would be reliable for patients with a baseline MoCA from 14 to 25. Reliable change thresholds varied across methods from 4 to 7 points for patients outside of this range. 10.1% had at least a 5-point increase from baseline to post-TT/ELD. Compared to patients who did not receive a shunt, patients who received a shunt did not have lower average MoCA at baseline (p = 0.88) or have better improvement in MoCA scores after the tap test (p = 0.17). Among shunted patients, 23.4% improved by at least 5 points on the MoCA from baseline to post-shunt. Time since onset of memory problems and post-TT/ELD gait function were the only clinical factors significantly associated with having a reliable change in MoCA after shunt insertion (p = 0.019; p = 0.03, respectively).

Conclusions

In patients with iNPH, clinicians could consider using a threshold of 5 points for determining whether iNPH-symptomatic patients have experienced cognitive benefits from cerebrospinal fluid drainage at an individual level. However, a reliable change cannot be detected for patients with a baseline MoCA of 26 or greater, necessitating a different cognitive assessment tool for these patients.

Efficacy of C-Mill gait training for improving walking adaptability in early and middle stages of Parkinson's disease

BACKGROUND

Walking adaptability is an obvious manifestation of Parkinson's disease (PD). Augmented reality technologies such as interactive walkways may improve walking adaptability in patients with Parkinson's Disease (PWP).

RESEARCH QUESTION

How effective is C-Mill gait adaptability training in the early and middle stages of PD for improving walking adaptability in motor subtypes of the disease?

METHODS

Fifty-two patients with early- or middle-stage PD were divided into two groups according to motor subtype (postural instability/gait disorder [PIGD] and non-PIGD) and received 7 days of training (0.5 h every day, 2 h after medication) on an augmented reality treadmill with built-in visual targets and obstacles. Functional assessments were performed before and after intervention, including posture control and walking, C-gait assessment, and participant experience. The Parkinson Disease Quality of Life questionnaire was administered at 3-month follow-up.

RESULTS

Both the PIGD (n = 29) and non-PIGD (n = 23) groups showed improved tandem walking, obstacle avoidance, and overall score in C-gait assessment and Timed Up and Go test after C-Mill training. However, there were no differences between the two groups. The PIGD group showed improvement in visually guided stepping and Speed adaptations, whereas the non-PIGD group did not improve. The non-PIGD group reported they could complete the training with less exertion after the intervention and at the 3-month follow-up, these patients reported improvement in quality of life.

SIGNIFICANCE

C-Mill gait adaptation training in the early and middle stages of PD improves walking adaptability in both motor subtypes. Cue strategies are the probable mechanism and may decrease fall risk after training. There was no difference between the groups in the improvements of perceived exertion and quality of life at follow-up. Although PIGD patients showed statistic improvements in visually guided stepping compared with non-PIGD patients, but the difference was not likely to be clinically meaningful. Specific effects of C-mill training for different types of PD were not observed in our study.

Test-Retest Reliability of the Timed Up and Go Test in Subjects with Parkinson's Disease: Implications for Longitudinal Assessments

BACKGROUND

Despite the frequent use of the Timed Up and Go (TUG) test in clinical trials, evaluation of longitudinal test-retest reliability is generally lacking and still inconclusive for patients with Parkinson's disease (PD).

OBJECTIVE

We aimed to further investigate long-term reliability and sensitivity of the TUG test among this population. Furthermore, we explored alternative assessment strategies of the test aimed at elucidating whether the inclusion or combination of timed trials may have potential implications on outcome measure.

METHODS

Relative and absolute reliability of the TUG performance were obtained in forty-three subjects with PD over three timed trials in two different testing sessions separated by a two-months period.

RESULTS

Our results reported excellent intra-session and moderate inter-session reliability coefficients. The use of different assessment strategies of the TUG was found to have an important impact on outcome measure, highlighting the averaging of several timed trials in each testing session as a recommended alternative to minimize measurement error and increase reliability in longitudinal assessments. Nevertheless, beyond acceptable reliability, poor trial-to-trial stability of the measure appears to exist, since the ranges of expected variability upon retesting were wide and the incidence of spurious statistical effects was not negligible, especially in longitudinal repeated testing.

CONCLUSION

Limitations may exist in the interpretation of the TUG outputs as part of longitudinal assessments aimed at evaluating treatment effectiveness in PD population. Researchers and practitioners should be aware of these concerns to prevent possible misrepresentations of functional ability in patients for a particular intervention.

Parkinson's Disease Motor Symptom Progression Slowed with Multisensory Dance Learning over 3-Years: A Preliminary Longitudinal Investigation

Parkinson's disease (PD) is a neurodegenerative disease that has a fast progression of motor dysfunction within the first 5 years of diagnosis, showing an annual motor rate of decline of the Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) between 5.2 and 8.9 points. We aimed to determine both motor and non-motor PD symptom progression while participating in dance classes once per week over a period of three years. Longitudinal data was assessed for a total of 32 people with PD using MDS-UPDRS scores. Daily motor rate of decline was zero (slope = 0.000146) in PD-Dancers, indicating no motor impairment, whereas the PD-Reference group showed the expected motor decline across three years (p < 0.01). Similarly, non-motor aspects of daily living, motor experiences of daily living, and motor complications showed no significant decline. A significant group (PD-Dancers and PD-Reference) by days interaction showed that PD who train once per week have less motor impairment (M = 18.75) than PD-References who do not train (M = 24.61) over time (p < 0.05). Training is effective at slowing both motor and non-motor PD symptoms over three years as shown in decreased scores of the MDS-UPDRS.

The functional reach test in people with multiple sclerosis: a reliability and validity study

