Internal Cueing Research Articles

Respiratory Responses to Two Voice Interventions for Parkinson's Disease.

The purpose of this study was to examine the respiratory strategies used by persons with Parkinson's disease (PD) to support louder speech in response to two voice interventions. Contrasting interventions were selected to investigate the role of internal and external cue strategies on treatment outcomes. LSVT LOUD, which uses an internal cueing framework, and the SpeechVive prosthesis, which employs an external noise cue to elicit louder speech, were studied. Thirty-four persons with hypophonia secondary to idiopathic PD were assigned to one of three groups: LSVT LOUD (n = 12), SpeechVive (n = 12), or a nontreatment clinical control (n = 10). The LSVT LOUD and SpeechVive participants received 8 weeks of voice intervention. Acoustic and respiratory kinematic data were simultaneously collected at pre-, mid- and posttreatment during a monologue speech sample. Intervention outcomes included sound pressure level (SPL), utterance length, lung volume initiation, lung volume termination, and lung volume excursion. As compared to controls, the LSVT LOUD and SpeechVive participants significantly increased SPL at mid- and posttreatment, thus confirming a positive intervention effect. Treatment-related changes in speech breathing were further identified, including significantly longer utterance lengths (syllables per breath group) at mid- and posttreatment, as compared to pretreatment. The respiratory strategies used to support louder speech varied by group. The LSVT LOUD participants terminated lung volume at significantly lower levels at mid- and posttreatment, as compared to pretreatment. This finding suggests the use of greater expiratory muscle effort by the LSVT LOUD participants to support louder speech. Participants in the SpeechVive group did not significantly alter their respiratory strategies across the intervention period. Single-subject effect sizes highlight the variability in respiratory strategies used across speakers to support louder speech. This study provides emerging evidence to suggest that the LSVT LOUD and SpeechVive therapies elicit different respiratory adjustments in persons with PD. The study highlights the need to consider respiratory function when addressing voice targets in persons with PD.

Evaluation of Compensation Strategies for Gait Impairment in Patients With Parkinson Disease.

Compensation strategies are essential in Parkinson disease (PD) gait rehabilitation. However, besides external cueing, these strategies have rarely been investigated systematically. We aimed to perform the following: (1) establish the patients' perspective on the efficacy and usability of 5 different compensation strategies; (2) quantify the efficacy of these strategies on spatiotemporal gait parameters; and (3) explore associations between the effects of specific strategies and patient characteristics. We recruited persons with PD and self-reported disabling gait impairments for this laboratory-based, within-subject study. Clinimetrics included the following: questionnaires (New Freezing of Gait Questionnaire, Vividness of Movement Imagery Questionnaire, Goldsmiths Musical Sophistication Index), cognitive assessments (Attentional Network Test and Montreal Cognitive Assessment [MoCA], Brixton), and physical examinations (Movement Disorders Society Unified Parkinson's Disease Rating Scale [MDS-UPDRS III], Mini-Balance Evaluation Systems Test, tandem gait, and rapid turns test). Gait assessment consisted of six 3-minute trials of continuous walking around a 6-m walkway. Trials comprised the following: (1) baseline gait; (2) external cueing; (3) internal cueing; (4) action observation; (5) motor imagery; and (6) adopting a new walking pattern. Spatiotemporal gait parameters were acquired using 3-dimensional motion capture analysis. Strategy efficacy was determined by the change in gait variability compared with baseline gait. Associated patient characteristics were explored using regression analyses. A total of 101 participants (50 men; median [range] age: 66 [47-91] years) were included. The effects of the different strategies varied greatly among participants. While participants with higher baseline variability showed larger improvements using compensation strategies, participants without freezing of gait, with lower MDS-UPDRS III scores, higher balance capacity, and better performance in orienting attention also showed greater improvements in gait variability. Higher MoCA scores were associated with greater efficacy of external cueing. Our findings support the use of compensation strategies in gait rehabilitation for PD but highlight the importance of a personalized approach. Even patients with high gait variability are able to improve through the application of compensation strategies, but certain levels of cognitive and functional reserve seem necessary to optimally benefit from them.

