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Sinha Siddharth M.P.T. (Neurology)*, Bhatt Sunil M.P.T. (Neuro-science)**

ABSTRACT AIM: The effect of cueing has been well proved in PD but almost all of the studies are done in on drug phase of the disease. So in this study we tried to investigate the efficacy of a supervised cueing training in on drug as well as off drug phase of Parkinson patients. METHODOLOGY: Experimental study sample 8 individuals with idiopathic PD are selected on basis of inclusion criteria- Idiopathic Parkinsons , in stage 2-3 on hoer and yahr staging, excluded those MMSE < 24, any known Cardio respiratory complication that hinders the exercise program, any other known neurological condition ,any fracture or surgery of lower limb in last one year . Group A is OFF drug phase and group B ON drug phase. Both groups were assessed in both ON drug phase and OFF drug phase. Intervention consisted of a sensory cuing visual (floor markers) and auditory (beep) cues. The data analyzed within group and between groups for any improvements in both the phases. RESULTS AND CONCLUSION: cueing techniques is helpful in improving gait and balance in PD. But we suggest that treatment given in OFF drug phase is more beneficial. KEYWORDS: ON drug phase, OFF drug phase, PD, sensory cueing.

INTRODUCTION Parkinsons disease (PD) is one of the most

common neurological disorders in elderly people. Between the age of 55 and 85 years, 4.2% of all women and 6.1% of all men develop PD. The major

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motor symptoms in PD are tremor, rigidity, bradykinesia, and postural instability, resulting in problems with gait, balance, transfers, and posture. These problems can lead to reduced mobility and decreased levels of physical activity, which in turn can cause increased dependency and social isolation and thereby reduce quality of life.19 it is therefore important to encourage patients to maintain their mobility and to stay active, for example, by referring them to physical training programs. These physical exercise programs include use of rhythmic cues. Cueing can be defined as using external temporal or spatial stimuli to facilitate movement (gait) initiation and continuation. Cueing can be defined as using external temporal or spatial stimuli to facilitate movement (gait) initiation and continuation.

limited. Although there is evidence to support the use of sensory cues to improve gait, balance and other impairments in PD but almost all of the literature available is using this technique in ON drug phase of disease i.e. when the PD patient is under the effect of antiparkinsons medicine. Secondary the definitive effect of sensory cueing in ON and OFF drug phase of the disease has not been compared.

BACKGROUND Sean Ledger, Rose Galvin et al. in their randomized controlled trial evaluated the effect of an individual auditory cueing device on freezing and gait speed in people with Parkinson's disease. In this study they used an Apple iPod-Shuffle and similar devices provide a cost effective and an innovative platform for integration of individual auditory cueing devices into clinical, social and home environments and are shown to have immediate effect on gait, with improvements in walking speed, stride length and freezing. Visual, auditory and somatosensory cueing devices have also been used in conjunction with walking aids, to improve gait in individuals with Parkinsons disease. Given the challenge that this clinical population may have with initiating motor movements during gait (i.e. freezing gait).37 The freezing phenomena are difficult to treat. Pharmacological treatment is usually disappointing. Rehabilitation in particular the efficacy of auditory and visual cues, is a new rehabilitation strategy based on treadmill training associated with auditory and visual cues. Giuseppe Frazzitta, MD, Roberto Maestri, MD et al. in their study investigated the effectiveness of a cueing with treadmill. One group of patient get treated with treadmill and other get

Unfortunately, evidence-based knowledge about effects of cueing in PD is limited. Best-evidence synthesis of 24 studies, up to 2002, showed only 1 high- quality study. Specifically focused on the effects of auditory rhythmical cueing. Studies claim positive effects of cueing on gait speed of patients with PD; however, it was unclear whether positive effects identified can be generalized to improved activities of daily living in patients own home setting and reduced frequency of falls in the community. In addition, the sustainability of a cueing training program remains uncertain.19 A recent review on cueing suggests that cueing can have an immediate and powerful effect on gait in PD. Vision-to facilitate locomotors activity was first described by Martin over 25 years ago. In a later study, Forsberg et a reported beneficial effects of visual guidance on gait movements in patients with Parkinson's disease. Unfortunately, evidencebased knowledge about effects of cueing in PD is
14 19

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conventional treatment.15 Cueing strategies are thought to reroute the movement


Appropriate and precaution taken to avoid any fall. For subject both the groups were assessed in both ON and OFF drug phase. Group A (is ON drug patient) subject received training in ON drug phase. Group B (is OFF drug patient) subject received training in OFF drug phase. Each




removing it from the automatic basal ganglia pathway. Leland E. Dibble found that visual and auditory cueing technique in functional and

movement time task separately and results suggest that both technique get improve but visual cueing effects are not limited to gait tasks and auditory cuing results that cadence and stride length has been shown to consistently increase when auditory cues are present relative to when cues are not present.

participant received cueing training in the supervised situation with the help of a prototype cueing device. This cueing device provided 2 rhythmical cueing modalities: (a) an auditory modality (a beep), (b) a visual feedback Cueing training was delivered in the home setting. Participants were instructed to listen to the cueing when they are performing tasks. They were encouraged to listen to the rhythmical cue and to try to match their heel strike with the beat of the beep sound on the device and try to match heel strike with visual cue make on ground. The results were analyzed for within group and between the groups

Sensory cue enhanced gait training in mild to moderate PD patients. Treadmill with music has been proved to give additional benefits for improving gait related parameters.6

METHODOLOGY Subjects were selected through convenient sampling. After having the informed consent of 8 subjects and fulfillment of inclusion criteria


systematic randomization was done and the subject were assigned to the particular group according to their sequence of approach i.e. 1st, 3ed, 5th, 7th in group A and 2ed, 4th, 6th, 8th in group B . Protocol All subjects underwent 20 minutes of each session including rest time (2 min), rest time to decrease the effect of fatigue, 1 session (Monday to Saturday) in a day for 2 weeks for 11 day , one day rest between the two subsequent weeks.

