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Every person with Parkinson disease (PD) will face balance difficulties during the course of the disease. In fact, some balance and gait abnormalities appear very early in the disease. Balance is essential for mobility and is very important for quality of life, even more so than limb function. Balance problems lead to falls and falls are more common, more severe, and more life threatening in PD than other neurological diseases. Balance disturbances in Parkinson disease include multiple aspects of balance control, including standing balance, reactive postural responses, anticipatory postural adjustments prior to gait initiation, and dynamic balance during walking and turning. Balance disturbances are more than just a manifestation of motor dysfunction in PD. Cognitive, affective, sensory, and autonomic dysfunctions contribute to balance disorders in PD. Unfortunately, levodopa and DBS have both positive and negative effects on balance, so exercises focused on balance are an important contributor to treating balance problems in PD.

Made available in DSpace on 2019-10-05T01:12:50Z (GMT). No. of bitstreams: 0 Previous issue date: 2018-11-01 Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) NIH National Institutes on Aging This study examined the coupling between visual information and body sway in patients with Parkinson's disease (PD) compared with healthy controls. Postural control performance was compared between 14 patients with PD (age: 69.6 +/- 8.8 years - stages 1-3 of the Hoehn and Yahr scale) and 14 healthy control participants (age: 68.6 +/- 3.0 years). Participants stood upright in a moving room that remained motionless or continuously oscillated in the anterior-posterior direction. Ten trials were performed in the following conditions: no movement of the room (1 trial) and with the room moving at frequencies of 0.1, 0.17, and 0.5 Hz (3 trials each frequency). Body sway and moving room displacement were recorded. The results indicated that patients with PD displayed larger body sway magnitude in the stationary room condition. Body sway of patients with PD was induced by visual manipulation in all three visual stimulus frequencies, but body sway of patients with PD was less coherent compared to that of the control participants. However, no difference was observed in the visualbody sway coupling structure. These results indicate that patients with PD can unconsciously couple body sway to visual information in order to control postural sway in a similar manner to healthy participants with intact visual-motor coupling for posture control. However, this coupling is marked by greater variability, indicating that people with PD have a motor system with greater inherent noise leading to a more varied behavior. Univ Cruzeiro Sul, Inst Phys Act & Sport Sci, Sao Paulo, SP, Brazil Univ Sao Paulo, Sch Arts Sci & Humanities, Sao Paulo, SP, Brazil Univ Sao Paulo, Fac Med, Sao Paulo, SP, Brazil Brazilian Parkinson Assoc, Sao Paulo, SP, Brazil Univ Fed Minas Gerais, Sch Phys Educ Physiotherapy & Occupat Therapy, Belo Horizonte, MG, Brazil Portland Vet Affairs Hlth Care Serv, Portland, OR USA Oregon Hlth & Sci Univ, Portland, OR 97201 USA Sao Paulo State Univ, Inst Biosci, Rio Claro, SP, Brazil Sao Paulo State Univ, Inst Biosci, Rio Claro, SP, Brazil NIH National Institutes on Aging: R01 AG006457 29

An emerging body of literature has examined cortical activity during walking and balance tasks in older adults and in people with Parkinson’s disease, specifically using functional near infrared spectroscopy (fNIRS) or electroencephalography (EEG). This review provides an overview of this developing area, and examines the disease-specific mechanisms underlying walking or balance deficits. Medline, PubMed, PsychInfo and Scopus databases were searched. Articles that described cortical activity during walking and balance tasks in older adults and in those with PD were screened by the reviewers. Thirty-seven full-text articles were included for review, following an initial yield of 566 studies. This review summarizes study findings, where increased cortical activity appears to be required for older adults and further for participants with PD to perform walking and balance tasks, but specific activation patterns vary with the demands of the particular task. Studies attributed cortical activation to compensatory mechanisms for underlying age- or PD-related deficits in automatic movement control. However, a lack of standardization within the reviewed studies was evident from the wide range of study protocols, instruments, regions of interest, outcomes and interpretation of outcomes that were reported. Unstandardized data collection, processing and reporting limited the clinical relevance and interpretation of study findings. Future work to standardize approaches to the measurement of cortical activity during walking and balance tasks in older adults and people with PD with fNIRS and EEG systems is needed, which will allow direct comparison of results and ensure robust data collection/reporting. Based on the reviewed articles we provide clinical and future research recommendations.

