Sinha Siddharth, Bhatt Sunil. Effect of Sensory Cueing on Gait and Balance During Both "On" and "Off" Drug Phase of Parkinson's Disease, SRJI Vol- 2, Issue- 1, Year- 2013

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EFFECT OF SENSORY CUEING ON GAIT AND BALANCE DURING BOTH

“ON” AND “OFF” DRUG PHASE OF PARKINSON’S DISEASE

Sinha Siddharth M.P.T. (Neurology)*, Bhatt Sunil M.P.T. (Neuro-science)**

ABSTRACT

AIM: The effect of cueing has been well proved in PD but almost all of the studies are done in “on” drug phase

of the disease. So in this study we tried to investigate the efficacy of a supervised cueing training in “on” drug as

well as “off” drug phase of Parkinson patients. METHODOLOGY: Experimental study sample 8 individuals

with idiopathic PD are selected on basis of inclusion criteria- Idiopathic Parkinson’s , in stage 2-3 on hoer and

yahr staging, excluded those MMSE < 24, any known Cardio respiratory complication that hinders the exercise

program, any other known neurological condition ,any fracture or surgery of lower limb in last one year . Group

A is “OFF” drug phase and group B “ON” drug phase. Both groups were assessed in both “ON” drug phase

and “OFF” drug phase. Intervention consisted of a sensory cuing visual (floor markers) and auditory (beep)

cues. The data analyzed within group and between groups for any improvements in both the phases. RESULTS

AND CONCLUSION: cueing techniques is helpful in improving gait and balance in PD. But we suggest that

treatment given in “OFF” drug phase is more beneficial.

KEYWORDS: “ON” drug phase, “OFF” drug phase, PD, sensory cueing.

INTRODUCTION

Parkinson’s disease (PD) is one of the most

common neurological disorders in elderly people.

Between the age of 55 and 85 years, 4.2% of all

women and 6.1% of all men develop PD. The major

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

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motor symptoms in PD are tremor, rigidity,

bradykinesia, and postural instability, resulting in

problems with gait, balance, transfers, and posture.

These problems can lead to reduced mobility and

decreased levels of physical activity, which in turn

can cause increased dependency and social isolation

and thereby reduce quality of life.19 it is therefore

important to encourage patients to maintain their

mobility and to stay active, for example, by referring

them to physical training programs.19 These physical

exercise programs include use of rhythmic cues.

Cueing can be defined as using external temporal or

spatial stimuli to facilitate movement (gait) initiation

and continuation. Cueing can be defined as using

external temporal or spatial stimuli to facilitate

movement (gait) initiation and continuation.

Unfortunately, evidence-based knowledge about

effects of cueing in PD is limited. Best-evidence

synthesis of 24 studies, up to 2002, showed only 1

high- quality study. Specifically focused on the

effects of auditory rhythmical cueing. Studies claim

positive effects of cueing on gait speed of patients

with PD; however, it was unclear whether positive

effects identified can be generalized to improved

activities of daily living in patients’ own home

setting and reduced frequency of falls in the

community. In addition, the sustainability of a

cueing training program remains uncertain.19

A recent review on cueing suggests that cueing

can have an immediate and powerful effect on gait

in PD.19 Vision-to facilitate locomotors activity was

first described by Martin over 25 years ago. In a

later study, Forsberg et a reported beneficial effects

of visual guidance on gait movements in patients

with Parkinson's disease.14 Unfortunately, evidence-

based knowledge about effects of cueing in PD is

limited. Although there is evidence to support the

use of sensory cues to improve gait, balance and

other impairments in PD but almost all of the

literature available is using this technique in “ON”

drug phase of disease i.e. when the PD patient is

under the effect of antiparkinson’s medicine.

Secondary the definitive effect of sensory cueing in

“ON” and “OFF” drug phase of the disease has not

been compared.

BACKGROUND

Sean Ledger, Rose Galvin et al. in their

randomized controlled trial evaluated the effect of an

individual auditory cueing device on freezing and

gait speed in people with Parkinson's disease. In this

study they used an Apple iPod-Shuffle™ and similar

devices provide a cost effective and an innovative

platform for integration of individual auditory

cueing devices into clinical, social and home

environments and are shown to have immediate

effect on gait, with improvements in walking speed,

stride length and freezing. Visual, auditory and

somatosensory cueing devices have also been used

in conjunction with walking aids, to improve gait in

individuals with Parkinson’s disease. Given the

challenge that this clinical population may have with

initiating motor movements during gait (i.e. freezing

gait).37 The freezing phenomena are difficult to treat.

