A Technological Review of the Cueing Device for

Rehabilitation of Patients with Parkinson´s Disease

Andressa H M Costa1[0000-0001-7906-3108] , Marcelo A. A. Sanches2[0000-0002-2067-4382], Juli-

ano A. Pires3, Fabian C. Forero4, Jorge E. B. Rodriguez5, Fábio Nazaré6, Regina H. F.
Chueire7, Aparecido A. de Carvalho8

UNESP – São Paulo State University, Ilha Solteira, SP, Brazil

1-2-4-5-8
3-6-7 Rehabilitation Institute Lucy Montoro, São José do Rio Preto, SP, Brazil
andressahmc@gmail.com

Abstract. This paper aims to present a technical review, based on the main sci-
entific papers that developed devices that provide cueing for the rehabilitation
of patients with Parkinson's Disease (PD). The PD is a progressive, degenera-
tive disease of the central nervous system, capable of causing movement disor-
der, and consequently, changes in gait, which in turn may cause decreased ac-
tivity, muscle atrophy, or even falls. Among the treatment methods, all pallia-
tive, the physiotherapy has great relevance, and the cueing (visual, tactile and
auditory cueing) are one of the methods applied. The results of the bibliograph-
ic research, found works that proposes the development of cueing devices, em-
ploying different types of cueing, and several control methods, besides, they
showed considerable attention in identifying the Freezing of Gait (FOG). A
technological comparison was made between the works, allowing future
achievable scientific contributions on this theme, and a more objective use of a
eletronic device for treatment aid.

Keywords: Parkinson´s Disease, Review, Physiotherapy, FOG, Cueing Device.

1 Introduction

The Parkinson´s Disease (PD) is a progressive, degenerative disease of the central

nervous system [1], which mainly affects the elderly [2]. According to the World
Health Organization (WHO), this disease affects from 4.5 to 19 inhabitants per
100,000 people per year worldwide. [3]. Its origin is considered idiopathic until now
[4]. The degeneration of dopaminergic neurons, can cause movement disorder [5],
and trigger off non-motor symptoms [6].

1.1 Symptoms
The PD occurs due to a marked decrease in dopamine [5], causing symptoms, as
bradykinesia, muscle rigidity, tremors, and postural instability.
2

The tremor is usually the first symptom [4]. Another common symptom is the de-
crease in postural reflexes, which leaves the patient in a curved posture, causing falls
and a festinating gait (short and fast gait) [1][5].
Muscle rigidity, other symptom, is the increase of the resistance in the passive
movement, making abnormal the balance of the arm, increasing the risk of falls [7].
Bradykinesia is the difficulty in initiating the movements, causing difficulty in per-
forming sequential and simultaneous movements [5] [1]. This symptom can lead to
(FOG) [2], which is non-voluntary stop of the walk and the difficulty in restarting it
[8]. The FOG is a serious problem, because it is associated with anxiety, loss of mo-
bility, falls and even death from fall [2]. The occurrence of muscle rigidity and brady-
kinesia causes muscle weakness, fatigue and hardening, causing concern to patients.
The patient´s gait with PD has different characteristics to the normal gait, like the
action of get up and walk, because in normal gait the two actions are carried out in an
integrated way. This does not occur in patients with PD, since first, the patient gets up
completely, and only after ensuring the equilibrium, the gait is started [9][10]. Other
changes can be observed, like the speed of the gait, which becomes slower, the ca-
dence and the length of the step [11].
Recognition of the above symptoms is important, because the diagnosis is based on
clinical characteristics [5].

1.2 Treatment
PD treatment may involve three techniques: 1) medications, 2) neurosurgical and 3)
physiotherapy [2]. Although pharmacological therapy is the basis of treatment, the
physiotherapy has great relevance, since its objective is to minimize the motor prob-
lems, helping the patient to improve their quality of life. [2].
The disease progression impairs motor functions, causing the patient to decrease
his activities, triggering muscular atrophy. However, the exercises can not prevent the
progression of the disease, but modify how it progresses [11].
Studies also show that visual, auditory and vibratory cueing can improve gait in pa-
tients with PD, causing decreasing FOG episodes and, consequently, improving the
execution of activities [2][7][8]. This treatment is defined as the application of exter-
nal sensorial stimulation that allows start the march, restart or maintain the rhythm,
and act by causing a motor modulation, through the cerebellum-nigro-thalamus-
cortical pathway, which remain preserved in PD [12].