Freezing of gait (FOG) is a poorly understood symptom affecting many patients with Parkinson's disease (PD). Despite growing evidence of a behavioral link between anxiety, attention and FOG in PD, no research to date has investigated the neural mechanisms that might explain this relationship. The present study therefore examined resting-state MRI functional connectivity between the amygdala, striatum and frontoparietal attentional control network in PD patients with (freezers: n = 19) and without FOG (non-freezers: n = 21) in the dopaminergic 'off' state. Functional connectivity was subsequently correlated with an objective measure of FOG severity and a subjective scale of affective disorder within each group. Connectivity between the right amygdala and right putamen was significantly increased in freezers compared to non-freezers (p 0.01). Furthermore, freezers showed increased anti-coupling between the frontoparietal network and left amygdala (p = 0.011), but reduced anti-coupling between this network and the right putamen (p = 0.027) as compared to non-freezers. Key functional connections between the amygdala, putamen and frontoparietal network were significantly associated with FOG severity and a fear of falling. This study provides the first evidence that dysfunctional fronto-striato-limbic processes may underpin the link between anxiety and FOG in PD. It is proposed that freezers have heightened striato-limbic load and reduced top-down attentional control at rest, which when further challenged by the parallel processing demands of walking may precipitate FOG.

OBJECTIVES To determine whether spatial auditory cues provided by cochlear implants can improve postural balance in adults with severe deafness. METHODS In the presence of spatial white noise, 13 adult cochlear implantees wore head and lumbar-mounted inertial sensors while standing in the dark for 30 seconds in two auditory conditions: hearing assistive devices on and off. RESULTS Stability was improved with implants on (aided condition) compared to off (unaided condition) with respect to differences in mean head velocity (Cohen's d = 0.912, P = 0.006) as well as to root mean square (RMS) acceleration (Cohen's d = 0.456, P = 0.048). This was particularly evident in measures of anteroposterior accelerations (mean difference = 0.034 m/s2 ; Cohen's d = 0.612; P = 0.011). CONCLUSION The decrease in RMS head acceleration and velocity while wearing cochlear implants suggests that they could be recognized as balance implants in addition to auditory implants. The clinical importance of this finding in various patient populations remains to be determined. LEVEL OF EVIDENCE 4. Laryngoscope, 128:1676-1680, 2018.

Freezing of gait (FoG) in people with Parkinson's disease (PD) is an environmentally sensitive, intermittent problem that occurs most often during turning. FoG is difficult for clinicians to evaluate and treat because it can be difficult to elicit during a clinical visit. Here, we aimed to develop a clinically valid objective measure of freezing severity during a 2-min 360-degree turning-in-place. Twenty-eight subjects with PD (16 freezers, FoG+, and 12 nonfreezers, FoG-) in the "off" state and 14 healthy control subjects were tested. Subjects wore three inertial sensors (one on each shin and one on the waist) while (1) turning in place for 2 min (alternating 360 degrees to the right with 360 degrees to the left) and (2) performing an Instrumented 7-m Timed Up and Go test (ITUG). Performance was videotaped, and clinical severity of FoG was independently rated by two movement disorders specialists (co-authors). Turning in place consistently resulted in FoG (13 out of 16 subjects with PD) while FoG was clinically observed in only two subjects with PD during the ITUG test. The Freezing Ratio during the turning test was significantly correlated with the clinical ratings (ρ=0.7, p=0.003) and with score on the new FoG questionnaire (ρ=0.5, p=0.03). After correcting for symptom severity (UPDRS-III), out of the four objective measures of the turning test (total number of turns, average turn peak speed and average turn smoothness), only the Freezing Ratio was significantly different across groups (p=0.04). Freezing can be well quantified with body-worn inertial sensors during a 2-min turning-in-place protocol.