Pharmacological treatment is usually disappointing.

Rehabilitation in particular the efficacy of auditory

and visual cues, is a new rehabilitation strategy

based on treadmill training associated with auditory

and visual cues. Giuseppe Frazzitta, MD, Roberto

Maestri, MD et al. in their study investigated the

effectiveness of a cueing with treadmill. One group

of patient get treated with treadmill and other get

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conventional treatment.15

Cueing strategies are thought to reroute the

movement through a nonautomatic pathway,

removing it from the automatic basal ganglia

pathway.9 Leland E. Dibble found that visual and

auditory cueing technique in functional and

movement time task separately and results suggest

that both technique get improve but visual cueing

effects are not limited to gait tasks and auditory

cuing results that cadence and stride length has been

shown to consistently increase when auditory cues

are present relative to when cues are not

present.1,7,13,23,36,37,38

Sensory cue enhanced gait training in mild to

moderate PD patients. Treadmill with music has

been proved to give additional benefits for

improving gait related parameters.6

METHODOLOGY

Subjects were selected through convenient

sampling. After having the informed consent of 8

subjects and fulfillment of inclusion criteria

systematic randomization was done and the subject

were assigned to the particular group according to

their sequence of approach i.e. 1st, 3ed, 5th, 7th in

group A and 2ed, 4th, 6th, 8th in group B . Protocol -

All subjects underwent 20 minutes of each session

including rest time (2 min), rest time to decrease the

effect of fatigue, 1 session (Monday to Saturday) in

a day for 2 weeks for 11 day , one day rest between

the two subsequent weeks.

DESIGN AND PROCEDURE

They were then randomly directed into 2 groups

at baseline, all subject were assessed for gait (10

MWT), balance (BBS), and function (NQS).

Appropriate and precaution taken to avoid any fall.

For subject both the groups were assessed in both

“ON” and “OFF” drug phase. Group A (is “ON”

drug patient) subject received training in “ON” drug

phase. Group B (is “OFF” drug patient) subject

received training in “OFF” drug phase. Each

participant received cueing training in the supervised

situation with the help of a prototype cueing device.

This cueing device provided 2 rhythmical cueing

modalities: (a) an auditory modality (a beep), (b) a

visual feedback Cueing training was delivered in the

home setting. Participants were instructed to listen to

the cueing when they are performing tasks. They

were encouraged to listen to the rhythmical cue and

to try to match their heel strike with the beat of the

beep sound on the device and try to match heel strike

with visual cue make on ground. The results were

analyzed for within group and between the groups

comparison.


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RESULTS AND DISCUSSION

Both of the groups showed clinically significant

improvement in both on and off drug phases. Both

phases have shown improvement in gait and balance

parameters specially step length, speed, sit to stand,

turning, time taken.

Graph of mean difference between Group A and

Group B.

Clinically and subjectively significant

improvement in both “ON” and “OFF” drug phases,

both phases have shown improvement in gait and

balance parameters specially time taken for 10

meter, sitt to stand timing and speed.

Graph of mean difference between Group A and

Group B significant variable.

WITHIN THE GROUP

Within the groups subject improved

significantly in all the parameters namely gait,

balance and function. Both of the groups showed

clinically significant improvement in both on and off

drug phases. Both phases have shown improvement

in gait and balance parameters specially step length,

speed, sit to stand, turning, time taken.

ON Drug Phase

Group A patient initially did not have any

difficulty to start the training as compared to Group

B. The on phase of the disease in group A was

improved i.e. these patients showed an increased

step length, increased step per minute, reduced

timing of sit to stand, during their on drug period.

Also they had positive effects of cueing on gait and

gait related mobility. These patients had shown an

improvement in their balance because of the

challenges they faced during the gait training.

Subjectively also these patients reported that after

intervention they were able to walk much more

independently and safely and their day to day

activities were much easier now. Some of the

subjects in this group who complained of giddiness

during initial assessment and training were now

much better and their giddiness disappeared after the

intervention. Also they had better endurance and

their breathing abilities were improved; as reported

by these subjects. These changes were evident in

both “ON” drug and “OFF” drug periods of these

subjects.

