Adjustability of gait speed in clinics and free-living environments in people with Parkinson's disease.

Objective: Gait speed is regulated by varying gait parameters depending on the diverse contexts of the environment. People with Parkinson's disease (PwPD) have difficulty in adapting to gait control in their environment; however, the relationship between gait speed and spatiotemporal parameters in free-living environments has not been clarified. This study aimed to compare gait parameters according to gait speed in clinics and free-living environments. Methods: PwPD were assessed at the clinic and in a free-living environment using an accelerometer on the lower back. By fitting a bimodal Gaussian model to the gait speed distribution, gait speed was divided into lower and higher speeds. We compared the spatiotemporal gait parameters using a 22 (environment [clinic/free-living]  speed [lower/higher]) repeated-measures analysis of variance. Associations between Parkinson's disease symptoms and gait parameters were evaluated using Bayesian Pearson's correlation coefficients. Results: In the 41 PwPD included in this study, spatiotemporal gait parameters were significantly worse in free-living environments than in clinics and at lower speeds than at higher speeds. The fit of the walking speed distribution to the bimodal Gaussian model (adjustability of gait speed) in free-living environments was related to spatiotemporal gait parameters, severity of Parkinson's disease, number of falls, and quality of life. Conclusions: The findings suggest that gait control, which involves adjusting gait speed according to context, differs between clinics and free-living environments in PwPD. Gait assessment for PwPD in both clinical and free-living environments should interpret gait impairments in a complementary manner.

Modeling the Heterogeneity of Post-Stroke Gait Control in Free-Living Environments Using a Personalized Causal Network.

Post-stroke gait control is a complex, often fail to account for the heterogeneity and continuity of gait in existing gait models. Precisely evaluating gait speed adjustability and gait instability in free-living environments is important to understand how individuals with post-stroke gait dysfunction approach diverse environments and contexts. This study aimed to explore individual causal interactions in the free-living gait control of persons with stroke. To this end, fifty persons with stroke wore an accelerometer on the fifth lumbar vertebra (L5) for 24 h in a free-living environment. Individually directed acyclic graphs (DAGs) were generated based on the spatiotemporal gait parameters at contemporaneous and temporal points calculated from the acceleration data. Spectral clustering and Bayesian model comparison were used to characterize the DAGs. Finally, the DAG patterns were interpreted via Bayesian logistic analysis. Spectral clustering identified three optimal clusters from the DAGs. Cluster 1 included persons with moderate stroke who showed high gait asymmetry and gait instability and primarily adjusted gait speed based on cadence. Cluster 2 included individuals with mild stroke who primarily adjusted their gait speed based on step length. Cluster 3 comprised individuals with mild stroke who primarily adjusted their gait speed based on both step length and cadence. These three clusters could be accurately classified based on four variables: Ashman's D for step velocity, Fugl-Meyer Assessment, step time asymmetry, and step length. The diverse DAG patterns of gait control identified suggest the heterogeneity of gait patterns and the functional diversity of persons with stroke. Understanding the theoretical interactions between gait functions will provide a foundation for highly tailored rehabilitation.

A comprehensive multivariate analysis of the center of pressure during quiet standing in patients with Parkinson's disease.

BACKGROUND: We hypothesized that postural instability observed in individuals with Parkinson's disease (PD) can be classified as distinct subtypes based on comprehensive analyses of various evaluated parameters obtained from time-series of center of pressure (CoP) data during quiet standing. The aim of this study was to characterize the postural control patterns in PD patients by performing an exploratory factor analysis and subsequent cluster analysis using CoP time-series data during quiet standing. METHODS: 127 PD patients, 47 aged 65 years or older healthy older adults, and 71 healthy young adults participated in this study. Subjects maintain quiet standing for 30 s on a force platform and 23 variables were calculated from the measured CoP time-series data. Exploratory factor analysis and cluster analysis with a Gaussian mixture model using factors were performed on each variable to classify subgroups based on differences in characteristics of postural instability in PD. RESULTS: The factor analysis identified five factors (magnitude of sway, medio-lateral frequency, anterio-posterior frequency, component of high frequency, and closed-loop control). Based on the five extracted factors, six distinct subtypes were identified, which can be considered as subtypes of distinct manifestations of postural disorders in PD patients. Factor loading scores for the clinical classifications (younger, older, and PD severity) overlapped, but the cluster classification scores were clearly separated. CONCLUSIONS: The cluster categorization clearly identifies symptom-dependent differences in the characteristics of the CoP, suggesting that the detected clusters can be regarded as subtypes of distinct manifestations of postural disorders in patients with PD.

