Short-Term Effects of Single-Session Split-Belt Treadmill Training on Dual-Task Performance in Parkinson's Disease and Healthy Elderly

On-Demand Cueing for Freezing of Gait in Parkinson's Disease: A Randomized Controlled Trial

BACKGROUND

Cueing can alleviate freezing of gait (FOG) in people with Parkinson's disease (PD), but using the same cues continuously in daily life may compromise effectiveness. Therefore, we developed the DeFOG-system to deliver personalized auditory cues on detection of a FOG episode.

OBJECTIVES

We aimed to evaluate the effects of DeFOG during a FOG-provoking protocol: (1) after 4 weeks of DeFOG-use in daily life against an active control group; (2) after immediate DeFOG-use (within-group) in different medication states.

METHOD

In this randomized controlled trial, 63 people with PD and daily FOG were allocated to the DeFOG or active control group. Both groups received feedback on their daily living step counts using the device, but the DeFOG group also received on-demand cueing. Video-rated FOG severity was compared pre- and post-intervention through a FOG-provoking protocol administered at home off and on-medication, but without using DeFOG. Within-group effects were tested by comparing FOG during the protocol with and without DeFOG.

RESULTS

DeFOG-use during the 4 weeks was similar between groups, but we found no between-group differences in FOG-severity. However, the within-group analysis showed that FOG was alleviated by DeFOG (effect size d = 0.57), regardless of medication state. Combining DeFOG and medication yielded an effect size of d = 0.67.

CONCLUSIONS

DeFOG reduced FOG considerably in a population of severe freezers both off and on medication. Nonetheless, 4 weeks of DeFOG-use in daily life did not ameliorate FOG during the protocol unless DeFOG was worn. These findings suggest that on-demand cueing is only effective when used, similar to other walking aids. © 2024 International Parkinson and Movement Disorder Society.

Uncorking the limitation-improving dual tasking using transcranial electrical stimulation and task training in the elderly: a systematic review

Introduction

With aging, dual task (DT) ability declines and is more cognitively demanding than single tasks. Rapidly declining DT performance is regarded as a predictor of neurodegenerative disease. Task training and non-invasive transcranial electrical stimulation (tES) are methods applied to optimize the DT ability of the elderly.

Methods

A systematic search was carried out in the PUBMED, TDCS (transcranial direct current stimulation) databases, as well as Web of Science, and a qualitative analysis was conducted in 56 included studies. Aiming to summarize the results of studies that implemented tES, task training, or the combination for improving DT ability and related performance changes in healthy elderly and geriatric patients. For different approaches, the training procedures, parameters, as well as outcomes were discussed.

Results

Task training, particularly cognitive-motor DT training, has more notable effects on improving DT performance in the elderly when compared to the neuromodulation method.

Discussion

Anodal transcranial direct current stimulation (tDCS) over the left dorsolateral prefrontal cortex (L-DLPFC), or its combination with task training could be promising tools. However, additional evidence is required from aged healthy people and patients, as well as further exploration of electrode montage.

Beyond timing and step counting in 360° turning-in-place assessment: a scoping review

BACKGROUND

Turning in place is a challenging motor task and is used as a brief assessment test of lower limb function and dynamic balance. This review aims to examine how research of instrumented analysis of turning in place is implemented. In addition to reporting the studied population, we covered acquisition systems, turn detection methods, quantitative parameters, and how these parameters are computed.

METHODS

Following the development of a rigorous search strategy, the Web of Science and Scopus were systematically searched for studies involving the use of turning-in-place. From the selected articles, the study population, types of instruments used, turn detection method, and how the turning-in-place characteristics were calculated.

RESULTS

Twenty-one papers met the inclusion criteria. The subject groups involved in the reviewed studies included young, middle-aged, and older adults, stroke, multiple sclerosis and Parkinson's disease patients. Inertial measurement units (16 studies) and motion camera systems (5 studies) were employed for gathering measurement data, force platforms were rarely used (2 studies). Two studies used commercial software for turn detection, six studies referenced previously published algorithms, two studies developed a custom detector, and eight studies did not provide any details about the turn detection method. The most frequently used parameters were mean angular velocity (14 cases, 7 studies), turn duration (13 cases, 13 studies), peak angular velocity (8 cases, 8 studies), jerkiness (6 cases, 5 studies) and freezing-of-gait ratios (5 cases, 5 studies). Angular velocities were derived from sensors placed on the lower back (7 cases, 4 studies), trunk (4 cases, 2 studies), and shank (2 cases, 1 study). The rest (9 cases, 8 studies) did not report sensor placement. Calculation of the freezing-of-gait ratio was based on the acceleration of the lower limbs in all cases. Jerkiness computation employed acceleration in the medio-lateral (4 cases) and antero-posterior (1 case) direction. One study did not reported any details about jerkiness computation.

