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Parkinson's Recovery

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There's a problem loading this menu right now. Get fast, free shipping with Amazon Prime. Your recently viewed items and featured recommendations. View or edit your browsing history. Get to Know Us. English Choose a language for shopping. Not Enabled Word Wise: Not Enabled Enhanced Typesetting: The disease is caused by the degeneration of dopaminergic DA neurons in the substantia nigra associated with neuronal inclusions called Lewy bodies, leading to DA deficiency in the basal ganglia BG This deficiency results in four cardinal symptoms of PD that can be remembered by the tremor at rest, rigidity, akinesia or bradykinesia , and postural instability 33 — These symptoms are often accompanied by gait impairments 36 that are particularly prominent in the postural instability gait difficulty PIGD , in contrast to the tremor dominant, subtype of PD Gait abnormalities become also more severe in the late-stage PD Gait disorders in PD are characterized by stooped posture, shuffling steps, flexed knees, narrow base, reduced arm-swing, turning en bloc , and FOG, which is one of the most debilitating features of PD 1 , While walking, patients suddenly lose the ability to lift their feet and become stuck in place for several seconds or even minutes despite their efforts to initiate forward movement FOG can be provoked by perceived obstructive environmental cues, such as attempting to walk through narrow doorways.

Compared to healthy adults, PD patients have a shorter stride length, slower velocity, and more unpredictable fluctuations between consecutive strides 1 , 38 , 41 — Indeed, FOG has been shown to be associated with marked disruption to internal rhythmic timing Basic parameters of gait and their definitions and units of measurement.


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Emergence of gait abnormalities often indicates a poor prognosis for PD patients as they correlate with bradykinesia, rigidity, and cognitive impairment associated with cortical Lewy bodies 36 , 48 and leads to more frequent falling, a major cause of death among patients with PD 1. Several studies have shown that FOG in patients with PD correlates with poor quality of life, disease severity, apathy, and exposure to anticholinergic drugs; it may, but not always, improve with DA therapy Impaired functional connectivity between the BG and the dorsolateral prefrontal cortex and the posterior parietal cortex has been suggested by recent connectivity studies 50 , Although DA deficits clearly play an important role in gait disturbances associated with PD, FOG often does not respond well to DA therapy, suggesting extranigral pathology in this particular gait disorder.

Conventional therapeutic interventions for PD, such as pharmacotherapy and deep brain stimulation DBS , can be effective for treating the cardinal motor symptoms but have shown limited efficacy in gait abnormalities Levodopa, a DA precursor and one of the main pharmacotherapies of PD, has limited therapeutic effects on balance and gait disturbances Furthermore, anti-PD medications may produce side effects including lightheadedness, drowsiness, and dyskinesias which can exacerbate gait abnormalities 1.

Although DBS typically improves tremor, rigidity, bradykinesia, and levodopa-related motor complications 54 , this therapeutic modality results in only minimal benefits in patients whose primary symptoms are PIGD 1 , 55 , In recent years, there have been numerous studies demonstrating the therapeutic efficacy of RAS in gait abnormalities associated with PD.

An increasing body of research suggests that PD involves a deficit in temporal processing 57 and that internal rhythmic timing is more disrupted among PD with gait deficits than among patients without gait deficits It has been proposed that internal timing is dependent on striatal DA levels 58 , and that timing problems may be a potential marker for frontal and striatal dysfunctions in PD Accordingly, we hypothesize that the temporal deficits in PD are a major contributor to gait impairments. This is supported by the finding that DA replacement therapy reduces the timing deficits in PD 60 , and that timing deficits are induced by changes in the expression levels of striatal D2 receptors Furthermore, timing deficits are also found in other DA-related disorders including schizophrenia 58 , 62 , To understand temporal dysfunction, one must consider the two fundamental modes of timing: Explicit timing is required to make deliberate estimates of duration and relies on internal sense of time Implicit timing utilizes external cues and relies less on conscious time-based judgments, engaging automatic timing systems.

An example of an implicit timing task is the serial prediction task, which requires the subject to use a regularly timed stimulus to make temporal predictions about future stimuli 64 , Patients with PD have greater difficulty with explicit timing than with implicit timing. More specifically, PD patients have problems with explicit temporal discrimination tasks involving tactile, visual, and auditory stimuli, and explicit timing performance decreases as disease severity increases 66 — The underlying neural networks of implicit and explicit timing are distinct.

