Rhythmic Auditory Cueing Research Articles

Efeitos do estímulo acústico rítmico na marcha de pacientes com Doença de Parkinson

Objetivo. Investigar quais parâmetros da marcha sofrem maior altera­ção com Estímulo Acústico Rítmico (EAR) em pacientes com Doença de Parkinson (DP). Método. Foram avaliados 21 sujeitos diagnosti­cados com DP, com média de idade de 69±11,6, por meio do teste de caminhada dos 10 metros em duas situações: em marcha livre e com auxílio de EAR, calculado em 10% acima da marcha preferi­da. As variáveis dependentes foram cadência, comprimento de passo e velocidade de marcha e foram comparadas através do coeficiente de variação. O Teste t para as variáveis dependentes foi utilizado, consi­derando-se o nível de significância de 5% para todas as análises. Re­sultados. Houve diferença entre marcha livre e marcha com EAR para as variáveis: velocidade (p<0,001), cadência (p<0,001) e comprimento de passo (p=0,015), com valores mais altos para a marcha com EAR em comparação à marcha livre. O cálculo de coeficiente de variação apresentou maior variação no parâmetro velocidade (9,6%), compara­do à cadência (5,3%) e comprimento de passo (4,3%). Conclusão. O uso de estímulo acústico rítmico em 10% acima da frequência prefe­rida aumenta a velocidade em comparação à cadência e comprimento de passo de indivíduos com DP.

Listenmee® and Listenmee® smartphone application: Synchronizing walking to rhythmic auditory cues to improve gait in Parkinson’s disease

Evidence supports the use of rhythmic external auditory signals to improve gait in PD patients (Arias & Cudeiro, 2008; Kenyon & Thaut, 2000; McIntosh, Rice & Thaut, 1994; McIntosh et al., 1997; Morris, Iansek, & Matyas, 1994; Thaut, McIntosh, & Rice, 1997; Suteerawattananon, Morris, Etnyre, Jankovic, & Protas , 2004; Willems, Nieuwboer, Chavert, & Desloovere, 2006). However, few prototypes are available for daily use, and to our knowledge, none utilize a smartphone application allowing individualized sounds and cadence. Therefore, we analyzed the effects on gait of Listenmee®, an intelligent glasses system with a portable auditory device, and present its smartphone application, the Listenmee app®, offering over 100 different sounds and an adjustable metronome to individualize the cueing rate as well as its smartwatch with accelerometer to detect magnitude and direction of the proper acceleration, track calorie count, sleep patterns, steps count and daily distances. The present study included patients with idiopathic PD presented gait disturbances including freezing. Auditory rhythmic cues were delivered through Listenmee®. Performance was analyzed in a motion and gait analysis laboratory. The results revealed significant improvements in gait performance over three major dependent variables: walking speed in 38.1%, cadence in 28.1% and stride length in 44.5%. Our findings suggest that auditory cueing through Listenmee® may significantly enhance gait performance. Further studies are needed to elucidate the potential role and maximize the benefits of these portable devices.

Efeitos do estímulo acústico rítmico na marcha de pacientes com Doença de Parkinson

Objective. To determine which gait parameters is more affected by the use of Rhythmic Auditory Cue (RAC) in patients with Parkinson’s Disease. Method. 21 patients with a diagnosis of PD were evaluated, with a mean age of 69±11.6, by a 10 meter gait test at two situations: unaided walking and with the aid of RAC calculated at 10% above the preferred gait. Cadence, stride length and gait speed were compared using the coefficient of variation. Test T for dependent variables was used considering a significance level of 5% for all analyzes. Results. We found a difference between unaided walking and walking with RAC for the variables: gait speed (p<0.001), cadence (p<0.001) and stride length (p=0.015), with higher values for walking with RAC compared to unaided walking. The calculation of the coefficient of variation showed greater variation in the speed (9.6%) parameter compared to cadence (5.3%) and step length (4.3%). Conclusion. the use of RAC in 10% above the preferred gait leads to an increase in gait parameters with the greatest change in speed gait in comparison to the cadence and stride length in people with PD.