Background: Limits of stability (LOS) is a major component of balance dysfunction in people with multiple sclerosis (MS). The functional reach test (FRT) is a clinical LOS assessment; however, its psychometric properties have not been investigated in people with MS yet. Objectives: To investigate: (1) the intrarater, interrater, and test-retest reliability of the FRT in people with MS; (2) the minimum detectable change (MDC) in the FRT distances; (3) the concurrent and discriminant validity of the FRT; and (4) the cutoff distance that best discriminates people with MS from healthy people and fallers from non-fallers with MS.Methods: Forty-three people with MS and 36 healthy people participated in this study. The FRT was administered along with the instrumented LOS test, Berg Balance Scale, Four Square Step Test, Timed Up and Go Test, and Expanded Disability Status Scale. The FRT was repeated by the same rater after 2 min from the first test session to determine the intrarater reliability and was simultaneously conducted by two independent raters to determine the interrater reliability. The FRT was also repeated after 7-10 days to determine the test-retest reliability. The reliability was quantified using intraclass correlation coefficients (ICC), Bland-Altman plots, and the MDC. The validity was assessed by correlating the FRT distances with the scores of other measures and by comparing the FRT distances between the MS group and healthy people, and between the fallers and non-fallers in the MS group.Results: The FRT demonstrated good to excellent intrarater, interrater, and test-retest reliability with an ICC (3,1) of 0.80-0.88 (p < .001), an ICC (3,2) of 0.94-0.97 (p < .001), an ICC (2,3) of 0.84-0.86 (p < .001), respectively. Bland-Altman analyses showed no systematic bias between the assessments. The MDC was 8.28 centimeters. The FRT was correlated with the other outcome measures (correlation coefficients ranged from 0.31 to 0.79, p < .05 for all). Significant differences in the FRT distances were found between people with MS and healthy people; however, no significant difference was found between the fallers and non-fallers with MS (p < .001 and p = .09, respectively). The cutoff distance of 35.5 centimeters best discriminates healthy people from people with MS while of 28.5 centimeters did not discriminate between the fallers and non-fallers with MS.Conclusions: The FRT is a reliable, valid, and easy-to-administer tool for assessing LOS in people with MS.

Clinical and laboratory measures of balance and comparison of balance performances according to postural instability and gait disorders in individuals with Parkinson's disease

PURPOSE/AIM

Primary aim was to investigate the association between laboratory measures of balance and clinical balance tests in individuals with Parkinson's disease (PD). The secondary aim was to compare the balance performances according to postural instability and gait disorders (PIGD).

MATERIALS AND METHODS

Sixty-four individuals with PD were included in the study. Clinical data were investigated using modified Hoehn and Yahr Scale and Unified Parkinson's Disease Rating Scale (UPDRS). Berg Balance Scale (BBS), Timed Up&Go Test (TUG), Five Times Sit-to-Stand Test (FTSST) were used for clinical measures of balance. Laboratory measures of balance were evaluated by Balance Master System including the modified Clinical Test of Sensory Interaction of Balance (mCTSIB), Limits of Stability Test (LOS), Sit to Stand Test (STS), and Tandem Walk Test (TW). The relationship between clinical and laboratory measures of balance was determined. After participants were divided into two groups based on UPDRS: patients with and without PIGD, their balance performance was compared.

RESULTS

There were significant correlations between BBS and mCTSIB, LOS-Movement Velocity, and LOS-Endpoint Excursion. FTSST was correlated with STS-Weight Transfer and STS-Rising Index, and TUG was correlated with TW-Speed. Patients with PIGD had worse scores of balance assessments including FTSST, LOS-Movement Velocity, STS-Rising Index.

CONCLUSION

Laboratory measures are associated with clinical balance tests and they may reflect clinical balance outcome measures. Furthermore, PIGD may negatively affect balance performance in patients with PD.

Automatic clinical gait test detection from inertial sensor data

The analysis of gait data is one approach to support clinicians with the diagnosis and therapy of diseases, for example Parkinson's disease (PD). Traditionally, gait data of standardized tests in the clinic is analyzed, ensuring a predefined setting. In recent years, long-term home-based gait analysis has been used to acquire a more representative picture of the patient's disease status. Data is recorded in a less artificial setting and therefore allows a more realistic perception of the disease progression. However, fully unsupervised gait data without additional context information impedes interpretation. As an intermediate solution, performance of gait tests at home was introduced. Integration of instrumented gait test requires annotations of those tests for their identification and further processing. To overcome these limitations, we developed an algorithm for automatic detection of standardized gait tests from continuous sensor data with the goal of making manual annotations obsolete. The method is based on dynamic time warping, which compares an input signal with a predefined template and quantifies similarity between both. Different templates were compared and an optimized template was created. The classification scored a F1-measure of 86.7% for evaluation on a data set acquired in a clinical setting. We believe that this approach can be transferred to home-monitoring systems and will facilitate a more efficient and automated gait analysis.

The Mini-BESTest is an independent predictor of falls in Parkinson Disease

BACKGROUND

Falls in Parkinson Disease (PD) are a complex health problem, with multidimensional causes and consequences.

OBJECTIVES

To identify the fall predictors in individuals with PD and compare fallers and non-fallers considering their socio-demographic, anthropometric, clinical and functional status.

METHODS

A multicenter cross-sectional design was employed. Variables included: age, sex, body mass index, PD progression, levodopa dosage, activities limitation and motor impairments (UPDRS ADL/Motor), level of physical activity (human activity profile - HAP), fear of falls (Falls Efficacy Scale-International-FES-I), freezing of gait (Freezing of Gait Questionnaire - FOG-Q), gait speed (10 meters walk test - 10-MWT), lower limb functional strength (Five Times Sit-to-Stand Test - FTSST), balance (Mini-BESTest), mobility (Timed "Up & Go" - TUG) and dual-task dynamic (TUG-DT). Seventeen potential predictors were identified. Logistic regression and ROC curve were applied.

RESULTS

Three-hundred and seventy individuals (44.87% fallers and 55.13% non-fallers) completed the study. Fallers presented worse performance in UPDRS motor/ADL/Total, FES-I, FOG-Q, Mini-BESTest, HAP, TUG and TUG-DT and the majority were inactive. The Mini-BESTest Total was the main independent predictor of falls (OR=0.92; p<0.001; 95% CI=0.89, 0.95). For each one-unit increase in the Mini-BESTest, there was an average reduction of 8% in the probability of being a faller. A cut-off point of 21.5/28 (AUC=0.669, sensitivity 70.7% and specificity 55.1%) was determined.

CONCLUSION

Besides characterizing and comparing fallers and non-fallers, this study showed that the Mini-BESTest was the strongest individual predictor of falls in individuals with PD, highlighting the importance of evaluating dynamic balance ability during fall risk assessment.

Evaluation of the psychometric properties and clinical applications of the Timed Up and Go test in Parkinson disease: a systematic review

To review and systematically summarize the psychometric and clinical properties (reliability, validity, responsiveness) of the Timed Up and Go test applied to persons diagnosed with Parkinson disease. A systematic review was performed by screening four scientific databases (MED-LINE, CINAHL, and PubMed). Independent reviewers selected and extracted data from articles that assessed the reliability, validity, sensitivity to change, and/or clinical properties of the Timed Up and Go test in persons with Parkinson disease. Twenty-four studies were selected. Nine analyzed reliability and yielded “good” to “moderate” scores. Seventeen used a range of different contrast tests to assess validity of the Timed Up and Go test and found “good” quality scores in those that assessed balance. Only two studies analyzed sensitivity to change and they reported “poor” quality scores. The use of Timed Up and Go in Parkinson disease patients presents good reliability and validity (when compared to tests that assess balance).