CONCLUSION

This review identified the capabilities of turning-in-place assessment in identifying movement differences between the various subject groups. The results, based on data acquired by inertial measurement units across studies, are comparable. A more in-depth analysis of tests developed for gait, which has been adopted in turning-in-place, is needed to examine their validity and accuracy.

Prevention of Falls in Parkinson's Disease: Guidelines and Gaps

Background

People living with Parkinson's disease (PD) have a high risk for falls.

Objective

To examine gaps in falls prevention targeting people with PD as part of the Task Force on Global Guidelines for Falls in Older Adults.

Methods

A Delphi consensus process was used to identify specific recommendations for falls in PD. The current narrative review was conducted as educational background with a view to identifying gaps in fall prevention.

Results

A recent Cochrane review recommended exercises and structured physical activities for PD; however, the types of exercises and activities to recommend and PD subgroups likely to benefit require further consideration. Freezing of gait, reduced gait speed, and a prior history of falls are risk factors for falls in PD and should be incorporated in assessments to identify fall risk and target interventions. Multimodal and multi-domain fall prevention interventions may be beneficial. With advanced or complex PD, balance and strength training should be administered under supervision. Medications, particularly cholinesterase inhibitors, show promise for falls prevention. Identifying how to engage people with PD, their families, and health professionals in falls education and implementation remains a challenge. Barriers to the prevention of falls occur at individual, environmental, policy, and health system levels.

Conclusion

Effective mitigation of fall risk requires specific targeting and strategies to reduce this debilitating and common problem in PD. While exercise is recommended, the types and modalities of exercise and how to combine them as interventions for different PD subgroups (cognitive impairment, freezing, advanced disease) need further study.

Differential gait adaptation patterns in Parkinson's disease - a split belt treadmill pilot study

BACKGROUND

Interventions using split belt treadmills (SBTM) aim to improve gait symmetry (GA) in Parkinson's disease (PD). Comparative effects in conjugated SBTM conditions were not studied systematically despite potentially affecting intervention outcomes. We compared gait adaptation effects instigated by SBTM walking with respect to the type (increased\decreased speed) and the side (more/less affected) of the manipulated belt in PD.

METHODS

Eight individuals with PD performed four trials of SBTM walking, each consisted of baseline tied belt configuration, followed by split belt setting - either WS or BS belt's speed increased or decreased by 50% from baseline, and final tied belt configuration. Based on the disease's motor symptoms, a 'worst' side (WS) and a 'best' side (BS) were defined for each participant.

RESULTS

SB initial change in GA was significant regardless of condition (p ≤ 0.02). This change was however more pronounced for BS-decrease compared with its matching condition WS-increase (p = 0.016). Similarly, the same was observed for WS-decrease compared to BS-increase (p = 0.013). Upon returning to tied belt condition, both BS-decrease and WS-increased resulted in a significant change in GA (p = 0.04). Upper limb asymmetry followed a similar trend of GA reversal, although non-significant.

CONCLUSIONS

Stronger effects on GA were obtained by decreasing the BS belt's speed of the best side, rather than increasing the speed of the worst side. Albeit a small sample size, which limits the generalisability of these results, we propose that future clinical studies would benefit from considering such methodological planning of SBTM intervention, for maximising of intervention outcomes. Larger samples may reveal arm swinging asymmetries alterations to match SBTM adaptation patterns. Finally, further research is warranted to study post-adaption effects in order to define optimal adaptation schemes to maximise the therapeutic effect of SBTM based interventions.

Split-Belt Treadmill Training to Improve Gait Adaptation in Parkinson's Disease

BACKGROUND

Gait deficits in people with Parkinson's disease (PD) are triggered by circumstances requiring gait adaptation. The effects of gait adaptation training on a split-belt treadmill (SBT) are unknown in PD.

OBJECTIVE

We investigated the effects of repeated SBT versus tied-belt treadmill (TBT) training on retention and automaticity of gait adaptation and its transfer to over-ground walking and turning.

METHODS

We recruited 52 individuals with PD, of whom 22 were freezers, in a multi-center randomized single-blind controlled study. Training consisted of 4 weeks of supervised treadmill training delivered three times per week. Tests were conducted pre- and post-training and at 4-weeks follow-up. Turning (primary outcome) and gait were assessed over-ground and during a gait adaptation protocol on the treadmill. All tasks were performed with and without a cognitive task.

