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Video Game May Help Detect Early Gait Impairment in Parkinson’s Patients

Goalkeeper video game

The Goalkeeper Game, a video game in which people assume the role of a goalkeeper in a soccer penalty shootout, may be a novel tool to detect early decline in gait performance in Parkinson’s disease patients, helping them receive treatment sooner, a study suggests.

The test is designed to non-invasively assess the gait of Parkinson’s disease patients under complex conditions — such as climbing stairs or walking over an obstacle — and was better at predicting a decline in gait performance in those situations than the well-established Montreal Cognitive Assessment (MoCA) test, which assesses cognitive decline.

The study, “Goalkeeper Game: A New Assessment Tool for Prediction of Gait Performance Under Complex Condition in People With Parkinson’s Disease,” was published in Frontiers in Aging Neuroscience.

Patients with Parkinson’s disease usually are diagnosed based on the presence of classical motor symptoms. However, there is an earlier phase — called the prodromal phase — in which signs and symptoms of the disease are present, though still insufficient to make a definite diagnosis.

Identifying patients in this prodromal phase would ensure they receive treatment early, before their disease progresses to more advanced stages and significantly affects daily activities.

The motor and cognitive decline seen in Parkinson’s patients often leads to gait impairments, and appears to be present already in the prodromal stage. In particular, gait “under-challenging” conditions — such as avoiding or climbing obstacles, adapting gait to unexpected targets, etc., — requires a higher interplay between cognitive and motor processes, and is more affected in Parkinson’s patients than the action of simply walking without obstacles.

That is why detecting early decline in gait performance under complex situations may help diagnose the condition earlier and make sure that patients receive timely treatment.

A team of Brazilian researchers  explored whether a video game — the Goalkeeper Game — could predict gait impairments under complex conditions in people with Parkinson’s, and subsequently enable early therapeutic interventions.

The game requires that players guess the position of the goal where the ball will go (left, right, or center) and is expected to mimic the decision-making process required for unexpected obstacles during walking.

The game consists of three phases, each evaluating distinct motor or cognitive components. First, patients are told the shooting direction and need only to select the correct direction; no decision-making is required. Then the learning phase requires them to identify the correct sequence of shooting directions, which has higher cognitive demand.

Finally, the third phase is designed to evaluate attention and memory, as patients are asked to memorize the sequence of shooting directions presented on a screen before starting the game.

The study included 74 Parkinson’s patients without dementia, who played the Goalkeeper Game 40 to 120 minutes after their L-dopa (levodopa) dose (“on”  period). They also underwent assessments with the MoCA test — a tool used routinely to evaluate cognitive decline in Parkinson’s patients — and the Dynamic Gait Index (DGI).

The DGI evaluates not only walking without obstacles, but also more complex abilities like walking while changing speed, walking while moving one’s head vertically and horizontally, and walking while stepping over an obstacle.

MoCA has been used to assess impairments in patients’ abilities to adapt gait to obstacles, and its ability to predict declines in gait performance in more complex situations — or DGI scores — was compared with that of the video game.

Researchers found that scores in the memory phase of the video game were strongly associated with DGI scores, meaning that patients who got more responses wrong in the memory phase had higher gait impairment in complex situations. MoCA, meanwhile, was associated only moderately with DGI scores.

While the video game was able to predict which patients had high or low DGI scores with a 65% accuracy, MoCA’s accuracy reached only 56%.

“The main finding of this study is that [Goalkeeper Game] had a slightly higher predictive power for decline in gait performance under complex situations than MoCA,” researchers wrote, adding that a free and friendly game such as this may help detect early decline in gait performance without the need for expensive screening tools.

Additional studies, they noted, are warranted to validate this tool as a potential marker of early gait decline in Parkinson’s patients.

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Be the Dancer and Be the Artist

dance

Would you — a person with Parkinson’s — ever call yourself a dancer? An artist? Graceful? Well, it’s possible. Be open to the idea. You may be surprised. I certainly was.

Recently, I met David Leventhal, the program director of Dance for PD. The program brings together trained dancers who are experts at moving alongside people with Parkinson’s who face movement challenges. Elements of dance addressing balance, gait, coordination, flexibility, isolation, depression, and other challenges of Parkinson’s are neatly interwoven throughout the entire class experience.

After a wonderful adventure on the subway, I arrived at the studios of the Mark Morris Dance Group in Brooklyn, New York, and waited for class to begin. I had seen videos of the program. I had also watched a documentary called “Capturing Grace,” which featured many of the dancers with Parkinson’s. Yes, dancers.