Unveiling the Impact of Outpatient Physiotherapy on Specific Motor Symptoms in Parkinson's Disease: A Prospective Cohort Study.

Understanding how outpatient physiotherapy impacts on specific motor symptoms in Parkinson's disease (PD) is important for multidisciplinary care, but these points have not been clarified. We investigated the impact of outpatient physiotherapy on individual motor symptoms in PD patients. Fifty-five PD patients participated in the prospective cohort study, which examined the changes in motor symptoms after 90 min of outpatient physiotherapy program (1×/week for 10 weeks) and at 3 months follow-up. Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor score and tremor, rigidity, bradykinesia, and axial scores were assessed and compared pre-intervention, post-intervention, and at follow-up. Significant level was set at 0.05. Their MDS-UPDRS motor score and axial score significantly decreased post-intervention and at the follow-up. In the analysis differentiating effects based on the severity of motor symptoms according to the MDS-UPDRS motor score, only the moderate-severe group showed significant decreases in their MDS-UPDRS motor score, bradykinesia, and axial scores post-intervention, as well as in their MDS-UPDRS motor score, rigidity, bradykinesia, and axial scores at the follow-up. These findings suggest the outpatient physiotherapy might provide benefits, particularly in managing axial symptoms and bradykinesia, for community dwelling PD patients with moderate-severe motor symptoms within a multidisciplinary care framework.

Effects of postural-control training with different sensory reweightings in a patient with body lateropulsion: a single-subject design study.

INTRODUCTION: Body lateropulsion (BL) is an active lateral tilt of the body during standing or walking that is thought to be affected by a lesion of the vestibulospinal tract (VST) and the subjective visual vertical (SVV) tilt. Interventions for BL have not been established. OBJECTIVE: We examined the effects of postural-control training with different sensory reweighting on standing postural control in a patient with BL. METHODS: The patient had BL to the left when standing or walking due to a left-side medullary and cerebellar infarct. This study was a single-subject A-B design with follow-up: Phase A was postural-control training with visual feedback; phase B provided reweighting plantar somatosensory information. Postural control, VST excitability, and SVV were measured. RESULTS: At baseline and phase A, the patient could not stand with eyes-closed on a rubber mat, but became able to stand in phase B. The mediolateral center of pressure (COP) position did not change significantly, but the COP velocity decreased significantly during phase B and the follow-up on the firm surface. VST excitability was lower on the BL versus the non-BL side, and the SVV deviated to the right throughout the study. CONCLUSION: Postural-control training with reweighting somatosensory information might improve postural control in a patient with BL.

A novel form of transcutaneous electrical nerve stimulation for the reduction of dysesthesias caused by spinal nerve dysfunction: A case series.

Background: Current therapeutic interventions for dysesthesias caused by spinal cord dysfunctions are ineffective. We propose a novel intervention using transcutaneous electrical nerve stimulation (TENS) for dysesthesias, and we present an in-depth case series. Patients and methods: Conventional high-frequency TENS and the novel dysesthesia-matched TENS (DM-TENS) were applied to 16 hands of nine patients with spinal cord dysfunction. The dysesthesia-matched TENS' stimulus intensity and frequency matched the intensity and somatosensory profile of the patients' dysesthesias. The Short-Form McGill Pain Questionnaire version-2 (SF-MPQ2) and quantitative sensory testing (QST) were applied during electrical stimulation/no stimulation. We determined intraclass correlation coefficients (ICCs) to evaluate the reliability of the setting and the effects on the dysesthesias and the change in subjective dysesthesia between each patient's baseline without TENS and DM-TENS. Results: We were able to apply electrical stimulation matching the patients' subjective dysesthesia for 14 hands (eight patients). TENS could not be applied for the remaining patient due to severe sensory deficits. Compared to the patients' baseline and high-frequency TENS, the DM-TENS provided significant decreases in tingling/pins-and-needles and numbness on the SF-MPQ2, and it significantly improved the dynamic and static mechanical detection on QST. Regarding the reliability of the dysesthesia-matched TENS settings, the ICCs (1,5) were intensity, 0.95; frequency, 1.00; and effect on dysesthesia, 0.98. Conclusion: DM-TENS improved the dysesthesias and mechanical hypoesthesia caused by spinal cord dysfunction. The effectiveness of DM-TENS particularly for tingling and numbness was clearly higher and was reliable within the patients. These results may suggest an effective treatment of dysesthesias in patients with spinal cord dysfunction. Clinical trial registration: [https://rctportal.niph.go.jp/s/detail/um?trial_id=UMIN000045332], identifier [UMIN000045332].

Interaction between spatial neglect and attention deficit in patients with right hemisphere damage.

Unilateral spatial neglect (USN) was originally regarded as a parietal syndrome, but it has become evident that USN is a disturbance in the widespread attention network. Here, we focused on an interaction between spatial neglect and non-spatial aspect of attention deficit, and aimed to establish a novel evaluation approach based on the characteristics of the spatial distribution of reaction times. We tested 174 patients with right hemisphere damage and divided them based on their prescreening scores on the Behavioral Inattention Test (BIT): (1) USN++ (n = 79: BIT<131), (2) USN+ (n = 47: BIT≥131 with history of USN), and (3) RHD (n = 48: without neglect symptom). The patients were asked to conduct a touch panel-based pointing task toward 2D-arranged (seven columns × five rows) circular targets on a PC monitor, and the reaction time to each object was recorded. To evaluate aspects of attention deficit and neglect symptoms, we calculated the total average of the reaction time for all objects (RTmean) and the ratios of the right and left space (L/Rratio), respectively. The results revealed that RTmean and L/Rratio can be regarded as independent evaluation parameters for attention deficit and neglect symptoms, respectively. Voxel-based lesion-symptom mapping based on RTmean and L/Rratio values revealed relevant lesions with attention-related brain areas (middle temporal gyrus, angular gyrus, and inferior frontal gyrus), and neglect-related brain areas (superior temporal gyrus and superior longitudinal fascicules). A cluster analysis with Gaussian mixture model detected six different states of USN with an interaction between neglect symptoms and attention deficit. Interestingly, the recovery process after USN can be properly explained by the transition pattern from one cluster to another. Our results suggest that a novel evaluation approach to distinguish between neglect symptoms and attention deficit, namely the characterization of the interaction between RTmean and L/Rratio, provides useful information for understanding pathological features of USN.

Reliability and laterality of the soleus H-reflex following galvanic vestibular stimulation in healthy individuals.

The vestibulospinal tract (VST) plays an important role in the control of the ipsilateral antigravity muscles, and the balance of left and right VST excitability is important in human postural control. A method for measuring VST excitability is the application of galvanic vestibular stimulation (GVS) before tibial nerve stimulation that evokes the soleus H-reflex; the change rate of the H-reflex amplitude is then evaluated. Assessments of VST excitability and the left and right balance could be useful when determining the pathology for interventions in postural control impairments. However, the reliability and laterality of this assessment have not been clarified, nor has its relationship to postural control. We investigated the reliability, laterality and standing postural control in relation to the degree of facilitation of the H-reflex following GVS in 15 healthy adults. The assessments were performed in two sessions, one each for the left- and right-sides, in random order. The inter-session reliability of the short-interval assessments of an increase in the H-reflex following GVS on both sides were sufficient. The degree of H-reflex facilitation by GVS showed no significant difference between the left- and right-sides in any session. There was a moderate positive correlation between the mediolateral position of the center of pressure in the eyes-closed standing on foam condition and the left/right ratio of the degree of increased H-reflex in the first-session. We concluded that this method for evaluating the increase in the soleus H-reflex following GVS has high inter-session reliability in the short-interval that did not differ between sides.

Role of somatosensory and/or vestibular sensory information in subjective postural vertical in healthy adults.

The body's subjective postural vertical (SPV) has been thought to be affected by somatosensory information. How the SPV is perceived based on what types of somatosensory information has not been determined experimentally by manipulating somatosensory conditions. We investigated the effects of disturbing the somatosensory information from a seat pad and/or vestibular sensory information on the SPV in 15 healthy adults. Their SPV values were measured under four conditions (control, somatosensory, vestibular, and somatosensory + vestibular) in random order. The average and absolute SPV values were measured. In the somatosensory condition, a foam rubber pad was placed on the seating surface and the subject's SPV was measured. In the vestibular condition, the SPV was measured during galvanic vestibular stimulation (GVS). The somatosensory + vestibular condition was used to measure the SPV during combined somatosensory and vestibular stimulation. The mean SPV value was significantly increased in the somatosensory + vestibular condition compared to the other three conditions. The absolute value of SPV was significantly increased in the somatosensory and somatosensory + vestibular conditions compared to the control and vestibular conditions. There was no significant difference in the average or absolute SPV values in the vestibular condition compared to the other conditions. There was no significant difference between SPV errors when somatosensory information was disturbed or when somatosensory + vestibular information was disturbed. When the somatosensory information from the seat was disturbed, the SPV error increased, and it also shifted under the influence of the vestibular sensory information modulation. These results indicate that somatosensory information from the seat plays an important role in SPV in healthy adults.

Comparison of the Effect of Sensory-Level and Conventional Motor-Level Neuromuscular Electrical Stimulations on Quadriceps Strength After Total Knee Arthroplasty: A Prospective Randomized Single-Blind Trial.

OBJECTIVE: To compare sensory-level neuromuscular electrical stimulation (NMES) and conventional motor-level NMES in patients after total knee arthroplasty. DESIGN: Prospective randomized single-blind trial. SETTING: Hospital total arthroplasty center: inpatients. PARTICIPANTS: Patients with osteoarthritis (N=66; mean age, 73.5±6.3y; 85% women) were randomized to receive either sensory-level NMES applied to the quadriceps (the sensory-level NMES group), motor-level NMES (the motor-level NMES group), or no stimulation (the control group) in addition to a standard rehabilitation program. INTERVENTIONS: Each type of NMES was applied in 45-minute sessions, 5d/wk, for 2 weeks. MAIN OUTCOME MEASURES: Data for the quadriceps maximum voluntary isometric contraction, the leg skeletal muscle mass determined using multiple-frequency bioelectrical impedance analysis, the timed Up and Go test, the 2-minute walk test, the visual analog scale, and the range of motion of the knee were measured preoperatively and at 2 and 4 weeks after total knee arthroplasty. RESULTS: The motor-level NMES (P=.001) and sensory-level NMES (P=.028) groups achieved better maximum voluntary isometric contraction results than did the control group. The motor-level NMES (P=.003) and sensory-level NMES (P=.046) groups achieved better 2-minute walk test results than did the control group. Some patients in the motor-level NMES group dropped out of the experiment because of discomfort. CONCLUSIONS: Motor-level NMES significantly improved muscle strength and functional performance more than did the standard program alone. Motor-level NMES was uncomfortable for some patients. Sensory-level NMES was comfortable and improved muscle strength and functional performance more than did the standard program alone.

Influence of the stimulus parameters of galvanic vestibular stimulation on unilateral spatial neglect.

Galvanic vestibular stimulation (GVS) stimulates the vestibular system electrically with low-amplitude direct current through surface electrodes applied to the left and right mastoids. The effects of GVS on unilateral spatial neglect (USN) in poststroke patients were recently reported, but the influence of the current intensity and application duration of GVS on USN has not been sufficiently investigated. Here we explored the influence of these stimulus parameters on USN. We recruited seven patients with right-hemisphere stroke and left-sided USN (four female) for this single-blind, sham-controlled cross-over trial. Their scores on the line cancellation test were measured under three stimulation conditions [left-cathodal/right-anodal GVS (L-GVS), right-cathodal/left-anodal GVS, and sham] at three time points (before the start of GVS, 10 min after the start of GVS, and 20 min after the start of GVS). The GVS intensity was set below the sensory threshold and differed among the patients (0.4-2.0 mA). The cancellation scores were significantly increased after 10 and 20 min L-GVS, with a greater increase observed after the latter (P<0.0001). The other stimulus conditions had no significant effect. There was a significant positive correlation between the change in the increase in the cancellation score with L-GVS and the total charge (r=0.81, P=0.0004). The effect of GVS on USN may depend on its application duration, current intensity, and polarity.

Effects of galvanic vestibular stimulation combined with physical therapy on pusher behavior in stroke patients: a case series.

BACKGROUND: A recent study investigated the effects of galvanic vestibular stimulation (GVS) on pusher behavior (PB) in post-stroke patients. However, there have been no reports about the effects of multisession GVS on PB. OBJECTIVE: The purpose of this study was to investigate the feasibility and effects of multisession GVS combined with physical therapy for PB in stroke patients. METHODS: Two stroke patients who showed PB were enrolled. The ABAB single-case design was used. Each phase lasted 1 wk. In phases A1 and A2, the patients underwent a 60-min-long physical therapy session 5 days a week. In phases B1 and B2, they underwent GVS for 20 min before each physical therapy session, and then the same physical therapy program as in phases A1 and A2 were performed. PB was evaluated using the Scale for Contraversive Pushing (SCP) and the Burke Lateropulsion Scale (BLS). Outcomes were tested at the baseline and after each phase. RESULTS: In both patients, the SCP scores were reduced only during phase B2. Although the BLS scores improved at the A1 phase, a larger improvement was seen at the two B phases. CONCLUSIONS: Multisession GVS combined with physical therapy may have positive effects on PB in clinical setting.