In this network, the dorsal striatum caudate and putamen of the BG serves the most crucial role since it generates the internal pacing required for time estimation 73 , Thus, the BG is directly involved in perceptual and motor timing 77 — The D2 receptors in the striatum mediate the DA signaling that controls the speed of this internal pacing 80 — The lack of DA innervation to the BG in PD causes slower internal pacing 76 , which leads to impairments in motor and perceptual timing abilities 17 , 69 , 72 , 86 , Given that gait and other motor deficits in PD are strongly associated with timing impairments, RAS is a promising strategy for gait rehabilitation.

Although PD patients have impairments with external timing due to internal pacing dysfunction, patients still have the ability to make temporal predictions through implicit timing. In other words, PD patients can still use external rhythmic cues to inform temporal-based decisions, such as when the next footstep should occur.

Since implicit timing is still mostly intact in PD patients, they compensate for the disruption in the BG—SMA—PMC explicit timing by recruiting the cerebellum 89 essential for implicit timing. Although internal pacing is disrupted in PD patients, this timing alteration can be corrected and recalibrated through motor—sensory interaction with the world 3 , Cued gait training utilizes the implicit timing abilities still present in PD patients to recalibrate the internal clock. In RAS, PD patients are instructed to walk while synchronizing their footsteps to the salient beats of the music or metronome.

RAS can be combined with visual cues such as patterned tiles or stripes placed along the walkway for multisensory cueing. In the absence of external cueing, internal cueing signals generated by the BG—SMA—PMC circuit feed into the motor programs, which are carried out in the medial motor areas comprised of the SMA and the cingulate motor area During locomotion, the spinocerebellar, the spinothalamic, the spinoreticular, and the spinohypothalamic tracts carry somatosensory information, such as proprioception back to the brain 3 , The information carried by the somatosensory feedback modulates the internal clock of explicit timing 62 in the BG—SMA—PMC circuit and helps plan and predict future cued motor tasks.

Neurological schema of cued gait training. The motor programs of gait appear to be relatively intact in PD patients, but due to impaired internal timing, the programs cannot be easily accessed without external cues 1 , 3 , External rhythmic cues include visual and auditory sensory stimuli and can serve as surrogate cues for the impaired internal timing 93 , Accordingly, auditory and visual stimuli can bypass the damaged BG and help the patients improve their gait by inducing motor—sensory feedback signals that recalibrate internal pacing. After the correct temporal scheme is re-established with RAS and potentiated through the BG—SMA—PMC circuit, patients can sustain improved locomotion for a period of time in the absence of external cueing.

In , Thaut et al. Since then there have been numerous reports on the effect of music- or metronome-based gait training in PD patients. Below, we will discuss some of the recent key studies on cued gait training to better understand the challenges of gait therapy and to formulate a future direction for RAS in PD.

Gait-training studies in PD patients have used either music or simple isochronous sounds, such as a metronome, as cues for RAS. Although there has not yet been a published direct comparison between music and metronome in gait rehabilitation in PD patients, several studies have done this with healthy participants. One study reports that healthy young adults walked faster with music than with metronome cues While the studies in healthy subjects suggest that cues with music are more effective than with a metronome at increasing gait velocities, a study by Leow et al.

The same study further compares the effects of two types of music on gait: Between these two types of musical cues, high-groove music elicited better gait synchronization and faster gait velocity. Low-groove music was not as effective, and even had a detrimental effect on gait in weak beat-perceivers Music familiarity is also an important factor in RAS. RAS with familiar songs results in faster gait velocity and less stride variability than with unfamiliar songs.

This is likely due to the fact that synchronizing footsteps to a familiar beat structure require less cognitive demand. Enjoyment of familiar music may also have had a role in eliciting a faster gait A variety of devices have been developed to provide customized fixed-temp RAS. The glasses are portable and contain built-in headphones that allow the user to listen to isochronous metronome-like auditory cues while walking.

The sounds are customizable to various styles, such as ambient, percussive, electronic, and vocal. The research groups plan to turn the device into an auditory feedback system by integrating feedback to spatial movements. The device will include a built-in video camera and a laser emitter to assess motion in the visual field and provide responsive visual cueing. The group has yet to publish the results of the efficacy of this integrated visual and auditory feedback system.

Inclusion factors consisted of a history of frequent FOG and falling as well as failure to respond to medication and physical therapy. Five of the patients received DBS with minimal gait improvement prior to the study. In this study, patients were instructed to walk while off DA therapy. Cadence, stride length, and walking speed were measured with and without RAS. Patients showed significant improvement for all three gait parameters while listening to auditory cues. A recent study by Benoit et al.