I would like to call myself a dancer. Thanks to weekly dance lessons with my husband, I am familiar with ballroom dancing, line dancing, etc. However, to say I am an artistic dancer is really stretching it. Hoping I would not draw attention to myself in the class, I settled on a seat near the back.

“When the dance class is going on, there are no patients … only dancers.” – Reggie, dancer, “Capturing Grace.”

The theme of the class was one of clay or dough. We reached, pulled, and used many variations of movement. With each movement, I was realizing that this program targeted Parkinson’s while also teaching artistry and grace.

Some movements were big and made with amplitude while others were intentionally small. There were also variations in speed — some were fast, others were slow. However, at the same time, all of our movements made a statement. We were moving with a purpose. As the pianist played the music, there were crescendos and decrescendos. Our bodies responded with movements that were unintentionally choreographed perfectly.

Our dough became bread through a series of movements. We tore our imaginary bread and passed it to others around the room in a way that reflected how we felt. There were big, sweeping movements from one person who in turn gently reached and passed it to the next.

Next, it was time to move around the room during a segment using body language to invite each other to dance, and then it was time to waltz. I was excited. I knew how to waltz. However, there was an added element of pushing and pulling the hands and arms of my partner. This introduced an element of balance and being in touch with my body to have a connection with my partner.

Graceful is not a word I would use to describe myself. Yet, I found myself gliding, switching partners, and waltzing around the room. Together, the group transformed into a graceful, moving work of art.

We ended the class in a circle, passing our dough into the hands of the person beside us. Each pass was different and had its own expression. I was last to pass my dough to the teacher, David Leventhal. It was a pass of gratitude and thankfulness. I spent an hour with people I had never met but shared their experience of dancing as art. It was obvious that our Parkinson’s didn’t matter. It made each one of us unique and that was reflected in our movements and the art we created.

“One thing I’ve come to believe about Parkinson’s is that it’s a disease of subtraction. It takes things from you one by one. And one of the many things I learned from the people in the class is that if you are confronted with a disease of subtraction, you better believe in addition. You better start adding things back into your life.”Dave Iverson, producer, “Capturing Grace.”

I do believe that Parkinson’s can add things to life. Good things. You may have to look for them but they are out there somewhere. Like the dancers I met in class, for me dance has been one addition to offset the many subtractions.

What will be yours?

***

Note: Parkinson’s News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. The opinions expressed in this column are not those of Parkinson’s News Today or its parent company, BioNews Services, and are intended to spark discussion about issues pertaining to Parkinson’s disease.

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Keeping Songs Going in the Head Helps Parkinson’s Patients Walk More Naturally, Study Says

walking and music

Singing a rhythmic tune out loud or, even better, simply listening to it play in your head can help older adults — including those with Parkinson’s disease — to walk more naturally and at a steadier pace, a study reports.

The study, “Mental Singing Reduces Gait Variability More Than Music Listening for Healthy Older Adults and People With Parkinson Disease” was published in the Journal of Neurologic Physical Therapy.

People with Parkinson’s disease tend to walk slower and with less stability than healthy adults of similar age. Lower gait speed is thought to be a consequence of shorter step lengths and decreased step frequency, indicating a decline in overall health.

Listening to music (what scientists refer to as an external auditory cue) is known to help normalize gait speed in Parkinson’s patients. “By creating an external template to which people can align their footfalls, auditory cues impose a walking cadence that, presumably, reduces reliance on defective internal timing mechanisms and increases motivation, thereby increasing walking speed,” the researchers wrote.

External cues essentially set a pace that listeners respond to, restoring a rhythm to their gait and reducing variability.

But it doesn’t always work as intended, the researchers noted. Some studies have found that listening to music can actually increase gait variability in some Parkinson’s patients and older adults, possibly reflecting “the difficulty of synchronizing to an outside source.”

Washington University (WUSTL) researchers previously reported that singing aloud (an internal cue) leads to motor benefits in Parkinson’s patients similar to those in people who did well listening to music (an external cue).

This team now set out to determine whether singing aloud without music or singing to oneself mentally could elicit similar gait improvements as listening to music, reasoning that such an internal cue “utilizes vocal-motor coupling to match one’s movement to one’s own voice,” they wrote.

A total of 60 people, 30 men and 30 women, were included in the study. Half were diagnosed Parkinson’s patients and the other half were healthy older adults serving as controls. Patients (all tested in an “on” state of medication) had a mean age of 65.8, and controls a mean age of 64.9.

