Gait Impairments In Parkinsons And Current Therapies
Parkinsons disease, the second most common neurodegenerative disorder , is a complex neurological disorder that negatively impacts both motor and non-motor functions . The disease is caused by the degeneration of dopaminergic neurons in the substantia nigra associated with neuronal inclusions called Lewy bodies, leading to DA deficiency in the basal ganglia . This deficiency results in four cardinal symptoms of PD that can be remembered by the tremor at rest, rigidity, akinesia , and postural instability . These symptoms are often accompanied by gait impairments that are particularly prominent in the postural instability gait difficulty , in contrast to the tremor dominant, subtype of PD . Gait abnormalities become also more severe in the late-stage PD .
Table 1. Basic parameters of gait and their definitions and units of measurement.
Emergence of gait abnormalities often indicates a poor prognosis for PD patients as they correlate with bradykinesia, rigidity, and cognitive impairment associated with cortical Lewy bodies and leads to more frequent falling, a major cause of death among patients with PD . Several studies have shown that FOG in patients with PD correlates with poor quality of life, disease severity, apathy, and exposure to anticholinergic drugs it may, but not always, improve with DA therapy .
Effects Of Auditory Rhythm And Music On Gait Disturbances In Parkinsons Disease
- 1Columbia University College of Physicians & Surgeons, New York, NY, USA
- 2Department of Neuroscience, Baylor College of Medicine, Houston, TX, USA
- 3Department of Neurology, Parkinsons Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, TX, USA
Gait abnormalities, such as shuffling steps, start hesitation, and freezing, are common and often incapacitating symptoms of Parkinsons disease and other parkinsonian disorders. Pharmacological and surgical approaches have only limited efficacy in treating these gait disorders. Rhythmic auditory stimulation , such as playing marching music and dance therapy, has been shown to be a safe, inexpensive, and an effective method in improving gait in PD patients. However, RAS that adapts to patients movements may be more effective than rigid, fixed-tempo RAS used in most studies. In addition to auditory cueing, immersive virtual reality technologies that utilize interactive computer-generated systems through wearable devices are increasingly used for improving brainbody interaction and sensorymotor integration. Using multisensory cues, these therapies may be particularly suitable for the treatment of parkinsonian freezing and other gait disorders. In this review, we examine the affected neurological circuits underlying gait and temporal processing in PD patients and summarize the current studies demonstrating the effects of RAS on improving these gait deficits.
Metronome Therapy Has Been Clinically Proven To Help Manage Shortened Steps Reduced Walking Speed And Freezing
No two people with Parkinsons are the same and handing technology over with no support would really do them a disservice. Which is why someone from the Beats Medical team assesses and individually prescribes the correct beat for that particular day, which the user listens to while walking for 10 minutes. It acts as a daily mobility exercise.
The speech exercises we have developed work in a similar way, in that they provide tailored, real time feedback on the volume and clarity of the voice helping to control speech. The exercises can be tailored further to allow patients or their therapist to manually enter words or sentences that are important to them. We also have treatments for the fine hand movement issues to help work on the skills required for handwriting and doing up buttons and zips.
How did you secure funding for the project and how did you test the app?
How many people around the world are currently using the service?
We have patient users in more than 40 countries. As our technology is easy to use we have users of all ages our youngest is 25 and our oldest is 94.
Most of our users are concentrated in Ireland, the UK and the US, but we also have lots in India and various European countries. Many of the exercises built into the app are visual rather than language-based which means it can be used universally, but we now have versions of the app in different languages.
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Into The Groove: Can Rhythm Influence Parkinson’s Disease
Review of rhythmic auditory stimulation on pathological conditions as Parkinson’s disease.
Rhythmic auditory training improves gait velocity, cadence and stride length in parkinsonian patients.
Gait, temporal stability, step length and gait cadence may be impaired by not properly adapted auditory stimulus.
Future therapies should focus on patient-based stimuli, attending to the individual’s clinical features.