OFF Drug Phase

Group B patients initially had many difficulties

in starting and performing the training sessions. As


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training for these subjects was given in “OFF” drug

phase, without the effect of medication they had

difficulty in concentrating visual and auditory cueing

simultaneously. Patient use to get puzzled between

visual and auditory cues but after 2 days of training

they learnt how to synchronies the visual and

auditory cue to use them simultaneously. They had

improved gait parameter like sit to stand, speed, time

taken for 10 meter, step length after intervention.

Neurophysiologically these improvements in

both the groups can be attributed to the fact that

sensory cueing training strengthens the neurons in

cerebral cortex bypassing the damaged basal ganglia

thereby cortex is independent of the damaged basal

ganglia signals for performing the movements and

functions.14

Several authors have suggested that predictive

external sensory cues, such as auditory rhythm, can

provide the necessary trigger in Parkinson's disease

to switch from one movement component in a

movement sequence to the next and thus bypass

defective internal pallidocortical projections, 25, 26

possibly via the lateral premotor cortex which

receives sensory information in the context of

externally guided movements.27, 32

However, the neurophysiologic basis for

auditory-motor interactions is not well understood.

There is some evidence that rhythmic sound patterns

can increase the excitability of spinal motor neurons

via the reticulospinal pathway, thereby reducing the

amount of time required for the muscles to respond

to a given motor command.32

Recent work with animal models of PD indicate

that rehabilitative training can stimulate a number of

plasticity-related events in the brain, including

neurotrophic factor expression and

synaptogenesis7,36,37,38,13,9

Cueing technique acts like a pacemaker and

provides an external rhythm that is able to stabilize

the defective internal rhythm of the basal ganglia.

Increased activation of the lateral premotor cortex in

PD patients during cueing lends support to this view

(Hanakawa et al., 1999b).14

BETWEEN THE GROUPS

Subjectively also group B patient reported

better improvement compare with group A.

Subjectively, after intervention these subjects (group

B) reported, that now if some time they have a delay

in taking medicine timely or skip the drug dosage,

still their symptoms did not worsen; infect they were

better now compared to pre-intervention time. Also

the fear of fall became less after the treatment,

confidence level was increased.

Because of training was given to them in the

same phase (OFF drug). This “context specific

training” helped them for better learning and hence

more benefits. Carr and Sepherd.27 in their works

have emphasized the importance of “context specific

training” in rehabilitation.

Plasticity is a general term describes the ability

to show modification. Plasticity, or neural

modifiability, may be seen as a continuum from

short-term changes in the efficiency or strength of

synaptic connection to long term structural changes

in the organization and number of connections

among neurons.4, 33

Learning also can be seen as a continuum of

short term to long term changes in the ability to

produce skilled action. The gradual shift from short

term to long term learning reflects a move along the

continuum of neural modifiability, as increased


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synaptic efficiency gradually gives way to structural

changes, which are the underpinning of long term

modification of behavior.5

CONCLUSION

Sensory cueing using visual and auditory cues

is beneficial for Parkinson’s disease. It improves

their gait, balance and functional activity.

Subjectively and objectively group B (subjects for

whom training was given in off drug phase) showed

significantly better results. We suggest that training

given in “OFF” drug phase to Parkinson’s patients

will improve their balance, gait and function in

much more beneficial way and may reduce or alter

their dependency on drugs; thereby providing them a

complete rehabilitation. So rehabilitation given in

“OFF” drug phase may help to decrease or alter the

drug usage by these patients and to provide an

overall rehabilitation program to this population give

the treatment in “OFF” drug phase because patient

have more difficulty in “OFF” drug phase and

context specific training, tasks specific training give

better results.

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CORRESPONDING AUTHOR:

* Department of Physiotherapy, Dolphin (P.G.) institute of bio medical and natural sciences, Dhradun , H.N.B.

Garhwal University, Srinagar, Uttarakhand, India. Email: [email protected]

** Department of Physiotherapy, Dolphin (P.G.) institute of bio medical and natural sciences, Dhradun , H.N.B.

Garhwal University, Srinagar, Uttarakhand, India.

Documents

Sinha Siddharth, Bhatt Sunil. Effect of Sensory Cueing on Gait and Balance During Both "On" and "Off" Drug Phase of Parkinson's Disease, SRJI Vol- 2, Issue- 1, Year- 2013