Objectives: Gait and mobility problems are difficult to treat in people with Parkinson's disease. The Rehabilitation in Parkinson's Disease: Strategies for Cueing (RESCUE) trial investigated the effects of a home physiotherapy programme based on rhythmical cueing on gait and gait-related activity. Methods: A single-blind randomised crossover trial was set up, including 153 patients with Parkinson's disease aged between 41 and 80 years and in Hoehn and Yahr stage II-IV. Subjects allocated to early intervention (n = 76) received a 3-week home cueing programme using a prototype cueing device, followed by 3 weeks without training. Patients allocated to late intervention (n = 77) underwent the same intervention and control period in reverse order. After the initial 6 weeks, both groups had a 6-week follow-up without training. Posture and gait scores (PG scores) measured at 3, 6 and 12 weeks by blinded testers were the primary outcome measure. Secondary outcomes included specific measures on gait, freezing and balance, functional activities, quality of life and carer strain. Results: Small but significant improvements were found after intervention of 4.2% on the PG scores (p = 0.005). Severity of freezing was reduced by 5.5% in freezers only (p = 0.007). Gait speed (p = 0.005), step length (p,0.001) and timed balance tests (p = 0.003) improved in the full cohort. Other than a greater confidence to carry out functional activities (Falls Efficacy Scale, p = 0.04), no carry-over effects were observed in functional and quality of life domains. Effects of intervention had reduced considerably at 6-week follow-up. Conclusions: Cueing training in the home has specific effects on gait, freezing and balance. The decline in effectiveness of intervention effects underscores the need for permanent cueing devices and follow-up treatment. Cueing training may be a useful therapeutic adjunct to the overall management of gait disturbance in Parkinson's disease.

Objective: To compare gait parameters in Parkinson's disease (PD) during the on-phase of medication cycle with those of healthy elderly control subjects.Design: A group-comparison study. Setting: Gait analysis laboratory of a university hospital. Participants: Fifteen patients with PD and 9 healthy elderly controls.Interventions: Not applicable. Main Outcome Measures: Spatiotemporal, kinematic, and kinetic gait parameters.Results: The PD spatiotemporal results showed a significant reduction in step length and walking velocity compared with controls. In the kinematics, the major feature of the PD group was a markedly reduced ankle plantarflexion excursion (at 50%-60% of the gait cycle). Most important, the kinetics showed reduced ankle push-off power and hip pull-off power. Unlike the control subjects, the patients with PD did not show any correlation between ankle generation (push-off) power and stride length (rϭ.19) or with gait speed (rϭ.29). Correction for walking velocity did not result in significant changes in the kinetics between the groups.Conclusions: Reduced ankle (push-off) power generation and reduced hip flexion (pull-off) power persisted in PD gait despite being tested in the on-phase of the medication cycle. Lack of a correlation between ankle and hip power generation and walking velocity suggests that peripheral and central factors contribute to lack of forward progression. Patients with PD may benefit from intervention strategies that correct the kinematic and the kinetic gait components.

This study points to fact that physiotherapists might need to carefully adjust the cueing frequency to the needs of patients with and without freezing. On the basis of the present results we recommend to lower the frequency setting for freezers, whereas for non-freezers an increase of up to +10% may have potential therapeutic use.

Summary Changes in gait performance in 153 subjects with PD using three rhythmical cues (auditory, visual and somatosensory) were measured during a simple walking task and a dual walking task in the home. Subjects were 'on' medication and were cued at preferred step frequency. Accelerometers recorded gait and walking speed, step amplitude and step frequency were determined from raw data. Data were analysed with SAS using linear regression models. Gait performance during a single task reduced with cues in contrast to a dual task where PD subjects appeared to benefit from rhythmical cues (increased speed and step length). Effects were dependent on cue modality with significant improvements for auditory cues compared to others. A significant short-term carry-over effect of cues reduced 3 weeks later. Cues may reduce attentional demands by facilitating attentional allocation, accounting for differences of cue seen during single and dual task. Furthermore cue modality may influence attentional demand which is an important consideration for rehabilitation.

