Visual Cues for Turning in Parkinson’s Disease

Abstract

Turning is a common impairment of mobility in people with Parkinson’s disease (PD), which increases freezing of gait (FoG) episodes and has implications for falls risk. Visual cues have been shown to improve general gait characteristics in PD. However, the effects of visual cues on turning deficits in PD remains unclear. We aimed to (i) compare the response of turning performance while walking (180° and 360° turns) to visual cues in people with PD with and without FoG; and (ii) examine the relationship between FoG severity and response to visual cues during turning. This exploratory interventional study measured turning while walking in 43 participants with PD (22 with self-reported FoG) and 20 controls using an inertial sensor placed at the fifth lumbar vertebrae region. Participants walked straight and performed 180° and 360° turns midway through a 10 m walk, which was done with and without visual cues (starred pattern). The turn duration and velocity response to visual cues were assessed using linear mixed effects models. People with FoG turned slower and longer than people with PD without FoG and controls (group effect: p < 0.001). Visual cues reduced the velocity of turning 180° across all groups and reduced the velocity of turning 360° in people with PD without FoG and controls. FoG severity was not significantly associated with response to visual cues during turning. Findings suggest that visual cueing can modify turning during walking in PD, with response influenced by FoG status and turn amplitude. Slower turning in response to visual cueing may indicate a more cautious and/or attention-driven turning pattern. This study contributes to our understanding of the influence that cues can have on turning performance in PD, particularly in freezers, and will aid in their therapeutic application.

Visual Exploration While Walking With and Without Visual Cues in Parkinson’s Disease: Freezer Versus Non-Freezer

“…This is an important finding as it shows that underlying visuo-cognitive mechanisms may be different in Parkinson’s compared to controls and within freezer versus non-freezer sub-groups. 48,54…”

“…Visuo-cognitive processes, particularly attentional processing, has been implicated in visual cue response in PwPD in our previous research. 23,25,26,28,48 To examine the influence of attention, the present study used attentional distraction through dual tasking, which was found to have no significant effect on any of the eye movement outcomes when walking with visual cues compared to single-task conditions, which is similar to findings by Stuart et al 25 Visual cues may reduce the visuo-cognitive processing of the environment that is required when walking in PwPD which allows specific focus on task relevant areas of interest (lines on the floor) and frees attentional resources to be applied to concurrent tasks (ie, the dual-task). 49…”

“…This is an important finding as it shows that underlying visuo-cognitive mechanisms may be different in Parkinson's compared to controls and within freezer versus non-freezer sub-groups. 48,54 Limitations There are several limitations to highlight. First, this study only examined immediate effect of visual cues on visual exploration and gait outcomes, rather than continuous homebased cue use as performed in clinical practice.…”

One cue does not fit all: A systematic review with meta-analysis of the effectiveness of cueing on freezing of gait in Parkinson’s disease

“…Below, data are reported as mean ± SD. Seven trials (Mancini et al, 2018;Spildooren et al, 2017;Spildooren et al, 2012;Nieuwboer et al, 2009;Tang et al, 2017;Willems et al, 2007;Das et al, 2022) assessed cueing effectiveness on FOG exclusively during turning tasks. Plus, five studies (Arias and Cudeiro, 2010;Bryant et al, 2010;Gál et al, 2019;Holmes et al, 2015;Sijobert et al, 2017), already included in the previous section, reported also data on turning performance.…”

“…Men:women ratio was about 2:1 (122:71), and sample sizes ranged from 6 to 68. Seven studies (Arias and Cudeiro, 2010;Bryant et al, 2010;Gál et al, 2019;Holmes et al, 2015;Nieuwboer et al, 2009;Willems et al, 2007;Das et al, 2022) assessed FOG severity using FOGQ (score: 14.5 ± 4.7). Disease duration was 10.2 ± 5.9 years, and H&Y scale ranged from II to IV.…”