Participants walked under three distinct test conditions: listening to music, or singing aloud without music and singing mentally. All three tests were also performed at three different tempos: at the person’s preferred walking speed (cadence), 10% slower, and 10% faster.

“All conditions were cued using an instrumental version of ‘Row, Row, Row your Boat’ designed with a salient beat that could be readily detected by participants. Everyone was familiar with the lyrics and melody of the song and able to sing it without difficulty,” the researchers wrote.

As expected, Parkinson’s patients walked slower, took shorter steps, and had higher levels of gait variability and asymmetry that did healthy adults.

Both controls and patients showed a better walking performance with mental singing, with benefits similar to those triggered by external cues.  “However, only internal cues elicited improvements in gait variability as well,” the researchers wrote.

In their earlier work, these researchers showed that singing aloud generally lowered gait variability measures in ways that compared with externally generated cues. This time around, they found that singing to yourself mentally elicited even greater reductions in variability than overt singing.

Walking at a faster than the usual pace — prompted by a faster tempo — was also associated with improved velocity and lesser gait variability in both groups. “Variability decreases were more substantial during mental singing at tempos at or above preferred cadence,” the researchers wrote.

“[M]ental singing provides more benefit to gait variability than singing aloud, which makes internal cueing more practical for everyday use,” they concluded, adding that optimizing the use of internal cues to aid movement “is an important step toward more effectively meeting the needs of people with gait disorders related to aging or neurological disease.”

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Molecule May Halt Parkinson’s Progression, Study Using New Mouse Model Finds

anle138b molecule

A molecule called anle138b was able to reduce toxic alpha-synuclein aggregates, or clumps, in the brain — a key event linked to Parkinson’s — and reverse motor symptoms associated with the disease in a novel Parkinson’s mouse model.

The study, “Depopulation of dense α-synuclein aggregates is associated with rescue of dopamine neuron dysfunction and death in a new Parkinson’s disease model,” was published in Acta Neuropathologica. The work was funded by the charity Parkinson’s UK.

Many neurodegenerative disorders involve aggregation of misfolded (harmful) proteins in the brain. Parkinson’s is characterized by a buildup of the protein alpha-synuclein in the brain, which forms clumps known as Lewy bodies that damage and kill nerve cells, or neurons.

Anle138b has been shown to reduce toxic protein accumulation and delay disease progression in models of multiple system atrophy, Alzheimer’s disease and Parkinson’s.

Investigators from the University of Cambridge now evaluated the effects of anle138b in a new mouse model of Parkinson’s disease.

Although this molecule had previously been shown to reduce the clumping of proteins in other Parkinson’s models, the team wanted to understand its potential to treat the condition during its natural progression. To that end, they created a new mouse model that mimics the way alpha-synuclein gradually accumulates in specific areas of the brain, impairing neuronal communication and resulting in motor alterations.

The animals were nine months old before treatment initiation — around 46 human years. At the start of the treatment, the mice already showed low levels of dopamine in their striatum, a brain region involved in voluntary movement control that is severely affected in Parkinson’s. This reduction was associated with the onset of motor symptoms, including changes in gait that resembled some of the early motor symptoms seen in individuals with the disease.

However, the animals’ substantia nigra, another brain region involved in motor function that is also affected by the disease, had not yet been significantly damaged. Mice striatal (meaning “of the striatum”) and nigral (meaning “of the substantia nigra“) dopamine-producing neurons also exhibited alpha-synuclein aggregation.

Starting at nine months of age, mice were treated with anle138b for three months. Treatment reduced alpha-synuclein clumps, restored dopamine levels in the brain, and prevented dopaminergic nerve cell death. This was accompanied by gait improvements, suggesting that anle138b can effectively reverse, or at least halt, Parkinson’s progression.

These results indicated that “there is a window of time when it is possible to prevent [dopaminergic] neuronal death, even when striatal [dopaminergic] release is already impaired,” the researchers said. This means that if anle138b is given early on — before advanced nerve cell death — it may reduce  alpha-synuclein aggregates, potentially halting Parkinson’s progression.

“Our study demonstrates that by affecting early alpha-synuclein aggregation with the molecule anle138b in a novel transgenic mouse model, one can rescue the dopaminergic dysfunction and motor features that are typical of Parkinson’s,” Maria Grazia Spillantini, professor in the department of clinical neurosciences at the University of Cambridge, and the study’s lead researcher, said in a press release.

“The evidence from this early stage study builds on our understanding of how alpha-synuclein is involved in Parkinson’s and provides a new model that could unlock future treatments,” added Beckie Port, research manager at Parkinson’s UK.

