Consensus Paper: Ataxic Gait.

The aim of this consensus paper is to discuss the roles of the cerebellum in human gait, as well as its assessment and therapy. Cerebellar vermis is critical for postural control. The cerebellum ensures the mapping of sensory information into temporally relevant motor commands. Mental imagery of gait involves intrinsically connected fronto-parietal networks comprising the cerebellum. Muscular activities in cerebellar patients show impaired timing of discharges, affecting the patterning of the synergies subserving locomotion. Ataxia of stance/gait is amongst the first cerebellar deficits in cerebellar disorders such as degenerative ataxias and is a disabling symptom with a high risk of falls. Prolonged discharges and increased muscle coactivation may be related to compensatory mechanisms and enhanced body sway, respectively. Essential tremor is frequently associated with mild gait ataxia. There is growing evidence for an important role of the cerebellar cortex in the pathogenesis of essential tremor. In multiple sclerosis, balance and gait are affected due to cerebellar and spinal cord involvement, as a result of disseminated demyelination and neurodegeneration impairing proprioception. In orthostatic tremor, patients often show mild-to-moderate limb and gait ataxia. The tremor generator is likely located in the posterior fossa. Tandem gait is impaired in the early stages of cerebellar disorders and may be particularly useful in the evaluation of pre-ataxic stages of progressive ataxias. Impaired inter-joint coordination and enhanced variability of gait temporal and kinetic parameters can be grasped by wearable devices such as accelerometers. Kinect is a promising low cost technology to obtain reliable measurements and remote assessments of gait. Deep learning methods are being developed in order to help clinicians in the diagnosis and decision-making process. Locomotor adaptation is impaired in cerebellar patients. Coordinative training aims to improve the coordinative strategy and foot placements across strides, cerebellar patients benefiting from intense rehabilitation therapies. Robotic training is a promising approach to complement conventional rehabilitation and neuromodulation of the cerebellum. Wearable dynamic orthoses represent a potential aid to assist gait. The panel of experts agree that the understanding of the cerebellar contribution to gait control will lead to a better management of cerebellar ataxias in general and will likely contribute to use gait parameters as robust biomarkers of future clinical trials.

Classifying Idiopathic Rapid Eye Movement Sleep Behavior Disorder, Controls, and Mild Parkinson's Disease Using Gait Parameters.

BACKGROUND: Subtle gait changes associated with idiopathic rapid eye movement sleep behavior disorder (iRBD) could allow early detection of subjects with future synucleinopathies. OBJECTIVE: The aim of this study was to create a multiclass model, using statistical learning from probability distribution of gait parameters, to distinguish between patients with iRBD, healthy control subjects (HCs), and patients with Parkinson's disease (PD). METHODS: Gait parameters were collected in 21 participants with iRBD, 21 with PD, and 21 HCs, matched for age, sex, and education level. Lasso sparse linear regression explored gait features able to classify the three groups. RESULTS: The final model classified iRBD from HCs and from patients with PD equally well, with 95% accuracy, 100% sensitivity, and 90% specificity. CONCLUSIONS: Gait parameters and a pretrained statistical model can robustly distinguish participants with iRBD from HCs and patients with PD. This could be used to screen subjects with future synucleinopathies in the general population and to identify a conversion threshold to PD. © 2022 International Parkinson and Movement Disorder Society.

BeatWalk: Personalized Music-Based Gait Rehabilitation in Parkinson's Disease.

Taking regular walks when living with Parkinson's disease (PD) has beneficial effects on movement and quality of life. Yet, patients usually show reduced physical activity compared to healthy older adults. Using auditory stimulation such as music can facilitate walking but patients vary significantly in their response. An individualized approach adapting musical tempo to patients' gait cadence, and capitalizing on these individual differences, is likely to provide a rewarding experience, increasing motivation for walk-in PD. We aim to evaluate the observance, safety, tolerance, usability, and enjoyment of a new smartphone application. It was coupled with wearable sensors (BeatWalk) and delivered individualized musical stimulation for gait auto-rehabilitation at home. Forty-five patients with PD underwent a 1-month, outdoor, uncontrolled gait rehabilitation program, using the BeatWalk application (30 min/day, 5 days/week). The music tempo was being aligned in real-time to patients' gait cadence in a way that could foster an increase up to +10% of their spontaneous cadence. Open-label evaluation was based on BeatWalk use measures, questionnaires, and a six-minute walk test. Patients used the application 78.8% (±28.2) of the prescribed duration and enjoyed it throughout the program. The application was considered "easy to use" by 75% of the patients. Pain, fatigue, and falls did not increase. Fear of falling decreased and quality of life improved. After the program, patients improved their gait parameters in the six-minute walk test without musical stimulation. BeatWalk is an easy to use, safe, and enjoyable musical application for individualized gait rehabilitation in PD. It increases "walk for exercise" duration thanks to high observance. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02647242.