The influence of auditory-motor coupling on fractal dynamics in human gait.

Humans exhibit an innate ability to synchronize their movements to music. The field of gait rehabilitation has sought to capitalize on this phenomenon by invoking patients to walk in time to rhythmic auditory cues with a view to improving pathological gait. However, the temporal structure of the auditory cue, and hence the temporal structure of the target behavior has not been sufficiently explored. This study reveals the plasticity of auditory-motor coupling in human walking in relation to ‘complex' auditory cues. The authors demonstrate that auditory-motor coupling can be driven by different coloured auditory noise signals (e.g. white, brown), shifting the fractal temporal structure of gait dynamics towards the statistical properties of the signals used. This adaptive capability observed in whole-body movement, could potentially be harnessed for targeted neuromuscular rehabilitation in patient groups, depending on the specific treatment goal.

Manipulating the stride length/stride velocity relationship of walking using a treadmill and rhythmic auditory cueing in non-disabled older individuals. A short-term feasibility study

One target for rehabilitating locomotor disorders in older adults is to increase mobility by improving walking velocity. Combining rhythmic auditory cueing (RAC) and treadmill training permits the study of the stride length/stride velocity ratio (SL/SV), often reduced in those with mobility deficits. We investigated the use of RAC to increase velocity by manipulating the SL/SV ratio in older adults. Nine participants (6 female; age: 61.1±8.8years) walked overground on a gait mat at preferred and fast speeds. After acclimatization to comfortable speed on a treadmill, participants adjusted their cadence to match the cue for 3min at 115% of preferred speed by either (a) increasing stride length only or (b) increasing stride frequency only. Following training, participants walked across the gait mat at preferred velocity without, and then with, RAC. Group analysis determined no immediate overground velocity increase, but reintroducing RAC did produce an increase in velocity after both conditions. Group and single subject analysis determined that the SL/SV ratio changed in the intended direction only in the stride length condition. We conclude that RAC is a powerful organizer of gait parameters, evidenced by its induced after-effects following short duration training.

Musically cued gait-training improves both perceptual and motor timing in Parkinson's disease.

It is well established that auditory cueing improves gait in patients with idiopathic Parkinson’s disease (IPD). Disease-related reductions in speed and step length can be improved by providing rhythmical auditory cues via a metronome or music. However, effects on cognitive aspects of motor control have yet to be thoroughly investigated. If synchronization of movement to an auditory cue relies on a supramodal timing system involved in perceptual, motor, and sensorimotor integration, auditory cueing can be expected to affect both motor and perceptual timing. Here, we tested this hypothesis by assessing perceptual and motor timing in 15 IPD patients before and after a 4-week music training program with rhythmic auditory cueing. Long-term effects were assessed 1 month after the end of the training. Perceptual and motor timing was evaluated with a battery for the assessment of auditory sensorimotor and timing abilities and compared to that of age-, gender-, and education-matched healthy controls. Prior to training, IPD patients exhibited impaired perceptual and motor timing. Training improved patients’ performance in tasks requiring synchronization with isochronous sequences, and enhanced their ability to adapt to durational changes in a sequence in hand tapping tasks. Benefits of cueing extended to time perception (duration discrimination and detection of misaligned beats in musical excerpts). The current results demonstrate that auditory cueing leads to benefits beyond gait and support the idea that coupling gait to rhythmic auditory cues in IPD patients relies on a neuronal network engaged in both perceptual and motor timing.

