Alice Nieuwboer

Cueing training in the home improves gait-related mobility in Parkinson’s disease: the RESCUE trial

Objectives: Gait and mobility problems are difficult to treat in people with Parkinson’s disease. The Rehabilitation in Parkinson’s Disease: Strategies for Cueing (RESCUE) trial investigated the effects of a home physiotherapy programme based on rhythmical cueing on gait and gait-related activity. Methods: A single-blind randomised crossover trial was set up, including 153 patients with Parkinson’s disease aged between 41 and 80 years and in Hoehn and Yahr stage II–IV. Subjects allocated to early intervention (n = 76) received a 3-week home cueing programme using a prototype cueing device, followed by 3 weeks without training. Patients allocated to late intervention (n = 77) underwent the same intervention and control period in reverse order. After the initial 6 weeks, both groups had a 6-week follow-up without training. Posture and gait scores (PG scores) measured at 3, 6 and 12 weeks by blinded testers were the primary outcome measure. Secondary outcomes included specific measures on gait, freezing and balance, functional activities, quality of life and carer strain. Results: Small but significant improvements were found after intervention of 4.2% on the PG scores (p = 0.005). Severity of freezing was reduced by 5.5% in freezers only (p = 0.007). Gait speed (p = 0.005), step length (p<0.001) and timed balance tests (p = 0.003) improved in the full cohort. Other than a greater confidence to carry out functional activities (Falls Efficacy Scale, p = 0.04), no carry-over effects were observed in functional and quality of life domains. Effects of intervention had reduced considerably at 6-week follow-up. Conclusions: Cueing training in the home has specific effects on gait, freezing and balance. The decline in effectiveness of intervention effects underscores the need for permanent cueing devices and follow-up treatment. Cueing training may be a useful therapeutic adjunct to the overall management of gait disturbance in Parkinson’s disease.

Freezing of gait: moving forward on a mysterious clinical phenomenon

Freezing of gait (FoG) is a unique and disabling clinical phenomenon characterised by brief episodes of inability to step or by extremely short steps that typically occur on initiating gait or on turning while walking. Patients with FoG, which is a feature of parkinsonian syndromes, show variability in gait metrics between FoG episodes and a substantial reduction in step length with frequent trembling of the legs during FoG episodes. Physiological, functional imaging, and clinical-pathological studies point to disturbances in frontal cortical regions, the basal ganglia, and the midbrain locomotor region as the probable origins of FoG. Medications, deep brain stimulation, and rehabilitation techniques can alleviate symptoms of FoG in some patients, but these treatments lack efficacy in patients with advanced FoG. A better understanding of the phenomenon is needed to aid the development of effective therapeutic strategies.

Effects of external rhythmical cueing on gait in patients with Parkinson's disease: a systematic review

Objective: To critically review studies evaluating the effects of external rhythmical cueing on gait in patients with Parkinsons disease. Methods: Articles published from 1966 to January 2005 were searched by two physiotherapists in MEDLINE, PiCarta, PEDRo, Cochrane, DocOnline, CINAHL and SUMSEARCH. To be included, articles had to investigate the effects of external rhythmical cueing (i.e., auditory, visual or tactile cueing) on gait parameters in patients with idiopathic Parkinsons disease. Both controlled and noncontrolled studies were included. Based on the type of design and methodological quality a meta-analysis or best-evidence synthesis was applied. Results: Twenty-four studies (total number of patients = 626) out of the 159 screened studies were evaluated in this systematic review. Two out of 24 were randomized controlled trails (RCT), both of high methodological quality. One RCT did not focus specifically on external rhythmical cueing of individual patients with Parkinsons disease, but on group exercises in general, including walking with cues. All other studies were pre-experimental studies. Best-evidence synthesis showed strong evidence for improving walking speed with the help of auditory cues. Insufficient evidence was found for the effectiveness of visual and somatosensory cueing. Conclusion: Only one high-quality study, specifically focused on the effects of auditory rhythmical cueing, suggesting that the walking speed of patients with Parkinsons disease can be positively influenced. However, it is unclear whether positive effects identified in the laboratory can be generalized to improved activities of daily living (ADLs) and reduced frequency of falls in the community. In addition, the sustainability of a cueing training programme remains uncertain.

Abnormalities of the spatiotemporal characteristics of gait at the onset of freezing in Parkinson's disease.

We investigated the spatiotemporal variables of gait leading up to freezing. Gait analysis was carried out on 14 patients with Parkinsons disease in the off phase of the medication cycle. A computerised, three‐dimensional gait analysis system was used to measure the walking pattern. After several trials of normal walking with voluntary stopping, distracting manoeuvres and obstacles on the walkway were used to provoke freezing or festination. The gait variables of normal (off phase), festinating, prestop, and prefreezing strides were analysed using analysis of variance for repeated‐measures. Cadence was excessively increased (68%) and stride length decreased (69%) during festination compared with normal off walking; a pattern which remained pronounced when comparing prefreezing strides with normal stopping. Analysing in more detail the three steps before a freeze, we found a progressive decrease of stride length and stable cadence rates and proportions of double support phases. The relationship between cadence and stride length exhibited an exponential increase of cadence with a decreasing stride length during festination and freezing. Results suggest that freezing is caused by a combination of an increasing inability to generate stride length superimposed on a dyscontrol of the cadence of walking.