Rhythm disturbances as a potential early marker of Parkinson's disease in idiopathic REM sleep behavior disorder.

OBJECTIVE: We aimed to identify timing distortions in production and perception of rhythmic events in patients with idiopathic REM sleep behavior disorder (iRBD) as early markers of Parkinson's disease (PD). METHODS: Rhythmic skills, clinical characteristics, dysautonomia, depression, and olfaction were compared in 97 participants, including 21 participants with iRBD, 38 patients with PD, and 38 controls, matched for age, gender, and education level. Rhythmic disturbances can be easily detected with dedicated motor tasks via a tablet application. Rhythm production was tested in two conditions: to examine the ability to generate a spontaneous endogenous rhythm, tapping rate and variability in a finger tapping task without external stimulation was measured, while the ability to synchronize to an external rhythm was tested with finger tapping to external auditory cues. Rhythm perception was measured with a task, in which the participants had to detect a deviation from a regular rhythm. Participants with iRBD had dopamine transporter imaging. RESULTS: Participants with iRBD and PD revealed impaired spontaneous rhythm production and poor rhythm perception compared to controls. Impaired rhythm production was correlated with olfaction deficits, dysautonomia, impaired non-motor aspects of daily living, and dopamine uptake measures. CONCLUSIONS: Participants with iRBD show impaired rhythm production and perception; this impairment is correlated with other early markers for PD. Testing rhythmic skills with short and inexpensive tests may be promising for screening for potential future PD in iRBD patients.

Why do we move to the beat? A multi-scale approach, from physical principles to brain dynamics.

Humans' ability to synchronize movement with auditory rhythms relies on motor networks, such as cortical areas, basal ganglia and the cerebellum, which also participate in rhythm perception and movement production. Current research has provided insights into the dependence of this action-perception coupling upon the entrainment of neuronal activity by external rhythms. At a physical level, advances on wearable robotics have enriched our understanding of the dynamical properties of the locomotor system showing evidence of mechanical entrainment. Here we defend the view that modelling brain and locomotor oscillatory activities as dynamical systems, at both neural and physical levels, provides a unified theoretical framework for the understanding of externally driven rhythmic entrainment of biological systems. To better understand the underlying mechanisms of this multi-level entrainment during locomotion, we review in a common framework the core questions related to the dynamic properties of biological oscillators and the neural bases of auditory-motor synchronization. Illustrations of our approach, using personalized auditory stimulation, to gait rehabilitation in Parkinson disease and to manipulation of runners' kinematics are presented.

The influence of tennis court surfaces on player perceptions and biomechanical response.

This study aimed to examine player perceptions and biomechanical responses to tennis surfaces and to evaluate the influence of prior clay court experience. Two groups with different clay experiences (experience group, n = 5 and low-experience group, n = 5) performed a 180° turning movement. Three-dimensional ankle and knee movements (50 Hz), plantar pressure of the turning step (100 Hz) and perception data (visual analogue scale questionnaire) were collected for two tennis courts (acrylic and clay). Greater initial knee flexion (acrylic 20. 8 ± 11.2° and clay 32.5 ± 9.4°) and a more upright position were reported on the clay compared to the acrylic court (P < 0.05). This suggests adaptations to increase player stability on clay. Greater hallux pressures and lower midfoot pressures were observed on the clay court, allowing for sliding whilst providing grip at the forefoot. Players with prior clay court experience exhibited later peak knee flexion compared to those with low experience. All participants perceived the differences in surface properties between courts and thus responded appropriately to these differences. The level of previous clay court experience did not influence players' perceptions of the surfaces; however, those with greater clay court experience may reduce injury risk as a result of reduced loading through later peak knee flexion.

The effects of surface traction characteristics on frictional demand and kinematics in tennis.

