Extensive CArdioVAscular Characterization and Follow-Up of Patients Receiving Immune Checkpoint Inhibitors: A Prospective Multicenter Study.

BACKGROUND: The increasing use of immune checkpoint inhibitors (ICIs) in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in the incidence of cardiovascular (CV) immune-related adverse events (irAEs). The current follow-up guidelines are based on anecdotal evidence and expert opinions, due to a lack of solid data and prospective studies. As many questions remain unanswered, cardiac monitoring, in patients receiving ICIs, is not always implemented by oncologists. Hence, an urgent need to investigate the possible short- and long-term CV effects of ICIs, as ICI approval is continuing to expand to the (neo)adjuvant setting. METHODS: We have initiated a prospective, multicenter study, i.e., the CAVACI trial, in which a minimum of 276 patients with a solid tumor, eligible for ICI treatment, will be enrolled. The study consists of routine investigations of blood parameters (troponin and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, in particular) and a thorough CV follow-up (electrocardiograms, transthoracic echocardiograms, and coronary calcium scoring) at fixed time points for a total period of two years. The primary endpoint is the cumulative incidence of troponin elevation in the first three months of ICI treatment, compared to baseline levels. Furthermore, secondary endpoints include incidence above the upper limit of normal of both troponin and NT-proBNP levels, evolution in troponin and NT-proBNP levels, the incidence of CV abnormalities/major adverse cardiac events, evaluation of associations between patient characteristics/biochemical parameters and CV events, transthoracic echocardiography parameters, electrocardiography parameters, and progression of coronary atherosclerosis. Recruitment of patients started in January 2022. Enrolment is ongoing in AZ Maria Middelares, Antwerp University Hospital, AZ Sint-Vincentius Deinze, and AZ Sint-Elisabeth Zottegem. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05699915, registered 26 January 2023.

Lifestyle behaviour and risk factor control in coronary patients: Belgian results from the cross-sectional EUROASPIRE surveys.

OBJECTIVE: The aim of this study was to assess lifestyle behaviour as well as risk factor management across Belgian coronary patients who participated in the cross-sectional European Action on Secondary Prevention through Intervention to Reduce Events (EUROASPIRE) surveys. METHODS: Analyses are based on a series of coronary patients by combining data from the Belgian participants in the EUROASPIRE III (328 patients; in 2006-2007) and EUROASPIRE IV (343 patients; in 2012-2013) surveys. Four hospitals located in the Ghent area participated in the surveys. Patients included in the analyses were ≥18 years old and had been hospitalised for a coronary event. Information on cardiovascular risk factors, lifestyle behaviour and medical treatment were obtained. RESULTS: Overall, the proportion of smokers was 11% with 40% persistent smokers. Adequate physical activity levels were reported by 17%, 28% of patients were obese, 47% was central obese and known diabetes was prevalent in 21% of patients. Hypertension was observed in 46% of patients and 20% had a total cholesterol ≥5 mmol/L. About 80% had participated in a cardiac rehabilitation programme and the majority of patients were treated with blood pressure (92%) or lipid-lowering drugs (92%). Anxiety and depressive symptoms were reported by 30% and 24%, respectively. Differences between EUROASPIRE III and IV were limited. CONCLUSIONS: Compared to the overall EUROASPIRE results in Europe, Belgian CHD patients seem to do slightly better. However, tackling obesity, physical inactivity, hypertension and psychosocial distress remains an important challenge in the management of coronary patients.

The impact of drop-out in cardiac rehabilitation on outcome among coronary artery disease patients.