Understanding and treating freezing of gait in parkinsonism, proposed working definition, and setting the stage

Although the term “freezing of gait” (FOG) was not used by early authors and notably not by Parkinson himself,1 the typical propulsive high frequency stepping associated with this gait disturbance was described by him as a feature of Parkinson’s disease (PD). Martin2 also reported examples of an inability to initiate locomotion accompanied by disturbed stepping patterns in postencephalitic parkinsonism with a dramatic response to visual cues. It was not until the early 1970s that FOG started to get increased attention, based on the realization that its response to levodopa was more complex than that of bradykinesia and rigidity. During those early days, it was first suggested that levodopa can sometimes induce or even worsen FOG.3 Based on those reports and the occurrence of FOG in atypical parkinsonism, it has long been considered a levodopa-resistant symptom. It took 30 years of experience with levodopa treatment to understand that this is a misconception. Schaafsma et al. demonstrated that “off”-related FOG episodes were significantly shorter in duration and markedly fewer in frequency when turning from “off” to “on.”4 However, the concept of a complex relationship with levodopa treatment still holds, as is evidenced by the continued manifestation of FOG in the “on” period, and its relationship with other levodopa-resistant symptoms such as postural instability.5,6 Despite its fascinating and unique nature, its common appearance among people with advanced PD, and its significant contribution to the development of major disability and frequent falls,7 research about the pathophysiology and treatment of FOG moved slowly forward. One possible reason for that delay is the unpredictable and episodic nature of freezing, which makes it very difficult to capture true spontaneous episodes. In addition, FOG appears most frequently at home during unobserved behavior and in response to specific environmental triggers8 and rarely in the gait lab.9 Another difficulty that might have slowed down FOG research is its lack of definition. This is of special importance, considering the fact that FOG is very heterogeneous in nature and can frequently be confused with bradykinesia or akinesia. Taking all those difficulties together, we thought it is time to join forces and move research about FOG forward to a better understanding of its mechanisms and hopefully with time leading to more effective treatment. This supplement is the result of a satellite symposium which was held just prior to the Kyoto International Movement Disorders Congress in late October 2006. In this meeting, a number of state-of-the-art presentations were put forward, summarizing the most recent clinical and research findings. All speakers and two additional leading figures in the field of FOG research were subsequently invited to contribute to this first ever supplement devoted to FOG in parkinsonism. As part of the introduction to this supplement, we propose a working definition of FOG. We are aware of the difficulties inherent to this task but believe that this first step has to be taken to improve communication and upgrade the quality of scientific terminology among researchers. The most common feature associated with FOG is the unique subjective feeling of patients describing that “their feet get glued to the ground.” As suggested in one of the supplement papers on the clinimetrics of FOG,10 this characteristic feeling may aid in accurate history *Correspondence to: Alice Nieuwboer, Departement Revalidatiewetenschappen, Faculteit Bewegingsen Revalidatiewetenschappen, Katholieke Universiteit Leuven, Tervuursevest 101, 3001-B Leuven (Heverlee), Belgium. E-mail: alice.nieuwboer@faber.kuleuven.be Received 26 November 2007; Accepted 29 November 2007 Published online 25 July 2008 in Wiley InterScience (www. interscience.wiley.com). DOI: 10.1002/mds.21927 Movement Disorders Vol. 23, Suppl. 2, 2008, pp. S423–S425

The Trunk Impairment Scale: a new tool to measure motor impairment of the trunk after stroke

Objective: To examine the clinimetric characteristics of the Trunk Impairment Scale (TIS). This newly developed scale evaluates motor impairment of the trunk after stroke. The TIS scores, on a range from 0 to 23, static and dynamic sitting balance as well as trunk co-ordination. It also aims to score the quality of trunk movement and to be a guide for treatment. Design: Two physiotherapists observed each patient simultaneously, but scored independently. Each patient was re-examined by one of the therapists. Subjects: Twenty-eight patients in a rehabilitation setting. Results: Kappa and weighted kappa values for item per item reliability ranged for all but two, from 0.62 to 1. All percentages of agreement exceeded 81%. Intraclass correlations (ICC) for the summed scores of the different subscales were between 0.85 and 0.99. Test–retest and interobserver reliability for the TIS total score (ICC) was 0.96 and 0.99, respectively. The 95% limits of agreement for the test–retest and interexaminer measurement error were -2.90, 3.68 and -1.84, 1.84, respectively. Cronbach alpha coefficients for internal consistency ranged from 0.65 to 0.89. Content validity was defined. Spearman rank correlations with the Barthel Index (r5=0.86) and the Trunk Control Test (r5=0.83) was used to examine construct and concurrent validity, respectively. Conclusions: Analysis of different clinimetric parameters support the use of the TIS in both clinical use and future stroke research. Guidelines for treatment and level of quality of trunk activity can be derived from the assessment.