To investigate the impact of unilateral balance training on postural control of the trained and contralateral limb in healthy elderly. Fifty-one healthy old adults were randomly assigned into training group (TG) and control group (CG). Participants of the TG performed unilateral balance training (dominant (DOM) leg) over 4 weeks (4×/week). Centre of pressure analysis was performed at baseline, 5 weeks follow-up and 9 weeks follow-up under the following conditions: (1) one-leg stance without additional task, (2) one-leg stance with motor task and (3) one-leg stance with cognitive task. From baseline to 5 weeks follow-up, a mixed analysis of variance detected a significant time × group interaction for the DOM leg (P 0.05), indicating higher improvement of the TG in comparison to CG. No significant interaction effect was found for the non-DOM leg. Within the TG, the non-DOM leg significantly improved in mean velocity (P = 0.001) and anterior-posterior range (P 0.001). Unilateral balance training was effective to improve postural control of the trained leg. The effect on the contralateral leg was small and not significant within this study design. Improvements were retained after 4 weeks without training. A tendency is given that unilateral balance training might be beneficial to improve postural control of the contralateral leg.

Although balance and gait deteriorate as a person ages, it is unknown if all balance and gait measures change similarly across the adult age span. We developed the Instrumented Stand and Walk test (ISAW) to provide a quick quantification of key components of balance and walking: postural sway, anticipatory postural adjustments during step initiation, gait, and turning using body-worn, inertial sensors. Our aims were to characterize how different balance and gait measures change with age and to identify key age-related measures of mobility, in a wide age range of healthy, community-dwelling adults. A total of 135 healthy, community-dwelling subjects of age range 21-89 years with no history of falls were enrolled. Subjects wore inertial sensors on the wrists, ankles, sternum and lumbar area; 37 reliable and valid measures of postural sway, step initiation, gait and turning were computed. Univariate and multivariate regression analyses were performed to examine how the measures changed with age. Several distinct correlation patterns between age and ISAW measures were observed: linear deterioration, deterioration after plateau, and subtle, or no, worsening. Spatial, but not temporal, measures of gait were age-related. The strongest age correlation was found for centroidal frequency of mediolateral postural sway (r=−0.50, p≤0.001). A hierarchical regression model revealed that age was the most important predictor of mediolateral centroidal frequency, with lower sway frequencies associated with older age, independent of gender, weight, and height. Our results showed that balance and gait represent independent control systems for mobility and not all balance and gait measures deteriorate the same way with age. Postural sway during stance was more strongly related to age than any gait, gait initiation or turning measure.

Background and purpose Gait and turning impairments are common in people with Parkinson disease (PwPD). Tactile cues delivered in open- or closed-loop modalities may improve gait and turning in PwPD, but underlying mechanisms are unclear. Attention stemming from the prefrontal cortex (PFC) may play a role in cue response, but PFC contributions to specific cue modalities are unclear. Examining how open- and closed-loop cueing influences PFC activity during walking and turning in PwPD may elucidate mechanisms involved in cue response, which could advance development of effective therapeutics. We examined PFC activity during walking and turning in response to open- and closed-loop cueing in PwPD, and explored relationships between PFC activity and behavioral measures. Methods A mobile functional near-infrared spectroscopy device measured PFC activity during walking and turning in 25 PwPD (n = 13 freezers, n = 12 nonfreezers). Participants performed 180° and 360° turns while walking, and a 2-minute walk under single- and dual-task (AX-CPT) conditions with and without an open- (metronome-like vibration) or closed-loop (biofeedback vibration) tactile cue. Results PFC activity did not change when walking or turning in PwPD; freezing status or task demands did not influence PFC activity. With both open- and closed-loop cueing dual-task cost of gait significantly improved, whereas turning slowed. Discussion and conclusions Our preliminary results indicate that both open- and closed-loop cueing can improve gait without additional burden to the PFC beyond usual walking. However, turning while walking slowed with cueing with no PFC activity change. Further investigations are necessary to establish these findings in a larger cohort.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, the Video, available at: http://links.lww.com/JNPT/A280).