The study consisted of 15 non-demented patients with idiopathic PD Hoehn and Yahr stage 2.


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  • The patients had no prior musical training and maintained their DA therapy regimen during the trials. During each session, the participants walked to the salient beats of German folk music without explicit instructions to synchronize their footsteps to the beat. Compared to pretraining gait performance, the PD patients showed significant improvement in gait velocity and stride length during the training sessions.

    This RAS training also significantly improved motor and perceptual timing. Thus, in addition to gait, RAS improves perceptual timing with continued therapeutic effect even in the absence of auditory cueing. This study in the context of the previously mentioned study by Leow et al.

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    Effects of Auditory Rhythm and Music on Gait Disturbances in Parkinson’s Disease

    Self-improving relationship between beat perception and gait training efficacy. Although the efficacy of gait training with RAS has been proven, the rigid, fixed-tempo of the cues implemented by most studies has limited applications to PD patients. Fixed-tempo RAS requires increased demand for attention to synchronize footsteps with auditory cues, thus invoking higher-level cognitive processes This can be problematic for PD patients, in whom multitasking while walking can trigger or exacerbate their gait difficulties — Even in healthy participants, fixed-tempo RAS can result in random and unpredictable stride intervals Therefore, attempts have been made to improve RAS by integrating an adaptive system that provides feedback from human rhythm to determine cueing rhythm.

    The device utilizes pressure sensors in the shoes that feed gait timing data into a computer system, and adjust the metronome cueing tempo in real-time.

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    Gait dynamics were analyzed using the detrended fluctuation analysis DFA fractal-scaling exponent, which is associated with gait adaptability and one of the best measures of predicting falling 46 , , In a silent-control condition the PD patients had significantly lower fractal scaling higher variability in stride than the healthy subjects. Interactive rhythmic auditory stimulation using WalkMate. Error bars represent six SEM. Reproduced from Hove et al. More recently, a similar device named D-Jogger was tested on healthy subjects to study the synchronization of gait to adaptive rhythmic cues In the most effective adaptive strategy out of the four adaptive strategies tested , the participant initially begins walking in the absence of music.

    The results from healthy participants motivate further testing of D-Jogger on patients with PD or other movement disorders. Reproduced from Moens et al. In PD patients, locomotion and postural control have an increased dependence on perceptual vision , that can be corrected using visual cues , Multiple studies have shown that matching footsteps to visual cues such as equidistant horizontal lines along a walkway improves gait and reduces FOG in PD patients — Although visual cueing can be beneficial, replicating clinical scenarios would be unfeasible for patients who wish to train at home in a daily basis.

    Instead, an ideal cueing system would involve adaptive feedback and include both visual and auditory stimuli. Immersive virtual reality VR technology could fill this gap by optimizing visually cued gait training. VR is an immersive and interactive computer-generated environment that simulates the real-world experience and can be operated using a custom-made or commercially available head-mounted display. The use of VR with visual cueing for clinical rehabilitation is still in its infancy, though multiple studies have found that in chronic stroke patients VR-based training improves cadence, step length, stride length, symmetry, and other gait parameters — Recently, immersive VR was shown to be effective for gait rehabilitation in PD Twenty PD patients with a mean age of While wearing the device, the patients tried to match their steps with the adjacent tile to regulate their gait via the VR visual feedback.

    Rehabilitation of gait using virtual reality feedback cues. Error bars represent SEM. Adopted from Badarny et al.

    Introduction

    Although these findings are promising, more well-controlled studies are needed to demonstrate the efficacy of VR-based therapies for PD. A potential expansion of VR gait training should involve adaptive, multisensory visual e. Simultaneous multisensory cues could have a stronger combined effect than each cue alone.


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    • VR systems can be portable, enabling patients to train their gait in the comfort of their home. VR devices already have the computing capacity required for the integration of simultaneous adaptive cueing and can be internally processed or remotely processed in a smartphone connected to the VR device via Bluetooth.

      Thus, a multisensory and adaptive VR device with performance tracking should be explored as a superior gait-training therapy. Similar to how the metronome helps musicians maintain a steady tempo during a musical performance, RAS provides an effective approach for reducing gait impairments in PD patients. The efficacy of RAS reflects the overlapping neurological domains involved in gait and beat perception. Importantly, RAS is safe , inexpensive, non-invasive, and free of adverse health effects.