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Ballet Not Seen to Greatly Improve Gait or Balance in Small Study in Parkinson’s Patients

Ballet practice may not improve balance and gait in people with Parkinson’s disease — at least not over the long term, a small study in patients engaged in dance for at least a year suggests, possibly contradicting earlier research reporting evidence of such benefits.

But the work did find probable social and psychological gains, noting a “high levels of adherence” among the Parkinson’s group, indicating motivation “to continue attending.”

Researchers for this study, “Effects of a ballet-based dance intervention on gait variability and balance confidence of people with Parkinson’s,” published in the journal Arts & Health, suggesting that more research needs to be done to understand whether and how dance therapy can be effective.

Dance can be beneficial for many, and especially people with neurodegenerative diseases. It is a form of physical movement that is often easier to “stick with” than just exercising, and offers social contact that rewards a person’s mental health and psychological well-being. Some previous studies specifically indicated that dance may improve motor skills in people with Parkinson’s.

The U.K. team here wondered whether ballet — a dance form that requires many balancing movements, like stabilizing weight on one leg while moving the other  — would be of benefit for Parkinson’s patients.

They recruited 19 patients already enrolled in weekly “dance for Parkinson’s” classes. Participants had to have been dancing for at least three months, although most had already been participating for over a year.

Another 13 patients who refrained from ballet classes for the study’s duration served as a control group.

Over the course of a year, people in both groups were examined for changes in gait and balance. To analyze gait, a sensor was placed on a participant’s lower back when they walked across the room, allowing for measurements of stability as they walked.

For balance, the Activities-specific Balance Confidence Scale was given to participants. This questionnaire is a measurement of confidence in balance, not balance itself, since it’s asking participants questions about their perceptions of their own balance.

No significant difference in all of the above measures was seen between the two groups over the study’s year. This contradicted pro-benefit findings of previous research, and the investigators offer two likely explanations for this disparity.

“First,” they write in their study, “gait variability as an indication of dynamic stability has not been assessed in previous dance for Parkinson’s research.” Further, measures of gait variability used in this study might “not be comparable” to “commonly used clinical rating scales” that look more at “static balance tasks,” and reliance on their  different variables may make all the difference.

“Secondly,” the researchers said, “previous studies evidencing changes to balance, gait, and functional mobility have often included a class frequency of two to three dance classes per week,” while participants in this study had one class per week.

They also suggested that a study limitation was the fact that its patient group had been taking the weekly classes for about a year prior to the study’s start. Regular long-term dance classes made it “possible that a ceiling effect may have occurred whereby any resulting change in gait variability as a result of the ballet-based sessions was no longer visible,” the researchers concluded.

“It is possible that the ballet-based sessions had a positive affect on gait variability for the participants; however, the measurements were not able to capture this early change at the beginning of their dance programme.”

 

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Study Assessing Smartphone Technology to Track Parkinson’s Motor Symptoms, Researchers Report

smartphone technology

Researchers are conducting a study assessing the use of different motion-tracking sensors to remotely gather data from Parkinson’s disease patients.

The technology holds the potential to noninvasively monitor Parkinson’s motor symptoms, as well as the effects of medication, over the course of patients’ normal daily lives at home.

The study, “Identification of Motor Symptoms Related to Parkinson Disease Using Motion-Tracking Sensors at Home (KÄVELI): Protocol for an Observational Case-Control Study,” was published in JMIR Research Protocols.

Parkinson’s motor symptoms are usually assessed using the motor part of the Movement Disorders Society — Unified Parkinson’s Disease Rating Scale (MDS-UPDRS). This rating scale requires patients to perform a series of repetitive movements, which are then rated by a clinician from zero (normal) to four (severe) to reflect a patient’s level of motor impairment.

However, this scoring method is not sensitive enough and is dependent on an individual clinician’s observations, making it somewhat subjective and prone to variability.

“The symptoms present during the clinic appointment may not reveal all of the issues that are present at home, and the ability to cope independently may vary substantially between the on and off states,” the researchers wrote.

Antiparkinsonian medications can help control Parkinson’s motor symptoms (on periods), but as the disease progresses, patients typically need to gradually increase the treatment dose for maximum benefit. Even after increasing the dose, they might sometimes experience a reappearance or worsening of symptoms (off periods) due to the diminishing effects of the therapy.

There is an urgent need for developing objective, effective, and convenient measurements to help clinicians accurately identify Parkinson’s motor symptoms.