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Virtual Reality: A Potential For Combined Visual And Auditory Cueing
In PD patients, locomotion and postural control have an increased dependence on perceptual vision that can be corrected using visual cues . Multiple studies have shown that matching footsteps to visual cues such as equidistant horizontal lines along a walkway improves gait and reduces FOG in PD patients . Although visual cueing can be beneficial, replicating clinical scenarios would be unfeasible for patients who wish to train at home in a daily basis. Furthermore, as with auditory cueing, fixed walkway strips may be less effective than an interactive system that adjusts cueing based on the patients movement and gait parameters. Instead, an ideal cueing system would involve adaptive feedback and include both visual and auditory stimuli. Immersive virtual reality technology could fill this gap by optimizing visually cued gait training. VR is an immersive and interactive computer-generated environment that simulates the real-world experience and can be operated using a custom-made or commercially available head-mounted display. The use of VR with visual cueing for clinical rehabilitation is still in its infancy, though multiple studies have found that in chronic stroke patients VR-based training improves cadence, step length, stride length, symmetry, and other gait parameters .
What Are The Causes
In Parkinsons disease, nerve cells in a part of the brain called the basal ganglia start to die and produce less of a neurotransmitter called dopamine. The basal ganglia use dopamine to form connections between neurons. This means when theres less dopamine, there are fewer connections.
The basal ganglia are responsible for making sure your body movements are smooth. When there arent as many connections in this area of the brain, it cant do that job as well. This leads to Parkinsonian gait and the other movement symptoms of Parkinsons disease.
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Metronome Cueing Of Walking Reduces Gait Variability After A Cerebellar Stroke
- 1School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, UK
- 2School of Psychology, University of Birmingham, Birmingham, UK
- 3Institute of Sport and Exercise Science, University of Worcester, Worcester, UK
- 4West Midlands Rehabilitation Centre, Birmingham Community Healthcare Trust, Birmingham, UK
- 5Faculty of Life Sciences & Medicine, Kings College London, London, UK
Exercises To Improve Gait
Physical therapy, along with other exercises to help you practice walking strategies, can help reduce Parkinsonian gait. Some of these exercises can be done at home. Consult a physical therapist to help you figure out which exercises will be the most beneficial for you. Potential exercises include:
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Each Week We Hear Of Incredible Achievements From The Parkinsons Community
What role does technology have in the management of chronic conditions?
Technology can play a vital role in the day-to-day management of chronic conditions. It can enable people to take control of their conditions in a way that, previously, may not have been cost effective. That said, technology is not the only answer, as technology is not a replacement for specialist care but merely a way to augment the months or even years between clinic visits. I like to think of Beats Medical as more than a technology its a service with daily therapy that would otherwise cost quite a lot per day to provide at home.
The Beats Medical app interface
You have a background in physiotherapy, what made you specialise in Parkinsons?
I first witnessed the impact of Parkinsons disease when I was in my teens, and at the same time saw the impact that physiotherapy could have on symptoms. It was only while working as a physiotherapist that I realised that I was falling short, and not doing everything I could. There were clinically proven treatments, which had a profound impact on Parkinsons symptoms in clinic, but these symptoms persisted at home.
What Is Parkinsonian Gait
Parkinsonian gait is a defining feature of Parkinsons disease, especially in later stages. Its often considered to have a more negative impact on quality of life than other Parkinsons symptoms. People with Parkinsonian gait usually take small, shuffling steps. They might have difficulty picking up their feet.
Parkinsonian gait changes can be episodic or continuous. Episodic changes, such as freezing of gait, can come on suddenly and randomly. Continuous changes are changes in your gait that happen all the time while walking, such as walking more slowly than expected.
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Improving Flexibility And Range Of Motion
Improving your flexibility can help you improve your balance and gait, as well as reduce rigidity. Try these exercises:
- Sit in a chair and bend your upper body at the waist to your right and left.
- Get on all fours and turn your upper body to the right and left. Lift your arm on the side youre turning to as you turn.
Also work on lower-body strength training. Strength training can help you improve your balance, walk further distances, and potentially increase your walking speed. Some exercises to try include:
- Leg presses. While sitting down, push a weight away from your body using your legs.