2 Cueing Device: state of art

Cueing are objects of studies of several works, which aim to promote gait improve-
ment in patients with PD. Thus, the Wegen´s work. [13] investigated the use of
rhythmic somatosensory stimulation in patients with PD. The results showed, that
somatosensory rhythmic stimulations are able to improve the walking pattern in indi-
viduals with PD.
Ivkovic, Fisher and Palosk [12] investigated the efficacy and limitations of tactile
cues for the modulation of motor tasks. For this study, the use of a smart cell attached
 3

to the dominant arm of the patient with PD and FOG history, the device was con-
trolled via an Android app, and the stimulations were provided by the embedded vi-
brator in the cell phone. The study showed, that tactile cueing can be used to improve
simple and complex motor performance in patients with PD.
McCandless [14] explored three different types of cueing, somatosensory, auditory
and visual, in patients with PD. Significant differences were observed using visual
cueing. Auditory cueing promoted improvements in forward and lateral velocity,
already the vibration seemed to disturb the movements.
For to apply the techniques evaluated by the mentioned papers, the works that will
be presented in sequence, developed or evaluated devices providing cueing for the
treatment of individuals with PD.

2.1 LISTENMEE®: study of a product

Lopez [15] analyzed the Listenmme product, a smart glasses and a smartphone app to
control the functions of the product, which offers auditory and visual clueing.
To evaluate the product, the tests were carried out in the laboratory, with 10 volun-
teers with PD, all showed difficulty in starting or maintaining gait.
All patients improved gait quality, after the use of the device the average im-
provement in the three main variables was: walking speed 40.6%, cadence 30.2% and
step length 50.3% in a single analysis session.

2.2 Health Assistant with Wearable Technology

Bӓchlin [16] presented a health assistant with wearable technology to help patients
with PD. The device uses auditory cueing, which is offered in FOG moments, since
the device identifies FOG instantly.
For the FOG identification, the system is based on Moore et al´s principle [17],
which analyzes the Spectral Power Density (PSD) of the acceleration signal.
Regarding patients' perception of FOG, 5 of 8 volunteers reported fewer episodes
of FOG, and 5 of 8 perceived a shorter FOG duration, one patient felt that the FOG
got longer and two of them did not notice change.
Regarding the recognition of FOG, the system did not work equally for all patients,
presenting problems of specificity (differentiate between walks and short freezes), and
sensitivity (distinguish between voluntary stop and freeze). Based on the results, the
authors described some changes, adjusting the system to the user's walking style, and
thus, decreasing the latency time, and providing faster system performance. Although
the latency has decreased, the minimum FOG recognition time is 4.5 sec, making it
difficult to recognize short episodes of FOG.

2.3 Portable multi-stimulation unit (MuCU)

Zhao [2] proposed the development of a multi-stimulation unit. The device provides
auditory and somatosensory cueing. and allows the application of cueing in a non-
automatic way, using intermittent or manual way, and there is still the possibility of
4

using it in automatic mode, provided when MuCU is connected to MiMed-pant,

shown forward.
For the tests, volunteers used the device in two ways (intermittent and manual).
Despite the unanimity that the device is light, one patient considered the dimensions
disturbing. Four patients perceived shorter freezing periods, the others did not notice
any difference. Four patients thought that the stimulation would be more efficient if it
happened in periods of freezing.

MiMed-Pant. The MiMed-Pant [18] is an pants integrated with accelerometer and a

gait and transmission evaluation unit (ETU), and that can identify the FOG in real
time. When the MuCU auto mode is activated, cueing are only triggered at FOG iden-
tification points.
To do FOG identification, the device uses two techniques simultaneously, the
Power Spectral Density (PSD) and the time-area analysis. With this combination, the
device's latency dropped to 1 second.

2.4 A Biofeedback System

Harrington [19] developed and tested a biofeedback system with tactile stimulation, to
relieve FOG. The system consists of three parts: a unit for detecting gait parameters, a
mobile control unit and an actuation unit to generate the vibration.
The tests analyzed patients' gait and FOG episodes, whether or not they used exter-
nal cueing. The patients initially walked without cueing, then a metronome was in-
serted, and finally the biofeedback system.
Preliminary results suggested an apparent decrease in FOG in the use conditions of
metronome and biofeedback. All the patients said that the system is easy to use.

2.5 The PDShoe

Winfree [8] developed PDShoe, a vibratory biofeedback system. Each shoe has three
sensors, in the heel, in the sole of the foot and in the toe, capable of detecting gait.
This detection is used to provide cueing at specific moments of walking.
In total, 4 subjects participated in the tests, 2 with PD and 2 healthy controls, one
of the patients with PD had episodes of FOG, the other patient used DBS (Deep Brain
Stimulation). The FOG patient did not show improvement in the balance test, unlike
the patient with DBS, and both showed improvements in the time get up and exit time
test. Both subjects showed improvements in gait indexes and clinical measures after
the use of PDShoe for one week.