      One major limitation to most RAS methods is the fixed-tempo design that requires increased cognitive demand and can negatively impact gait. Further investigation of mechanisms of gait impairment in various parkinsonian disorders is needed. For example, an unresolved question is whether lower body parkinsonism, which is frequently associated with FOG, is a subtype of PD 37 or whether it represents a separate entity, such as vascular parkinsonism , , cortical Lewy Body disease 48 , or atypical parkinsonism such as progressive supranuclear palsy or normal pressure hydrocephalus 1.

      Novel methods and instruments, such as quantitative stepping-in-place with a concurrent mental task using a fourth generation iPod Touch sensor system , are needed to assess the effects of RAS on gait and mental function. The type of music and rhythm needed to optimize response to RAS should also be further evaluated.

      We suggest that different types of music, rather than the traditional rhythmic auditory cues, are carefully evaluated in patients with PD to determine which music most effectively improves PD-related gait disorders. Another approach to gait rehabilitation is the use of VR for PD. While initial research to this immersive approach is promising, further studies are required and should integrate RAS.

      VR technology holds the potential to deliver more effective rhythmic cues by combining RAS and visual cueing, which we term rhythmic auditory and visual stimulation. With modern technology, VR-based rehabilitation could be made portable, and smartphones could be programed to process adaptive cue algorithms. Portability and ease of use could increase the frequency of gait-training sessions and improve compliance.

      Parkinsons Recovery Magazine December 2010

      Adaptive auditory and visual cueing could also be combined with tactile stimulation as a more salient gait therapy for PD patients. Concepts of tactile stimulation could be informed by recent innovations, such as the versatile extrasensory transducer VEST , a non-invasive, low-cost vibratory VEST developed by Novich and Eagleman Thus, RAS is a promising therapy for the gait impairments in PD and other movement disorders, and combining adaptive RAS with visual and tactile cues in a VR device could further enhance the efficacy of this therapy.

      The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. We would like to thank Amanda M. Buch, a research scientist at Columbia University Medical Center, for her editing and valuable comments. National Center for Biotechnology Information , U. Journal List Front Neurol v. Published online Nov Aidin Ashoori , 1 David M. This article was submitted to Movement Disorders, a section of the journal Frontiers in Neurology.

      Received Sep 17; Accepted Oct The use, distribution or reproduction in other forums is permitted, provided the original author s or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

      This article has been cited by other articles in PMC. Table 1 Basic parameters of gait and their definitions and units of measurement. Open in a separate window. Musically Cued Gait Training: Interactive Cueing Systems Although the efficacy of gait training with RAS has been proven, the rigid, fixed-tempo of the cues implemented by most studies has limited applications to PD patients. A Potential for Combined Visual and Auditory Cueing In PD patients, locomotion and postural control have an increased dependence on perceptual vision , that can be corrected using visual cues , Conclusion Similar to how the metronome helps musicians maintain a steady tempo during a musical performance, RAS provides an effective approach for reducing gait impairments in PD patients.

      Conflict of Interest Statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Acknowledgments We would like to thank Amanda M. Neurol Clin 33 1: Parkinsonism Relat Disord Sensory aspects of movement disorders. Lancet Neurol 13 1: Music and the mind: Ann N Y Acad Sci Lancet Neurol 11 6: Musical training as an alternative and effective method for neuro-education and neuro-rehabilitation. Front Psychol 6: Tales of Music and the Brain.

      Roseanne Dobkin (Author of Parkinsons Recovery Magazine November )

      Jankovic J, Ashoori A. Movement disorders in musicians. Mov Disord 23 Phenomenology and classification of dystonia: Mov Disord 28 7: Kennedy M, Kennedy JB. The Concise Oxford Dictionary of Music. Oxford University Press; Haueisen J, Knosche TR. Involuntary motor activity in pianists evoked by music perception. J Cogn Neurosci 13 6: Bangert M, Altenmuller EO.

      Mapping perception to action in piano practice: BMC Neurosci 4: A network for sensory-motor integration: Shared networks for auditory and motor processing in professional pianists: Neuroimage 30 3: Action representation of sound: J Neurosci 27 2: When the brain plays music: Nat Rev Neurosci 8 7: Listening to musical rhythms recruits motor regions of the brain. Cereb Cortex 18 Neurobiological foundations of neurologic music therapy: Front Psychol 5: