Effect of One Single Auditory Cue on Movement Kinematics in Patients with Parkinson???s Disease

Lack of visual information alters lower limb motor coordination to control center of mass trajectory during walking

Vision, as queen of the senses, plays a critical role in guiding locomotion. Little is known about the effects of vision on gait coordination in terms of variability. The uncontrolled manifold (UCM) approach offers a window to the structure of motor variability that has been difficult to obtain from the traditional correlation analysis. In this study, we used the UCM analysis to quantify how the lower limb motion is coordinated to control the center of mass (COM) while walking under different visual conditions. We also probed how synergy strength evolved along the stance phase. Ten healthy participants walked on the treadmill with and without visual information. Leg joint angle variance with respect to the whole-body COM was partitioned into good (i.e., the one that kept the COM) and bad (i.e., the one that changed the COM) variances. We observed that after vision was eliminated, both variances increased throughout the stance phase while the strength of the synergy (the normalized difference between the two variances) decreased significantly and even reduced to zero at heel contact. Thus, walking with restricted vision alters the strength of the kinematic synergy to control COM in the plane of progression. We also found that the strength of this synergy varied across different walking phases and gait events in both visual conditions. We concluded that the UCM analysis can quantify altered coordination of COM when vision is blocked and sheds insights on the role of vision in the synergistic control of locomotion.

Modeling Cues May Reduce Sway Following Sit-To-Stand Transfer for People with Parkinson's Disease

Cues are commonly used to overcome the effects of motor symptoms associated with Parkinson's disease. Little is known about the impact of cues on postural sway during transfers. The objective of this study was to identify if three different types of explicit cues provided during transfers of people with Parkinson's disease results in postural sway more similar to healthy controls. This crossover study had 13 subjects in both the Parkinson's and healthy control groups. All subjects completed three trials of uncued sit to stand transfers. The Parkinson's group additionally completed three trials of sit to stand transfers in three conditions: external attentional focus of reaching to targets, external attentional focus of concurrent modeling, and explicit cue for internal attentional focus. Body worn sensors collected sway data, which was compared between groups with Mann Whitney U tests and between conditions with Friedman's Tests. Sway normalized with modeling but was unchanged in the other conditions. Losses of balance presented with reaching towards targets and cueing for an internal attentional focus. Modeling during sit to stand of people with Parkinson's disease may safely reduce sway more than other common cues.

Measurement and Correction of Stooped Posture during Gait Using Wearable Sensors in Patients with Parkinsonism: A Preliminary Study

Stooped posture, which is usually aggravated during walking, is one of the typical postural deformities in patients with parkinsonism. However, the degree of stooped posture is difficult to quantitatively measure during walking. Furthermore, continuous feedback on posture is also difficult to provide. The purpose of this study is to measure the degree of stooped posture during gait and to investigate whether vibration feedback from sensor modules can improve a patient's posture. Parkinsonian patients with stooped posture were recruited for this study. Two wearable sensors with three-axis accelerometers were attached, one at the upper neck and the other just below the C7 spinous process of the patients. After being calibrated in the most upright posture, the sensors continuously recorded the sagittal angles at 20 Hz and averaged the data at every second during a 6 min walk test. In the control session, the patients walked with the sensors as usual. In the vibration session, sensory feedback was provided through vibrations from the neck sensor module when the sagittal angle exceeded a programmable threshold value. Data were collected and analyzed successfully in a total of 10 patients. The neck flexion and back flexion were slightly aggravated during gait, although the average change was <10° in most patients in both measurement sessions. Therefore, it was difficult to evaluate the effect of sensory feedback through vibration. However, some patients showed immediate response to the feedback and corrected their posture during gait. In conclusion, this preliminary study suggests that stooped posture could be quantitatively measured during gait by using wearable sensors in patients with parkinsonism. Sensory feedback through vibration from sensor modules may help in correcting posture during gait in selected patients.