Cortical Correlates of Gait Compensation Strategies in Parkinson Disease.

ObjectiveGait impairment in persons with Parkinson disease is common and debilitating. Compensation strategies (eg, external cues) are an essential part of rehabilitation, but their underlying mechanisms remain unclear. Using electroencephalography (EEG), we explored the cortical correlates of 3 categories of strategies: external cueing, internal cueing, and action observation.MethodsEighteen participants with Parkinson disease and gait impairment were included. We recorded 126‐channel EEG during both stance and gait on a treadmill under 4 conditions: (1) uncued, (2) external cueing (listening to a metronome), (3) internal cueing (silent rhythmic counting), and (4) action observation (observing another person walking). To control for the effects of sensory processing of the cues, we computed relative power changes as the difference in power spectral density between walking and standing for each condition.ResultsRelative to uncued gait, the use of all 3 compensation strategies induced a decrease of beta band activity in sensorimotor areas, indicative of increased cortical activation. Parieto‐occipital alpha band activity decreased with external and internal cueing, and increased with action observation. Only internal cueing induced a change in frontal cortical activation, showing a decrease of beta band activity compared to uncued gait.InterpretationThe application of compensation strategies resulted in changed cortical activity compared to uncued gait, which could not be solely attributed to sensory processing of the cueing modality. Our findings suggest there are multiple routes to control gait, and different compensation strategies seem to rely on different cortical mechanisms to achieve enhanced central motor activation in persons with Parkinson disease. ANN NEUROL 2022;91:329–341

Rhythm and groove as cognitive mechanisms of dance intervention in Parkinson's disease.

Parkinson's disease (PD) is associated with a loss of internal cueing systems, affecting rhythmic motor tasks such as walking and speech production. Music and dance encourage spontaneous rhythmic coupling between sensory and motor systems; this has inspired the development of dance programs for PD. Here we assessed the therapeutic outcome and some underlying cognitive mechanisms of dance classes for PD, as measured by neuropsychological assessments of disease severity as well as quantitative assessments of rhythmic ability and sensorimotor experience. We assessed prior music and dance experience, beat perception (Beat Alignment Test), sensorimotor coupling (tapping to high- and low-groove songs), and disease severity (Unified Parkinson's Disease Rating Scale in PD individuals) before and after four months of weekly dance classes. PD individuals performed better on UPDRS after four months of weekly dance classes, suggesting efficacy of dance intervention. Greater post-intervention improvements in UPDRS were associated with the presence of prior dance experience and with more accurate sensorimotor coupling. Prior dance experience was additionally associated with enhanced sensorimotor coupling during tapping to both high-groove and low-groove songs. These results show that dance classes for PD improve both qualitative and quantitative assessments of disease symptoms. The association between these improvements and dance experience suggests that rhythmic motor training, a mechanism underlying dance training, impacts improvements in parkinsonian symptoms following a dance intervention.

Assessing the Development of Fine Motor Control in Elementary School Children Using Drawing and Tracing Tasks.

Adequately quantifying fine motor control is imperative for understanding individual motor behavior development and mastery. We recently showed that using different tasks to evaluate fine motor control may produce different results, suggesting that multiple measures for fine motor control may be evaluating different skills and/or underlying processes. Specifically, drawing behavior may depend on internal cueing, whereas tracing depends more on external cueing. To better understand how an individual develops a certain preference for cueing, we evaluated fine motor control in 265 typically developing children (aged 6-11) by measuring their accuracy for both drawing and tracing a circle. Our results first confirmed that there was no significant correlation between tracing and drawing task performances during this phase of development and, secondly, showed a significant developmental improvement in tracing, especially between 2nd and 3rd graders, whereas drawing ability improved only moderately. We discuss the potential roles of attentional focus and cognitive development as possible influencing factors for these developmental patterns. We conclude that using both a drawing and tracing task to evaluate fine motor control is rapid, economic and valuable for monitoring motor development among elementary school children.