- Squats. Start in an upright position with your legs slightly wider than hip distance. Bend your knees while pushing your glute muscles back, so that your knees dont come over your toes. You can hold onto something if necessary. You dont have to go down more than a few inches.
- Exercise bike. If you have access to a recumbent exercise bike , using the bike can help strengthen your legs.
- Repeatedly sit in and rise out of a chair. Repeating the motions of sitting down and rising helps strengthen your leg and core muscles. It also helps you practice a functional activity.
Neural Mechanisms Of Cued Gait Training
In recent years, there have been numerous studies demonstrating the therapeutic efficacy of RAS in gait abnormalities associated with PD. An increasing body of research suggests that PD involves a deficit in temporal processing and that internal rhythmic timing is more disrupted among PD with gait deficits than among patients without gait deficits . It has been proposed that internal timing is dependent on striatal DA levels , and that timing problems may be a potential marker for frontal and striatal dysfunctions in PD . Accordingly, we hypothesize that the temporal deficits in PD are a major contributor to gait impairments. This is supported by the finding that DA replacement therapy reduces the timing deficits in PD , and that timing deficits are induced by changes in the expression levels of striatal D2 receptors . Furthermore, timing deficits are also found in other DA-related disorders including schizophrenia .
Although internal pacing is disrupted in PD patients, this timing alteration can be corrected and recalibrated through motorsensory interaction with the world . Cued gait training utilizes the implicit timing abilities still present in PD patients to recalibrate the internal clock. In RAS, PD patients are instructed to walk while synchronizing their footsteps to the salient beats of the music or metronome. RAS can be combined with visual cues such as patterned tiles or stripes placed along the walkway for multisensory cueing.
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Auditory Cueing As Interval
One form of sensory cueing for gait is to present a person with rhythmic sound, such as a metronome or beat-based music, and ask them to walk in time with the sound. This Rhythmic Auditory Stimulation as gait cues for PD has been shown to lead to improvements in different aspects of gait, such as step length, duration, speed, and variability . An explanation for these improvements is that the cerebellar-thalamocortical circuits in the brain that support detection and synchronization to regular perceptual events are relatively preserved in PD, whereas the basal ganglia-thalamocotrical network that supports actions to one’s own internal beat are impaired by the disease . Because the timing for action is externalized in RAS, each movement can be matched to each perceptual cue , resulting in a more stable gait pattern with larger steps .
Figure 1. Different models of auditory cueing of gait. Walking to a beat is depicted as discrete movement-to-discrete sound mapping. The task for participants is to temporally match a particular instance within the gait cycle to the onset of each beat, whether represented by a metronome or by the down-beat of musical rhythm. walking to a repeated sound is depicted as the coupling of the gait cycle to dynamic information in the auditory event, in this case the continuous sound made by footsteps on gravel, with the intensity envelope of the sound highlighted in the representation.
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Participants were divided into two groups, experimental and control. Both groups received RAS training up to week 8, after which the control group stopped training and the experimental group continued. Then training was resumed for the control group between weeks 16 and 24. Patients in the experimental group received RAS training for the entire 24 weeks.
Participants were assessed at the beginning of the study and at eight, 16, and 24 weeks following that. Assessment criteria included stride length, speed, balance, and falls.
As expected, no significant differences were seen between the two groups at week eight. However, at week 16, the experimental group showed significant improvement in velocity, cadence, stride length, decreased number of falls, and fear of falling compared to the control group.
At week 24 after the control group had resumed RAS training the signifiant differences in velocity, cadence, stride length, and fear of falling remained, but there were no longer significant differences in the number of falls.
Taken together, the findings indicate that RAS gait training significantly reduced the number of falls and modified key in gait control in patients with Parkinsons disease, researchers wrote.
This clinical investigation demonstrates that RAS gait training is a potential intervention to reduce the risk of falling, since it directly addresses temporal instability, which is one of the most detrimental variables associated with falls, they concluded.
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