DESIGN AND PROCEDURE They were then randomly directed into 2 groups at baseline, all subject were assessed for gait (10 MWT), balance (BBS), and function (NQS).

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RESULTS AND DISCUSSION Both of the groups showed clinically significant improvement in both on and off drug phases. Both phases have shown improvement in gait and balance parameters specially step length, speed, sit to stand, turning, time taken.

WITHIN THE GROUP Within the groups subject improved significantly in all the parameters namely gait, balance and function. Both of the groups showed clinically significant improvement in both on and off drug phases. Both phases have shown improvement in gait and balance parameters specially step length, speed, sit to stand, turning, time taken.

ON Drug Phase Group A patient initially did not have any difficulty to start the training as compared to Group B. The on phase of the disease in group A was improved i.e. these patients showed an increased step length, increased step per minute, reduced timing of sit to stand, during their on drug period. Also they had positive effects of cueing on gait and Graph of mean difference between Group A and Group B. gait related mobility. These patients had shown an improvement in their balance because of the challenges they faced during the gait training. Clinically and subjectively significant Subjectively also these patients reported that after intervention they were able to walk much more independently and safely and their day to day activities were much easier now. Some of the subjects in this group who complained of giddiness during initial assessment and training were now much better and their giddiness disappeared after the intervention. Also they had better endurance and their breathing abilities were improved; as reported by these subjects. These changes were evident in both ON drug and OFF drug periods of these subjects.

improvement in both ON and OFF drug phases, both phases have shown improvement in gait and balance parameters specially time taken for 10 meter, sitt to stand timing and speed.

Graph of mean difference between Group A and Group B significant variable.

OFF Drug Phase Group B patients initially had many difficulties in starting and performing the training sessions. As

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training for these subjects was given in OFF drug phase, without the effect of medication they had difficulty in concentrating visual and auditory cueing simultaneously. Patient use to get puzzled between visual and auditory cues but after 2 days of training they learnt how to synchronies the visual and auditory cue to use them simultaneously. They had improved gait parameter like sit to stand, speed, time taken for 10 meter, step length after intervention. Neurophysiologically these improvements in both the groups can be attributed to the fact that sensory cueing training strengthens the neurons in cerebral cortex bypassing the damaged basal ganglia thereby cortex is independent of the damaged basal ganglia signals for performing the movements and functions.

synaptogenesis7,36,37,38,13,9 Cueing technique acts like a pacemaker and provides an external rhythm that is able to stabilize the defective internal rhythm of the basal ganglia. Increased activation of the lateral premotor cortex in PD patients during cueing lends support to this view (Hanakawa et al., 1999b).14

BETWEEN THE GROUPS Subjectively also group B patient reported better improvement compare with group A.

Subjectively, after intervention these subjects (group B) reported, that now if some time they have a delay in taking medicine timely or skip the drug dosage, still their symptoms did not worsen; infect they were better now compared to pre-intervention time. Also the fear of fall became less after the treatment, confidence level was increased. Because of training was given to them in the same phase (OFF drug). This context specific training helped them for better learning and hence more benefits. Carr and Sepherd.27 in their works have emphasized the importance of context specific training in rehabilitation. Plasticity is a general term describes the ability

Several authors have suggested that predictive external sensory cues, such as auditory rhythm, can provide the necessary trigger in Parkinson's disease to switch from one movement component in a movement sequence to the next and thus bypass defective internal pallidocortical projections,
25, 26

possibly via the lateral premotor cortex which receives sensory information in the context of externally guided movements.27, 32 However, the neurophysiologic basis for







auditory-motor interactions is not well understood. There is some evidence that rhythmic sound patterns can increase the excitability of spinal motor neurons via the reticulospinal pathway, thereby reducing the amount of time required for the muscles to respond to a given motor command.32 Recent work with animal models of PD indicate that rehabilitative training can stimulate a number of plasticity-related events in the brain, including neurotrophic factor expression and

modifiability, may be seen as a continuum from short-term changes in the efficiency or strength of synaptic connection to long term structural changes in the organization and number of connections among neurons.4, 33 Learning also can be seen as a continuum of short term to long term changes in the ability to produce skilled action. The gradual shift from short term to long term learning reflects a move along the continuum of neural modifiability, as increased

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synaptic efficiency gradually gives way to structural changes, which are the underpinning of long term modification of behavior.

will improve their balance, gait and function in much more beneficial way and may reduce or alter their dependency on drugs; thereby providing them a complete rehabilitation. So rehabilitation given in

CONCLUSION Sensory cueing using visual and auditory cues is beneficial for Parkinsons disease. It improves their gait, balance and functional activity.

OFF drug phase may help to decrease or alter the drug usage by these patients and to provide an overall rehabilitation program to this population give the treatment in OFF drug phase because patient have more difficulty in OFF drug phase and context specific training, tasks specific training give better results.

Subjectively and objectively group B (subjects for whom training was given in off drug phase) showed significantly better results. We suggest that training given in OFF drug phase to Parkinsons patients

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CORRESPONDING AUTHOR: * Department of Physiotherapy, Dolphin (P.G.) institute of bio medical and natural sciences, Dhradun , H.N.B. Garhwal University, Srinagar, Uttarakhand, India. Email: sidd2sinha@gmail.com ** Department of Physiotherapy, Dolphin (P.G.) institute of bio medical and natural sciences, Dhradun , H.N.B. Garhwal University, Srinagar, Uttarakhand, India.