The interaction between footwear and surfaces influences the forces experienced by tennis players. The purpose of this study was to investigate traction demand and kinematic adaptation during tennis-specific movements with changes in traction characteristics of surfaces. We hypothesised that players would increase the utilised coefficient of friction (horizontal to vertical ground reaction force ratio) when the shoe surface combination had a high coefficient of friction and flex their knee after contact to facilitate braking. Eight participants performed two separate movements, side jump out of stance and running forehand. Ground reaction force was measured and three-dimensional kinematic data were recorded. Clay surface and cushioned acrylic hard court (low vs. high shoe-surface friction) were used. The peak utilised coefficient of friction was greater on clay than the hard court. The knee was less flexed at impact on clay (-5.6 +/- 10.2 degrees) and at peak flexion (-13.1 +/- 12.0 degrees) during the running forehand. Our results indicate that tennis players adapt the level ofutilised friction according to the characteristics of the surface, and this adaptation favours sliding on the low friction surface. Less knee flexion facilitates sliding on clay, whereas greater knee flexion contributes to braking on the hard court.

Skills of novices early trained or traditionaly trained versus experienced drivers confronted to simulated urban accidents' scenarios.

In order to prevent the over-representation of young drivers in car crashes, France instated an early driver training from the age of 16, but the positive effects of this opportunity have not yet been proven. Three groups of male drivers (12 subjects each) were confronted with some prototypical accident scenarios introduced in a simulated urban circuit. The first and second groups were composed of young drivers having less than one month of driving licence; twelve have had a traditional learning course, and twelve had followed, in addition to the initial course, an early driver training under the supervision of an adult. The third group was composed of experienced drivers. Strategies of the three groups were analyzed through their response time, speed and maneuvers. No difference appeared across groups regarding obstacle detection. But traditionally-trained drivers' position control was more conservative than the two others groups, which were more likely to involve efficient evasive action. The exposure gained during early training could thus increase the development of visuo-motor coordination and involve better skills in case of difficult situations. Others accidents' scenarios could be used to confront young drivers with difficult situations not commonly encountered in natural driving.

The evaluation of traditional and early driver training with simulated accident scenarios.

OBJECTIVE: We assessed the driving skills of novice traditionally trained, novice early-trained, and experienced drivers to evaluate whether supervised early training could improve young drivers' skills. BACKGROUND: The overall representation of young male drivers in car crashes is a recurrent problem in developed countries.To prevent this overrepresentation, France institutes an early driver training program from the age of 16 with the supervision of an adult. However, evidence of the positive effects of this system is still lacking. METHOD: Three groups of drivers (12 participants each) were confronted with five prototypical accident scenarios introduced in a simulated urban circuit. Drivers' response time, speed, and vehicle position in the lane were analyzed. RESULTS: No difference was detected across groups regarding obstacle detection, as revealed by the analysis of response times. But in some unexpected scenarios, position control by traditionally trained drivers was more conservative than for more experienced drivers, and early-trained drivers were far more likely to respond with efficient evasive action. CONCLUSION: The exposure gained by an early training program could thus increase the development of visuomotor coordination and involve better skills in challenging situations. APPLICATION: The supplementary driving experience gained with the supervision of an adult during early training could promote the skills necessary to deal with risky situations. Driving simulators could be used to confront young drivers with a broad range of hazardous scenarios not commonly encountered in natural driving.

Physiological basis of limb-impedance modulation during free and constrained movements.

Arm stiffness is a critical factor underlying stable interactions with the environment. When the hand moves freely through space, a stiff limb would most effectively maintain the hand on the desired path in the face of external perturbations. Conversely, when constrained by a rigid surface, a compliant limb would allow the surface to guide the hand while minimizing variations in contact forces. We aimed to identify the physiological basis of stiffness adaptation for these two classes of movement. Stiffness can be regulated by two mechanisms: coactivation of antagonistic muscles and modulation of reflex gains. We hypothesized that subjects would select high stiffness (high coactivation and/or reflex gains) in free space and high compliance (low coactivation and reflex gains) for constrained movements. We measured EMG and the H-reflex during constrained and unconstrained movement of the wrist. As predicted, subjects coactivated antagonist muscles more when performing the unconstrained movement. Contrary to our hypothesis, however, H-reflex amplitude was higher for the constrained movement despite the a priori preference for lower reflex gains in this situation. In addition, the H-reflex depended on the task and the net force exerted by the limb on the environment, rather than showing a simple dependence on the level of muscle activation. Thus stiffness seems to increase in free space compared with constrained motion through the use of coactivation, whereas spinal loop gains are adjusted to better regulate the influence of afferences on the ongoing movement. These observations support the hypothesis of movement programming in terms of impedance.