Besides allowing for the collection of quantifiable data regarding the progression of disease-related symptoms, wearable sensors enable remote monitoring of the patient.

This kind of technology may assist clinicians in recognizing on/off periods, helping them to adjust medication doses and schedule to prevent unexpected worsening of symptoms.

Investigators at Tampere University in Finland designed an observational, prospective, case-control study (NCT03366558), called KÄVELI, to help them find new methods to identify and categorize disease-related motor symptoms.

During the study, patients must wear accelerometers connected to the wrist and sensors built into a mobile phone worn on a belt. Long-term motion tracking measurements are acquired at home while patients are going about their everyday lives.

Scientists want to see if motor symptoms related to different stages of Parkinson’s disease can be identified using motion tracking sensors and if the time at which the antiparkinsonian medicine is taken can be detected from the movement signals.

Movement data collection started a year ago, but participant recruitment is continuing throughout spring of this year.

Researchers plan to enroll 50 early-stage Parkinson’s disease (no abnormal involuntary movements, known as dyskinesia, and no on/off state changes), 50 patients in the later stage of the disease (with dyskinesia and on/off state changes), and 50 healthy individuals used as controls. In 2018, the researchers managed to enrolled 103 people, 66 of whom were diagnosed with Parkinson’s.

Patients first have to complete a telephone screening and visit to the hospital. Background characteristics and disease stage is evaluated in the hospital using UPDRS questionnaires and a standardized 20-step walking test.

Before the walking test, a Movesense smart sensor is attached to the nondominant wrist. In addition, the participant wears a smartphone that has a built-in accelerometer, gyroscope (a device that uses Earth’s gravity to help determine orientation), and phone orientation sensor. Patients must also wear a Forciot smart insole, so that scientists can measure the forces applied on the feet. Based on the questionnaires and walking test study, the physiotherapist classifies the participant into one of the study groups.

After this, participants must wear the smartphone at home for three consecutive days. Due to technical requirements, wrist and insole sensors are only used in the 20-step walking test. The motion-tracking system is not worn during sleep or while showering or swimming.

During the three-day period, the participant records the time at which all Parkinson’s disease medications are taken in a smartphone app, as well as in a paper diary format.

“This manual recording was added, since the patients were having problems using the medication registration button despite the simple user interface. The double registration process ensures that medication intake is recorded as accurately as possible. The subjects also record other events, such as falls and other adverse effects, and feedback in the diary,” the researchers said.

“This study will provide quantitative information on PD [Parkinson’s disease] motor symptoms and their statistical properties. The collected dataset will be used to develop algorithms and create tools for remote monitoring of PD progression by physicians and to assist with adjusting the medication,” they concluded.

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Trunk Exercises May Improve Balance in Parkinson’s Disease, Study Finds

Falls and Parkinson's

Exercise and fall prevention education can improve front-to-back trunk mobility in Parkinson’s patients with a history of falls, according to a Phase 2 clinical trial.

The study, “Trunk exercises improve gait symmetry in Parkinson disease: A blind phase II randomized-controlled trial” was published in the American Journal of Physical Medicine & Rehabilitation.

People with Parkinson’s disease are twice as likely to fall as those with other neurological disorders. Previous studies suggest that Parkinson’s patients underestimate the muscle work needed to produce a certain movement.  This lack of motor and perceptual ability leads them to adopt distinct postural strategies to keep their balance, both during static and dynamic movements.

Studies have associated falls to deficits in step-to-step symmetry and trunk muscle function.

Although antiparkinsonian medications can help control Parkinson’s motor symptoms as the disease progresses, patients typically need to gradually increase the treatment dose for maximum benefit. Even after increasing the dose, they might sometimes experience a reappearance or worsening of symptoms due to the diminishing effects of the therapy.

Therefore, there is a need for non-pharmacological therapies that alleviate patients’ motor symptoms and improve their quality of life.

Australian Catholic University researchers set up to investigate whether an exercise program geared to improving the strength and endurance of the trunk muscles could improve standing and walking balance in those with Parkinson’s disease.

The Phase 2 study (ACTRN12613001175763), evaluated 22 Parkinson’s patients (15 men and seven women, mean age 65.4 years) with a history of falls who were randomly assigned to either 12-weeks of exercise and fall prevention education (11 participants) or fall prevention education alone (11 participants).

For the exercise intervention, patients had to attend a supervised 90-minute training session once a week for 12 weeks. Each session was conducted in groups of up to three subjects.