RESULTS

We found that SBT-training improved gait adaptation with moderate to large effects sizes (P < 0.02) compared to TBT, effects that were sustained at follow-up and during dual tasking. However, better gait adaptation did not transfer to over-ground turning speed. In both SBT- and TBT-arms, over-ground walking and Movement Disorder Society-Unified Parkinson's Disease Rating Scale III (MDS-UPDRS-III scores were improved, the latter of which reached clinically meaningful effects in the SBT-group only. No impact was found on freezing of gait.

CONCLUSION

People with PD are able to learn and retain the ability to overcome asymmetric gait-speed perturbations on a treadmill remarkably well, but seem unable to generalize these skills to asymmetric gait off-treadmill. Future study is warranted into gait adaptation training to boost the transfer of complex walking skills. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Modulation of the gait pattern during split-belt locomotion after lateral spinal cord hemisection in adult cats

Most previous studies investigated the recovery of locomotion in animals and people with incomplete spinal cord injury (SCI) during relatively simple tasks (e.g., walking in a straight line on a horizontal surface or a treadmill). We know less about the recovery of locomotion after incomplete SCI in left-right asymmetric conditions, such as turning or stepping along circular trajectories. To investigate this, we collected kinematic and electromyography data during split-belt locomotion at different left-right speed differences before and after a right thoracic lateral spinal cord hemisection in nine adult cats. After hemisection, although cats still performed split-belt locomotion, we observed several changes in the gait pattern compared with the intact state at early (1-2 wk) and late (7-8 wk) time points. Cats with larger lesions showed new coordination patterns between the fore- and hindlimbs, with the forelimbs taking more steps. Despite this change in fore-hind coordination, cats maintained consistent phasing between the fore- and hindlimbs. Adjustments in cycle and phase (stance and swing) durations between the slow and fast sides allowed animals to maintain 1:1 left-right coordination. Periods of triple support involving the right (ipsilesional) hindlimb decreased in favor of quad support and triple support involving the other limbs. Step and stride lengths decreased with concurrent changes in the right fore- and hindlimbs, possibly to avoid interference. The above adjustments in the gait pattern allowed cats to retain the ability to locomote in asymmetric conditions after incomplete SCI. We discuss potential plastic neuromechanical mechanisms involved in locomotor recovery in these conditions.NEW & NOTEWORTHY Everyday locomotion often involves left-right asymmetries, when turning, walking along circular paths, stepping on uneven terrains, etc. To show how incomplete spinal cord injury affects locomotor control in asymmetric conditions, we collected data before and after a thoracic lateral spinal hemisection on a split-belt treadmill with one side stepping faster than the other. We show that adjustments in kinematics and muscle activity allowed cats to retain the ability to perform asymmetric locomotion after hemisection.

Acute effects of virtual reality treadmill training on gait and cognition in older adults: A randomized controlled trial

INTRODUCTION

Everyday walking often involves walking with divided attention (i.e., dual-tasking). Exercise interventions for older adults should mimic these simultaneous physical and cognitive demands. This proof-of-concept study had a two-fold purpose: 1) identify acute cognitive and gait benefits of a single session of virtual reality treadmill training (VRTT), relative to conventional treadmill training (CTT), and 2) identify differences between those who reduced dual-task costs (i.e., responders) on gait or cognition and those who did not, after the session.

METHODS

Sixty older adults were randomized to complete a single 30-minute session of VRTT (n = 30, 71.2±6.5 years, 22 females) or CTT (n = 30, 72.0±7.7 years, 21 females). Pre- and post-exercise session, participants performed single-task walking, single-task cognitive, and dual-task walking trials while gait and cognition were recorded. Gait variables were gait speed and gait speed variability. Cognition variables were response reaction time, response accuracy, and cognitive throughput. Dual-task effects (DTE) on gait and cognition variables were also calculated.

RESULTS

Post-exercise, there were no group differences (all p>0.05). During single- and dual-task trials, both groups walked faster (single-task: F(1, 58) = 9.560, p = 0.003; dual-task: F(1, 58) = 19.228, p<0.001), responded more quickly (single-task: F(1, 58) = 5.054, p = 0.028; dual-task: F(1, 58) = 8.543, p = 0.005), and reduced cognitive throughput (single-task: F(1, 58) = 6.425, p = 0.014; dual-task: F(1, 58) = 28.152, p<0.001). Both groups also exhibited reduced DTE on gait speed (F(1, 58) = 8.066, p = 0.006), response accuracy (F(1, 58) = 4.123, p = 0.047), and cognitive throughput (F(1, 58) = 6.807, p = 0.012). Gait responders and non-responders did not differ (all p>0.05), but cognitive responders completed fewer years of education (t(58) = 2.114, p = 0.039) and better information processing speed (t(58) = -2.265, p = 0.027) than cognitive non-responders.