Home-Based Exercise Program With Telephone Coaching: A Feasibility Study

Exercise is crucial to maintain mobility, reduce falls and delay functional decline in older adults, but effective implementation strategies are lacking. Self-directed home-based exercise therapy is recommended by clinicians to overcome barriers such as cost, travel and availability. However, non-adherence is a major challenge due to lack of motivation, real time feedback or social support. To overcome these barriers, we conducted a feasibility study to evaluate a home-based exercise program with telephone coaching to improve mobility in frail older adults. Four non-demented, frail community-dwelling older adults were taught one of two exercise routines at our research center. The first involved complex exercises with internal and external cueing techniques that have been associated with neuroplasticity in previous studies (N=3). The second was a lesser cognitively demanding control program that included aerobic, balance and strengthening exercises (N=1). One week later, the participants were asked to repeat the exercises in their own home. The research assistant coached the patient over the telephone. A board-certified physiatrist was present during the home session to monitor adherence and fidelity to the protocol as well as address safety. The study produced qualitative findings regarding recruitment strategies, exercise feasibility, and other logistical issues relating to participant understanding, safety, and monitoring. Based on direct observation of participants at home, safety assessment protocols, instructions, and exercises were all refined. Building on this data, we plan to design a clinical trial to evaluate the impact of complex exercises designed to promote neuroplasticity and reduce cognitive and motoric decline in older adults.

Mental Singing Reduces Gait Variability More Than Music Listening for Healthy Older Adults and People With Parkinson Disease.

Previously, we showed that internal cues (such as singing) produce similar motor benefits as external cues (such as listening to music) for people with Parkinson disease (PD). This study takes that research further by exploring how singing-either aloud or mentally-at different tempos can ameliorate gait, and it offers insight into how internal cueing techniques may enhance motor performance for older adults and people with PD. Sixty participants aged 50 years and older (30 female) were recruited; 30 had PD and 30 were healthy age-matched controls. Participants completed walking trials involving internal and external cueing techniques at 90%, 100%, and 110% of preferred cadence. The effects of different cue types and rates were assessed in a repeated-measures cross-sectional study by comparing gait characteristics (velocity, cadence, stride length) and variabilities (coefficients of variation of stride length, stride time, single support time). All participants modified their cadence and stride length during cued conditions, resulting in changes in gait velocity closely reflecting expected changes based upon cue rate. External cues resulted in increased gait variability, whereas internal cues decreased gait variability relative to uncued walking. Variability decreases were more substantial during mental singing at tempos at or above preferred cadence. Matching movement to one's own voice improves gait characteristics while reducing gait variability for older adults and people with PD. Optimizing the use of internal cues to facilitate movement is an important step toward more effectively meeting the needs of people with gait disorders related to aging or neurological disease.Video Abstract available for more insights from authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A286).

Internal cueing improves gait more than external cueing in healthy adults and people with Parkinson disease

Walking can be challenging for aging individuals and people with neurological disorders such as Parkinson disease (PD). Gait impairment characterized by reduced speed and higher variability destabilizes gait and increases the risk of falls. External auditory cueing provides an effective strategy to improve gait, as matching footfalls to rhythms typically increases gait speed and elicits larger steps, but the need to synchronize to an outside source often has a detrimental effect on gait variability. Internal cueing in the form of singing may provide an alternative to conventional gait therapy. In the present study, we compare the effects of internal and external cueing techniques on forward and backward walking for both people with PD and healthy controls. Results indicate that internal cueing was associated with improvements in gait velocity, cadence, and stride length in the backward direction, and reduced variability in both forward and backward walking. In comparison, external cueing was associated with minimal improvement in gait characteristics and a decline in gait stability. People with gait impairment due to aging or neurological decline may benefit more from internal cueing techniques such as singing as compared to external cueing techniques.