Background The effect of adherence to cardiac rehabilitation (CR) on outcome is not clear. Therefore, we aimed to assess the impact of drop-out for non-medical reasons of CR on event-free survival in coronary artery disease (CAD). Methods A total of 876 patients who attended CR after acute coronary syndrome (ACS), percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) were included. Drop-out was defined as attending ≤50% of the training sessions. A combined endpoint of all-cause mortality and rehospitalization for a cardiovascular event was used to specify event-free survival. Differences in clinical characteristics were assessed and parameters with p < 0.10 were entered in a multiple Cox regression analysis. Results A total of 15% died or had a cardiovascular event during a median follow-up period of 33 months (interquartile range 24, 51). Overall, 17% dropped out before finishing half of the program. Patients who withdrew prematurely had a risk twice as high for a cardiovascular event or death (hazard ratio 1.92, 95% confidence interval 1.28-2.90) than those who attended more than half of the sessions. Both ACS (2.36, 1.47-3.58) and PCI (2.20, 1.22-3.96), as primary indicators for CR, were associated with an adverse outcome and also a prior history of chronic heart failure (CHF) remained negatively associated with event-free survival (3.67, 1.24-10.91). Finally, the presence of hyperlipidemia was independently related to a worse outcome (1.48, 1.02-2.16). Conclusions Drop-out for non-medical reasons was independently associated with a negative outcome in CAD. Therefore, underlying factors for drop-out should gain more attention in future research and should be taken into account when organizing CR.

Comorbidities and Psychosocial Characteristics as Determinants of Dropout in Outpatient Cardiac Rehabilitation.

BACKGROUND: Despite the clear benefits of cardiac rehabilitation (CR), a considerable number of patients drop out early. OBJECTIVE: Therefore, we wanted to evaluate dropout in CR with a special focus on comorbidities and psychosocial background. METHODS: Patients who attended CR after acute coronary syndrome, cardiac surgery, or heart failure (N = 489) were prospectively included. Dropout was defined as attending 50% of the training sessions or less (n = 96 [20%]). Demographic and clinical characteristics, exercise parameters, and psychosocial factors were analyzed according to dropout, and those with a trend toward a significant difference (P < .10) were entered in a multivariate logistic model. RESULTS: The presence of a cerebrovascular accident (4.18 [1.39-12.52]) involved a higher risk of dropout, and a comparable trend was seen for the presence of chronic obstructive pulmonary disease (2.55 [0.99-6.54]). Attending the training program only twice per week also implicated a higher risk of an early withdrawal (3.76 [2.23-6.35]). In contrast, patients on ß-blockers were less likely to withdraw prematurely (0.47 [0.22-0.98]). Singles were more likely to drop out (2.89 [1.56-5.35]), as well as those patients who were dependent on others to get to CR (2.01 [1.16-3.47]). Finally, the reporting of severe problems on the anxiety/depression subscale of the EuroQOL-5D questionnaire involved a higher odds for dropout (7.17 [1.46-35.29]). CONCLUSIONS: Neither demographic characteristics nor clinical status or exercise capacity could independently identify patients who were at risk of dropout. The presence of comorbidities and a vulnerable psychosocial background rather seem to play a key role in dropout.

Participation in cardiac rehabilitation after hospitalisation for heart failure: a report from the BIO-HF registry.

OBJECTIVE: Participation in cardiac rehabilitation (CR) after hospitalisation for heart failure (HF) is estimated to below, but specific data for Belgium are lacking. Therefore, we wanted to evaluate attendance after HF hospitalisation compared to patients after cardiac surgery or acute coronary syndrome (ACS). Moreover, the improvement in exercise capacity was compared with the other patient groups. METHODS AND RESULTS: Patients who were hospitalized for HF (n=428), cardiac surgery (n=358) or ACS (n=467) in a single hospital, were prospectively included between January 2010 and May 2012. After hospitalisation for HF only 9% participated, compared to 29% after ACS and 56% after cardiac surgery. Non-participants in HF were older, more frequently women (P <0.01) and had a better left ventricular ejection fraction (P < 0.05). In addition, they had more frequently atrial fibrillation and problems to walk independently (P <0.01). At the start of the CR, HF patients had a worse clinical status and exercise capacity than patients after cardiac surgery or ACS (all P <0.001). However, exercise training resulted in a significant improvement in each group separately (all P < 0.001) and the relative improvement in exercise capacity in HF was comparable with the other groups. CONCLUSIONS: Only 9% of HF patients participated in CR after hospitalisation. Age, female gender, a relatively well-preserved ventricular function and atrial fibrillation seem to impede attendance to CR. However, HF patients can have as much improvement in exercise capacity as other patient populations, suggesting that more effort is needed to increase participation in CR among HF patients.

Activation of the ergoreceptors in cardiac patients with and without heart failure.