Wristbands Containing Accelerometers for Objective Arm Swing Analysis in Patients with Parkinson's Disease

In patients with Parkinson’s disease (PD), arm swing changes are common, even in the early stages, and these changes are usually evaluated subjectively by an expert. In this article, hypothesize that arm swing changes can be detected using a low-cost, cloud-based, wearable, sensor system that incorporates triaxial accelerometers. The aim of this work is to develop a low-cost, assistive diagnostic tool for use in quantifying the arm swing kinematics of patients with PD. Ten patients with PD and 11 age-matched, healthy subjects are included in the study. Four feature extraction techniques were applied: (i) Asymmetry estimation based on root mean square (RMS) differences between arm movements; (ii) posterior–anterior phase and cycle regularity through autocorrelation; (iii) tremor energy, established using Fourier transform analysis; and (iv) signal complexity through the fractal dimension by wavelet analysis. The PD group showed significant (p < 0.05) reductions in arm swing RMS values, higher arm swing asymmetry, higher anterior–posterior phase regularities, greater “high energy frequency” signals, and higher complexity in their XZ plane signals. Therefore, the novel, portable system provides a reliable means to support clinical practice in PD assessment.

LSVT BIG® and long-term retention of functional gains in individuals with Parkinson's disease

PURPOSE

The purpose of this study was to determine the long-term effects of LSVT BIG® on the function of individuals with Parkinson's Disease (PD).

METHODS

Eighteen participants gave informed consent, and met the inclusion criteria. Time since diagnosis of PD ranged from .5 to 16 years (mean 4.5 years), time since discharge from 3-23 months (mean 6.5 months). Hoehn and Yahr scores were from 2 to 4. Subjects were posttested by blinded evaluators on the same 8 measures used at evaluation and discharge, the 6 Minute Walk (6WMT), Timed Up and Go (TUG), TUG-manual, TUG-cognitive, 10 Meter Walk(10MWT), 30 Second Sit to Stand (30 CST), Berg Balance Scale (BBS), and the Functional Gait Assessment (FGA). Test means were compared from evaluation to discharge, discharge to posttesting, and evaluation to posttest using repeated measures ANOVA with a Tukey correction, p value < .05.

RESULTS

The time between discharge and posttesting was not a confounding variable. Significant improvement in all measures were displayed from evaluation to discharge. No significant change was found from discharge to posttesting except for 6MWT. Significant improvements were noted when comparing initial evaluation to posttesting: TUG p = .001; TUG-manual p = .003; TUG-cognitive p = .001; 10MWT p < .001; BBS p < .001; and FGA p < .001.

CONCLUSIONS

Subjects were able to maintain significant gains noted at discharge from the program in measures of functional mobility and balance. The exception was endurance, as assessed by the 6MWT and the 30 CST. This suggests that the LSVT BIG® protocol has the potential for long term improvement in functional mobility in individuals with PD.

EFFECT OF MOTOR IMAGERY TRAINING IN COMBINATION WITH ELECTROMYOGRAPHY-TRIGGERED ELECTRICAL STIMULATION IN STROKE WITH HEMIPLEGIA PATIENTS: A RANDOMIZED CONTROLLED STUDY

Recently, motor imagery training combined with electromyography-triggered electrical stimulation (MIT EMG-ES) has been reported as a remedial treatment for stroke patients. However, the clinical evidence of the effect is still lacking. To investigate the effect of MIT EMG-ES on lower extremities and activities of daily of living (ADL) in patients with stroke, the participants were randomly assigned to an experimental group ([Formula: see text]) or control group ([Formula: see text]). The experimental group underwent MIT EMG-ES, whereas the control group performed underwent motor imagery training. In addition, both groups received the same conventional rehabilitation therapy. All participants underwent treatment for 30[Formula: see text]min a day, 5 sessions per week, for 4 weeks. Lower extremities function was measured by the Fugl–Meyer Assessment Lower Extremity (FMA-LE), Timed Up-and-Go (TUG) test and 10 m Walk (10[Formula: see text]MW) test. ADL were measured by the Korea version of the Modified Barthel Index (K-MBI). The experimental group except for the FMA-LE group showed more improvement in TUG and 10[Formula: see text]MW test scores than the control group ([Formula: see text]). The effect size showed FMA-LE, TUG, and 10[Formula: see text]MW test (0.7, 1.0, 0.7, respectively). However, there was no statistically significant difference between the two groups in K-MBI ([Formula: see text]). Our findings suggest that MIT EMG-ES may be a novel treatment for lower extremities function in patients with stroke better than MIT alone.

Selecting Clinically Relevant Gait Characteristics for Classification of Early Parkinson's Disease: A Comprehensive Machine Learning Approach

Parkinson's disease (PD) is the second most common neurodegenerative disease; gait impairments are typical and are associated with increased fall risk and poor quality of life. Gait is potentially a useful biomarker to help discriminate PD at an early stage, however the optimal characteristics and combination are unclear. In this study, we used machine learning (ML) techniques to determine the optimal combination of gait characteristics to discriminate people with PD and healthy controls (HC). 303 participants (119 PD, 184 HC) walked continuously around a circuit for 2-minutes at a self-paced walk. Gait was quantified using an instrumented mat (GAITRite) from which 16 gait characteristics were derived and assessed. Gait characteristics were selected using different ML approaches to determine the optimal method (random forest with information gain and recursive features elimination (RFE) technique with support vector machine (SVM) and logistic regression). Five clinical gait characteristics were identified with RFE-SVM (mean step velocity, mean step length, step length variability, mean step width, and step width variability) that accurately classified PD. Model accuracy for classification of early PD ranged between 73-97% with 63-100% sensitivity and 79-94% specificity. In conclusion, we identified a subset of gait characteristics for accurate early classification of PD. These findings pave the way for a better understanding of the utility of ML techniques to support informed clinical decision-making.

Determinants of the use of physiotherapy services among individuals with Parkinson's disease living in Brazil

OBJECTIVES

To identify the factors affecting the use of physiotherapy services among individuals with Parkinson's disease (PD) living in Brazil.

METHODS

Overall, 479 individuals with idiopathic PD, of both sexes, at any stage of the Hoehn & Yahr (HY) scale, and from seven capital cities in Brazil were recruited from 2014 to 2016. Multivariate logistic regression was the main statistical tool. For the construction of the logistic model, the association of the dependent variable "physiotherapy" with the independent sociodemographic/economic and clinical variables: age, education, family income, time of PD since onset, HY, the activities of daily living and motor subscales of the Unified Parkinson's Disease Rating Scale, cognitive aspects, depressive symptoms, fear of falling, freezing gait, history of falls, physical activity level, gait speed, walking performance and balance, were verified.