Precision in drawing and tracing tasks: Different measures for different aspects of fine motor control

Drawing and tracing tasks, by being relatively easy to execute and evaluate, have been incorporated in many paradigms used to study motor control. While these tasks are helpful when examining various aspects relative to the performance, the relationship in proficiency between these tasks was not evaluated to our knowledge. Seeing that drawing is thought to be an internally cued and tracing an externally cued task, differences in performances are to be expected. In this study, a quantitative evaluation of the precision of circle drawing and tracing, and spiral tracing was made on 150 healthy subjects. Our results show that, while precision is correlated when repeating drawing circles, tracing spirals, or tracing circles as well as between tracing spirals and tracing circles; there is no correlation when subjects performed drawing circles and tracing spirals or between drawing and tracing of circles. These results suggest that this lack of correlation is task dependent and not shape dependent. We suggest that the evaluation of fine motor control should include both a tracing and a drawing task, taking in consideration the precision in each task. We believe that this approach could help not only to evaluate fine motor control more accurately, but also to identify subjects who are more reliant on either internal or external cueing and to what extent.

Gestural Economies and Production Pedagogies in Deaf West’s Spring Awakening

In Deaf West’s Broadway revival of Spring Awakening, embodied gestures expose and challenge representational and infrastructural norms that drive commercial musical theatre. The company’s blend of ASL and spoken text extends the overarching message about failed sociocultural ideals to the realm of deaf culture. Micro-practical actions and interactions function tacitly to denaturalize audio-centric standards that guide theatrical reception, internal cueing, and technical production.

Chronostructure of blood pressure in shift-workers in the Arctic polar region

Objective. To study clinical differences of arterial hypertension (HTN), to conduct both standard comparative analysis of 24‑hour blood pressure (BP) monitoring and cosinor-analysis for chronobiological assessment of HTN circadian rhythms in shift workers of the Arctic polar region and native residents of Tyumen city. Design and methods. Altogether 373 patients with HTN stage I–II (control group) and 144 patients with HTN stage I–II (comparative group) were examined and underwent 24‑hour BP monitoring, echocardiography, brachiocephalic artery ultrasound, treadmill ergometer test, 24‑hour ECG Holter monitoring. Results. In the conditions of Arctic shift work, clinical implications of HTN were more evident and associated with structural heart alterations, high frequency of atherosclerosisin brachiocephalic arteries, dyslipidemia, low exercise tolerance and level of adaptive potential. In northern citizens with HTN circadian BP profile was associated with low circadian rhythm indices, high BP variability, mainly night hyperbaric overload that explains high frequency of HTN circadian BP profile («non-dipper» and «night-peaker»). Chronobiological disturbances in HTN circadian rhythm in shift workers was caused by the malfunction of correspondence in internal and external cueing of physiological processes (desynchronosis) influenced by the conditions of shiftwork.

Post-cueing deficits with maintained cueing benefits in patients with Parkinson's disease dementia.

In Parkinson’s disease (PD), internal cueing mechanisms are impaired leading to symptoms like hypokinesia. However, external cues can improve movement execution by using cortical resources. These cortical processes can be affected by cognitive decline in dementia. It is still unclear how dementia in PD influences external cueing. We investigated a group of 25 PD patients with dementia (PDD) and 25 non-demented PD patients (PDnD) matched by age, sex, and disease duration in a simple reaction time task using an additional acoustic cue. PDD patients benefited from the additional cue in similar magnitude as did PDnD patients. However, withdrawal of the cue led to a significantly increased reaction time in the PDD group compared to the PDnD patients. Our results indicate that even PDD patients can benefit from strategies using external cue presentation but the process of cognitive worsening can reduce the effect when cues are withdrawn.

Multiple Factors Are Involved in the Dysarthria Associated With Parkinson's Disease: A Review With Implications for Clinical Practice and Research

Motor speech abnormalities are highly common and debilitating in individuals with idiopathic Parkinson's disease (IPD). These abnormalities, collectively termed hypokinetic dysarthria (HKD), have been traditionally attributed to hypokinesia and bradykinesia secondary to muscle rigidity and dopamine deficits. However, the role of rigidity and dopamine in the development of HKD is far from clear. The purpose of the present study was to offer an alternative view of the factors underlying HKD. The authors conducted an extensive, but not exhaustive, review of the literature to examine the evidence for the traditional view versus the alternative view. The review suggests that HKD is a highly complex and variable phenomenon including multiple factors, such as scaling and maintaining movement amplitude and effort; preplanning and initiation of movements; internal cueing; sensory and temporal processing; automaticity; emotive vocalization; and attention to action (vocal vigilance). Although not part of the dysarthria, nonmotor factors, such as depression, aging, and cognitive-linguistic abnormalities, are likely to contribute to the overall speech symptomatology associated with IPD. These findings have important implications for clinical practice and research.