This study aimed to determine the most sensitive objective measures of balance dysfunction that differ between people with Parkinson&rsquo, s Disease (PD) and healthy controls. One-hundred and forty-four people with PD and 79 age-matched healthy controls wore eight inertial sensors while performing tasks to measure five domains of balance: standing posture (Sway), anticipatory postural adjustments (APAs), automatic postural responses (APRs), dynamic posture (Gait) and limits of stability (LOS). To reduce the initial 93 measures, we selected uncorrelated measures that were most sensitive to PD. After applying a threshold on the Standardized Mean Difference between PD and healthy controls, 44 measures remained, and after reducing highly correlated measures, 24 measures remained. The four most sensitive measures were from APAs and Gait domains. The random forest with 10-fold cross-validation on the remaining measures (n = 24) showed an accuracy to separate PD from healthy controls of 82.4%&mdash, identical to result for all measures. Measures from the most sensitive domains, APAs and Gait, were significantly correlated with the severity of disease and with patient-related outcomes. This method greatly reduced the objective measures of balance to the most sensitive for PD, while still capturing four of the five domains of balance.

Introduction: Mobility declines with age and further with neurodegenerative disorders, such as Parkinson's disease (PD). Walking and turning ability, in particular, are vital aspects of mobility that deteriorate with age and are further impaired in PD. Such deficits have been linked with reduction in automatic control of movement and the need for compensatory cognitive cortical control via the pre-frontal cortex (PFC), however the underlying neural mechanisms remain unclear. Establishing and using a robust methodology to examine PFC activity during continuous walking and turning via mobile functional near infra-red spectroscopy (fNIRS) may aid in the understanding of mobility deficits and help with development of appropriate therapeutics. This study aimed to: (1) examine test re-test reliability of PFC activity during continuous turning and walking via fNIRS measurement; and (2) compare PFC activity during continuous turning and walking in young, old and Parkinson's subjects. Methods: Twenty-five young (32.3 ± 7.5 years), nineteen older (65.4 ± 7.0 years), and twenty-four PD (69.3 ± 4.1 years) participants performed continuous walking and 360° turning-in-place tasks, each lasting 2 min. Young participants repeated the tasks a second time to allow fNIRS measurement reliability assessment. The primary outcome was PFC activity, assessed via measuring changes in oxygenated hemoglobin (HbO2) concentrations. Results: PFC activity during continuous walking and turning was moderately reproducible (Intra-class correlation coefficient = 0.67). The PD group had higher PFC activation than young and older adults during walking and turning, with significant group differences for bilateral PFC activation (p = 0.025), left PFC activation (p = 0.012), and the early period (first 40 s) of walking (p = 0.007), with greater activation required in PD. Interestingly, older adults had similar PFC activation to young adults across conditions, however older adults required greater activation than young adults during continuous turning, specifically the early period of the turning task (Cohens d = 0.86). Conclusions: PFC activity can be measured during continuous walking and turning tasks with acceptable reliability, and can differentiate young, older and PD groups. PFC activation was significantly greater in PD compared to young and older adults during walking, particularly when beginning to walk.