CONCLUSIONS

The results indicate that both VRTT and CTT may acutely improve gait and cognition. Therefore, older adults will likely benefit from participating in either type of exercise. The study also provides evidence that baseline cognition can impact training effects on DTE on cognition.

Dual Task Turning in Place: A Reliable, Valid, and Responsive Outcome Measure of Freezing of Gait

BACKGROUND

Freezing of gait (FOG) is a complex symptom in Parkinson's disease (PD) that is both elusive to elicit and varied in its presentation. These complexities present a challenge to measuring FOG in a sensitive and reliable way, precluding therapeutic advancement.

OBJECTIVE

We investigated the reliability, validity, and responsiveness of manual video annotations of the turning-in-place task and compared it to the sensor-based FOG ratio.

METHODS

Forty-five optimally medicated people with PD and FOG performed rapid alternating 360° turns without and with an auditory stroop dual task, thrice over two consecutive days. The tasks were video recorded, and inertial sensors were placed on the lower back and shins. Interrater reliability between three raters, criterion validity with self-reported FOG, and responsiveness to single-session split-belt treadmill (SBT) training were investigated and contrasted with the sensor-based FOG ratio.

RESULTS

Visual ratings showed excellent agreement between raters for the percentage time frozen (%TF) (ICC [intra-class correlation coefficient] = 0.99), the median duration of a FOG episode (ICC = 0.90), and the number of FOG episodes (ICC = 0.86). Dual tasking improved the sensitivity and validity of visual FOG ratings resulting in increased FOG detection, criterion validity with self-reported FOG ratings, and responsiveness to a short SBT intervention. The sensor-based FOG ratio, on the contrary, showed complex FOG presentation-contingent relationships with visual and self-reported FOG ratings and limited responsiveness to SBT training.

CONCLUSIONS

Manual video annotations of FOG during dual task turning in place generate reliable, valid, and sensitive outcomes for investigating therapeutic effects on FOG. © 2021 International Parkinson and Movement Disorder Society.

Repeated Gait Perturbation Training in Parkinson's Disease and Healthy Older Adults: A Systematic Review and Meta-Analysis

Background: Gait impairments are common in healthy older adults (HOA) and people with Parkinson's disease (PwPD), especially when adaptations to the environment are required. Traditional rehabilitation programs do not typically address these adaptive gait demands in contrast to repeated gait perturbation training (RGPT). RGPT is a novel reactive form of gait training with potential for both short and long-term consolidation in HOA and PwPD. The aim of this systematic review with meta-analysis is to determine whether RGPT is more effective than non-RGPT gait training in improving gait and balance in HOA and PwPD in the short and longer term. Methods: This review was conducted according to the PRISMA-guidelines and pre-registered in the PROSPERO database (CRD42020183273). Included studies tested the effects of any form of repeated perturbations during gait in HOA and PwPD on gait speed, step or stride length. Studies using balance scales or sway measures as outcomes were included in a secondary analysis. Effects of randomized controlled trials (RCT) on RGPT were pooled using a meta-analysis of final measures. Results: Of the 4421 studies, eight studies were deemed eligible for review, of which six could be included in the meta-analysis, totaling 209 participants (159 PwPD and 50 HOA). The studies were all of moderate quality. The meta-analysis revealed no significant effects of RGPT over non-RGPT training on gait performance (SMD = 0.16; 95% CI = -0.18, 0.49; Z = 0.92; P = 0.36). Yet, in some individual studies, favorable effects on gait speed, step length and stride length were observed immediately after the intervention as well as after a retention period. Gait variability and asymmetry, signifying more direct outcomes of gait adaptation, also indicated favorable RGPT effects in some individual studies. Conclusion: Despite some promising results, the pooled effects of RGPT on gait and balance were not significantly greater as compared to non-RGPT gait training in PwPD and HOA. However, these findings could have been driven by low statistical power. Therefore, the present review points to the imperative to conduct sufficiently powered RCT's to verify the true effects of RGPT on gait and balance in HOA and PwPD. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php? Identifier: CRD42020183273.