Differential Frontal Involvement in Shifts of Internal and Perceptual Attention

BackgroundPerceptual attention enhances the processing of items in the environment, whereas internal attention enhances processing of items encoded in visual working memory. In perceptual and internal attention cueing paradigms, cues indicate the to-be-probed item before (pre-cueing) or after (retro-cueing) the memory display, respectively. Pre- and retro-cues confer similar behavioral accuracy benefits (pre-: 14–19%, retro-: 11–17%) and neuroimaging data show that they activate overlapping frontoparietal networks. Yet reports of behavioral and neuroimaging differences suggest that pre- and retro-cueing differentially recruit frontal and parietal cortices (Lepsien and Nobre, 2006). Objective/hypothesisThis study examined whether perceptual and internal attention are equally disrupted by neurostimulation to frontal and parietal cortices. We hypothesized that neurostimulation applied to frontal cortex would disrupt internal attention to a greater extent than perceptual attention. MethodsCathodal transcranial direct current stimulation (tDCS) was applied to frontal or parietal cortices. After stimulation, participants completed a change detection task coupled with either pre- or retro-cues. ResultsCathodal tDCS across site (frontal, parietal) hindered performance. However, frontal tDCS had a greater negative impact on the retro-cued trials demonstrating greater frontal involvement during shifts of internal attention. ConclusionsThese results complement the neuroimaging data and provide further evidence suggesting that perceptual and internal attention are not identical processes. We conclude that although internal and perceptual attention are mediated by similar frontoparietal networks, the weight of contribution of these structures differs, with internal attention relying more heavily on the frontal cortex.

A biomechanical study of gait initiation in Huntington's disease

Background Akinesia in basal ganglia disorders is essentially defined by delayed movement initiation; the reaction time increases and it becomes difficult (or even impossible) for the subject to initiate movement. A biomechanical study of gait initiation would help evaluate the role of akinesia in early stage Huntington's disease (HD) patients. Methods We recorded kinematic, spatiotemporal and angular parameters (using video motion analysis, a force platform and an optoelectronic system) for the first two steps taken by 15 HD patients and 15 gender- and age-matched controls. In order to evaluate the influence of an external cue on gait initiation parameters, we studied two movement paradigms: self-triggered initiation and initiation triggered (cued) by a “beep” sound. We analyzed kinematic, spatiotemporal (the speed, length and duration of the two first steps) and angular parameters (range of joint angles) as well as kinetic data (the trajectory of the centre of pressure (COP); the speed and trajectory of the centre of mass (COM)). Results HD patients presented akinesia in both externally triggered and self-triggered conditions. Patients had more difficulties with self-triggered gait than with triggered gait. In HD, anticipatory postural adjustments (APAs) were more impaired in self-triggered gait initiation than in cued initiation. Indeed, an alteration in the kinetic parameters revealed a reduction in first step speed in both conditions. Hypokinesia (as assessed by a reduction in the range of angle joints) played an important role in this reduction. Conclusion Akinesia is a major feature of impaired gait initiation in HD. The deficiencies in self-triggered initiation in HD seen here fit with a hypothesis whereby deficient internal cueing can be replaced by an external trigger.

Influence of visual cues on gait in Parkinson's disease: Contribution to attention or sensory dependence?

Sensory cueing is used for a long time to improve gait in patients with Parkinson's disease. This has been established for visual cues such as stripes on floor and for rhythmic auditory cues. Concerning visual cueing two main mechanisms of action have been suggested and may be suitable depending on the instruction given to the patients. Stripes placed on the walking surface may draw attention to the stepping process if patients are talked to put their feet on the stripes. In another paradigm, the stripes on floor are just used to enhance the optical flow and the motion of the stripes is essential to improve gait. These findings are not found in normal controls suggesting that patients with Parkinson's disease are more dependent on dynamic visual cues for gait control than controls. Several common characteristics exist between attention and sensory contribution in gait control. First, their potential beneficial effect may be contre-balanced by a negative influence: visual information may be helpful for gait in patients or may disrupt locomotion and induce freezing (for example passing a door). Attention focused on gait allows a partial correction of the troubles by intentional modulation of the stride length but a dual task flowing attention away produces deterioration. Another point is that both strategies are probably used by the central nervous system to compensate deficits: visual dependence to compensate an impaired kinesthetic feed-back and attentional processing to alleviate automaticity in locomotion and so, to by-pass the deficit of internal cueing.