Efficacy and Task Structure of Bimanual Training Post Stroke: A Systematic Review

Background: Bimanual training has been shown to be as effective as, but not superior to, unimanual paretic upper extremity (UE) training interventions in improving paretic UE function and use post stroke. However, it is still unclear whether different training interventions or task structures within bimanual interventions may differentially affect the outcomes. Objective: The objectives of this review were to (1) systematically determine the efficacy of bimanual training in relation to the International Classification of Functioning, Disability and Health model components and (2) explore the structure of current bimanual training interventions. Method: A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eleven studies were accepted for review. Results: Three main types of bimanual training emerged: functional task training (FTT), bilateral training with rhythmic auditory cues (BATRAC), and robot-assisted training (RAT). Bimanual training is generally efficacious overall in improving paretic UE movement in individuals with subacute and/or chronic stroke as compared with other interventions. FTT, BATRAC, and RAT showed no significant differences compared with conventional therapy. Bimanual training may have greater proximal control benefits but fewer benefits in terms of subjects’ perceived amount and quality of use as compared with constraint-induced movement therapy. Conclusion: There were not enough data to draw any conclusions about the effects of bimanual task symmetry or commonality of goal.

Persistent Fluctuations in Stride Intervals under Fractal Auditory Stimulation

Stride sequences of healthy gait are characterized by persistent long-range correlations, which become anti-persistent in the presence of an isochronous metronome. The latter phenomenon is of particular interest because auditory cueing is generally considered to reduce stride variability and may hence be beneficial for stabilizing gait. Complex systems tend to match their correlation structure when synchronizing. In gait training, can one capitalize on this tendency by using a fractal metronome rather than an isochronous one? We examined whether auditory cues with fractal variations in inter-beat intervals yield similar fractal inter-stride interval variability as isochronous auditory cueing in two complementary experiments. In Experiment 1, participants walked on a treadmill while being paced by either an isochronous or a fractal metronome with different variation strengths between beats in order to test whether participants managed to synchronize with a fractal metronome and to determine the necessary amount of variability for participants to switch from anti-persistent to persistent inter-stride intervals. Participants did synchronize with the metronome despite its fractal randomness. The corresponding coefficient of variation of inter-beat intervals was fixed in Experiment 2, in which participants walked on a treadmill while being paced by non-isochronous metronomes with different scaling exponents. As expected, inter-stride intervals showed persistent correlations similar to self-paced walking only when cueing contained persistent correlations. Our results open up a new window to optimize rhythmic auditory cueing for gait stabilization by integrating fractal fluctuations in the inter-beat intervals.

Non-gait Related Benefits of Auditory Cueing in Parkinson's Disease

Parkinson's disease (PD) is a neurodegenerative disorder that targets mainly dopaminergic neurons of the basal ganglia. PD is characterized by motor symptoms typically leading to dysfunctional gait. External rhythmic auditory cues have shown beneficial effects on gait kinematics in PD patients. These effects are likely to be mediated by a general-purpose neuronal network including a cerebello-thalamo-cortical circuit involved in stimulus-driven allocation of attention (i.e., by entrainment), temporal prediction, and sensorimotor synchronization. This implies that the benefits of auditory rhythmical cueing may extend beyond gait functions, a possibility which has not been assessed so far. In the current study, we investigate whether auditory cueing has a positive effect on perceptual and motor timing. Fifteen PD patients were submitted to a standard auditory cueing program (3 times/week for 30min, for one month). Gait performance was evaluated using motion capture. In addition, motor (via tapping tasks) and perceptual timing abilities were assessed using the Battery for the Assessment of Auditory Sensorimotor and Timing Abilities (BAASTA). The patients were evaluated before the program, immediately after, and one month after the therapy. Their performance was compared to that of healthy age-matched controls. Improved gait kinematics was observed as a result of the therapy and persisted one month later. Interestingly, these benefits extended to timing abilities. Improved duration discrimination, enhanced detection of misaligned sounds to the beat of music and benefits in paced tapping to a metronome were observed. Our findings indicate that the effects of auditory cueing in PD extend to both perceptual and motor timing. Sensorimotor coupling is likely to foster brain plasticity leading to non-gait related effects. These findings raise the possibility of applying cueing therapy for the rehabilitation of timing and motor functions in other basal ganglia disorders (e.g., Huntington's disease, stroke).

