F Chavret

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.

The use of rhythmic auditory cues to influence gait in patients with Parkinson's disease, the differential effect for freezers and non-freezers, an explorative study

Purpose. To study the effect of rhythmic auditory cues on gait in Parkinsons disease subjects with and without freezing and in controls. Method. A volunteer sample of 20 patients (10 freezers, 10 non-freezers) and 10 age-matched controls performed five randomized cued walking conditions in a gait-laboratory. Auditory cues were administered at baseline frequency, at an increased step frequency of 10 and 20% above baseline and at a decreased step frequency of 10 and 20% below baseline. Mean step frequency, walking speed, stride length and double support duration were collected. Results. Rhythmical auditory cueing induced speed changes in all subjects. Stride length was not influenced by rhythmical auditory cues in controls, whereas patients showed a larger stride length in the −10% condition (p < 0.01). Freezers and non-freezers showed the same response to rhythmical auditory cues. Within group analysis for stride length showed different cueing effects. Stride length decreased at the +10% condition for freezers (p < 0.05), whereas it increased for non-freezers. Conclusions. This study points to fact that physiotherapists might need to carefully adjust the cueing frequency to the needs of patients with and without freezing. On the basis of the present results we recommend to lower the frequency setting for freezers, whereas for non-freezers an increase of up to +10% may have potential therapeutic use.

The attentional cost of external rhythmical cues and their impact on gait in Parkinson’s disease: effect of cue modality and task complexity

SummaryChanges in gait performance in 153 subjects with PD using three rhythmical cues (auditory, visual and somatosensory) were measured during a simple walking task and a dual walking task in the home. Subjects were ‘on’ medication and were cued at preferred step frequency. Accelerometers recorded gait and walking speed, step amplitude and step frequency were determined from raw data. Data were analysed with SAS using linear regression models. Gait performance during a single task reduced with cues in contrast to a dual task where PD subjects appeared to benefit from rhythmical cues (increased speed and step length). Effects were dependent on cue modality with significant improvements for auditory cues compared to others. A significant short-term carry-over effect of cues reduced 3 weeks later. Cues may reduce attentional demands by facilitating attentional allocation, accounting for differences of cue seen during single and dual task. Furthermore cue modality may influence attentional demand which is an important consideration for rehabilitation.

Turning in Parkinson's Disease Patients and Controls: The Effect of Auditory Cues

Turning is an impaired activity in persons with Parkinsons disease (PwPD). The current study examines the turning characteristics in PwPD (9 freezers and 10 nonfreezers) and 9 controls, and explores the effect of rhythmic auditory cues while turning. Turning parameters were collected from a 180° left U‐turn during a noncued and a cued condition, using a 3D measuring system. Auditory cues were supplied with a metronome at a rhythm equaling the subjects comfortable step frequency during straight line walking. Results showed that in contrast to controls, PwPD used a wider turning‐arc and took smaller, narrower steps. In addition, they demonstrated a higher Coefficient of Variation (CV) of step duration (6.92%) compared to controls (4.88%, P < 0.05). The “wide‐arc” turning strategy of PwPD was more prominent in freezers than in nonfreezers. Auditory cues reduced the CV of step duration in PwPD (both freezers and nonfreezers) during turning (from 6.92 to 6.00%, P < 0.05). In summary: Cueing reduced the gait‐timing variability during turning, but PwPD maintained a wider arc to turn compared with controls.

Does freezing in Parkinson's disease change limb coordination? : A kinematic analysis

The aim of this study was to analyse the kinematic characteristics of the strides before freezing and compare this with a voluntary stop and ongoing gait. Also, we investigated whether gait profiles were different as a function of the side of the body. Ten patients were included with a mean age of 64.8 years (SD 5.1). Within a Vicon 3D gait laboratory, patients performed several trials of normal walking and voluntary stops or were exposed to circumstances, which provoked freezing in the off-phase of the medication cycle. Spatiotemporal and key kinematic data of the four strides prior to freezing were compared between body sides and walking conditions using multiple regression models for repeated measures. Prior to freezing patients had severely decreased movement ranges in the sagittal plane (ranging between 31% and 61.5%), most notably in the ankle and hip joints. The general shape of movement remained in the pre-freezing profiles with largely intact dissociation of knee and hip movement in stance but reduced dissociation in swing. Also present were reduced push-off movements in the ankle with fixed dorsiflexion, increased flexion in hip and knee and anterior tilt of the pelvis. During both voluntary (stopping) and involuntary deceleration (freezing), the body side with the last complete stride before the freeze, showed significantly smaller joint ranges (p < .01). Body side differences were larger than sequential deterioration of consecutive steps within each side. Freezing is distinct from normal deceleration of gait in that the reduction of propulsive movement is much greater. Despite hastening of steps, timing deficits did not affect overall movement shapes, except for the tendency to have a flexed walking pattern. The side of the body where gait terminated before freezing was in most cases the side of symptom-dominance, but not consistently so.