“In short, the exercise-based intervention comprised three parts; i) a warm-up focusing on trunk mobility exercises to improve range of motion; ii) an exercise routine focusing on the endurance and stability of the trunk muscles …; and iii) a cool-down involving stretching and walking in a real-world environment,” researchers stated.

The exercise group also received health advice (same as the education-only group), in the form of weekly educational brochures, aimed at preventing falls.

Participants in the education-only group were encouraged to continue their day-to-day lives, but received a weekly multidisciplinary health tip for 12 weeks that explained how exercise, nutrition and/or sleep quality could influence their fall risk and quality of life.

Initial assessment showed that there were no differences in cognition, vision, neurological function and mobility between study groups. Nonetheless, the exercise sample had a greater body mass index (measure of body fat based on height and weight) compared to the education-only group.

Twelve and 24 weeks after initial assessment, investigators examined patients’ symptom severity, balance confidence, mobility and quality of life.

All 22 patients were reassessed at 12 weeks, but four subjects (two in the exercise group and two in the education-only group) did not complete the 24-week follow-up.

At 12 weeks, the exercise sample had significant and clinically relevant improvements in front-to-back step-to-step symmetry of head and trunk movements, meaning these patients might be able to balance themselves more easily. The exercise group also had improved trunk muscle function.

The education-only group also had significant and clinically relevant improvements but in side-to-side and vertical step-to-step trunk symmetry, as measured by the harmonic ratio — a mathematical analysis of trunk acceleration used to measure walking smoothness, walking rhythmicity, or dynamic stability.

Step-to-step symmetry remained unchanged from the 12- to the 24-week evaluation in the exercise group. “The lack of significant changes in step-to-step symmetry between the 12- and 24-week assessments for the exercise group also suggests that the benefits of the weekly exercise program may be retained for up to 12 weeks following the cessation of the training regimen,” researchers said.

Regarding the education-only sample, their reduced step-to-step trunk symmetry at 12 weeks had almost been restored to initial assessment (baseline) values at 24 weeks.

These results indicate that torso-specific exercises may improve (or at the very least, maintain) trunk mobility in Parkinson’s patients and that measures of step-to-step symmetry, such as the harmonic ratio, could be used to assess subtle changes in postural control.

“Given the encouraging outcomes of this study, future research might seek to establish whether increasing the frequency of this exercise program offers greater improvements in step-to-step symmetry and/or has the potential to reduce the rate of falls in people with [Parkinson’s disease],” researchers said.

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Synchronizing Finger Taps to Regular Beats Improves Gait of Parkinson’s Patients, Study Suggests

gait, finger tapping, Parkinson's

Parkinson’s disease patients improved their gait after undergoing training in which they tapped their fingers in synchrony to regular bets set at a faster pace than their walking speed, a study has found.

The research, “Rhythmic priming across effector systems: A randomized controlled trial with Parkinson’s disease patients,” appeared in the journal Human Movement Science.

Clinical studies have shown that rhythmic auditory stimulation (RAS), using rhythm and music, significantly improved gait and upper extremity function for stroke, Parkinson’s disease, traumatic brain injury, and other conditions.

Auditory stimuli have been used in the motor rehabilitation of patients with Parkinson’s disease, who increased their walking speed, stride length, and stability after RAS training, an approach that uses rhythmic cues to improve motor function.

It is still unclear whether short-term RAS of arm or finger movements also improves gait, although studies have suggested that rhythmic arm movements while walking enable arm-leg coordination to improve gait.

Therefore, researchers at the University of Toronto and Colorado State University decided to investigate whether RAS training of arm or finger movements would modulate gait speed in 37 patients with idiopathic (of unknown cause) Parkinson’s disease.

A group of 11 patients (with seven men, a mean age of 68.4 years, and disease duration of 4.8 years) underwent a four-minute training — three one-minute blocks separated by 30 seconds — in which arm or finger movements were performed in synchrony to beats (using a metronome) set to a 20% faster pace than their pre-training walking speed. The patients used the index finger of the least affected hand for tapping. Auditory stimuli were delivered with a speaker placed one meter away from the participant.

A separate group of 14 participants (with six men, a mean age of 64.2 years, and disease duration of 7.7 years) was asked to swing both arms in an alternating manner in synchrony with the metronome. Both finger-tapping and arm swing tasks were performed with participants seated in an armless chair.

The 12 patients in the control group — with four men, a mean age of 67.3 years, and disease duration of 11.7 years — did not receive any training.

All participants were on Parkinson’s medication and had a Hoehn & Yahr (H&Y) scale score of one or two, which indicates that their balance was not impaired.