2.6 ArmSense
Thompson [7] developed a device (ArmSense - Patented), capable of improving gait
characteristics, as consequence of better arm swing. The ArmSense measures arm
swing during gait, and offers real-time cueing to encourage patients to reach an ap-
propriate arm angle.
 5

Patients, who participated in the tests, reached the goal of step length and arm bal-
ance more than 95%. Significant effects were felt for cadence and lateral swing bal-
ance, but no effect was verified related to speed.

2.7 Muscle Vibration Device

Pereira [20] devoted himself to the development of a muscular vibration device, also
evaluated the effects of manipulation of the proprioceptive system on loco-motion of
patients with PD. The tests showed a relevant effect as the application occurred im-
mediately before the start of a task.
As for the tests in patients with PD, it was highlighted the worsening performance
in get up and walking, but it was noticed an improvement in the task of starting the
walk, in addition to less serious FOG episodes, when the vibration was applied to the
less affected leg.

3 A Technological Comparative

The table 1 presents some technical characteristics of the works already mentioned, to
provide a better comparison.

Table 1. Technical characteristics of the devices.

Device Cueing Control Supply Others functions

Wearable Autonomy - Bluetooth
Auditory FOG - PSD (6 hr) - Headphones
Assistant
- - Bluetooth
Auditory and - Wireless
Listenmee Manually (app)
Visual - Memory Card

Auditory and FOG – PSD and Time- Lithium - Headphones

MuCU - Memory Card
Tactile area
Rechargeable - Inertial Motion
Biofeedback Tactile Manually (18 hr) Monitor

Autonomy - Wireless
PDShoe Tactile Moment of pressure
(70 min)
ArmSense Tactile Arm angle - -
Muscle - -
Tactile Manually
Vibration

Analyzing the types of cueing arranged in the table, it is possible to note that tactile
cueing was the most used, followed by auditory cueing, and visual stimulation, of-
fered only by the Listenmee product. In addition to different cueing techniques, the
6

studies also used different control methods, and four of the works controlled the de-
vice automatically and in real time.

4 Cueing Device: Perspectives

Regarding the FOG recognition time, one of the devices has a small latency (1 sec-
ond) [18] presenting efficiency in recognizing FOG. However only one type of mani-
festation of FOG was the object of studies of the work. Despite this, according to
literature [21] there are three different types of FOG manifestation, the most recurrent
is associated with small shuffling footsteps (dragging the foot), the second most pre-
sent, and mentioned in the papers presented, it's FOG with shaky legs (local tremor),
Finally, less frequent FOG is the that with complete akinesia (without observable
movement of the legs). In this way, it is expected that future works contribute with
techniques efficient for the real-time identification of other FOG manifestations.
Another point to highlight, is when the application of the cueing. One of the papers
[20] besides developing a device, also investigated this theme, relating the moment of
application of the cueing and the effectiveness in the treatment of the gait. However,
the tests were performed in healthy elderly patients, not considering any patient with
PD. Thus, there are still doubts as to how best to provide cueing to patients with PD,
and such a topic can be explored by future studies.

5 Conclusion

As shown, there is a growing search for the development of a suitable device cue-
ing for the treatment of patients with PD, but there is nothing consolidated yet.
However, it is perceptible that the use of devices presents an improvement in gait
decrease of FOG, and also shorted periods of FOG, when this occurs.
Thus, the present article is relevant in pointing out the current conjuncture of the
reported theme, and indicating possible the paths that are being used and their contri-
butions from a therapeutics and scientific point of review.

References

1. Souza, C. F. M., Almeida, H. C. P., Sousa, J. B.; Costa, P. H., Silveira, Y. S. S., Bezerra, J.
C. L.: A Doença de Parkinson e o Processo de Envelhecimento Motor: Uma Revisão de
Literatura. Neurocienc, 2011
2. Zhao, Y., Anhalt, F., Fietzek, U. M., D’angelo, L. T.: Multi-Cue Unit: An Independent
Device and Actuator of a Wearable System for Gait-Support in Parkinson Patients. IEEE
International Conference on Microwaves, Communications, Antennas and Electronic Sys-
tems. Tel Aviv, Israel, 2013.
3. World Health Organization: Neurological Disorders: public health challenges.
 7