Freezing of gait in Parkinson's disease: The impact of dual‐tasking and turning

Background: Turning is the most important trigger for freezing of gait (FOG) in Parkinsons disease (PD), and dual‐tasking has been suggested to influence FOG as well. Objective: To understand the effects of dual tasking and turning on FOG. Methods: 14 Freezers and 14 non‐freezers matched for disease severity and 14 age‐matched controls were asked to turn 180° and 360° with and without a cognitive dual‐task during the off‐period of the medication cycle. Total number of steps, duration, cadence, freezing‐frequency, and secondary‐task performance were measured. Results: Seven freezers froze during the protocol. Freezing occurred in 37.5% of trials during 180° turning compared to 0% during straight‐line walking (X2 = 10.44, p < 0.01). The occurrence of FOG increased during 360° when also a dual‐task was added (X2 = 4.23, p = 0.04). Freezers took significantly more steps and were slower than controls in all conditions. The presence of a dual‐task increased these differences. Cadence increased significantly for freezers during 360° and 180° compared to straight‐line walking. In contrast, cadence was decreased during turning in controls and non‐freezers. During straight‐line walking, only freezers made errors in the secondary task. Controls increased their error‐rate during 180° turning, whereas freezers deteriorated their secondary task performance during 360°. Conclusions: 360° turning in combination with a dual‐task is the most important trigger for freezing. During turning, non‐freezers and controls decreased their cadence whereas freezers increased it, which may be related to FOG. Freezers adopted a posture second strategy in contrast to non‐freezers when confronted with a dual task.

Summary of the recommendations of the EFNS/MDS-ES review on therapeutic management of Parkinson's disease

To summarize the 2010 EFNS/MDS‐ES evidence‐based treatment recommendations for the management of Parkinsons disease (PD). This summary includes the treatment recommendations for early and late PD.

Trunk performance after stroke and the relationship with balance, gait and functional ability

Objective: To evaluate trunk performance in non-acute and chronic stroke patients by means of the Trunk Control Test and Trunk Impairment Scale and to compare the Trunk Control Test with the Trunk Impairment Scale and its subscales in relation to balance, gait and functional ability after stroke. Subjects: Fifty-one stroke patients, attending a rehabilitation programme, participated in the study. Main measures: Subjects were evaluated with the Trunk Control Test, Trunk Impairment Scale, Tinetti balance and gait subscales, Functional Ambulation Category, 10-m walk test, Timed Up and Go Test and motor part of the Functional Independence Measure. Results: Participants obtained a median score of 61 out of 100 on the Trunk Control Test and 11 out of 23 for the Trunk Impairment Scale. Twelve participants (24%) obtained the maximum score on the Trunk Control Test; no subject reached the maximum score on the Trunk Impairment Scale. Measures of trunk performance were significantly related with values of balance, gait and functional ability. Multivariate linear regression analysis showed an additional, significant contribution of the dynamic sitting balance subscale of the Trunk Impairment Scale in addition to the Trunk Control Test total score for measures of gait and functional ability (model R2 = 0.55-0.62). Conclusions: This study clearly indicates that trunk performance is still impaired in non-acute and chronic stroke patients. When planning future follow-up studies, use of the Trunk Impairment Scale has the advantage that it has no ceiling effect.

Motor learning in Parkinson's disease: limitations and potential for rehabilitation

The striatum is very much involved in learning motor sequences particularly in the consolidation phase, predicting that motor learning is affected in Parkinsons disease (PD). We conducted a literature review on this question and showed that behavioural studies indicate a relatively preserved acquisition as well as retention of motor learning in PD. Persons with PD did demonstrate slower learning-rates than controls. Brain imaging studies highlighted that much more brain activity is needed and different neural networks are recruited in PD, suggesting a reduced efficiency of learning. Using additional sensory information may optimize motor learning in PD. There is abundant evidence that cueing helps to achieve better movement performance and that these effects are retained immediately after withdrawal, possibly indicating the first signs of consolidation. Also, automatization of cued learning was demonstrated, as cues not only enhanced dual-task performance but these increments were retained after cue withdrawal. However, the effect of longer periods of cued training on retention of cued and uncued performance is not well established and some studies suggest that learning effects may be cue-dependent. The results of this review support the notion that adopting motor learning principles could benefit rehabilitation in PD. Even so, the limitations of reduced flexibility, efficiency and increased context-specificity of motor learning in PD need to be taken into account.