Gait assessments pre- and post-training required walking on a 14-meter flat walkway at the participant’s preferred walking speed with no auditory cueing.

The results revealed a significant 9.5% increase in gait velocity after the finger-tapping training, from an average of 69.75 meters/min before training to 76.03 meters/min post-training. No differences were seen in the arm-swing and control groups.

Patients who underwent finger-tapping training also showed an 8% increase in gait cadence, or the number of steps per minute — from 109.25 to 117.5 — unlike those in the other groups. No post-training differences in stride length were seen in any group.

“The present study supports the hypothesis that rhythmic priming is possible across effector systems by demonstrating that (RAS) training of finger movements had immediate effects on gait velocity and cadence of patients with Parkinson’s,” the researchers wrote.

“The present findings have direct implications for motor rehabilitation and extend the current application of rhythmic-based interventions,” they added.

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Changes in Gait, Cognition May Be Early Signs of Idiopathic Parkinson’s, Research Suggests

gait and Parkinson's

Changes in gait and cognition precede a diagnosis of idiopathic (without known cause) Parkinson’s disease, and may occur earlier than typical non-motor symptoms, a study has found.

The study, “Prediagnostic markers of idiopathic Parkinson’s disease: Gait, visuospatial ability and executive function,” was published in Gait & Posture.

Motor symptoms in idiopathic Parkinson’s disease (IPD) are identified relatively late in the disease course, reducing the odds of neuroprotective benefit from available treatment options. Identifying individuals during the prodromal (early) period that precedes motor symptoms could be of great use for clinical studies seeking new therapies to prevent or delay disease progression.

A team of French researchers sought to determine the existence of any subtle gait disorders or other signs that precede the diagnosis of IPD, based on data from a long-standing study of human aging across the adult lifespan: the Baltimore Longitudinal Study of Aging (BLSA).

Conducted by the National Institute on Aging (NIA) Intramural Research Program, the BLSA continuously enrolls healthy volunteers age 20 and older who are followed throughout their life independently of the development of age-related diseases.

Ten pre-diagnosed IPD patients (eight men and two women) and 30 healthy control subjects were chosen for this study.

Subjects were assessed for the disease approximately 2.6 years before diagnosis. Clinical examination included gait speed, spatio-temporal gait parameters, balance, upper-limb motor skills, neuropsychological profile, and non-motor symptoms.

In comparison to the control group, IPD patients had shorter step length and reduced gait speed in a usual gait speed testing condition. Despite also having shorter step length when testing maximum gait speed, no differences between the IPD and control samples were found in walking speed.

Moreover, patients had worse mental rotation ability (the ability to rotate mental representations of two-dimensional and three-dimensional objects, which is related to the brain’s capacity for visual representation), and impaired ability to name different examples that could be inserted into a category (for instance, naming all types of flowers one can think of in one minute).

Compared to control subjects, IPD patients had no changes in upper-limb motor function, no depression, no sleep disturbances, no urinary symptoms, and no orthostatic hypotension (when blood pressure suddenly drops when standing up quickly).

Researchers concluded that the observed “changes might serve as markers to improve the early detection of IPD patients, who could then benefit from pharmacological neuroprotection trials and/or prevention trials of lifestyle-related interventions in order to delay, or even prevent, clinical manifestations.”

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Design, Development of BeatHealth System for Parkinson’s Gait Impairments Described in Study

BeatHealth system

Researchers have developed a system — a mobile app and two websites — based on musical stimuli to improve gait and reduce freezing episodes in Parkinson’s disease patients, according to a study describing the design process of the new approach.

The project, called BeatHealth, involved patients, caregivers, and health professionals from the start to produce the most useful, usable, and easy-to-use final system, with the most appropriate functionalities.

The study, “Design and development of a gait training system for Parkinson’s disease,” was published in PLOS ONE.

Parkinson’s main motor symptoms are typically associated with impaired gait. Rhythmic auditory stimulation (RAS), an approach that consists of matching a patient’s walking speed to a rhythmic sound, or piece of music, has shown beneficial effects in improving gait and reducing freezing episodes in people with Parkinson’s.

The BeatHealth system uses RAS in the form of musical stimuli and has been developed to deliver a training session for Parkinson’s patients. It consists of two sensors worn on the lower legs, a mobile application on a smartphone — which receives data from the sensors and is able to adapt the music rhythm to the user’s gait — and a cloud platform accessed through a website to store the information and allow healthcare professionals and patients to track gait progress.