The Effects of Sensory Manipulations on Motor Behavior: From Basic Science to Clinical Rehabilitation

Modifying sensory aspects of the learning environment can influence motor behavior. Although the effects of sensory manipulations on motor behavior have been widely studied, there still remains a great deal of variability across the field in terms of how sensory information has been manipulated or applied. Here, the authors briefly review and integrate the literature from each sensory modality to gain a better understanding of how sensory manipulations can best be used to enhance motor behavior. Then, they discuss 2 emerging themes from this literature that are important for translating sensory manipulation research into effective interventions. Finally, the authors provide future research directions that may lead to enhanced efficacy of sensory manipulations for motor learning and rehabilitation.

Systematic review of the effectiveness of occupational therapy-related interventions for people with Parkinson's disease

We describe the results of a systematic review of the literature on occupational therapy-related interventions for people with Parkinson's disease (PD). Three broad categories of intervention emerged: (1) exercise or physical activity; (2) environmental cues, stimuli, and objects; and (3) self-management and cognitive-behavioral strategies. Moderate to strong evidence exists for task-specific benefits of targeted physical activity training on motor performance, postural stability, and balance. Low to moderate evidence indicates that more complex, multimodal activity training supports improvement in functional movement activities. The evidence is moderate that the use of external supports during functional mobility or other movement activities has positive effects on motor control. In addition, moderate evidence is available that individualized interventions focused on promoting participant wellness initiatives and personal control by means of cognitive-behavioral strategies can improve targeted areas of quality of life. The implications for practice, education, and research are discussed.

Improvement of upper extremity motor control and function after home-based constraint induced therapy in children with unilateral cerebral palsy: immediate and long-term effects

OBJECTIVE

To investigate the long-term effects of home-based constraint induced therapy (CIT) on motor control underlying functional change in children with unilateral cerebral palsy (CP).

DESIGN

Randomized controlled trial.

SETTING

Home based.

PARTICIPANTS

Children with unilateral CP (N=45; aged 6-12 y) were randomly assigned to receive home-based CIT (n=23) or traditional rehabilitation (TR) (n=22).

INTERVENTIONS

Both groups received a 4-week therapist-based intervention at home. The home-based CIT involved intensive functional training of the more affected upper extremity during which the less affected one was restrained. The TR involved functional unimanual and bimanual training.

MAIN OUTCOME MEASURES

All children underwent kinematic and clinical assessments at baseline, 4 weeks (posttreatment), and 3 and 6 months (follow-up). The reach-to-grasp kinematics were reaction time (RT), normalized movement time, normalized movement unit, peak velocity (PV), maximum grip aperture (MGA), and percentage of movement where MGA occurs. The clinical measures were the Peabody Developmental Motor Scales, Second Edition (PDMS-2), Bruininks-Oseretsky Test of Motor Proficiency (BOTMP), and Functional Independence Measure for children (WeeFIM).

RESULTS

The home-based CIT group showed a shorter RT (P<.05) and normalized movement time (P<.01), smaller MGA (P=.006), and fewer normalized movement units (P=.014) in the reach-to-grasp movements at posttreatment and follow-up than the TR group. The home-based CIT group improved more on the PDMS-2 (P<.001) and WeeFIM (P<.01) in all posttreatment tests and on the BOTMP (P<.01) at follow-up than the TR group.

CONCLUSIONS

The home-based CIT induced better spatial and temporal efficiency (smoother movement, more efficient grasping, better movement preplanning and execution) for functional improvement up to 6 months after treatment than TR.

Comparison of virtual reality versus physical reality on movement characteristics of persons with Parkinson's disease: effects of moving targets

OBJECTIVE

To compare the performance of reaching for stationary and moving targets in virtual reality (VR) and physical reality in persons with Parkinson's disease (PD).

DESIGN

A repeated-measures design in which all participants reached in physical reality and VR under 5 conditions: 1 stationary ball condition and 4 conditions with the ball moving at different speeds.

SETTING

University research laboratory.

PARTICIPANTS

Persons with idiopathic PD (n=29) and age-matched controls (n=25).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Success rates and kinematics of arm movement (movement time, amplitude of peak velocity, and percentage of movement time for acceleration phase).