RESULTS

The 479 individuals had an average age of 65.2 ± 11.0 years, 88% were in the HY I-III stages and 43.4% were under physiotherapy treatment. The analysis identified two determinant variables related to the use of the physiotherapy service: level of education (OR = 1.24) and walking performance (OR = 0.82). Decreased walking performance and a higher educational level increased the use of a physiotherapy service in individuals with PD living in Brazil.

CONCLUSIONS

The present study shows that individuals with PD, residents from different regions of Brazil, have limited access to physiotherapy services. In addition, the Brazilian Public Health Care System, as well as local programs, need to target PD individuals with a low educational level to improve their access to physiotherapy services. Goals should aim towards the development of physical exercise programs to improve the patients' functional performance for a longer period.

The Role of Movement Analysis in Diagnosing and Monitoring Neurodegenerative Conditions: Insights from Gait and Postural Control

Quantifying gait and postural control adds valuable information that aids in understanding neurological conditions where motor symptoms predominate and cause considerable functional impairment. Disease-specific clinical scales exist; however, they are often susceptible to subjectivity, and can lack sensitivity when identifying subtle gait and postural impairments in prodromal cohorts and longitudinally to document disease progression. Numerous devices are available to objectively quantify a range of measurement outcomes pertaining to gait and postural control; however, efforts are required to standardise and harmonise approaches that are specific to the neurological condition and clinical assessment. Tools are urgently needed that address a number of unmet needs in neurological practice. Namely, these include timely and accurate diagnosis; disease stratification; risk prediction; tracking disease progression; and decision making for intervention optimisation and maximising therapeutic response (such as medication selection, disease staging, and targeted support). Using some recent examples of research across a range of relevant neurological conditions-including Parkinson's disease, ataxia, and dementia-we will illustrate evidence that supports progress against these unmet clinical needs. We summarise the novel 'big data' approaches that utilise data mining and machine learning techniques to improve disease classification and risk prediction, and conclude with recommendations for future direction.

Evaluation of Balance Disorders in Parkinson's Disease Using Simple Diagnostic Tests-Not So Simple to Choose

Background: Balance disorders are one of the main symptoms in parkinson's Disease (PD)—patients have a tendency to fall, related traumas and also a significant restriction of mobility. Numerous tools may be used to evaluate the balance, but it is difficult to choose the proper one. The aim of this review was to compare simple diagnostic tools for PD and emphasize those characterized by a high reliability and sensitivity.

Methods: The global literature search was conducted in PubMED, Scopus, Science Direct, Web of Science, Cochrane, and Google Scholar for publications in English and Polish.

Results: According to the literature some scales and functional tests in which clinimetric properties had been assessed in PD population were selected and described.

Conclusion: Basing on current knowledge, psychometric properties, and clinical experience, the authors suggest the BESTest with its shortened versions and the Fullerton Advanced Balance Scale to be used for comprehensive balance assessment of parkinson's disease patients. These tests are easy in administration, not time-consuming and provide a professional diagnosis allowing to plan individual therapy for the patient being examined.

Reliability of functional outcome measures in adults with neurofibromatosis 1

Objectives:

To determine intra-rater and inter-rater reliability of functional outcome measures in adults with neurofibromatosis 1 and to ascertain how closely objective and subjective measures align.

Methods:

A total of 49 ambulant adults with neurofibromatosis 1 aged 16 years and over were included in this observational study: median age 31 years (range: 16–66 years), 29 females, 20 males. Participants were video-recorded or photographed performing four functional outcome measures. Four raters from the neurofibromatosis centre multi-disciplinary team independently scored the measures to determine inter-rater reliability. One rater scored the measures a second time on a separate occasion to determine intra-rater reliability. The measures evaluated were the functional reach, timed up and go, 10 m walk and a modified nine-hole peg tests. Participants also completed a disease-specific quality-of-life questionnaire.

Results:

Inter-rater reliability and intra-rater reliability scores (intra-class coefficient) were similar for each outcome measure. Excellent rater agreement (intra-class coefficient, r ⩾ 0.9) was found for the functional reach, timed up and go and the 10 m walk tests. Rater agreement was good for the modified nine-hole peg test: intra-class coefficient r = 0.75 for intra-rater reliability and 0.76 for inter-rater reliability. The timed up and go and the 10 m walk tests correlated highly with perceived mobility challenges in the quality-of-life questionnaire.

Conclusion:

The functional reach, timed up and go and 10 m walk tests are potentially useful outcome measures for monitoring neurofibromatosis 1 treatment and will be assessed in multi-centre and longitudinal studies.

Test-Retest Reliability and Minimal Detectable Change for the 10-Meter Walk Test in Older Adults With Parkinson's disease

BACKGROUND AND PURPOSE

Measurement of gait performance in individuals with Parkinson's disease (PD) can be challenging because of the daily fluctuations in performance and the progressive nature of the condition. The 10-Meter Walk Test (10MWT) is commonly used to measure gait speed of individuals with gait limitations. Existing research on the 10MWT in individuals with PD controls for many variables inherent to this condition, rendering the results of this test in settings where these variables are not controlled questionable. The purpose of this study was to estimate under commonly encountered clinical conditions the test-retest reliability and the minimal detectable change (MDC) of gait speed and step frequency determined during the 10MWT in individuals with PD.

METHODS

The 10MWT was administered by 2 testers, on 35 participants, across 2 sessions, separated by 5 to 14 days. Gait speed was measured using a hand-held stopwatch, and step frequency was assessed through visual observation. Test-retest reliability was calculated using the intraclass correlation coefficient (ICC) and the MDC was calculated using the standard error of measurement (SEM).

RESULTS AND DISCUSSION

Comfortable and fast gait speeds demonstrated excellent reliability between sessions (ICC = 0.92 and 0.96, respectively). The corresponding MDCs were 0.22 and 0.23 m/s, respectively. The test-retest reliability for step frequency was moderate for comfortable gait speed and good for fast gait speeds (ICC = 0.73 and 0.82, respectively). The corresponding MDCs were 15.1 and 17.4 steps per minute for comfortable and fast step frequency, respectively.

CONCLUSIONS

Under both comfortable and fast conditions, measurements of gait speed and step frequency during the 10MWT are reliable between sessions in individuals with PD.

