Effects of visual and auditory cues on gait in individuals with Parkinson's disease
Introduction
Gait disturbances are among the most troubling problems experienced by Parkinson's disease (PD) patients. Their gait pattern is typically characterized by: (1) hesitant, shuffling steps which are short and quick; (2) flexed forward posture with limited natural arm swing; and (3) difficulty initiating and/or altering their gait patterns [1]. Central to these gait problems is the inability of PD patients to generate proper stride length, which is often compensated by an increased gait cadence [2]. As the disease progresses, these gait deficits continue to impair movement, even though patients become aware of their slowed walking pattern [3].
Physical therapy is considered to be a useful adjunct to the medical treatment of this disorder. Both gait training and exercise therapy have been used by therapists to treat these patients. Although reports on the effectiveness of the interventions has varied, the use of sensory cues to improve gait in PD patients has been established as an effective assistance for improving gait [4]. Von Wilzenben advocated the use of visual cues for PD patients as early as 1942 [5]. More recently, Dunne et al. [6] reported PD patients improved their gait by using inverted walking sticks as a visual cue. Subsequent studies supported Dunne's findings related to the advantages of visual cues for the improvement of gait patterns of PD patients [2], [7], [8], [9], [10], [11]. Martin [10] also reported improved gait for PD patients' when they traversed a walkway with brightly colored lines as visual cues. Other studies reported improvement in stride length with visual cues marked on the floor [9], [12].
Auditory signals are another form of cueing reported to be helpful for improving PD patients' gait. Cueing techniques such as musical beats, metronomes or rhythmic clapping have been implemented as strategies for improving gait for PD patients [8], [13], [14], [15], [16]. Enzensberger et al. [17] found metronome stimulation significantly reduced the time and number of steps to complete a walking course, compared to uncued walking and also reduced the number of freezing episodes from three to zero during turns. The use of a metronome is clinically appealing because it is easy to use, portable and relatively inexpensive [17].
Clinical research into the effectiveness of visual and auditory cues on mobility function for PD patients has been limited, although several encouraging studies exist. Despite these studies, cuing strategies are not common clinical practice in the rehabilitative treatment of PD. The purpose of the present study was to examine the effect of combining visual and auditory cues to cues applied individually on the gait patterns of PD patients. Results from this study may help to establish simple strategies for addressing difficulties during gait encountered by individuals with PD.
Section snippets
Subjects
Individuals with idiopathic PD were recruited from local PD support groups and the Movement Disorders Clinic within the medical center. The disability and impairment status of these individuals was assessed using the Hoehn and Yahr Disability Scale of Parkinson's disease [18], the Unified Parkinson Disease Rating Scale (UPDRS) [19] and the Schwab and England activities of daily living scale, respectively. The Schwab and England activity of daily living scale is a self-assessment rating scale.
Experimental protocol
All measurements were collected during a single session. Each patient participated after abstaining from any antiparkinsonian medication for at least 12 h. Patients were asked to walk at their fastest speed along a 7.62-m (25-ft) walkway twice to establish baseline control data. Next, they completed the same walking task under each of three conditions: walking with visual cues, walking with auditory cues, and walking with both auditory and visual cues. Performance of conditions was randomly
Data analysis
All analyses were obtained using SPSS Windows version 10.0 [24]. Demographic data of patients including sex, age, disease duration, Hoehn and Yahr disability stage, type of assistive device, Schwab/England activities daily of living scale and the UPDRS scores were descriptively summarized. The dependent variables for statistical analysis were gait speed, gait cadence and stride length. A one-way multivariate analysis of variance (MANOVA) with repeated measures was performed to assess
Effect of cueing on gait performance
Assessment of gait performance in this experiment included three dependent variables: gait speed, gait cadence and stride length. One-way MANOVA demonstrated a significant difference in gait performance among the four conditions (F=11.58, p<0.005). Further analysis was performed to determine which dependent variable was significantly different among the conditions by using a follow-up univariate analysis of variance. Among the four conditions, there was a significant difference for gait speed (F
Discussion
This study examined the effects of cueing on gait performance in patients with PD. Consistent with earlier studies, gait speed, cadence and stride length of subjects were improved with cueing. Previous studies also found significant gains in gait speed, cadence and stride length as a result of using auditory cues with PD patients [15], [16], [23].
Gait speed can be increased by increasing cadence or stride length or both [28], [29]. The faster gait speed induced by auditory cues observed in this
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