RESULTS

In both VR and physical reality, the PD group had longer movement time (P<.001) and lower peak velocity (P<.001) than the controls when reaching for stationary balls. When moving targets were provided, the PD group improved more than the controls did in movement time (P<.001) and peak velocity (P<.001), and reached a performance level similar to that of the controls. Except for the fastest moving ball condition (0.5-s target viewing time), which elicited worse performance in VR than in physical reality, most cueing conditions in VR elicited performance generally similar to those in physical reality.

CONCLUSIONS

Although slower than the controls when reaching for stationary balls, persons with PD increased movement speed in response to fast moving balls in both VR and physical reality. This suggests that with an appropriate choice of cueing speed, VR is a promising tool for providing visual motion stimuli to improve movement speed in persons with PD. More research on the long-term effect of this type of VR training program is needed.

Effects of virtual reality training on functional reaching movements in people with Parkinson’s disease: a randomized controlled pilot trial

Objective: To investigate whether practising reaching for virtual moving targets would improve motor performance in people with Parkinson’s disease.

Design: Randomized pretest–posttest control group design.

Setting: A virtual reality laboratory in a university setting.

Participants: Thirty-three adults with Parkinson’s disease.

Interventions: The virtual reality training required 60 trials of reaching for fast-moving virtual balls with the dominant hand. The control group had 60 practice trials turning pegs with their non-dominant hand.

Main outcome measures: Pretest and posttest required reaching with the dominant hand to grasp real stationary balls and balls moving at different speeds down a ramp. Success rates and kinematic data (movement time, peak velocity and percentage of movement time for acceleration phase) from pretest and posttest were recorded to determine the immediate transfer effects.

Results: Compared with the control group, the virtual reality training group became faster ( F = 9.08, P = 0.005) and more forceful ( F = 9.36, P = 0.005) when reaching for real stationary balls. However, there was no significant difference in success rate or movement kinematics between the two groups when reaching for real moving balls.

Conclusion: A short virtual reality training programme improved the movement speed of discrete aiming tasks when participants reached for real stationary objects. However, the transfer effect was minimal when reaching for real moving objects.

Randomized trial of distributed constraint-induced therapy versus bilateral arm training for the rehabilitation of upper-limb motor control and function after stroke

BACKGROUND AND OBJECTIVE

This study compared the efficacy of distributed constraint-induced therapy (dCIT), bilateral arm training (BAT), and control treatment (CT) on motor control and functional performance of the upper limb in stroke patients.

METHODS

A total of 66 patients with mean stroke onset of 16.20 months and mild to moderate motor impairment were randomized to dCIT, BAT, or CT groups. Each group received treatment for 2 h/d and 5 d/wk for 3 weeks. Pretreatment and posttreatment measures included reaching kinematic variables in unilateral and bilateral tasks, the Wolf Motor Function Test (WMFT), and the Motor Activity Log (MAL).

RESULTS

The dCIT and BAT groups had smoother reaching trajectories in the unilateral and bilateral tasks than the CT group. The BAT group, but not the dCIT group, generated greater force at movement initiation than the CT group during the unilateral and bilateral tasks. The dCIT patients had decreased WMFT time and higher functional ability scores than the CT patients. MAL results pointed to better performance in the amount and quality of use of the affected arm than BAT and CT patients.

CONCLUSIONS

BAT and dCIT exhibited similar beneficial effects on movement smoothness but differential effects on force at movement initiation and functional performance. Therefore, BAT is a better option if improvement of force generation is the treatment goal, and dCIT is more appropriate for improving functional ability and use of the affected arm in daily life. These findings may assist in the planning of individually tailored rehabilitation therapies.

Use of harmonic ratios to examine the effect of cueing strategies on gait stability in persons with Parkinson's disease

OBJECTIVE

To determine if gait stability, as measured by harmonic ratios (HRs) derived from trunk accelerations, is improved during 3 amplitude-based cueing strategies (visual cues, lines on the floor 20% longer than preferred step length; verbal cues, experimenter saying "big step" every third; cognitive cues, participants think "big step") in people with Parkinson's disease.

