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Papers: A Nieuwboer, G Kwakkel, L Rochester, D Jones, E van Wegen, A M Willems, F Chavret, V Hetherington, K Baker, and I Lim Cueing training in the home improves gait-related mobility in Parkinson’s disease: the RESCUE trial J Neurol Neurosurg Psychiatry 2007; 78: 134-140 [Abstract] [Full text] [PDF]

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Cueing training in the home improves gait-related mobility in Parkinson’s disease:

Dr Sandip Kumar Dash   (12 February 2007)

Cueing training in the home improves gait-related mobility in Parkinson’s disease: 12 February 2007
Dr Sandip Kumar Dash, consultant Neurology Apollo Hospital,Dhaka. Send letter to journal: Re: Cueing training in the home improves gait-related mobility in Parkinson’s disease: drskdash{at}yahoo.co.in Dr Sandip Kumar Dash	Dear Editor, I have read the article (1) with interest and found it to be very useful for managing the Parkinson’s disease. In this context I would like to mention few things. In spite of advances in therapy of Parkinson’s disease, gait and balance deficits are the major problems causing loss of independence. More recently multi disciplinary neuro rehabilitation treatments have been proposed to treat Parkinson’s disease sequel. BenSidaway et al (2) have shown that one month gait training with visual cues was successful in establishing a lasting improvement in gait speed and length. Protas E J etal (3) found that gait and step training resulted in a reduction in falls and improvement in gait and dynamic balance. Gwyn N et al (4) suggested that improvement in Parkinson’s disease gait pattern with the use of visual cues may arise through the patient’s ability to use visual feedback to regulate movement amplitude, reducing their kinesthetic feedback. The present study is the largest study on gait training in Parkinson’s disease and also training, testing done at home environment. Suteerawattananon M et al (5) have shown in their study that both auditory and visual cues improved the gait performance, the former improves the cadence, while the latter improves the stride length, simultaneous use of both cues did not improve gait significantly more than each cues alone. In the present study, (1) with both visual and auditory cues there was a significant increase in walking speed and step amplitude, with a tendency to reduce step frequency. If the authors (1) had noted if there was any difference in gait velocities and step length between the two cues in this trial then it would have shown a new insight regarding which of the two cues is better, so as to develop a cuing device at a lower cost. Secondly, in this trial the cueing training period is only for a short period. Fitts P M. (6) proposed that people pass through three stages while acquiring new skills. The first stage ,during which the persons understands the requirement of the task, in the second stage, the fixation stage, specific requirements like speed, amplitude and force are refined through large amounts of practice. In the third stage, automatic phase, motor skill is well established and can be performed automatically with limited demands on attentional mechanism. Meg E Morris et al (7), in their study found that patients with Parkinson’s disease are in second stage of motor skill acquisition and preferred gait pattern had not yet become automatic due to insufficient training and also stated that visual cues training enhanced stride length in Parkinson’s disease by focusing attention on the criterion step size. So a prolonged period of gait training may be required to have some retention effect of training and to become automatic. In a study by Seitz et al (8) provide some indication that basal ganglion play a primary role in allowing movement performance to shift from conscious control to automaticity. In the present study the gait related attention also can not be ruled out, and may be a factor for training effects were not sustained at 6 weeks follow up. So further studies using longer periods of training with cues are needed to see whether the preferred gait parameters increase and become automatic with prolonged periods of training and the impact of visual cues vs. auditory cues in gait parameters to find out the better one, so as to develop a cueing device at a lower cost with better results. In the present trial the authors (1) have excluded the patients who have undergone D.B.S. In a recent study W,M.M.Schupbach et al (9), patients with early stage of Parkinson’s disease having D.B.S shown to improve in their quality of life. However long terms follow up in patients undergoing DBS are few. In a Multicenter trial M.C.Rodrogues-Oroz et al (10) assessing the long term efficacy of either STN or Gpi stimulation, a significant and substantial clinically improvement for at least 3-4 years. So if in the present study (1), patients already having DBS been included, it could have shed some lights on the effect of cuing training in patients having DBS, so as to see any additive effects in improvement in gait parameters. In conclusion, the study by A Nieuwboer et al (1) is a very useful study and shed a light for rehabilitation therapy at home environment for Parkinson’s disease with good results and future direction. Sandip Kumar Dash References 1. A Nieuwboer,G Kwarkkel,L Rochester,D Jones,E van Wegen, A MWillems,F Chavret,V Hetherington,K Baker,I Lim.—Cueing training In the home improves gait-related mobility in Parkinson’s disease: RESCUE trial. J Neurol.Neurosurg Psychiatry, 2007, 78,134-140. 2. Ben Sidaway,Jennifer Anderson,Garth Danielson,Lucas Martin ,Garth Smith.—Effects of Longterm gait training using visual cues in an individual with Parkinson’s disease.—Phys Ther,2006,vol.86 ,2,feb,186-194.Abstract. 3. Protas EJ,Mitchell K,Williams A, Quereshy H,Caroline k,Lai E C.—Gait and step training to reduce falls in Parkinson’s disease.-NeuroRehabilitation, 2005, 20, (3):183-90Abstract. 4. Gwyn N.Lewis,Winston D.Byblow,Sharon E.Walt.—Stride length regulation in Parkinson’s disease; the use of extrinsic ,visual cues.-Brain,2000,123,2077-209. 5. Suteerawattananon, M, Morris G S, Etnyre BR, Jancovic j, Protas EJ.—Effects of visual and auditory cues on gait in individuals with Parkinson’s disease,--J Neurol Sci. 2004, April 15,219(1-2):63-69.Abstract. 6. Fitts PM.-Perceptual motor skills learning in: Melton AW, Editor. Categories of human learning. New York: Academic Press, 1964, 243-85.Crossref. 7. Meg E Morris,Robert Lansek,Thomas A Matyas,Jeffery JSummers.—Stride length regulation in Parkinson’s disease Normalization strategies and underlying mechanisms.-Brain,1996,119,551-568. 8. Seitz R J,Roland PE.-Learning of sequential finger movements in man: a combined kinematics and positron emission tomography(PET)study.Eur J Neurosci,1992,4:154-165.Crossref. 9. W M M .Schupbach,D Maltete,J L Houet,S Tezenas du Montcel,L Mallet,M LWelter,M Gargiulo,C Behar,A M Bonnet,V Czernecki,B Pidoux,S Navarro,D Dormont,P Cornu,Y Agid—Neurosurgery at an earlier stage of Parkinson’s disease,Neurology,2007,68,267-271.Abstract. 10. M C Rodriguez-Oroz,J A Obeso,A E Lang,J L Houeto,P Pollak et al-Bilateral deep brain stimulation in Parkinson’s disease, a multicentre study with 4 years follow up, Brain, 2005, 128, (10) :2240-2249.