Different protocols for analyzing behavior and adaptability in obstacle crossing in Parkinson's disease

Imbalance and tripping over obstacles as a result of altered gait in older adults, especially in patients with Parkinson’s disease (PD), are one of the most common causes of falls. During obstacle crossing, patients with PD modify their behavior in order to decrease the mechanical demands and enhance dynamic stability. Various descriptions of dynamic traits of gait that have been collected over longer periods, probably better synthesize the underlying structure and pattern of fluctuations in gait and can be more sensitive markers of aging or early neurological dysfunction and increased risk of falls. This confirmation challenges the clinimetric of different protocols and paradigms used for gait analysis up till now, in particular when analyzing obstacle crossing. The authors here present a critical review of current knowledge concerning the interplay between the cognition and gait in aging and PD, emphasizing the differences in gait behavior and adaptability while walking over different and challenging obstacle paradigms, and the implications of obstacle negotiation as a predictor of falls. Some evidence concerning the effectiveness of future rehabilitation protocols on reviving obstacle crossing behavior by trial and error relearning, taking advantage of dual-task paradigms, physical exercise, and virtual reality have been put forward in this article.

Resistance Training with Instability for Patients with Parkinson's Disease

PURPOSE

This randomized controlled trial compared the effects of resistance training (RT) and RT with instability (RTI) on the timed up and go test (TUG), on-medication Unified Parkinson's Disease Rating Scale part III motor subscale score (UPDRS-III), Montreal Cognitive Assessment (MoCA) score, Parkinson's Disease Questionnaire (PDQ-39) score, and muscle strength in the leg press exercise (one-repetition maximum) of patients with Parkinson's disease (PD).

METHODS

Thirty-nine patients with moderate to severe PD were randomly assigned to a nonexercising control group (C), RT group, and RTI group. The RT and RTI groups performed progressive RT twice a week for 12 wk. However, only the RTI group used high motor complexity exercises (i.e., progressive RT with unstable devices), for example, half squat exercise on the BOSU® device. The primary outcome was mobility (TUG). The secondary outcomes were on-medication motor signs (UPDRS-III), cognitive impairment (MoCA), quality of life (PDQ-39), and muscle strength (one-repetition maximum).

RESULTS

There were no differences between RTI and RT groups for any of the outcomes at posttraining (P > 0.05). However, there were differences between RTI and C groups in the TUG, MoCA, and muscle strength values at posttraining (P < 0.05). Only the RTI group improved the TUG (-1.9 s), UPDRS-III score (-4.5 score), MoCA score (6.0 score), and PDQ-39 score (-5.2 score) from pre- to posttraining (P < 0.001). Muscle strength improved for both training groups (P < 0.001). No adverse events were reported during the trial.

CONCLUSIONS

Both training protocols improved muscle strength, but only RTI improved the mobility, motor signs, cognitive impairment, and quality of life, likely because of the usage of high motor complexity exercises. Thus, RTI may be recommended as an innovative adjunct therapeutic intervention for patients with PD.

Clinical utility of the 6-min walk test for patients with moderate Parkinson's disease

The aim of this study was to test the clinical utility of the 6-min walk test (6MWT) for patients with moderate Parkinson's disease (PD) through a determination of factors related to this test. This was a descriptive, observational study carried out at a General Hospital, in-patients. Twenty-four patients with moderate PD were studied. We used Hoehn and Yahr stage ratings (HY stage), Unified Parkinson Disease Rating Scales (UPDRS) motor examination score, 6MWT, Berg Balance scale, Timed 'Up & Go' test (TUG), 10-m walk test (10-m walk speed, 10-m walk steps and cadence), and the energy cost of walking (Ec). The average HY stage was 3.1±0.5 and 6MWT was 340.8±110.9 m. TUG (r=-0.68, P<0.01) and Ec (r=-0.65, P<0.01) were correlated significantly with 6MWT. Multiple regression analysis with age, HY stage, TUG, cadence, and Ec as variables indicated a significant degree of variability in the 6MWT results (R=0.77, P<0.001). The TUG (β=-0.47, P<0.01) and Ec (β=-0.4, P<0.01) were correlated independently with the 6MWT results. In contrast, age, HY stage, and cadence were not independently correlated. The 6MWT is a simple tool for assessing walking capacity for patients with PD. In this study, we confirmed the convergent validity and clinical utility of the 6MWT for patients with moderate PD. The 6MWT is useful for clinical assessment to guide the planning of rehabilitation treatment for patients with moderate PD.

Effects of 2 Years of Exercise on Gait Impairment in People With Parkinson Disease: The PRET-PD Randomized Trial

BACKGROUND AND PURPOSE

This study presents a secondary analysis from the Progressive Resistance Exercise Training in Parkinson Disease (PRET-PD) trial investigating the effects of progressive resistance exercise (PRE) and a Parkinson disease (PD)-specific multimodal exercise program, modified Fitness Counts (mFC), on spatial, temporal, and stability-related gait impairments in people with PD.

METHODS

Forty-eight people with PD were randomized to participate in PRE or mFC 2 times a week for 24 months; 38 completed the study. Gait velocity, stride length, cadence, and double-support time were measured under 4 walking conditions (off-/on-medication, comfortable/fast speed). Ankle strength was also measured off- and on-medication. Twenty-four healthy controls provided comparison data at one time point.

RESULTS

At 24 months, there were no significant differences between exercise groups. Both groups improved fast gait velocity off-medication, cadence in all conditions, and plantarflexion strength off-/on-medication. Both groups with PD had more gait measures that approximated the healthy controls at 24 months than at baseline. Plantarflexion strength was significantly associated with gait velocity and stride length in people with PD at baseline and 24 months, but changes in strength were not associated with changes in gait.

DISCUSSION AND CONCLUSIONS

Twenty-four months of PRE and mFC were associated with improved off-medication fast gait velocity and improved cadence in all conditions, which is important because temporal gait measures can be resistant to medications. Spatial and stability-related measures were resistant to long-term improvements, but did not decline over 24 months. Strength gains did not appear to transfer to gait.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A161).

Using Xbox kinect motion capture technology to improve clinical rehabilitation outcomes for balance and cardiovascular health in an individual with chronic TBI

BACKGROUND

Motion capture virtual reality-based rehabilitation has become more common. However, therapists face challenges to the implementation of virtual reality (VR) in clinical settings. Use of motion capture technology such as the Xbox Kinect may provide a useful rehabilitation tool for the treatment of postural instability and cardiovascular deconditioning in individuals with chronic severe traumatic brain injury (TBI). The primary purpose of this study was to evaluate the effects of a Kinect-based VR intervention using commercially available motion capture games on balance outcomes for an individual with chronic TBI. The secondary purpose was to assess the feasibility of this intervention for eliciting cardiovascular adaptations.

METHODS

A single system experimental design (n = 1) was utilized, which included baseline, intervention, and retention phases. Repeated measures were used to evaluate the effects of an 8-week supervised exercise intervention using two Xbox One Kinect games. Balance was characterized using the dynamic gait index (DGI), functional reach test (FRT), and Limits of Stability (LOS) test on the NeuroCom Balance Master. The LOS assesses end-point excursion (EPE), maximal excursion (MXE), and directional control (DCL) during weight-shifting tasks. Cardiovascular and activity measures were characterized by heart rate at the end of exercise (HRe), total gameplay time (TAT), and time spent in a therapeutic heart rate (TTR) during the Kinect intervention. Chi-square and ANOVA testing were used to analyze the data.

RESULTS

Dynamic balance, characterized by the DGI, increased during the intervention phase χ2 (1, N = 12) = 12, p = .001. Static balance, characterized by the FRT showed no significant changes. The EPE increased during the intervention phase in the backward direction χ2 (1, N = 12) = 5.6, p = .02, and notable improvements of DCL were demonstrated in all directions. HRe (F (2,174) = 29.65, p = < .001) and time in a TTR (F (2, 12) = 4.19, p = .04) decreased over the course of the intervention phase.

CONCLUSIONS

Use of a supervised Kinect-based program that incorporated commercial games improved dynamic balance for an individual post severe TBI. Additionally, moderate cardiovascular activity was achieved through motion capture gaming. Further studies appear warranted to determine the potential therapeutic utility of commercial VR games in this patient population.

TRIAL REGISTRATION

Clinicaltrial.gov ID - NCT02889289.

Outcome on Balance and Gait Following Botulinum Toxin Treatment for Striatal Foot in Parkinson's Disease

BACKGROUND

Striatal foot deformity can shorten the stance phase of gait and impair the ability to stand and walk. Botulinum neurotoxin type A (BoNT A) is a treatment option. However, no previous study has included clinical balance testing in the evaluation of treatment effects. The aim of this study was to evaluate gait and balance in patients with striatal foot deformities and Parkinson's disease (PD) before and after treatment with BoNT A injections.

METHOD

The study included 10 patients with PD and striatal foot deformity who visited a neurological clinic. The mean ± standard deviation age and PD-duration was 62.8 ± 8.8 years and 4.9 ± 3.6 years, respectively. Clinical assessment was made before and 4 and 16 weeks after injection and included 5 clinical gait and balance tests. The intensity of distress due to deformities was investigated with a visual analogue scale. Parkinsonian motor status was assessed with the Unified Parkinson's Disease Rating Scale part III (motor part). Based on ordinary clinical examination, electromyography-guided BoNT A injection was given in affected muscles. Clinically effective doses of BoNT A were used.

RESULTS

Improvements were observed regarding functional, dynamic, and standing balance as well as intensity of distress at 4 weeks but not at 16 weeks compared with baseline.

CONCLUSIONS

BoNT A injection treatment improved gait and balance in patients with PD and striatal foot deformities. Multicenter trials are needed; and, to achieve increased power, a randomized, double-blind controlled design is needed and should focus on the ability of tests to capture subtle changes in gait and balance.

Transcranial direct current stimulation associated with gait training in Parkinson's disease: A pilot randomized clinical trial

OBJECTIVE

The aim of this study is to investigate the effects of transcranial direct current stimulation (tDCS) combined with cueing gait training (CGT) on functional mobility in patients with Parkinson´s disease (PD).

METHODS

A pilot double-blind controlled, randomized clinical trial was conducted with 22 patients with PD assigned to the experimental (anodal tDCS plus CGT) and control group (sham tDCS plus CGT). The primary outcome (functional mobility) was assessed by 10-m walk test, cadence, stride length, and Timed Up and Go test. Motor impairment, bradykinesia, balance, and quality of life were analyzed as secondary outcomes. Minimal clinically important differences (MCIDs) were observed when assessing outcome data.

RESULTS

Both groups demonstrated similar gains in all outcome measures, except for the stride length. The number of participants who showed MCID was similar between groups.

CONCLUSION

The CGT provided many benefits to functional mobility, motor impairment, bradykinesia, balance, and quality of life. However, these effect magnitudes were not influenced by stimulation, but tDCS seems to prolong the effects of cueing therapy on functional mobility.

Are the average gait speeds during the 10meter and 6minute walk tests redundant in Parkinson disease?

We investigated the relationships between average gait speed collected with the 10Meter Walk Test (Comfortable and Fast) and 6Minute Walk Test (6MWT) in 346 people with Parkinson disease (PD) and how the relationships change with increasing disease severity. Pearson correlation and linear regression analyses determined relationships between 10Meter Walk Test and 6MWT gait speed values for the entire sample and for sub-samples stratified by Hoehn & Yahr (H&Y) stage I (n=53), II (n=141), III (n=135) and IV (n=17). We hypothesized that redundant tests would be highly and significantly correlated (i.e. r>0.70, p<0.05) and would have a linear regression model slope of 1 and intercept of 0. For the entire sample, 6MWT gait speed was significantly (p<0.001) related to the Comfortable 10 Meter Walk Test (r=0.75) and Fast 10Meter Walk Test (r=0.79) gait speed, with 56% and 62% of the variance in 6MWT gait speed explained, respectively. The regression model of 6MWT gait speed predicted by Comfortable 10 Meter Walk gait speed produced slope and intercept values near 1 and 0, respectively, especially for participants in H&Y stages II-IV. In contrast, slope and intercept values were further from 1 and 0, respectively, for the Fast 10Meter Walk Test. Comfortable 10 Meter Walk Test and 6MWT gait speeds appeared to be redundant in people with moderate to severe PD, suggesting the Comfortable 10 Meter Walk Test can be used to estimate 6MWT distance in this population.

Wearable Sensor-Based Biofeedback Training for Balance and Gait in Parkinson Disease: A Pilot Randomized Controlled Trial

OBJECTIVES

To analyze the feasibility and efficacy of a novel system (Gamepad [GAMing Experience in PArkinson's Disease]) for biofeedback rehabilitation of balance and gait in Parkinson disease (PD).

DESIGN

Randomized controlled trial.

SETTING

Clinical rehabilitation gym.

PARTICIPANTS

Subjects with PD (N=42) were randomized into experimental and physiotherapy without biofeedback groups.