4. Ferraz, H. B.: Doença de Parkinson: Prática Clínica e Terapêutica. 1st edn. Atheneu, São
Paulo (2005).
5. Leandro, L. A. Fatores Associados ao Desempenho Functional de Idosos Portadores da
Doença de Pakinson. Dissertação, Universidade Federal do Paraná, Curitiba, 2011.
6. Jankovic, J. Parkinson’s disease: clinical features and diagnosis. Journal Neurol Neurosurg
Psychiatry. USA, 2008. p. 368–376.
7. Thompson, E.: Agada, P.: Wright, W. G.: Reimann, H.: Jeka, J.: Spatiotemporal gait
changes with use of an arm swing cueing device in people with Parkinson’s disease. Gait
& Posture, 2017.
8. Winfree, K. N.: Pretzer-Aboff, I.: Hilgart, D.: Aggarwal, R.: Behari, M.: Agrawal, S. K.:
The Effect of Step-Synchronized Vibration on Patients With Parkinson’s Disease: Case
Studies on Subjects With Freezing of Gait or an Implanted Deep Brain Stimulator. IEEE
Transactions on Neural Systems and Reabilitation Engineering, 2013.
9. Pelicioni, P. H. S.: Impacto da Doença de Parkinson sobre as Características Cinéticas e
Cinemáticas da Tarefa de Levantar e Andar, em Caidores e não Caidores. Dissertação de
Mestrado. Universidade Estadual Paulista – Campus de Rio Claro. Rio Claro/SP, 2014.
10. Atta, F. J. S.: Lobo, B.: Mello, A.: Batista, A. S.: Mendes, S. M. D.: Sa, K. N. Alterações
na Postura e na Marcha do Portador da Doença de Parkinson. Revista de Pesquisa em Fisi-
oterapia, 9-18 (2010).
11. Sant, C. R. de: Oliveira, S. G. de: Rosa, E. L. de: Sandri, J.: Durante, M.: Posser, S. R.:
Abordagem Fisioterapêutica na Doença de Parkinson. Revista Brasileira de Ciência e En-
velhecimento Humano vol. 5 (2008).
12. Ivkovic, V.: Fisher, S.: Palosk, W. H.: Smartphone-based tactile cueing improves motor
performance in Parkinson's disease. Parkinsonism and Related Disorders (2015).
13. Wegen, V. van: Goede, C. de: Lim, I.: Rietberg, M.: Nieuwboer, A.: Willems, A.: The ef-
fect of rhythmic somatosensory cueing on gait in patients with Parkinson’s disease. Journal
of the Neurological Sciences (2006).
14. Mccandles, P. J.: Evans, B. J.: Janssen, J.: Selfe, J.: Churchill, A.: Richardas, J.: Effect of
three cueing devices for people with Parkinson’s disease with gait initiation difficulties.
Gait & Posture. 2015
15. Lopez, W. O. C.: Higueira, C. A. E.: Fonoff, E. T.: Souza, C. de O.: Albicker, U.: Mar-
tinez, J. A. E.: Listenmee® and Listenmee® smartphone application: Synchronizing walk-
ing to rhythmic auditory cues to improve gait in Parkinson’s disease. Human Movement
Science (2014).
16. Bächlin, M.: Plotnik, M.: Roggen, D.: Maidan, I.: Hoausdorff, J. M.: Giladi, N.: Tröster,
G.: Wearable Assistant for Parkinson’s Disease Patients With the Freezing of Gait Symp-
tom. IEEE Transactions on Information Technology in Biomedicine, Vol. 14 (2009).
17. Moore, S. T.: MacDougall, H. G.: . Ondoc, W. G: Ambulatory monitoring of freezing of
gait in Parkinson’s disease. Journal of Neuroscience Methods, vol.167, 340–348.
18. Harrington, W.: Greenberg, A.: King, E.: Macnames, J.: Holmstrom, L.: Horak, F. B.:
Mancini, M. Alleviating Freezing of Gait using phase-dependent tactile biofeedback. In
38th International Conference of the Annual Engineering in Medicine and Biology Socie-
ty. Orlando, FL, USA (2016).
19. Zhao, Y.: Tonn, K.: Niazmand, K.: Fietzek, U. M.: D'Angelo, L.T.: Ceballos-Baumann A.:
Lueth, T.C.: Online FOG Identification in Parkinson's disease with a time-frequency com-
8

bined Algorithm. IEEE-EMBS International Conference on Biomedical and Health Infor-

matics. 192-195. Hong Kong and Shenzhen, China (2012).
20.Pereira, M. P.: Os Efeitos da Manipulação do Sistema Proprioceptivo na Locomoção de
Pessoas com Doença de Parkinson com e sem Congelamento da Marcha: Desenvolvi-
mento, Otimização e Aplicabilidade de um Sistema de Vibração Muscular. Tese de Dou-
torado. Universidade Estadual Paulista. Rio Claro-SP (2015).
21. Thompson, P.D.: Marsden C.D.: Walking disorders. In: Bradley WG, Daroff RB, Fenichel
GM, Marsden CD, eds. Neurology in Clinical Practice – Principles of Diagnosis and Ma-
nagement. Butterworth-Heinemann, Boston - USA, 321–334 (1995).