Effects of visual and auditory cues on gait in individuals with Parkinson's disease

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Abstract

The purpose of this study was to determine if combining visual and auditory cues has a greater effect on the gait pattern of patients with Parkinson's disease (PD) than the cues applied individually. Twenty-four individuals with idiopathic PD were recruited. Patients, while off antiparkinsonian medications, were measured on a 7.62-m walkway during two trials for each of four conditions performed in random order: without cues, with a visual cue, with an auditory cue and with both cues simultaneously. The auditory cue consisted of a metronome beat 25% faster than the subject's fastest gait speed. Brightly colored parallel lines placed along the walkway at intervals equal to 40% of a subject's height served as the visual cue. Average gait speed, cadence and stride length were calculated for each condition. Gait velocity, cadence and stride length significantly improved (p<005) when cues were used. Visual and auditory cues improved gait performance in patients with PD, but they did so in different ways. Auditory cueing significantly improved cadence, but visual cueing improved stride length. The simultaneous use of auditory and visual cues did not improve gait significantly more than each cue alone.

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

References (45)

  • M.E. Morris et al.

    The pathogenesis of gait hypokinesia in Parkinson's disease

    Brain

    (1994)
  • H.D. Von Wilzelben
  • J.W. Dunne et al.

    Parkinsonism: upturned walking stick as an aid to locomotion

    Arch. Phys. Med. Rehabil.

    (1987)
  • G.C. McIntosh et al.

    Stride frequency modulation in parkinsonian gait using rhythmic auditory stimulation

    Ann. Neurol.

    (1994)
  • M.E. Morris et al.

    Ability to modulate walking cadence remains intact in Parkinson's disease

    J. Neurol. Neurosurg. Psychiatry

    (1994)
  • J.P. Martin
  • J.P. Azulay et al.

    Automatic motion analysis of gait in patients with Parkinson's disease: effects of levodopa and visual stimulations

    Rev. Neurol. (Paris)

    (1996)
  • H. Forssberg et al.

    Is parkinsonian gait caused by a regression to an immature walking pattern?

  • V. Nanton

    Parkinson's disease

  • M. Quintyn et al.

    Factors affecting the ability to initiate movement in Parkinson's disease

    Phys. Occup. Ther. Geriatr.

    (1986)
  • M.H. Thaut et al.

    Rhythmic auditory stimulation in gait training for Parkinson's disease patients

    Mov. Disord.

    (1996)
  • G.C. McIntosh et al.

    Rhythmic auditory-motor facilitation of gait patterns in patients with Parkinson's disease

    J. Neurol. Neurosurg. Psychiatry

    (1997)
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