INTERVENTIONS

Both groups underwent 20 sessions of training for balance and gait. The experimental group performed tailored functional tasks using Gamepad. The system, based on wearable inertial sensors, provided users with real-time visual and acoustic feedback about their movement during the exercises. The physiotherapy group underwent individually structured physiotherapy without feedback.

MAIN OUTCOME MEASURES

Assessments were performed by a blinded examiner preintervention, postintervention, and at 1-month follow-up. Primary outcomes were the Berg Balance Scale (BBS) and 10-m walk test (10MWT). Secondary outcomes included instrumental stabilometric indexes and the Tele-healthcare Satisfaction Questionnaire.

RESULTS

Gamepad was well accepted by participants. Statistically significant between-group differences in BBS scores suggested better balance performances of the experimental group compared with the physiotherapy without biofeedback group both posttraining (experimental group-physiotherapy without biofeedback group: mean, 2.3±3.4 points; P=.047) and at follow-up (experimental group-physiotherapy without biofeedback group: mean, 2.7±3.3 points; P=.018). Posttraining stabilometric indexes showed that mediolateral body sway during upright stance was significantly reduced in the experimental group compared with the physiotherapy without biofeedback group (experimental group-physiotherapy without biofeedback group: -1.6±1.5mm; P=.003). No significant between-group differences were found in the other outcomes.

CONCLUSIONS

Gamepad-based training was feasible and superior to physiotherapy without feedback in improving BBS performance and retaining it for 1 month. After training, 10MWT data were comparable between groups. Further development of the system is warranted to allow the autonomous use of Gamepad outside clinical settings, to enhance gait improvements, and to increase transfer of training effects to real-life contexts.

Test-Retest Reliability of Dual-Task Outcome Measures in People With Parkinson Disease

BACKGROUND

Dual-task (DT) training is gaining ground as a physical therapy intervention in people with Parkinson disease (PD). Future studies evaluating the effect of such interventions need reliable outcome measures. To date, the test-retest reliability of DT measures in patients with PD remains largely unknown.

OBJECTIVE

The purpose of this study was to assess the reliability of DT outcome measures in patients with PD.

DESIGN

A repeated-measures design was used.

METHODS

Patients with PD ("on" medication, Mini-Mental State Examination score ≥24) performed 2 cognitive tasks (ie, backward digit span task and auditory Stroop task) and 1 functional task (ie, mobile phone task) in combination with walking. Tasks were assessed at 2 time points (same hour) with an interval of 6 weeks. Test-retest reliability was assessed for gait while performing each secondary task (DT gait) for both cognitive tasks while walking (DT cognitive) and for the functional task while walking (DT functional).

RESULTS

Sixty-two patients with PD (age=39-89 years, Hoehn and Yahr stages II-III) were included in the study. Intraclass correlation coefficients (ICCs) showed excellent reliability for DT gait measures, ranging between .86 and .95 when combined with the digit span task, between .86 and .95 when combined with the auditory Stroop task, and between .72 and .90 when combined with the mobile phone task. The standard error of measurements for DT gait speed varied between 0.06 and 0.08 m/s, leading to minimal detectable changes between 0.16 and 0.22 m/s. With regard to DT cognitive measures, reaction times showed good-to-excellent reliability (digit span task: ICC=.75; auditory Stroop task: ICC=.82).

LIMITATIONS

The results cannot be generalized to patients with advanced disease or to other DT measures.

CONCLUSIONS

In people with PD, DT measures proved to be reliable for use in clinical studies and look promising for use in clinical practice to assess improvements after DT training. Large effects, however, are needed to obtain meaningful effect sizes.

Alterations of Diffusion Kurtosis and Neurite Density Measures in Deep Grey Matter and White Matter in Parkinson's Disease

In Parkinson’s disease (PD), pathological microstructural changes occur and such changes might be detected using diffusion magnetic resonance imaging (dMRI). However, it is unclear whether dMRI improves PD diagnosis or helps differentiating between phenotypes, such as postural instability gait difficulty (PIGD) and tremor dominant (TD) PD. We included 105 patients with PD and 44 healthy controls (HC), all of whom underwent dMRI as part of the prospective Swedish BioFINDER study. Diffusion kurtosis imaging (DKI) and neurite density imaging (NDI) analyses were performed using regions of interest in the basal ganglia, the thalamus, the pons and the midbrain as well as tractography of selected white matter tracts. In the putamen, the PD group showed increased mean diffusivity (MD) (p = .003), decreased fractional anisotropy (FA) (p = .001) and decreased mean kurtosis (MK), compared to HC (p = .024). High MD and a low MK in the putamen were associated with more severe motor and cognitive symptomatology (p < .05). Also, patients with PIGD exhibited increased MD in the putamen compared to the TD patients (p = .009). In the thalamus, MD was increased (p = .001) and FA was decreased (p = .032) in PD compared to HC. Increased MD and decreased FA correlated negatively with motor speed and balance (p < .05). In the superior longitudinal fasciculus (SLF), MD (p = .019) and f_iso were increased in PD compared to HC (p = .03). These changes correlated negatively with motor speed (p < .002) and balance (p < .037). However, most of the observed changes in PD were also present in cases with either multiple system atrophy (n = 11) or progressive supranuclear palsy (n = 10). In conclusion, PD patients exhibit microstructural changes in the putamen, the thalamus, and the SLF, which are associated with worse disease severity. However, the dMRI changes are not sufficiently specific to improve the diagnostic work-up of PD. Longitudinal studies should evaluate whether dMRI measures can be used to track disease progression.

The effects of Task-Oriented Motor Training on gait characteristics of patients with type 2 diabetes neuropathy

Background

It is known that general gait training improves lower extremity muscle strength and endurance in Diabetes Neuropathy (DN). But, it is still unknown whether Task-Oriented (TO) gait training would change gait biomechanics and the risk of falling in DN. TO gait training focuses on promoting timing and coordination of lower extremity movements through goal-directed practices with sufficient repetition.

Methods

A group of 14 patients with DN participated in a time-series study. All subjects participated in four sessions of assessments (Initial, Pre, Post and Follow-Up). Training was twice a week for 12 weeks. Vertical and horizontal Ground Reaction Forces (GRF), Time Get up and Go (TGUG) and Fall Efficacy Scale-International (FES-I) were evaluated. Gait training started with stepping patterns that progressively changed to complicated patterns of walking. Then, training continued combining walking patterns with upper extremity activities and then ended with treadmill-paced practice.

Results

DN patients significantly increased Second Vertical Peak Force and Horizontal Propulsive Force in addition decrease in Minimum Vertical Force. TGUG significantly decreased while FES-I reflected significant increase after gait training.