Feasibility study of a combined treatment of electromyography-triggered neuromuscular stimulation and mirror therapy in stroke patients: a randomized crossover trial.

BACKGROUND: Mirror therapy (MT) and electromyography-triggered neuromuscular stimulation (ETMS) are both effective treatments for impaired upper limbs following stroke. A combination of these two treatments (ETMS-MT) may result in greater gain than either treatment alone. OBJECTIVES: The feasibility and possible effects of ETMS-MT upon upper extremity function were investigated in stroke patients. METHODS: Thirteen post-acute stroke patients were randomly assigned to an immediate ETMS-MT group or a delayed ETMS-MT group and then underwent an 8-week training program. The immediate ETMS-MT group received ETMS-MT in addition to physical and occupational therapy (PT+OT) for 4 weeks. They then received only PT+OT for the next 4 weeks. In the delayed ETMS-MT group, interventions were provided in the reverse order. The main outcome measure was the Fugl-Meyer Assessment (FMA). RESULTS: The immediate ETMS-MT group showed significantly greater gain in FMA in the first 4 weeks. The delayed ETMS-MT group showed significantly greater gain in active range of motion during the latter 4 weeks. No adverse effects were reported following ETMS-MT. CONCLUSION: ETMS-MT might be as effective as independent MT or ETMS without causing any side effects. Future research should focus upon the direct comparisons between independent and combined interventions.

Effects of peripheral sensory nerve stimulation plus task-oriented training on upper extremity function in patients with subacute stroke: a pilot randomized crossover trial.

OBJECTIVE: To investigate the feasibility of peripheral sensory nerve stimulation combined with task-oriented training in patients with stroke during inpatient rehabilitation. DESIGN: A pilot randomized crossover trial. SETTING: Two rehabilitation hospitals. SUBJECTS: Twenty-two patients with subacute stroke. INTERVENTIONS: Participants were randomly assigned to two groups and underwent two weeks of training in addition to conventional inpatient rehabilitation. The immediate group underwent peripheral sensory nerve stimulation combined with task-oriented training in the first week, followed by another week with task-oriented training alone. The delayed group underwent the same training in reverse order. MAIN MEASURES: Outcome measures were the level of fatigue and Wolf Motor Function Test. Patients were assessed at baseline, one and two weeks. RESULTS: All participants completed the study with no adverse events. There was no significant difference in level of fatigue between each treatment. From baseline to one week, the immediate group showed larger improvements than the delayed groups in the Wolf Motor Function Test (decrease in mean time (± SD) from 41.9 ± 16.2 seconds to 30.6 ± 11.4 seconds versus from 46.8 ± 19.4 seconds to 42.9 ± 14.7 seconds, respectively) but the difference did not reach significance after Bonferroni correction (P = 0.041). Within-group comparison showed significant improvements in the Wolf Motor Function Test mean time after the peripheral sensory nerve stimulation combined with task-oriented training periods in each group (P < 0.01). CONCLUSION: Peripheral sensory nerve stimulation is feasible in clinical settings and may enhance the effects of task-oriented training in patients with subacute stroke.

Effect of a cognitive task during obstacle crossing in hemiparetic stroke patients.

Stroke patients are at a higher risk of falling than the community-dwelling elderly, and many falls are due to contact with an obstacle. This study compared the effects of the simultaneous addition of a cognitive task during obstacle crossing between stroke patients and community-dwelling older adults (control subjects). Participants comprised 20 stroke patients who could walk with or without supervision and 20 control subjects matched for age and height with the stroke patients. Participants were asked to cross a 4-cm-high obstacle while walking at a self-selected speed. The number of failures and the spatial and temporal parameters were compared between a single-task condition (i.e., crossing task only) and a dual-task condition (i.e., verbal fluency task: listing vegetables or animals). Under the dual-task condition, six stroke patients (30%) and three community-dwelling elderly individuals (15%) failed to complete the motor task. Task failure was only due to heel-obstacle contact after toe clearance. In both groups, obstacle-heel distance after clearance was reduced, and the time from heel contact to toe clearance and stride time were significantly increased under dual-task condition versus single-task condition. In addition, group-task interaction for the time from heel contact to toe clearance of the obstacle was significant; this increase in time was significantly greater under dual-task condition in stroke patients than in control subjects. Obstacle crossing in stroke patients involved an increase in crossing performance time and a risk of heel-obstacle contact after crossing. These tendencies appeared stronger under the dual-task condition.