BACKGROUND: The presence of ergoreflex activity and its current relationship to hyperventilation and prognosis in cardiac patients is unclear. Therefore, we evaluated ergoreflex activity in cardiac patients with and without heart failure (CHF) as well as in healthy subjects, and we examined how ergoreceptor activity was related to a mortality risk score in CHF (MAGGIC). METHODS AND RESULTS: Twenty-five healthy subjects and 76 patients were included, among whom were 25 with ischemic heart disease (IHD), 24 with stable CHF, and 27 with unstable CHF. Ergoreflex activity was measured with a dynamic handgrip exercise, followed by post-handgrip regional circulatory occlusion (PH-RCO). Ergoreflex activity contributed significantly to ventilation (median [interquartile range] %V) in unstable CHF (81 [73-91] %V without PH-RCO, 92 [82-107] %V with PH-RCO, and 11 [6-20] difference in %V; P < .001) and was positively correlated with the MAGGIC risk score (Spearman ρ = 0.431; P = .002). No ergoreflex activity was observed in healthy subjects (-4 [-10 to 5] difference in %V), IHD (0 [-8 to 3] Diff in %V) and stable CHF (-3 [-11 to 6] difference in %V). CONCLUSIONS: Ergoreflex activity contributes to hyperventilation, but only in CHF patients with persistent symptoms, and is closely related to the MAGGIC risk score. Ergoreflex activity was not present in patients with IHD or stable CHF, suggesting other reasons for the increased ventilatory drive in those patients.

Impact of the preoperative risk and the type of surgery on exercise capacity and training after valvular surgery.

Information on exercise capacity and training in patients who underwent valvular surgery is scarce. The aim of this study is to evaluate postoperative exercise capacity and functional improvement after exercise training according to the preoperative risk and type of surgery. In this prospective study, 145 patients who underwent aortic valve surgery (AVS) or mitral valve surgery (MVS) and who were referred for cardiac rehabilitation were stratified according to the preoperative risk (European System for Cardiac Operative Risk Evaluation [EuroSCORE]) and type of surgery (sternotomy vs ministernotomy or port access). Exercise capacity was evaluated at the start and end of cardiac rehabilitation. Postoperative exercise capacity and the benefit from exercise training were compared between the groups. Patients with a higher preoperative risk had a worse postoperative exercise capacity, with a lower load, peak VO2, anaerobic threshold and 6-minute walking distance (all p<0.001), and a higher VE/VCO2 slope (p=0.01). In MVS, port access patients performed significantly better at baseline (all p<0.05), but in AVS, ministernotomy patients performed better than sternotomy patients with a concomitant coronary artery bypass graft (p<0.05). Training resulted in an improvement in exercise capacity in each risk group and each type of surgery (all p<0.05). This gain in exercise capacity was comparable for the EuroSCORE risk groups and for the types of surgery, for patients after AVS or MVS. In conclusion, exercise capacity after cardiac surgery is related to the preoperative risk and the type of surgery. Despite these differences in postoperative exercise capacity, a similar benefit from exercise training is obtained, regardless of their preoperative risk or type of surgery.

Gender differences in the management and outcome of atrial fibrillation complicating acute heart failure.

BACKGROUND: Little is known about sex differences in the prevalence, treatment, and outcome of atrial fibrillation complicating acute heart failure. METHODS AND RESULTS: Among 957 patients (429 women, 528 men), included in the BIO-HF registry, 45.2% (n = 194) of the women and 45.1% (n = 238) of the men were admitted with atrial fibrillation. The primary end point was a composite of 1-year all-cause mortality and hospitalization for heart failure. Adjusted 1-year mortality and hospitalization rates were similar between sexes (women 38.5%, men 36.0%; OR for female gender: 1.1, 95% CI 0.65-1.86; P = .71. A significant interaction between female sex and age (P = .002) was observed; with worse prognosis for women <75 years (OR 7.17, 95% CI 1.79-28.66; P = .005) compared with men <75 years. No sex differences in in-hospital treatment, restoration of sinus rhythm (16.5% in women vs 14.2% in men; P = .58), or in-hospital mortality (5.7% in women vs 6.7% in men; P = .69) were observed. CONCLUSIONS: Among patients hospitalized with acute heart failure, no sex differences in the prevalence and management of atrial fibrillation were observed. In-hospital mortality and the composite of 1-year mortality and rehospitalization were not different between sexes, but a significant sex-age interaction was observed, with worse outcome in women <75 years versus men <75 years of age.

Does cueing training improve physical activity in patients with Parkinson's disease?

BACKGROUND: Patients with Parkinson's disease (PD) are encouraged to stay active to maintain their mobility. Ambulatory activity monitoring (AM) provides an objective way to determine type and amount of gait-related daily activities. OBJECTIVE: To investigate the effects of a home cueing training program on functional walking activity in PD. METHODS: In a single-blind, randomized crossover trial, PD patients allocated to early intervention received cueing training for 3 weeks, whereas the late intervention group received training in the following 3 weeks. Training was applied at home, using a prototype cueing device. AM was applied at baseline, 3, 6, and 12 weeks in the patient's home, to record body movements. Postures and motions were classified as percentage of total time spent on (a) static activity, further specified as % sitting and % standing, and (b) % dynamic activity, further specified as % walking, % walking periods exceeding 5 seconds (W>5s) and 10 seconds (W>10s). Random coefficient analysis was applied. RESULTS: A total of 153 patients participated in this trial. Significant improvements were found for dynamic activity (beta= 4.46; P < .01), static activity (beta=-3.34; P < .01), walking (beta= 4.23; P < .01), W>5s (beta = 2.63; P < .05), and W>10s (beta = 2.90; P < .01). All intervention effects declined significantly at 6 weeks follow-up. CONCLUSION: Cueing training in PD patients' own home significantly improves the amount of walking as recorded by AM. Treatment effects reduced after the intervention period, pointing to the need for permanent cueing devices and follow-up cueing training.

Evidence for motor learning in Parkinson's disease: acquisition, automaticity and retention of cued gait performance after training with external rhythmical cues.

People with Parkinson's disease (PD) have difficulty learning new motor skills. Evidence suggests external stimuli (cues) may enhance learning; however, this may be specific to cued rather than non-cued performance. We aimed to test effects of cued training on motor learning in PD. We defined motor learning as acquisition (single task), automaticity (dual task) and retention of single- and dual-task performance (follow-up). 153 subjects with PD received 3 weeks cued gait training as part of a randomised trial (the RESCUE trial). We measured changes in cued gait performance with three external rhythmical cues (ERC) (auditory, visual and somatosensory) during single and dual tasks after training and 6 weeks follow-up. Gait was tested without cues to compare specificity of learning (transfer). Subjects were 'on' medication and were cued at preferred step frequency during assessment. Accelerometers recorded gait and walking speed, step length and step frequency were determined from raw data. Data were analysed with SAS using linear regression models. Walking speed and step length significantly increased with all cues after training during both single- and dual-task gait and these effects were retained. Training effects were not specific to cued gait and were observed in dual-task step length, and walking speed however was more limited in single-task non-cued gait. These results support the use of ERC to enhance motor learning in PD as defined by increased acquisition, automaticity and retention. They also highlight the potential for sustained improvement in walking and complex task performance.

The short-term effects of different cueing modalities on turn speed in people with Parkinson's disease.

BACKGROUND: Turning has been associated with instability, falls, and freezing in people with Parkinson's disease (PD). OBJECTIVE: To investigate the effect of different modalities of rhythmic cueing on the duration of a functional turn in freezers and nonfreezers. METHODS: A total of 133 patients with idiopathic PD while in the on phase of the medication cycle participated in this study as part of a subanalysis from the RESCUE trial. The effect of 3 different cue modalities on functional turning performance was investigated, involving a 180 degrees turn while picking up a tray. Time to perform this task was measured using an activity monitor. Tests were performed without cues and with auditory, visual, and somatosensory cues delivered in a randomized order at preferred straight-line stepping frequency. RESULTS: Cueing (all types) increased the speed of the turn in all subjects. There was no difference between turn performance of freezers and nonfreezers in cued and noncued conditions. Auditory cues made turning significantly faster than visual cues (P < .01) but not compared with somatosensory cues, except in nonfreezers. There was a short-term carryover in the final noncued trial. CONCLUSIONS: Rhythmical cueing yielded faster performance of a functional turn in both freezers and nonfreezers. This may be explained by enhancing attentional mechanisms during turning. Although no harmful effects were recorded, the safety of cueing for turning as a therapeutic strategy needs further study.