The effect of instruction to synchronize over step frequency while walking with auditory cues on a treadmill

Walking to a pacing stimulus has proven useful in motor rehabilitation, and it has been suggested that spontaneous synchronization could be preferable to intentional synchronization. But it is still unclear if the paced walking effect can occur spontaneously, or if intentionality plays a role. The aim of this work is to analyze the effect of sound pacing on gait with and without instruction to synchronize, and with different rhythmic auditory cues, while walking on a treadmill.Firstly, the baseline step frequency while walking on a treadmill was determined for all participants, followed by experimental sessions with both music and footstep sound cues. Participants were split into two groups, with one being instructed to synchronize their gait to the auditory stimuli, and the other being simply told to walk. Individual auditory cues were generated for each participant: for each trial, cues were provided at the participant’s baseline walking frequency, at 5% and 10% above baseline, and at 5% and 10% below baseline.This study’s major finding was the role of intention on synchronization, given that only the instructed group synchronized their gait with the auditory cues. No differences were found between the effects of step or music stimuli on step frequency.In conclusion, without intention or cues that direct the individual’s attention, spontaneous gait synchronization does not occur during treadmill walking.

The effect of repetitive bilateral arm training with rhythmic auditory cueing on motor performance and central motor changes in patients with chronic stroke

The aim of this study was to compare the effects of bilateral arm training with auditory cueing (BATRAC) versus control intervention on motor performance of the upper extremity (UE) and to explore the central neurophysiological mechanism underlying this effect in moderately impaired chronic stroke patients. This was a randomized-controlled clinical trial. Overall, 76 chronic stroke patients (mean age = 50.2 ± 6.2 years), 6–67 months after the onset of the first stroke were enrolled. They received either BATRAC (with both UE trained simultaneously in symmetric and asymmetric patterns) or control intervention (unilateral therapeutic exercises for the paretic UE). Each session lasted for 1 h, scheduled as three sessions/week (on an alternate day) for 8 successive weeks. Outcome measures included the Fugl-Meyer motor performance test for the UE (FMUE) and percutaneous transcranial magnetic stimulation to elicit motor-evoked potential (MEP) in paretic abductor pollicis brevis muscle. Group comparisons indicated a significantly better improvement in the MEP parameters (transcranial magnetic stimulation threshold, central motor conduction time, and MEP amplitude) in the BATRAC group. The FMUE scores increased in both groups, but there was no significant difference between groups in the FMUE scores. These findings recommend the use of BATRAC in chronic stroke patients not only to improve motor performance but also to induce central neurophysiological effects.

Unilateral Versus Bilateral Upper Limb Training After Stroke

Background and Purpose— Unilateral and bilateral training protocols for upper limb rehabilitation after stroke represent conceptually contrasting approaches with the same ultimate goal. In a randomized controlled trial, we compared the merits of modified constraint-induced movement therapy, modified bilateral arm training with rhythmic auditory cueing, and a dose-matched conventional treatment. Modified constraint-induced movement therapy and modified bilateral arm training with rhythmic auditory cueing targeted wrist and finger extensors, given their importance for functional recovery. We hypothesized that modified constraint-induced movement therapy and modified bilateral arm training with rhythmic auditory cueing are superior to dose-matched conventional treatment. Methods— Sixty patients, between 1 to 6 months after stroke, were randomized over 3 intervention groups. The primary outcome measure was the Action Research Arm test, which was conducted before, directly after, and 6 weeks after intervention. Results— Although all groups demonstrated significant improvement on the Action Research Arm test after intervention, which persisted at 6 weeks follow-up, no significant differences in change scores on the Action Research Arm test were found between groups postintervention and at follow-up. Conclusions— Modified constraint-induced movement therapy and modified bilateral arm training with rhythmic auditory cueing are not superior to dose-matched conventional treatment or each other in improving upper limb motor function 1 to 6 months after stroke. Clinical Trial Registration— URL: http://www.trialregister.nl . Unique identifier: NTR1665.

