C. de Goede

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.

The effect of rhythmic somatosensory cueing on gait in patients with Parkinson's disease

BACKGROUND AND AIMS Gait and gait related activities in patients with Parkinsons disease (PD) can be improved with rhythmic auditory cueing (e.g. a metronome). In the context of a large European study, a portable prototype cueing device was developed to provide an alternative for rhythmic auditory cueing: rhythmic somatosensory cueing (RSC, a miniature vibrating cylinder attached to the wrist). We investigated whether PD patients could adapt their walking pattern using RSC under conditions of changing walking speed and the presence of potentially distracting visual flow while walking on a treadmill. METHODS A total of 17 patients with PD participated (mean age 63.4+/-10.3 years; Hoehn-Yahr score 2.5+/-0.9, mean Unified Parkinsons Disease Rating Scale score 49.8+/-13.7, mean disease duration 7.7+/-5.1 years). They performed systematic walking speed manipulations under 4 conditions in a random order: (1) no cue, no visual flow, (2) no cue, visual flow, (3) cue, no visual flow and (4) cue, visual flow. Visual flow in the form of a virtual corridor that moved at the current walking speed was projected on a 2 x 2 m rear-projection screen. The cueing rhythm was set at -10% of preferred stride frequency at each speed. Stride frequency was assessed using peaks in the trajectories of thigh sagittal plane segmental angles. RESULTS Walking with RSC resulted in lower stride frequencies, and thus larger step lengths (p-values <0.05), regardless of walking speed. The presence of visual flow did not impair the use of RSC, as evidenced by the lack of differences between conditions 3 and 4 (p>0.05). CONCLUSION Rhythmic somatosensory cueing may be a viable alternative for auditory cueing and is robust to changes in walking speed and visual distractors.

IV.P5 Efficacy of a group physical therapy program in patients with Parkinson's Disease: a randomized controlled trial

Objective: The objective of the study was to investigate the effects of a physical therapy (PT) program in groups of individuals with Parkinson’s Disease (PD). Methods: Two outpatient rehabilitation clinics in Boston and Amsterdam, respectively, participated in a multi-centered RCT with a cross-over design. Sixty-eight subjects (n = 31 in Amsterdam and n = 37 in Boston) diagnosed with typical, idiopathic PD, Hoehn and Yahr stage II or III and stable medication usage were included in the study. Within each site patients were randomly allocated to an early intervention group and a late intervention group.The early intervention group received PT and Medication Therapy (MT) for the first six weeks followed by only MT for the second six weeks. The late intervention group received only MT for the first six weeks and PT and MT for the second six weeks. The main outcome measures were the Sickness Impact Profile (SIP-68), the mobility portion of the SIP-68 (SIPM), the Unified Parkinson’s Disease Rating Scale (UPDRS) and comfortable walking speed (CWS) at baseline, 6 weeks, 12 weeks, and 3 months follow-up. Results: At six weeks, differences between groups were significant for the SIPM (p = 0.015; effect size [ES] = 0.55), CWS (p = 0.012; ES = 0.49), the ADL section of the UPDRS (p = 0.014; ES = 0.45) and for the total UPDRS (p = 0.007, ES = 0.56) in favour of the early intervention group. The total SIP and the mentation and motor sections of the UPDRS were not significantly different between groups. Significant improvements were still present at 3 months compared to baseline for CWS, the UPDRS ADL and total scores. Conclusions: People with PD derive short term benefits from PT group treatment, in addition to their MT, for quality of life related to mobility, comfortable walking speed, and ADL’s; long term effects remained significant until 3 months after therapy and then slowly decreased. IV.P6 Cueing therapy in the home environment of patients with Parkinson’s Disease: effects on ambulatory physical activity in the RESCUE trial