Freezing of gait, defined as sudden and usually brief episodes of inability to produce effective stepping, often results in falls and is both disabling and common in parkinsonism. In this narrative review, sprung from the 2nd International Workshop on freezing of gait in Leuven, we summarize the latest insights into clinical and methodological challenges for assessing freezing of gait. We also highlight the role of emerging wearable technology to improve the management of this debilitating symptom. © 2019 International Parkinson and Movement Disorder Society. ispartof: MOVEMENT DISORDERS vol:34 issue:6 pages:783-790 ispartof: location:United States status: published

Background A precise understanding of the neuronal circuits involved in the control of anticipatory postural adjustments (APAs) for gait initiation is missing. Neurostimulation in Parkinson's disease (PD) provides a method of modulating APAs to gain insight into the underlying circuitry. Objective Our objective was to investigate if APA kinematics for step initiation could be modulated by high frequency stimulation of the subthalamic nucleus (STN) or substantia nigra pars reticulata (SNr) in people with PD and freezing of gait (FoG). Methods We studied 14 people with PD and FoG using neurostimulation of the STN and SNr areas after overnight withdrawal of dopaminergic medication on the instrumented stand and walk test. We tested patients in the following randomized conditions: ‘off stimulation’, ‘STN’ stimulation (only), and ‘SNr’ stimulation (only). Patients were blinded to the stimulation condition. The APAs were recorded with inertial sensors and processed offline. Moreover, we assessed clinical scores with respect to motor symptoms, non-motor symptoms, executive function, and FoG. Results SNr but not STN stimulation modulated the anterio-posterior size of APA. The SNr modulation of APA was associated with the stimulation effect on FoG (trend; r = 0.580, P = 0.102). The APA modulation was not correlated with any other cognitive or clinical measures. Conclusion Neuromodulation of the SNr but not of the STN modulated APAs in PD patients with FoG. The different effects of STN or SNr on the kinematic parameters of APA support the concept of segregate targets in order to address diverse kinematic components of PD gait.

Background Body-worn, inertial sensors can provide many objective measures of balance and gait. However, the objective measures that best reflect patient perception of mobility disability and clinician assessment of Parkinson disease (PD) are unknown. Objective The purposes of this study were: (1) to determine which objective measures of balance and gait are most related to patient perception of mobility disability and disease severity in people with PD and (2) to examine the effect of levodopa therapy on these correlates. Design This was an experimental correlation study. Methods One hundred four people with idiopathic PD performed 3 trials of the Instrumented Stand and Walk Test (ISAW) in the “on” and “off” medication states. The ISAW consists of quiet standing (30 seconds), gait initiation, straight walking (7 m), and turning (180°), yielding 34 objective measures of mobility from body-worn inertial sensors. Patient perception of mobility disability was assessed with the Activities-specific Balance Confidence (ABC) scale and the mobility subscale of the Parkinson's Disease Questionnaire (PDQ-39). Disease severity was assessed with the Unified Parkinson's Disease Rating Scale, part III (motor UPDRS). Spearman correlations were used to relate objective measures of mobility to patient perception and disease severity. Results Turning speed, gait speed, and stride length were most highly correlated to severity of disease and patient perception of mobility disability. The objective measures of mobility in the off-medication state were more indicative of patient perception of mobility disability and balance confidence compared with on-medication state measures. Limitations Causation is an inherent problem of correlation studies. Conclusion Physical therapists should evaluate mobility in people with PD in the off-medication state because the off-medication state is more related to disease severity and patient perception of mobility disability than the on-medication state mobility. Assessment and treatment of mobility in people with PD should target specific measures (ie, turning, gait speed, and stride length) because these measures best reflect patients' quality of life and balance confidence.

This paper presents an experimental work about the design of a truss roof for a long-spanbuilding. This study makes use of an innovative hybrid truss that has been developed in a parallelstudy. The project presented herein shows the direct application of the technology on an existingbuilding, emphasizing its feasibility, potentiality and functionality. The paper highlights thecharacteristic of adaptability to both newly designed buildings and existing ones. Starting from thetruss prototype, different shape configurations that the technology allows are hypothesized. Thefinal roof shape is selected based on study aiming at optimizing the elements sections.

Altered postural control and balance are major disabling issues of Parkinson's disease (PD). Static and dynamic posturography have provided insight into PD's postural deficits; however, little is known about impairments in postural coordination. We hypothesized that subjects with PD would show more ankle strategy during quiet stance than healthy control subjects, who would include some hip strategy, and this stiffer postural strategy would increase with disease progression. We quantified postural strategy and sway dispersion with inertial sensors (one placed on the shank and one on the posterior trunk at L5 level) while subjects were standing still with their eyes open. A total of 70 subjects with PD, including a mild group (H&Y≤2, N=33) and a more severe group (H&Y≥3, N=37), were assessed while OFF and while ON levodopa medication. We also included a healthy control group (N=21). Results showed an overall preference of ankle strategy in all groups while maintaining balance. Postural strategy was significantly lower ON compared to OFF medication (indicating more hip strategy), but no effect of disease stage was found. Instead, sway dispersion was significantly larger in ON compared to OFF medication, and significantly larger in the more severe PD group compared to the mild. In addition, increased hip strategy during stance was associated with poorer self-perception of balance.

OBJECTIVES: Optimal balance control requires a complex integration of sensory information from the visual, vestibular and proprioceptive systems. The goal of this study was to determine if the instrumented modified Clinical Test of Sensory Integration and Balance (mCTSIB) was impaired acutely after mild traumatic brain injury (mTBI) when postural sway under varying sensory conditions was measured with a wearable inertial sensor. METHODS: Postural sway was assessed in athletes who had sustained a mTBI within the past 2–3 days (n=38) and control athletes (n=81). Postural sway was quantified with a wearable inertial sensor (Opal; APDM, Inc.) during four varying sensory conditions of quiet stance: 1) eyes open (EO) firm surface, 2) eyes closed (EC) firm surface, 3) eyes open (EO) foam surface and 4) eyes closed (EC) foam surface. Sensory reweighting deficits were computed by comparing the postural sway area in eyes closed versus eyes open conditions for firm and foam condition. RESULTS: Postural sway was higher for mTBI compared to the control group during three of the four conditions of instrumented mCTSIB (EO firm, EC Firm and EC foam; p

Turning impairments are common in Parkinson’s disease (PD) and can elicit freezing of gait (FoG). Extensive examination of open-loop cueing interventions has demonstrated that they can ameliorate gait deficits in PD; less is known about efficacy to improve turning. Here, we investigate the immediate effectiveness of open- and closed-loop cueing in improving turning characteristics in people with PD. Twenty-five subjects with and 18 subjects without FoG participated in the study. Subjects turned in place for one minute under single- and dual-task for 3 randomized conditions: (i) Baseline; (ii) Turning to the beat of a metronome (open-loop); and (iii) Turning with phase-dependent tactile biofeedback (closed-loop). Objective measures of freezing, such as % time spent freezing and FoG-ratio, significantly improved when turning with both open-loop and closed-loop cueing compared to baseline. Dual-tasking did not worsen FoG in freezers, but significantly slowed down turns in both groups. Both cueing modalities significantly improved turning smoothness in both groups, but reduced turning velocity and number of turns compared to baseline. Both open and closed-loop cueing markedly improved turning in people with PD. These preliminary observations warrant further exploration of vibrotactile closed-loop cueing to improve mobility in everyday life.

This pilot study investigated the impact of freezing of gait, objectively measured with three inertial sensors, on mobility function during seven days of community-living monitoring in people with Parkinson’s disease. Twenty-four subjects with PD, of which 14 experiencing freezing of gait, were recruited in this study. Subjects wore three inertial sensors (Opals, APDM) attached to both feet and the lumbar region for a week of continuous monitoring. Walking bouts, of at least 10s, were first identified, and then features of freezing, quantity and quality of mobility were extracted and averaged across the seven days. Results showed significant impairments in freezing and quality of mobility in the freezers group compared to the non-freezers. Our measures of average and variability of time spent freezing was associated to the subjects’ perception of freezing, assessed with the New Freezing of Gait Questionnaire. These preliminary results are introducing promising measures of mobility impairments measured during community-living in PD.