Impact of internal versus external cueing on driving performance in people with Parkinson's disease

Numerous aspects of driving performance seem compromised in people with Parkinson's disease (PD). Measures of cognitive impairment consistently correlate with poor driving simulator performance in this population; however, the effects of specific cognitive difficulties on discrete aspects of driving behavior have not been investigated thoroughly. Previous studies have demonstrated that people with PD exhibit difficulties internally cueing cognitive processes. This study examined the impact of impaired internal cueing on specific driving behaviors. A simulator measured the driving behavior of 18 current drivers in the mild-to-moderate stages of PD and 18 matched controls. Participants navigated through different driving conditions where the opportunity to use internal and external cues was manipulated. People with PD exhibited difficulties using internal cues to regulate driving behavior around traffic signals and curves. Instead of using internal cues, participants with PD were more reliant on external cues to regulate driving behavior. They were also less able to adapt their driving behavior to suit driving conditions. Because all participants with PD were current drivers in the mild-to-moderate stages of the disease, findings challenge the widely-held assumption that cognitive difficulties only impact on driving performance in the moderate-to-severe stages of PD.

Linkages between the Ultradian Patterns of Growth Hormone and Ghrelin: External versus Internal Cueing

Linkages between the Ultradian Patterns of Growth Hormone and Ghrelin: External versus Internal Cueing

Relationship Between Growth and Plasma Concentrations of Ghrelin and Growth Hormone in Juvenile Beagle Dogs

Although the release of growth hormone (GH) is known to be regulated mainly by GH-releasing hormone (GHRH) and somatostatin (SRIF) secreted from the hypothalamus, ghrelin also may be involved in GH release during juvenile period. We have examined plasma concentrations of acylated ghrelin, desacyl ghrelin, and GH in juvenile beagle dogs. Plasma acylated and desacyl ghrelin levels changed through aging; however, there was no closely correlation between ghrelin, body weight and circulating GH levels during juvenile period. The increase in body weight was essentially linear until 8 months of age, whereas plasma GH concentrations exhibited bimodal peaks for the meanwhile. The results suggest that ghrelin may not play internal cueing in GH secretion in juvenile beagle dogs.

Parkinsonian Motor Characteristics in Unipolar Major Depression

Clinical observation points to similarities between psychomotor retardation in major depression and bradykinesia in Parkinson's disease (PD). While common elements of neuropathology have been proposed to account for this, experimental investigations of this possible link have been few and inconclusive. The present study attempts to determine whether patients with depression display the characteristically Parkinsonian reliance on external cues; and if so, whether this is common to both melancholic and non-melancholic patients. Twenty three patients with unipolar major depression (11 melancholic and 12 non-melancholic) and 24 age-matched healthy controls performed a serial choice reaction time task known to be sensitive to Parkinsonian movement deficits. The melancholic patients showed a Parkinsonian pattern of impairment on the task, exhibiting a particular difficulty when initiating movements in the absence of external cues. This was largely alleviated when a moderate amount of external cueing was provided. At a high level of advance information, melancholic patients were again slow relative to controls. A base-line measure of bradykinesia and a derived measure of dependence upon external cues both correlated significantly with CORE (measure of psychomotor disturbance) ratings. The non-melancholic patients did not show any measurable motor impairment. This cue-dependent deficit may be due to an underlying basal ganglia dysfunction similar to that involved in PD, i.e. a failure of internal cueing. Difficulty with a high level of external cueing might reflect bradyphrenia or a prefrontal motor deficit of ability to plan multiple upcoming movements simultaneously. The results suggest that depression subtypes involve differing patterns of fronto-striatal impairment.