Discussion

Conclusively, training not only improved gait performance, confidence in daily activities and attenuated risk of falling, but also helped DN patients to improve feet biomechanics, muscles timing and coordination.

Conclusions

Gait training with respect to principles of motor learning allowed patients to effectively improve through sessions.

Cognitive predictors of balance in Parkinson's disease

Postural instability is one of the most incapacitating symptoms of Parkinson's disease (PD) and appears to be related to cognitive deficits. This study aims to determine the cognitive factors that can predict deficits in static and dynamic balance in individuals with PD. A sociodemographic questionnaire characterized 52 individuals with PD for this work. The Trail Making Test, Rule Shift Cards Test, and Digit Span Test assessed the executive functions. The static balance was assessed using a plantar pressure platform, and dynamic balance was based on the Timed Up and Go Test. The results were statistically analysed using SPSS Statistics software through linear regression analysis. The results show that a statistically significant model based on cognitive outcomes was able to explain the variance of motor variables. Also, the explanatory value of the model tended to increase with the addition of individual and clinical variables, although the resulting model was not statistically significant The model explained 25-29% of the variability of the Timed Up and Go Test, while for the anteroposterior displacement it was 23-34%, and for the mediolateral displacement it was 24-39%. From the findings, we conclude that the cognitive performance, especially the executive functions, is a predictor of balance deficit in individuals with PD.

Measurement instruments to assess posture, gait, and balance in Parkinson's disease: Critique and recommendations

BACKGROUND

Disorders of posture, gait, and balance in Parkinson's disease (PD) are common and debilitating. This MDS-commissioned task force assessed clinimetric properties of existing rating scales, questionnaires, and timed tests that assess these features in PD.

METHODS

A literature review was conducted. Identified instruments were evaluated systematically and classified as "recommended," "suggested," or "listed." Inclusion of rating scales was restricted to those that could be used readily in clinical research and practice.

RESULTS

One rating scale was classified as "recommended" (UPDRS-derived Postural Instability and Gait Difficulty score) and 2 as "suggested" (Tinetti Balance Scale, Rating Scale for Gait Evaluation). Three scales requiring equipment (Berg Balance Scale, Mini-BESTest, Dynamic Gait Index) also fulfilled criteria for "recommended" and 2 for "suggested" (FOG score, Gait and Balance Scale). Four questionnaires were "recommended" (Freezing of Gait Questionnaire, Activities-specific Balance Confidence Scale, Falls Efficacy Scale, Survey of Activities, and Fear of Falling in the Elderly-Modified). Four tests were classified as "recommended" (6-minute and 10-m walk tests, Timed Up-and-Go, Functional Reach).

CONCLUSION

We identified several questionnaires that adequately assess freezing of gait and balance confidence in PD and a number of useful clinical tests. However, most clinical rating scales for gait, balance, and posture perform suboptimally or have been evaluated insufficiently. No instrument comprehensively and separately evaluates all relevant PD-specific gait characteristics with good clinimetric properties, and none provides separate balance and gait scores with adequate content validity for PD. We therefore recommend the development of such a PD-specific, easily administered, comprehensive gait and balance scale that separately assesses all relevant constructs. © 2016 International Parkinson and Movement Disorder Society.

A Selective Corrective Exercise to Decrease Falling and Improve Functional Balance in Idiopathic Parkinson's Disease

BACKGROUND

Posture instability and unsteady gait disorders in Parkinson's Disease (PD) usually contribute to fall-related fractures. Fall-related trauma in PD is the most common reason for injury. Despite providing modern care for PD patients (PP) in the recent years, anti-PD drugs have no effect on falling. There is an urgent need to administer exercise interventions to reduce falls and related injuries in the rehabilitation program of PP.

OBJECTIVES

To explore the effect of a selective 10-week corrective exercise with an emphasis on gait training activities (GTA) on the number of falls (NOFs), fear of falling, functional balance, timed up and go (TUG) test among PD patients.

PATIENTS AND METHODS

A purposeful sampling was performed on PP who had fallen or were at risk of falling in 2014. The study intervention consisted of a 10-week (3 sessions each week, each lasting 60 min) corrective exercise program. Participants were randomly allocated to control and two exercise groups; the exercise group with balance pad (EGBP) or exercise group with no balance pad (EGNBP). The analysis of variance (ANOVA) and paired t-test were used for comparison between the groups (P ≤ 0.05).

RESULTS

Administrating a selective corrective exercise in exercise group with balance pad (EGBP) showed a significant difference in number of falls (NOF), Fall Efficacy Scale-international (FES-I), Berg balance scale (BBS) (and timed up and go) TUG (P = 0.001); while administrating the same exercise in exercise group with no balance pad (EGNBP) showed no significant difference in NOF (P = 0.225) and a significant difference in FES-I (P = 0.031), BBS (P = 0.047) and TUG (P = 0.012). The control group showed no significant difference in each of the dependent variables.

CONCLUSIONS

Performing a selective corrective exercise on balance pad improves falling and functional balance in idiopathic PD.

Gait speed and related factors in Parkinson's disease

[Purpose] The aim of this study was to investigate the relationship between gait speed and various factors in ambulatory patients with idiopathic Parkinson’s disease. [Subjects] Fifty ambulatory patients with idiopathic Parkinson’s disease who were admitted to an outpatient clinic were included in this cross-sectional study. [Methods] The Hoehn and Yahr Scale was used for measurement of the disease severity. Gait speed was measured by the 10-Meter Walk Test. Mobility status was assessed by Timed Up and Go Test. The Hospital Anxiety and Depression Scale was used for evaluation of emotional state. Cognitive status was examined with the Mini-Mental State Examination. The Downton Index was used for fall risk assessment. Balance was evaluated with the Berg Balance Scale. Comorbidity was measured with the Cumulative Illness Rating Scale. The 36-Item Short Form Health Survey was completed for measurement of quality of life. [Results] The mean age was 66.7 (47–83) years. Twenty-eight (56%) patients were men. Gait speed was correlated positively with height, male gender, Mini-Mental Examination score, Berg Balance Scale score and physical summary scores of the 36-Item Short Form Health Survey. On the other hand, there was a negative correlation between gait speed and age, disease severity, TUG time, Downton Index, fear of falling, previous falls and the anxiety and depression scores of the Hospital Anxiety and Depression Scale. There was no correlation between gait speed and comorbidity. [Conclusion] The factors related with the slower gait speed are, elder age, clinically advanced disease, poor mobility, fear of falling, falling history, higher falling risk, and mood disorder.