DESIGN

Gait analysis with a triaxial accelerometer.

SETTING

University research laboratory.

PARTICIPANTS

A volunteer sample of persons with Parkinson's disease (N=7) (Hoehn and Yahr stages 2-3).

INTERVENTIONS

Not applicable

MAIN OUTCOME MEASURES

Gait stability was quantified by anterior-posterior (AP), vertical, and mediolateral (ML) HRs; higher ratios indicated improved gait stability. Spatiotemporal parameters assessed were walking speed, stride length, cadence, and the coefficient of variation for stride time.

RESULTS

Of the amplitude-based cues, verbal and cognitive resulted in the largest improvements in the AP HR (P=.018) with a trend in the vertical HR as well as the largest improvements in both stride length and velocity. None of the cues positively affected stability in the ML direction. Descriptively, all participants increased speed and stride length, but only those in Hoehn and Yahr stage 2 (not Hoehn and Yahr stage 3) showed improvements in HRs.

CONCLUSIONS

Cueing for "big steps" is effective for improving gait stability in the AP direction with modest improvements in the vertical direction, but it is not effective in the ML direction. These data support the use of trunk acceleration measures in assessing the efficacy of common therapeutic interventions.

Occupational Therapy to Optimise Independence in Parkinson's Disease: The Designing and Recording of a Randomised Controlled Trial Intervention

PDOT (Parkinson's Disease Occupational Therapy) was a pilot randomised controlled trial investigating occupational therapy for people with Parkinson's disease (PD) exhibiting difficulties with activities of daily living (ADL). This article describes the process undertaken to design and record the intervention.

Intervention development was informed by the current evidence base and practice consensus. An expert steering group synthesised this information to develop an intervention framework. A recording tool was identified from a previous occupational therapy trial and adopted for PDOT. This was completed for all participants receiving the intervention, capturing the dose and content of therapy delivered.

Nineteen participants received occupational therapy. A mean number of 5.7 visits was delivered over 60.3 days, with the initial visit lasting 60 minutes (median) and subsequent visits lasting 50 minutes (median). The intervention log demonstrated that a large proportion of therapist visits involved equipment provision/environmental adaptation, mobility/transfers/ADL training, review/discussion, and the teaching of techniques/provision of education.

The intervention developed was found to be feasible and acceptable, and the findings of PDOT have been used to inform a phase III rehabilitation trial (PD REHAB). The intervention log has been revised in light of the findings and will be used within this trial.

Music attenuates excessive visual guidance of skilled reaching in advanced but not mild Parkinson's disease

Parkinson's disease (PD) results in movement and sensory impairments that can be reduced by familiar music. At present, it is unclear whether the beneficial effects of music are limited to lessening the bradykinesia of whole body movement or whether beneficial effects also extend to skilled movements of PD subjects. This question was addressed in the present study in which control and PD subjects were given a skilled reaching task that was performed with and without accompanying preferred musical pieces. Eye movements and limb use were monitored with biomechanical measures and limb movements were additionally assessed using a previously described movement element scoring system. Preferred musical pieces did not lessen limb and hand movement impairments as assessed with either the biomechanical measures or movement element scoring. Nevertheless, the PD patients with more severe motor symptoms as assessed by Hoehn and Yahr (HY) scores displayed enhanced visual engagement of the target and this impairment was reduced during trials performed in association with accompanying preferred musical pieces. The results are discussed in relation to the idea that preferred musical pieces, although not generally beneficial in lessening skilled reaching impairments, may normalize the balance between visual and proprioceptive guidance of skilled reaching.

Handle size as a task constraint in spoon-use movement in patients with Parkinson's disease

Objective: To examine the effect of spoon-handle size on kinematic performance in people with Parkinson's disease.

Design: A counterbalanced repeated-measures design.

Setting: A motor control laboratory in a university setting.

Subjects: Eighteen individuals with Parkinson's disease and 18 age-matched controls.

Experimental conditions: Each participant was instructed to scoop water (simulated soup) using spoons with three different-sized handles.