Frontotemporal oxyhemoglobin dynamics predict performance accuracy of dance simulation gameplay: Temporal characteristics of top-down and bottom-up cortical activities

We utilized the high temporal resolution of functional near-infrared spectroscopy to explore how sensory input (visual and rhythmic auditory cues) are processed in the cortical areas of multimodal integration to achieve coordinated motor output during unrestricted dance simulation gameplay. Using an open source clone of the dance simulation video game, Dance Dance Revolution, two cortical regions of interest were selected for study, the middle temporal gyrus (MTG) and the frontopolar cortex (FPC). We hypothesized that activity in the FPC would indicate top-down regulatory mechanisms of motor behavior; while that in the MTG would be sustained due to bottom-up integration of visual and auditory cues throughout the task. We also hypothesized that a correlation would exist between behavioral performance and the temporal patterns of the hemodynamic responses in these regions of interest. Results indicated that greater temporal accuracy of dance steps positively correlated with persistent activation of the MTG and with cumulative suppression of the FPC. When auditory cues were eliminated from the simulation, modifications in cortical responses were found depending on the gameplay performance. In the MTG, high-performance players showed an increase but low-performance players displayed a decrease in cumulative amount of the oxygenated hemoglobin response in the no music condition compared to that in the music condition. In the FPC, high-performance players showed relatively small variance in the activity regardless of the presence of auditory cues, while low-performance players showed larger differences in the activity between the no music and music conditions. These results suggest that the MTG plays an important role in the successful integration of visual and rhythmic cues and the FPC may work as top-down control to compensate for insufficient integrative ability of visual and rhythmic cues in the MTG. The relative relationships between these cortical areas indicated high- to low-performance levels when performing cued motor tasks. We propose that changes in these relationships can be monitored to gauge performance increases in motor learning and rehabilitation programs.

The effect of repetitive rhythmic precision grip task-oriented rehabilitation in chronic stroke patients

Most chronic stroke patients present with difficulty in the manipulation of objects. The aim of this study was to test whether an intensive program of precision grip training could improve hand functioning of patients at more than 6 months after a stroke. This was a cross-over study; hence, at inclusion, the patients were randomly divided into two groups: one group started with the bilateral movement therapy and the other group started with the unilateral movement therapy. The patients were assessed on four separate occasions across a 12-week period: (a) at inclusion in the study, (b) 4 weeks later, immediately before the first rehabilitation session, (c) after 4 weeks of one therapy, and (d) after a further 4 weeks of the other therapy. Ten patients completed two consecutive 4-week sessions (1 h, 3 days/week) of therapy. The therapy comprised unilateral and bilateral repetitive grip-lift task-oriented rehabilitation with rhythmic auditory cueing. The grip-lift force coordination, digital dexterity, manual ability, and the level of satisfaction (with activities and participation) were assessed. A one-way repeated-measure analysis of variance across the four evaluations did not detect any objective improvement in the measured variables after 8 weeks of specific intensive training. Precision grip training was shown to not generate significant improvement in the grip-lift task, digital dexterity, manual ability, or satisfaction in chronic stroke patients.

Non-linear dynamics of human locomotion: effects of rhythmic auditory cueing on local dynamic stability

It has been observed that times series of gait parameters [stride length (SL), stride time (ST), and stride speed (SS)], exhibit long-term persistence and fractal-like properties. Synchronizing steps with rhythmic auditory stimuli modifies the persistent fluctuation pattern to anti-persistence. Another non-linear method estimates the degree of resilience of gait control to small perturbations, i.e., the local dynamic stability (LDS). The method makes use of the maximal Lyapunov exponent, which estimates how fast a non-linear system embedded in a reconstructed state space (attractor) diverges after an infinitesimal perturbation. We propose to use an instrumented treadmill to simultaneously measure basic gait parameters (time series of SL, ST, and SS from which the statistical persistence among consecutive strides can be assessed), and the trajectory of the center of pressure (from which the LDS can be estimated). In 20 healthy participants, the response to rhythmic auditory cueing (RAC) of LDS and of statistical persistence [assessed with detrended fluctuation analysis (DFA)] was compared. By analyzing the divergence curves, we observed that long-term LDS (computed as the reverse of the average logarithmic rate of divergence between the 4th and the 10th strides downstream from nearest neighbors in the reconstructed attractor) was strongly enhanced (relative change +73%). That is likely the indication of a more dampened dynamics. The change in short-term LDS (divergence over one step) was smaller (+3%). DFA results (scaling exponents) confirmed an anti-persistent pattern in ST, SL, and SS. Long-term LDS (but not short-term LDS) and scaling exponents exhibited a significant correlation between them (r = 0.7). Both phenomena probably result from the more conscious/voluntary gait control that is required by RAC. We suggest that LDS and statistical persistence should be used to evaluate the efficiency of cueing therapy in patients with neurological gait disorders.