Background Protective stepping after a loss of balance is related to falls. Anticipatory postural responses (APAs) prior to protective stepping can impact step performance, may be larger in people with PD, and have been suggested to be related to freezing of gait (FOG). However, whether people with PD and FOG (PD + FOG) exhibit larger APAs than people with PD and no FOG (PD-FOG) is unknown. Research Question: Determine the impact of freezing status on APAs prior to protective steps, thus providing a better understanding of the link between FOG and APAs. Methods Twenty-eight people with PD (13 PD + FOG) were exposed to 50 support surface translations (25 forward, 25 backward, random order) resulting in protective steps. The size of medio-lateral weight shifts prior to the protective step (i.e. APAs), and the percentage of trials with an APA were calculated via force-plates. FOG status was assessed at the time of testing as well as 3.25(+/-0.43) years later. Participants without FOG at testing, but with FOG at follow-up were identified as “converters”. Results and significance For both forward and backward protective stepping, size and percentage trials with an APA were not statistically different between PD + FOG and PD-FOG, even after excluding converters from the PD-FOG group (p > 0.27 for all). No group by direction interactions were observed. These data suggest that, in mild to moderate PD, an inability to couple APAs with stepping, rather than an inappropriately sized APA, may be most related to freezing of gait.

Difficulty in turning while walking is common among patients with Parkinson’s disease (PD). This difficulty often leads to significant disability, falls, and loss of function; moreover, turning is a common trigger for freezing of gait (FoG). We hypothesized that the quantity and quality of turning mobility while walking during daily life would be different among subjects with PD with and without FoG. Here, we investigated, for the first time, the turning quality during daily life as it relates to FoG in people with PD using a single inertial sensor. Ninety-four subjects with PD (among whom 25 had FoG) wore an inertial sensor attached by a belt on the lower back during normal daily activity consecutively for 3 days. An algorithm identified periods of walking and calculated the number and quality metrics of turning. Quality, but not the quantity, of turning at home was different in freezers compared to the non-freezers. The number of turns (19.3 ± 9.2/30 min in freezers, 22.4 ± 12.9/30 min non-freezers; p = 0.194) was similar in the two groups. Some aspects of quality of turns, specifically mean jerkiness, mean and variability of medio-lateral jerkiness were significantly higher (p

Freezing of gait (FoG) is often described in subjects with Parkinson's disease (PD) as a sudden inability to continue the forward walking progression. FoG occurs most often during turning, especially at sharp angles. Here, we investigated 180 and 360 degrees turns in two groups: PD subjects reporting FoG (FoG+), and PD subjects without FoG (FoG-). Forty-three subjects (25 FoG+, 18 FoG-) wore an inertial sensor on their back while walking back and forth continuously for 2 min (reversing direction with a 180° turn), and while turning in place for 1 min (alternating 360° turning in opposite directions). Objective measures (turn duration, peak velocity, jerkiness and range of acceleration) were computed during the turns and compared across FoG+ and FoG-groups. Results showed that FoG+ compared to FoG-took significantly a longer time to complete 360° turns than 180° turns. A significant lower turn peak velocity, higher jerkiness and an increased range of medio-lateral acceleration was also found in FoG+. Significant differences between the two groups across the two turning tasks validated the hypothesis that sharper turns might cause higher instability in FoG+ compared to FoG-.