Is impact of fatigue an independent factor associated with physical activity in patients with idiopathic Parkinson's disease?

To investigate the longitudinal association between fatigue and physical activity in Parkinson's disease (PD) and determine whether this association is distorted by potential confounders. Data from baseline, 3, 6, and 12 week assessments in a single blind randomized clinical trial with cross-over design were used (N = 153). The Multidimensional Fatigue Inventory (MFI) was used to assess fatigue and an activity monitor to measure amount of physical activity (defined as % dynamic activity during each monitoring session). Time-independent and time-dependent factors were investigated for their possible univariate association with dynamic activity. Random coefficient analysis was applied. Candidate confounders were successively added to the longitudinal association model to determine if the association between dynamic activity and fatigue was distorted. A proportional change beyond 15% was considered to be significant. Fatigue was significantly associated with physical activity (beta = -0.099, SE = 0.032, P = 0.002). This association was not significantly distorted by type of intervention, age, gender, social support, disease duration, disease severity, motor impairment, cognition, anxiety, or medication intake. Depression caused proportional change of 22.2% in the regression coefficient of MFI. After controlling for depression, a significant association between MFI and dynamic activity remained (beta = -0.121, SE = 0.036, P = 0.000). The association found between fatigue and dynamic activity suggests that patients who experience higher levels of fatigue are less physically active. However, the total explained variance of dynamic activity by fatigue alone was small, suggesting that fatigue is only a minor factor in the complex of behavioral aspects that affect the amount of physical activity in patients with PD.

Identifying fallers with Parkinson's disease using home-based tests: who is at risk?

The objective of this work is to determine risk factors for falling in patients with Parkinson's disease (PD) using home-based assessments and develop a prediction model. Data on falls, balance, gait-related activities, and nonmotor symptoms were obtained from 153 PD patients (Hoehn-Yahr 2-4) in their home. Fifty-one candidate determinants for falling were independently tested using bivariate logistic regression analysis. A multivariate logistic regression model was developed to identify patients susceptible to falls. Sixty-six subjects (43%) were classified as fallers. Eighteen determinants for falling were selected. The final multivariate model showed an accuracy of 74% and included: (1) Freezing of Gait Questionnaire, (2) Timed Get Up and Go (TGUG) score, (3) disease duration, (4) item 15 of the Unified Parkinson's Disease Rating Scale. Based on disease duration, freezing symptoms, walking problems, and a prolonged TGUG duration, assessed in the home situation, it was possible to accurately identify 74% of PD patients as fallers.

Walking speed during single and dual tasks in Parkinson's disease: which characteristics are important?

The impact of dual tasks on gait in Parkinson's disease (PD) reveals lack of automaticity and increased cognitive demands. We explored which characteristics explained walking speed with and without dual task interference and if they reflected the cognitive demands of the task. In 130 people with PD, gait performance was quantified in the home using accelerometers allowing estimates of single and dual task walking speed and interference (difference between dual and single task). Multiple regression analysis was used to explore the effect of 12 characteristics representing four domains (personal, motor symptoms, cognitive, affective) on gait outcomes. Thirty-seven percent of variance in single task speed was explained by increased fear of falling, sex, age, disease severity, and depression; 34% of variance in dual task speed was explained by increased fear of falling, disease severity, medication, and depression; 12% of variance in interference scores was explained by greater disease severity and impaired executive function. Personal, motor, affective, and cognitive characteristics contribute to walking speed and interference, highlighting the multifactorial nature of gait. Different patterns of characteristics for each outcome indicates the impact of cognitive demand and task complexity, providing cautious support for dual task speed and interference as valid proxy measures of cognitive demand in PD gait.

Validity of the trunk impairment scale as a measure of trunk performance in people with Parkinson's disease.