Does the Use of an Auditory Cue Facilitate the Motor Control and Contribute to the Rehabilitation of Upper Extremity Movements After Stroke?

In stroke survivors, losing the use of one arm can have devastating effects on activities of daily living (Carod-Artal & Egido, 2009; Green & King, 2010). Therefore, much effort has been made to improve recovery through the use of techniques such as constraint-induced (CIT) (Wolf et al., 2010; Wolf et al., 2006) and robotic (Conroy et al., 2011; Lo et al., 2010) therapy where motor learning principles such as repetition, goal-setting, and task-specificity are maximized. Interestingly, when intensity is controlled, large-scale randomized controlled trials have not demonstrated comparative effectiveness for these newer techniques and systematic reviews are cautious in promoting any technique over another, leaving therapists with little concrete guidance (see Lo et al., 2010, for example). Another group of rehabilitation methods can be grouped under the term stimulation and these include direct electrical (or magnetic) stimulation of the brain and muscle and indirect stimulation such as visual, haptic/somatosensory and, the focus of this paper, auditory stimulation, also known as auditory cueing. It should be noted, that review papers on upper extremity (UE) stroke rehabilitation do not tend to promote any of these stimulation methods and that auditory cueing is usually only discussed with reference to gait rehabilitation. Our purpose, here, is to address this situation by specifically considering auditory cueing in the context of upper-extremity rehabilitation.So, to return to our title question, does use of an auditory cue facilitate motor control and contribute to rehabilitation of upper extremity movements after stroke, we would reply yes with just a few exceptions. We will use a combination of our own research and selected experiments from others to provide principles that can guide therapists in the potential use of auditory cueing in upper-extremity rehabilitation. Our position stems from our 15-year research program of adding a rhythmic auditory cue to a bilateral training approach for individuals with upper extremity hemiparesis. We begin with a description of how we chose to use an auditory cue in the first place, a description of the training method in some detail and a review of key studies that indicate potential benefits of the combined bilateral and rhythmic auditory cueing approach. Subsequently, we dissect why, with whom and when the use of an auditory cue appears to work. Finally, we discuss our findings and conceptualization in relation to the music therapy techniques of Rhythmic Auditory Stimulation and Patterned Sensory Enhancement and propose future directions for research and practice.Genesis of Bilateral Arm Training and Rhythmic Auditory CueingIn 1996, a colleague mentioned that she was able to alter spatial but not temporal gait parameters in a stroke rehabilitation study. We immediately thought of external auditory cueing because of the prevailing work on rhythmic interlimb coordination using dynamic principles (see Kelso, 1995). Specifically, we reasoned that an external rhythmic auditory cue would (a) guide the placement of footfalls using a combination of active attentional and feedback processes as well as (b) utilize the possibility of passive entrainment from the dynamics of oscillating systems. We soon found that others had already tested the efficacy of this idea (e.g., Thaut, McIntosh, Rice, & Prassas, 1993) and initiated our own student-based pilot project comparing 6 weeks of gait training (3 3 week) with an auditory cue versus gait training without an auditory cue versus no gait training in chronic stroke survivors. The results were promising in that 4 out of 5 participants with the auditory cue durably increased their gait velocity and symmetry while two participants with only gait training temporarily increased their gait velocity only and two controls did not demonstrate change (Whitall, McCombe Waller, Gordes, et al., 2000). So how did we decide to also transfer this approach to the upper extremity? …

