Cueing Paradigms to Improve Gait and Posture in Parkinson's Disease: A Narrative Review.

Niveditha Muthukrishnan,Holly A Shill,James J Abbas,Narayanan Krishnamurthi

doi:10.3390/s19245468

Abstract

Progressive gait dysfunction is one of the primary motor symptoms in people with Parkinson’s disease (PD). It is generally expressed as reduced step length and gait speed and as increased variability in step time and step length. People with PD also exhibit stooped posture which disrupts gait and impedes social interaction. The gait and posture impairments are usually resistant to the pharmacological treatment, worsen as the disease progresses, increase the likelihood of falls, and result in higher rates of hospitalization and mortality. These impairments may be caused by perceptual deficiencies (poor spatial awareness and loss of temporal rhythmicity) due to the disruptions in processing intrinsic information related to movement initiation and execution which can result in misperceptions of the actual effort required to perform a desired movement and maintain a stable posture. Consequently, people with PD often depend on external cues during execution of motor tasks. Numerous studies involving open-loop cues have shown improvements in gait and freezing of gait (FoG) in people with PD. However, the benefits of cueing may be limited, since cues are provided in a consistent/rhythmic manner irrespective of how well a person follows them. This limitation can be addressed by providing feedback in real-time to the user about performance (closed-loop cueing) which may help to improve movement patterns. Some studies that used closed-loop cueing observed improvements in gait and posture in PD, but the treadmill-based setup in a laboratory would not be accessible outside of a research setting, and the skills learned may not readily and completely transfer to overground locomotion in the community. Technologies suitable for cueing outside of laboratory environments could facilitate movement practice during daily activities at home or in the community and could strongly reinforce movement patterns and improve clinical outcomes. This narrative review presents an overview of cueing paradigms that have been utilized to improve gait and posture in people with PD and recommends development of closed-loop wearable systems that can be used at home or in the community to improve gait and posture in PD.

Highlights

Parkinson’s disease (PD), which is the second most common progressive neurodegenerative disease, results in motor and non-motor dysfunctions caused by the degeneration of dopamine-producing cells of the substantia nigra and other brain regions [1,2]
Pharmacological and deep brain stimulation (DBS) surgical treatments have been demonstrated to be partially effective in managing some of the manifestations of gait impairments and postural instability
Based on the review of the literature presented here, it is clear that cueing can be an effective component of locomotor therapy for people with PD who experience gait deficits

Summary

Introduction

Parkinson’s disease (PD), which is the second most common progressive neurodegenerative disease, results in motor and non-motor dysfunctions caused by the degeneration of dopamine-producing cells of the substantia nigra and other brain regions [1,2]. Some of the common manifestations of PD that affect gait and posture are stooped posture and shuffling of gait, increases in gait asymmetry and double support time, reductions in step length and walking speed, impairments in postural responses to perturbations, and increases in variability of step/stride time as well as step/stride length [7]. Pharmacological and deep brain stimulation (DBS) surgical treatments have been demonstrated to be partially effective in managing some of the manifestations of gait impairments and postural instability. As the primary pharmacological treatment in PD, the dopamine replacement therapy (i.e., levodopa) improves stride length, gait speed, and double support time variability, whereas it does not have any significant benefits on cadence and other temporal characteristics of gait [8]

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