Turning is an impaired activity in persons with Parkinson's disease (PwPD). The current study examines the turning characteristics in PwPD (9 freezers and 10 nonfreezers) and 9 controls, and explores the effect of rhythmic auditory cues while turning. Turning parameters were collected from a 180 degrees left U-turn during a noncued and a cued condition, using a 3D measuring system. Auditory cues were supplied with a metronome at a rhythm equaling the subject's comfortable step frequency during straight line walking. Results showed that in contrast to controls, PwPD used a wider turning-arc and took smaller, narrower steps. In addition, they demonstrated a higher Coefficient of Variation (CV) of step duration (6.92%) compared to controls (4.88%, P < 0.05). The "wide-arc" turning strategy of PwPD was more prominent in freezers than in nonfreezers. Auditory cues reduced the CV of step duration in PwPD (both freezers and nonfreezers) during turning (from 6.92 to 6.00%, P < 0.05). In summary: Cueing reduced the gait-timing variability during turning, but PwPD maintained a wider arc to turn compared with controls.

The aim of this study was to analyse the kinematic characteristics of the strides before freezing and compare this with a voluntary stop and ongoing gait. Also, we investigated whether gait profiles were different as a function of the side of the body. Ten patients were included with a mean age of 64.8 years (SD 5.1). Within a Vicon 3D gait laboratory, patients performed several trials of normal walking and voluntary stops or were exposed to circumstances, which provoked freezing in the off-phase of the medication cycle. Spatiotemporal and key kinematic data of the four strides prior to freezing were compared between body sides and walking conditions using multiple regression models for repeated measures. Prior to freezing patients had severely decreased movement ranges in the sagittal plane (ranging between 31% and 61.5%), most notably in the ankle and hip joints. The general shape of movement remained in the pre-freezing profiles with largely intact dissociation of knee and hip movement in stance but reduced dissociation in swing. Also present were reduced push-off movements in the ankle with fixed dorsiflexion, increased flexion in hip and knee and anterior tilt of the pelvis. During both voluntary (stopping) and involuntary deceleration (freezing), the body side with the last complete stride before the freeze, showed significantly smaller joint ranges (p < .01). Body side differences were larger than sequential deterioration of consecutive steps within each side. Freezing is distinct from normal deceleration of gait in that the reduction of propulsive movement is much greater. Despite hastening of steps, timing deficits did not affect overall movement shapes, except for the tendency to have a flexed walking pattern. The side of the body where gait terminated before freezing was in most cases the side of symptom-dominance, but not consistently so.

Cueing training in de thuissituatie verbetert de mobiliteit van mensen met de ziekte van Parkinson erwin van wegen, inge lim, alice nieuwboer, anne-marie willems, fabienne chavret, diana jones, lynn rochester, vicky hetherington, katherine baker en gert kwakkel De ziekte van Parkinson is een progressieve neurologische aandoening als gevolg van degeneratie van dopaminerge cellen van de substantie nigra in de basale kernen. De ziekte wordt onder andere gekenmerkt door symptomen zoals tremoren, rigiditeit, hypo-en bradykinesie, en posturale instabiliteit. Deze bewegingsstoornissen leiden tot problemen met activiteiten als lopen, het maken van transfers (d.w.z. veranderingen van lichaamspositie, bijvoorbeeld van zitten naar staan) en handhaven van het evenwicht tijdens het staan en het lopen (Marsden 1989;Morris et al. 2001;Rogers 1996). De prevalentie neemt toe met de leeftijd: in Europa wordt geschat dat in de leeftijdscategorie tot 65 jaar 1,8 op de 100 inwoners wordt gediagnosticeerd met de ziekte van Parkinson. In de categorie 65-69 jaar is dat 2,4 op de 100 inwoners en 2,6 op de 100 voor de categorie 85-89 jaar (De Rijk et al. 2000). 92 neuropraxis 3 | 2008 -www.neuropraxis.bsl.nl