Virtual Sensory Feedback for Gait Improvement in Neurological Patients

We review a treatment modality for movement disorders by sensory feedback. The natural closed-loop sensory-motor feedback system is imitated by a wearable virtual reality apparatus, employing body-mounted inertial sensors and responding dynamically to the patient’s own motion. Clinical trials have shown a significant gait improvement in patients with Parkinson’s disease using the apparatus. In contrast to open-loop devices, which impose constant-velocity visual cues in a “treadmill” fashion, or rhythmic auditory cues in a “metronome” fashion, requiring constant vigilance and attention strategies, and, in some cases, instigating freezing in Parkinson’s patients, the closed-loop device improved gait parameters and eliminated freezing in most patients, without side effects. Patients with multiple sclerosis, previous stroke, senile gait, and cerebral palsy using the device also improved their balance and gait substantially. Training with the device has produced a residual improvement, suggesting virtual sensory feedback for the treatment of neurological movement disorders.

The Use of Rhythmic Auditory Stimulation in Gait Habilitation for Children with Cerebral Palsy

While rehabilitation refers to the restoration of a skill that was previously learned, habilitation refers to learning a skill for the first time. Children with permanent and nonprogressive neurodevelopmental and congenital disorders such as cerebral palsy (CP) require medical treatment and habilitation (Kra geloh-Mann & Cans, 2009; Krigger, 2006). Because CP impacts the development of motor skills, children with CP require motor skill acquisition based on the concept of habilitation (Fasoli et al., 2008; Frascarelli et al., 2009).Deficits in gait function are a common problem for children with CP and reduced gait stability for this population is indicated by a stance-to-swing phase (Bell, Ounpuu, DeLuca, & Romness, 2002; Johnson, Damiano, & Abel, 1997) and an imbalance between skeletal growth and muscle length resulting in muscle tightness, contracture, or abnormal body torsions (Ziv, Backburn, & Rang, 1984). Traditional gait therapy with children with CP focuses on gait preparatory tasks (i.e., crawling, sitting, standing), stability, reduction of deformity, and abnormal gait patterns (Dodd, Taylor, & Damiano, 2002; Iosa, Marro, Paolucci, & Morelli, 2012; Wilson, 1987). Gait therapy is often based on neurodevelopmental therapy (NDT) (Hummelsheim, 1999) and commonly relies on task-oriented approaches such as treadmill exercise (Provost et al., 2007).As neurological research expands, rationales for new approaches to habilitation are developed. For example, rhythmic auditory cueing to repetition of gait movement is a newly developed approach that is gaining widespread usage. The effectiveness of using rhythmic aspects of music in the rehabilitation of adults with neurological disorders is now well researched and documented; however, the use of rhythm in the habilitation of children with cerebral palsy remains undefined. Drawing from the empirical evidence, this paper discusses the role of rhythm as a gait habilitation technique in facilitating gait movement for children with CP.Cerebral PalsyCerebral palsy is the most common neurodisability in childhood with a prevalence of 2.11 per 1000 births (Oskoui, Coutinho, Dykeman, Jette, & Pringsheim, 2013). The term CP encompasses various types of permanent and nonprogressive disturbances in the development of movement and posture. These impairments are secondary to lesions or malformations in the upper spinal cord, gray and/or white matter, and basal ganglia, as well as hypoxic-ischemic encephalopathy that occurs during prenatal and perinatal gestation or the postnatal period (Bax et al., 2005; Rosenbaum et al., 2007). As a result, individuals with CP often experience limitations in all facets of daily functioning (Kra geloh-Mann & Cans, 2009; Krigger, 2006). Cerebral Palsy is considered an umbrella term with some variation in the definition and classification occurring in different fields such as pediatrics, neuroradiology, and orthopedics (Rosenbaum et al., 2007). In this article, spastic diplegia CP, which is the most common type of CP and the most well-defined and well-documented variant of CP in the medical field, is the focus of the literature review that follows.Cerebral damage in CP is also known as upper motor neuron syndrome and it is related to spasticity, motor deficits, lack of coordination, and impaired voluntary movement with non-selective command. In this case, reflexes can be magnified (i.e., hyper-reflexia) or demonstrate a persistence of primitive movements such as the Babinski response (Blondis, 2004; Rosenbaum et al., 2007). It has been reported that the prevalence of spastic CP among children with CP is between 66% and 81% (Blondis, 2004; Kirby et al., 2011). The topographic classification of spastic CP commonly includes hemiplegia and diplegia/quadriplegia, depending on the affected areas (Blondis, 2004; Rosenbaum et al., 2007). Hemiplegia commonly describes total or partial paralysis of one side of the body that occurs on the side opposite the affected brain. …