Main measures: Kinematic variables (movement time, peak velocity and number of movement units) of arm movement, size of hand aperture and number of fingers to grasp the spoon.

Results: The movement of the participants with Parkinson's disease was faster (shorter movement time) and smoother (fewer movement units) when they used spoons with a small- or medium-sized handle than when using a spoon with a large-sized handle. In contrast, the healthy controls showed no significant differences in movement kinematics between handle sizes. Moreover, the participants with Parkinson's disease had a significantly smaller hand aperture and used more fingers to hold the spoons than the controls did.

Conclusions: These results suggest that, for people with Parkinson's disease, a small-to-medium-sized handle is more suitable than a large-sized built-up handle.

Effects of object use on reaching and postural balance: a comparison of patients with unilateral stroke and healthy controls

OBJECTIVE

To evaluate whether the functional use of certain task objects while standing influences reaching performance and postural balance in persons with left or right cerebral vascular accidents, and also in healthy individuals.

DESIGN

Thirty-five stroke patients (20 patients with left and 15 patients with right cerebral vascular accidents) and 31 healthy controls (15 using the left and 16 the right arm) performed two experimental reaching tasks (task object present vs. absent) using the less affected arm while standing. For the object-present task, subjects held a glass and moved it forward as far as possible. For the object-absent task, subjects simply reached forward as far as possible. We measured reaching performance using kinematic analysis and assessed postural control using derivatives of the center of pressure, including forward displacement, mediolateral shift, and average velocity.

RESULTS

Object presence did not significantly improve overall reaching performance in any group. However, for patients with left cerebral vascular accidents and controls (using either the left or the right arm), there were significant effects of object presence on the average velocity of the center of pressure. For patients with right cerebral vascular accidents, there were significant effects of task object on the forward distance and average velocity of the center of pressure.

CONCLUSIONS

The positive findings regarding center-of-pressure derivatives suggest that a functional use of objects during a standing reaching task can decrease postural sway, as represented by the average velocity of the center of pressure, in individuals with and without stroke. Patients with right cerebral vascular accidents may benefit considerably more from functional object use during a standing reaching task, apparently because such tasks can facilitate greater forward displacement of the center of pressure.

Kinematic and Clinical Analyses of Upper-Extremity Movements After Constraint-Induced Movement Therapy in Patients With Stroke: A Randomized Controlled Trial

OBJECTIVE

To study the effects of constraint-induced movement therapy (CIMT) relative to traditional intervention on motor-control strategies for upper-arm reaching and motor performance at the impairment and functional levels in stroke patients.

DESIGN

Two-group randomized controlled trial (RCT); pretreatment and posttreatment measures.

SETTING

Rehabilitation clinics.

PARTICIPANTS

Forty-seven stroke patients (mean age, 55y) 3 weeks to 37 months postonset of a first-ever cerebrovascular accident.

INTERVENTIONS

Forty-seven patients received either CIMT (restraint of the less affected hand combined with intensive training of the more affected upper extremity) or traditional intervention (control treatment) during the study. The treatment intensity was matched between the 2 groups (2h/d, 5d/wk for 3wk).

MAIN OUTCOME MEASURES

Outcomes were evaluated using (1) kinematic variables of reaching movement used to describe the control strategies for reaching, (2) the Fugl-Meyer Assessment (FMA) of motor-impairment severity, and (3) the Motor Activity Log (MAL) evaluating the functional ability of the upper extremity.

RESULTS

After treatment, the CIMT group showed better strategies of reaching control than the control group (P<.03). The CIMT group also showed less motor impairment on the FMA (P=.019) and higher functional ability on the MAL (P<.001).

CONCLUSIONS

This study is the first RCT to show differences in motor-control strategies as measured by kinematic variables after CIMT versus traditional intervention. In addition to improving motor performance at the impairment and functional levels, CIMT conferred therapeutic benefits on control strategies determined by kinematic analysis.