Cueing training in de thuissituatie verbetert de mobiliteit van mensen met de ziekte van Parkinson

SamenvattingDe ziekte van Parkinson is een progressieve neurologische aandoening als gevolg van degeneratie van dopaminerge cellen van de substantie nigra in de basale kernen. De ziekte wordt onder andere gekenmerkt door symptomen zoals tremoren, rigiditeit, hypo- en bradykinesie, en posturale instabiliteit. Deze bewegingsstoornissen leiden tot problemen met activiteiten als lopen, het maken van transfers (d.w.z. veranderingen van lichaamspositie, bijvoorbeeld van zitten naar staan) en handhaven van het evenwicht tijdens het staan en het lopen (Marsden 1989; Morris et al. 2001; Rogers 1996). De prevalentie neemt toe met de leeftijd: in Europa wordt geschat dat in de leeftijdscategorie tot 65 jaar 1,8 op de 100 inwoners wordt gediagnosticeerd met de ziekte van Parkinson. In de categorie 65–69 jaar is dat 2,4 op de 100 inwoners en 2,6 op de 100 voor de categorie 85-89 jaar (De Rijk et al. 2000).

Trunk impairment in Parkinson’s disease

Background: This study examines the effect of additional trunk activity on trunk performance in subacute stroke patients in an inpatient rehabilitation setting. Methods: In addition to usual therapy, subjects randomly allocated to an experimental group (n = 14) received 4 times a week 30 min of hands-on trunk therapy, for 5 weeks. Patients in the control group (n = 11) received no additional therapy. Main outcome measures were the Trunk Impairment Scale (TIS) total and subscale scores (static and dynamic sitting balance and trunk coordination). Because of a significant difference in age between the experimental and control group, a 2-way ANCOVA analysis was used. Paired t tests evaluated the evolution in the experimental and control group separately. Results: A significant effect of additional trunk therapy was found for the dynamic sitting balance subscale of the TIS (P = 0.027). When looking at the experimental and control group separately, significant improvements were found for the dynamic sitting balance subscale in the experimental group (P < 0.0001), the coordination subscale in the experimental (P = 0.022) and control group (P < 0.0001) and the total TIS score for the experimental (P < 0.0001) and control group (P = 0.008). Conclusion: This pilot study indicates that there is a potentially beneficial effect of additional trunk rehabilitation for stroke patients. Clinical practice and stroke research would benefit from future studies with larger number of patients and a placebo treatment for the control group.Background: A major challenge in stroke rehabilitation is to minimize psychologic morbidity to promote the reintegration of stroke survivors into their family and community. The prevalence of depression among Chinese stroke survivors has been found to range from 17% to 63%, and a clear understanding of this and the factors influencing its outcome helps health care professionals plan effective interventions to minimize such psychologic consequences. Methods: This was a longitudinal study and data were collected from 206 stroke survivors during a period of 6 months after their discharge from 2 rehabilitation hospitals. Data collection took place in either the patient’s home or other discharge destination such as old age home. The majority of patients were male, married, and with a right-side stroke. Results: At 6 months after discharge, 71 (35%) of patients screened positive for depression and was found to be significantly related to handicap (r = –.50), state self-esteem (r = –.75), social support (r = –.62), and functional ability (r = –.30). Those who lived in an old age home were more likely to have mild to severe depression. Regression analysis indicated that handicap, state selfesteem, and social support were predictors of depression and accounted for 63% of the variance. Conclusion: The results highlight the importance of assessing and attending to the psychologic sequelae of stroke to promote successful recovery. This investigation was supported by HK Health Care and Promotion Fund.Background: To assess the outcome of systematic physical activity in water for stroke survivors on endurance, gait speed, mobility in water, spasticity, anxiety and quality of life. Methods: 11 stroke survivors (greater than 12 months poststroke) followed a program of water activities 3 to 4 times a week during a 5-week period. The activities were designed to help the participants: 1) be safe and comfortable in water, 2) achieve independent movement, and 3) improve their cardiorespiratory fitness level through actual swimming. Results: All participants completed the 5-week intervention. There were significant improvements in 6-min endurance walking, (39.1%; P < 0.01), gait speed (16.7%; P = 0.02), and speed for 10-m water movement (23.5%; P = 0.02). Indications of depression were absent at the end of intervention in those with an initial level. Follow- up after 7 weeks showed a significant improvement in 6-min walking speed compared to baseline (25.4%; P = 0.02) but no further change compared to the 5th week. Gait speed slightly decreased compared to 5 weeks but remained better than baseline (P = 0.07). Feeling of well-being did not increase after 5 weeks but did at follow-up (8.9%; P < 0.01). No changes in spasticity or in anxiety and other parts of the EQ-5D were demonstrated during or after the intervention. Conclusion: Systematic physical activities in water are well tolerated by chronic stroke survivors and tend to improve their fitness level as well as the feeling of well-being, without an increase in the level of spasticity.