OBJECTIVE: To evaluate construct validity of the Trunk Impairment Scale (TIS) as a measure of trunk performance in Parkinson's disease (PD). DESIGN: A cross-sectional study of PD patients and healthy subjects. SETTING: University rehabilitation research unit. PARTICIPANTS: Twenty-six PD patients (Hoehn and Yahr stages 2-4) and 26 healthy subjects. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The TIS and its subscales; static and dynamic sitting balance and trunk coordination. RESULTS: Compared with healthy controls, PD patients showed significantly lower scores on the total TIS, static sitting balance, and coordination subscale. Healthy subjects scored significantly better on the total TIS and coordination subscale compared with patients in the early stage of PD. Patients with PD in the early stage scored significantly higher for the total TIS as well as static and dynamic sitting balance in comparison with PD patients in a later stage. Forward stepwise multiple linear regression analysis showed that trunk impairment in PD patients was significantly related to a combination of older age and a higher score on part III of the Unified Parkinson's Disease Rating Scale, which assesses motor impairments. CONCLUSIONS: Early detection of trunk deficits and the significant relation with PD severity advocates further evaluation and use of the TIS in PD.

Turning in Parkinson's disease patients and controls: the effect of auditory cues.

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.

Gait and gait-related activities and fatigue in Parkinson's disease: what is the relationship?

PURPOSE: To explore the relationship between gait and gait-related activities and fatigue in Parkinson's disease (PD). METHOD: Twenty people with idiopathic PD (12 male, 8 female; mean age 64.6 +/- 7.96) and 10 age, sex and education matched controls (6 male, 4 female; mean age 63.5 +/- 7.03) wore an activity monitor for approximately 24 h, from which the percentage time walking and standing, the number of periods of walking greater than 10 sec were derived. Prior to monitoring, levels of fatigue (Multi-dimensional Fatigue Index, MFI) were evaluated. RESULTS: Activity data related to gait were compared for the waking hours of the day, reflected by the period between 6 am and 10 pm. Overall, PD subjects demonstrated reduced activity compared to controls, however there was no significant difference between PD and controls for the percentage time spent walking (p = 0.149), standing (p = 1.0) or engaged in periods of walking that were greater than 10 sec (p = 0.059). Significantly greater levels of fatigue were experienced by PD subjects in all MFI domains compared to controls (physical p = 0.001; activity p = 0.001; general p = 0.001; mental p = 0.028; motivation p = 0.024). There was no clear association between activity and fatigue in PD subjects. CONCLUSIONS: Evidence of increased fatigue is not supported by evidence of significantly decreased levels of activity in PD subjects. The relationship between activity and fatigue therefore remains unclear, highlighting the complex nature of the relationship between these factors. Further work is required to increase our understanding of the impact of fatigue on gait and gait-related activity so that improved management can be explored.

The effect of external rhythmic cues (auditory and visual) on walking during a functional task in homes of people with Parkinson's disease.

OBJECTIVES: To evaluate (1) the influence of rhythmic cues on gait interference during a functional activity and (2) the relationship of clinical symptoms to gait interference. DESIGN: Repeated-measures study. SETTING: Participants' homes. PARTICIPANTS: Twenty subjects with idiopathic Parkinson's disease (PD) and a control group of 10 age-, sex-, and education-matched subjects. INTERVENTIONS: Subjects performed a simple functional task that included a walking component and a dual-motor task. The functional task was performed with and without external rhythmic (auditory and visual) cues. MAIN OUTCOME MEASURES: Walking speed, mean step length, and step frequency were compared during trials of the tasks. In addition, tests of cognitive executive function (Hayling and Brixton tests), anxiety and depression (Hospital Anxiety and Depression Scale), and fatigue (Multidimensional Fatigue Inventory) were undertaken. RESULTS: The use of auditory cues during a dual task involving gait reduced the interference effect on the task; significant increases in step length were observed in PD subjects ( P =.018), representing an increase of 19%. CONCLUSIONS: External auditory cues may be useful in reducing interference and maintaining gait performance during more complicated functional activities. Clinical symptoms, such as depression and fatigue, could influence the ability to focus attention and may increase gait interference during the performance of complex tasks, with subsequent implications for functional walking and safety.

Quantitative gait analysis in Parkinson's disease: comparison with a healthy control group.

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 ( r =.19) or with gait speed ( r =.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.