Effects of Modified Constraint-Induced Movement Therapy on Movement Kinematics and Daily Function in Patients With Stroke: A Kinematic Study of Motor Control Mechanisms

Background and Objective. Motor control of the upper extremity during unilateral and bimanual functional tasks and functional change during daily activities were evaluated in patients with stroke treated with modified constraint-induced movement therapy (mCIMT). Methods. In a pre-post randomized, controlled trial, 30 stroke patients received 2 hours of mCIMT or traditional rehabilitation (TR) for 3 weeks. Motor control of the upper extremity was evaluated using kinematic analysis in unilateral and bilateral tasks. Kinematic variables included spatial and temporal movement efficiency and type of movement control (preplanned control, representing well-learned movement, or feedback-guided control). Functional outcomes were evaluated using the Motor Activity Log (MAL) and the Functional Independence Measure (FIM). Results. Patients receiving mCIMT showed more temporally ( P = .013) and spatially ( P = .011) efficient movement and more preplanned movement control ( P = .009) during the bimanual task, and greater gains in FIM ( P = .004) and MAL scores (amount of use: P < .0001, and quality of movement: P = .012) than patients in the TR group. Patients receiving mCIMT produced more ballistic/preplanned reaching movement than did patients receiving TR ( P = .023) during the unilateral task; but there were no group differences in temporal or spatial efficiency in unilateral task performance. Conclusions. Relative to TR, mCIMT produced a greater improvement in functional performance and motor control. Improvement of motor control after mCIMT was based on improved spatial and temporal efficiency, apparently more salient during bimanual rather than unilateral task performance. This suggests that bilateral task performance should potentially be emphasized in kinematic study of changes in motor control after mCIMT.

Wheeling à petit pas: Parkinsonism detected by observation of wheelchair propulsion

We present a man with parkinsonism detected by the observation of wheelchair propulsion. His manual wheelchair propulsion technique was observed to include rapid, brief, low-power strokes resembling the marche à petit pas (walking with tiny steps) phenomenon of parkinsonism. We videotaped his wheelchair propulsion and compared him with ten age-, gender-, and diagnosis-matched controls. The patient had a propulsion velocity of 0.14 m/sec compared with a mean (+/- standard deviation) of 0.73 (+/- 0.16) m/sec for the controls, a cadence of 209 strokes/min vs. 60 (+/- 12) strokes/min for the controls, and a mechanical efficiency of 0.04 m/stroke compared with 0.75 (+/- 0.25) m/stroke for the controls. This observation shifted the course of his medical investigations and management as well as his rehabilitation care. This is the first detailed report of how parkinsonian features may affect manual wheelchair propulsion. It suggests that observation of wheelchair mobility should be a routine component of the physical examination of wheelchair users.

Training BIG to move faster: the application of the speed–amplitude relation as a rehabilitation strategy for people with Parkinson’s disease

We have used the phenomenon that speed increases with movement amplitude as a rehabilitation strategy. We tested the hypothesis that the generalized training of amplitude in the limb motor system may reduce bradykinesia and hypokinesia in the upper and lower limbs in subjects with Parkinson's disease (PD) across disease severity (Stage I, n=6; Stage II, n=7; Stage III, n=5). While studies have separately examined the relationship of amplitude to speed in reaching and gait, the same study has not reported the relationship for both limb systems. Moreover, the rehabilitation intervention, Training BIG, is unique in that it applies well-established treatment concepts from a proven treatment for the speech motor system in PD [Lee Silverman Voice Treatment (LSVT)] to the limb motor system. Subjects (n=18) participated in intense practice (1-h sessions/4x week/4 weeks) of large amplitude movements involving the whole body (i.e., head, arm, trunk, and leg) while focusing on the sensory awareness of "movement bigness." Testing procedures were designed to demonstrate the transfer of generalized amplitude practice to speed improvements during functional "untrained" tasks in "uncued" conditions with blinded testers. After therapy, the subjects significantly increased their speed of reaching and gait for the preferred speed condition. This effect was greater when the severity of the disease was less. The results support further application and efficacy studies of Training BIG. Amplitude-based behavioral intervention in people with PD appears to be a simple target that may be applied in different contexts for multiple tasks and results in improved speed-amplitude scaling relations across the upper and lower limbs.