BeatHealth’s design process was iterative and followed a user-centered methodology that incorporated the input of health professionals, patients, and caregivers.

This approach was intended to create an easy-to-use and easy-to-learn system over four phases: (1) research and exploration to adjust requirements, goals and context of use to the user; (2) concept and design to fulfill the requirements from phase one; (3) development and implementation, with input from users; and (4) evaluation of prototypes by final users to verify that requirements were met and to assess the system’s viability, usability, and functionality.

Personas, or fictional characters, interviews, standard validated questionnaires, and mock-ups were used along with the four phases. In the final phases, end-users also evaluated the system.

In phase one, 12 Parkinson’s patients and two relatives were interviewed about BeatHealth’s utility and its main functionalities. These patients were at various stages of disease severity and were also of different types of medication.

Ten patients said they would rather use this kind of system by themselves than under clinical supervision. Patients also indicated a preference for having access to step length, number of steps and time of training, and for using larger headphones due to hand function impairments.

Observation sessions were conducted in Montpellier, France, two with Parkinson’s patients and one with a healthy participant. The sessions were focused on better understanding the movement evaluation tools and techniques, as well as their impact on participants. The participants were mainly asked to walk around a marked circuit while listening to music with varying rhythmic characteristics.

In the third session, a patient had to complete tasks while using a memory app on a smartphone to evaluate issues related to managing a touch screen. Unlike when sitting or standing still, the patient was unable to complete any task when asked to walk.

“Witnessing this participant’s experience gave the observer a deeper understanding of user needs and the effects of [Parkinson’s] symptoms on the user’s interaction with their environment,” the researchers wrote.

Overall, the observation sessions led to breaking down the evaluation process into smaller parts, reducing multitasking, understanding the importance of motivation and goal-setting, simplifying data and instructions, designing the user interface, and establishing the distance to be walked during the task, as well as reducing the need for patients to enter data.

The scientists then decided to implement a web application, linked to one website for patients and another for health professionals, which, with patient authorization, enables the professional to create a training program for the patient and track his or her progress.

In phase two, the team generated paper prototypes initially evaluated by experts and stakeholders, but not by patients. A second mock-up was then created, which was evaluated by a team made up of a neurologist, a consultant, a physiotherapist, a patient, a human-computer interaction specialist, a computer science specialist, and a computer interaction designer.

Among the results of this second phase, the team found that the workflow required review to encourage the participants to send the data, the login screen needed simplification, the map screen required clarification, and volume buttons and text spacing needed improvement.

In phase three, a third version of the mock-up was evaluated, and the team focused on its viability. For the evaluation of the mobile app, four idiopathic (without known cause) Parkinson’s patients (one woman, three men, ages 64-74) with a walking disorder were recruited. They had to progress through a task flow using the prototype screens with additional tasks such as putting on sensors, connecting the charger, connecting headphones, or connecting to the WiFi network.

Interviews and discussions after the evaluation were aimed at addressing participants’ thoughts about the system, their evaluation experience, and any recommendations they had. The analyses showed that user experience in relation to connecting to WiFi and the time required to complete tasks needed improvement. In addition, the system needed further overall simplification and clarification.

A second evaluation of the mobile app was done by four patients (two women and two men, ages 46-84). They were asked to perform five tasks, which, in general, they were able to complete under appropriate guidance. They found the app user-friendly and simple, resulting in better usability and satisfaction over the previous version.

Website mock-ups were then evaluated by six patients, one relative of a Parkinson’s patient, and 11 healthcare professionals, who all valued the system’s simple and user-friendly structure. But healthcare professionals had difficulties finding particular functionalities, while patients mainly had problems in being able to read the text.

In phase four, the team incorporated changes based on the previous evaluations to create the final mobile application and websites. The most notable changes were to the home screen — such as direct access to music selection and user progress — and the screen flow associated with taking a walk.

Thirty-seven patients (20 women, ages 40-84) evaluated the final BeatHealth system over three months at home. Results showed that 78% of the participants were satisfied with the app, 72% found it easy to learn and understand, and 86% said it was clear enough. Issues with components such as sensors or phone buttons were the most frequent drawbacks. Satisfaction was higher than with the prototypes. However, only 32% of participants felt that the system helped them improve their gait.

“We can conclude that a complete methodology that involved stakeholders from the very beginning until the final evaluation of the design proved effective at producing a usable system in this particular case,” the researchers wrote.

Not measuring the system’s acceptance and adherence were among the study’s limitations and should be evaluated over longer trials, they noted.

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