Persistent and anti-persistent pattern in stride-to-stride variability of treadmill walking: Influence of rhythmic auditory cueing

It has been observed that long time series of Stride Time (ST), Stride Length (SL) and Stride Speed (SS=SL/ST) exhibited statistical persistence (long-range auto-correlation) in overground walking. Rhythmic auditory cueing induced anti-persistent (or anti-correlated) patterns in ST series, while SL and SS remained persistent. On the other hand, it has been shown that SS became anti-persistent in treadmill walking, while ST and SL remained persistent. The aim of this study was to analyze the effect of the combination of treadmill walking (imposed speed) and auditory cueing (imposed cadence) on gait dynamics. Twenty middle-aged subjects performed 6×5min walking trials at various imposed speeds on an instrumented treadmill. Freely chosen walking cadences were measured during the first three trials, and then imposed accordingly in the last three trials by using a metronome. Detrended fluctuation analysis (DFA) was performed on the times series of ST, SL, and SS. Treadmill induced anti-persistent dynamics in the time series of SS, but preserved the persistence of ST and SL. On the contrary, all the three parameters were anti-persistent under dual-constraints condition. Anti-persistent dynamics may be related to a tighter control: deviations are followed by a rapid over-correction, which produces oscillations around target values. Under single constraint condition, while SS is tightly regulated in order to follow the treadmill speed, redundancy between ST and SL would likely allow persistent pattern to occur. Conversely, under dual constraint conditions, the absence of redundancy among SL, ST and SS would explain the generalized anti-persistent pattern.

Effect of Rhythmic Auditory Cueing on Gait in People With Alzheimer Disease

ObjectiveTo determine whether rhythmic music and metronome cues alter spatiotemporal gait measures and gait variability in people with Alzheimer disease (AD). DesignA repeated-measures study requiring participants to walk under different cueing conditions. SettingUniversity movement laboratory. ParticipantsOf the people (N=46) who met study criteria (a diagnosis of probable AD and ability to walk 100m) at routine medical review, 30 (16 men; mean age ± SD, 80±6y; revised Addenbrooke's Cognitive Examination range, 26–79) volunteered to participate. InterventionsParticipants walked 4 times over an electronic walkway synchronizing to (1) rhythmic music and (2) a metronome set at individual mean baseline comfortable speed cadence. Main Outcome MeasuresGait spatiotemporal measures and gait variability (coefficient of variation [CV]). Data from individual walks under each condition were combined. A 1-way repeated-measures analysis of variance was used to compare uncued baseline, cued, and retest measures. ResultsGait velocity decreased with both music and metronome cues compared with baseline (baseline, 110.5cm/s; music, 103.4cm/s; metronome, 105.4cm/s), primarily because of significant decreases in stride length (baseline, 120.9cm; music, 112.5cm; metronome, 114.8cm) with both cue types. This was coupled with increased stride length variability compared with baseline (baseline CV, 3.4%; music CV, 4.3%; metronome CV, 4.5%) with both cue types. These changes did not persist at (uncued) retest. Temporal variability was unchanged. ConclusionsRhythmic auditory cueing at comfortable speed tempo produced deleterious effects on gait in a single session in this group with AD. The deterioration in spatial gait parameters may result from impaired executive function associated with AD. Further research should investigate whether these instantaneous cue effects are altered with more practice or with learning methods tailored to people with cognitive impairment.