Background Difficulty turning during gait is a major contributor to mobility disability, falls and reduced quality of life in patients with Parkinson's disease (PD). Unfortunately, the assessment of mobility in the clinic may not adequately reflect typical mobility function or its variability during daily life. We hypothesized that quality of turning mobility, rather than overall quantity of activity, would be impaired in people with PD over seven days of continuous recording. Methods Thirteen subjects with PD and 8 healthy control subjects of similar age wore three Opal inertial sensors (on their belt and on each foot) throughout seven consecutive days during normal daily activities. Turning metrics included average and coefficient of variation (CV) of: (1) number of turns per hour, (2) turn angle amplitude, (3) turn duration, (4) turn mean velocity, and (5) number of steps per turn. Turning characteristics during continuous monitoring were compared with turning 90 and 180 degrees in a observed gait task. Results No differences were found between PD and control groups for observed turns. In contrast, subjects with PD showed impaired quality of turning compared to healthy control subjects (Turn Mean Velocity: 43.3 ± 4.8°/s versus 38 ± 5.7°/s, mean number of steps 1.7 ± 1.1 versus 3.2 ± 0.8). In addition, PD patients showed higher variability within the day and across days compared to controls. However, no differences were seen between PD and control subjects in the overall activity (number of steps per day or percent of the day walking) during the seven days. Conclusions We show that continuous monitoring of natural turning during daily activities inside or outside the home is feasible for patients with PD and the elderly. This is the first study showing that continuous monitoring of turning was more sensitive to PD than observed turns. In addition, the quality of turning characteristics was more sensitive to PD than quantity of turns. Characterizing functional turning during daily activities will address a critical barrier to rehabilitation practice and clinical trials: objective measures of mobility characteristics in real-life environments.

The effects of levodopa on balance and gait function in people with Parkinson's disease (PD) is controversial. This study compared the relative responsiveness to l-dopa on six domains of balance and gait: postural sway in stance; gait pace; dynamic stability; gait initiation; arm swing; and turning in people with mild and severe PD, with and without dyskinesia. We studied 104 subjects with idiopathic PD (H & Y II [n = 52] and III-IV [n = 52]) and 64 age-matched controls. Subjects performed a mobility task in the practical off state and on l-dopa: standing quietly for 30 seconds, initiating gait, walking 7 meters, and turning 180 degrees. Thirty-four measures of mobility were computed from inertial sensors. Standardized response means were used to determine relative responsiveness to l-dopa. The largest improvements with l-dopa were found for arm swing and pace-related gait measures. Gait dynamic stability was unaffected by PD and not responsive to l-dopa. l-dopa reduced turning duration, but only in subjects with severe PD. In contrast to gait, postural sway in quiet standing increased with l-dopa, especially in the more severely affected subjects. The increase in postural sway, as well as decrease in turning duration and exaggerated arm swing with l-dopa was observed only for subjects with dyskinesia at the time of testing. The observed spectrum of l-dopa responsiveness in balance and gait measures suggests that multiple neural circuits control balance and gait. Many of the negative effects of l-dopa may be directly or indirectly caused by dyskinesia. © 2015 International Parkinson and Movement Disorder Society. Language: en

This perspective article will discuss the potential role of body-worn movement monitors for balance and gait assessment and treatment in rehabilitation. Recent advances in inexpensive, wireless sensor technology and smart devices are resulting in an explosion of miniature, portable sensors that can quickly and accurately quantify body motion. Practical and useful movement monitoring systems are now becoming available. It is critical that therapists understand the potential advantages and limitations of such emerging technology. One important advantage of obtaining objective measures of balance and gait from body-worn sensors is impairment-level metrics characterizing how and why functional performance of balance and gait activities are impaired. Therapy can then be focused on the specific physiological reasons for difficulty in walking or balancing during specific tasks. A second advantage of using technology to measure balance and gait behavior is the increased sensitivity of the balance and gait measures to document mild disability and change with rehabilitation. A third advantage of measuring movement, such as postural sway and gait characteristics, with body-worn sensors is the opportunity for immediate biofeedback provided to patients that can focus attention and enhance performance. In the future, body-worn sensors may allow therapists to perform telerehabilitation to monitor compliance with home exercise programs and the quality of their natural mobility in the community. Therapists need technological systems that are quick to use and provide actionable information and useful reports for their patients and referring physicians. Therapists should look for systems that provide measures that have been validated with respect to gold standard accuracy and to clinically relevant outcomes such as fall risk and severity of disability.

Balance task performance is affected in persons with multiple sclerosis (PwMS), but the control strategies used to perform specific tasks are not well understood. The purpose of this study was to evaluate segmental control during quiet standing in PwMS and controls to understand whether MS alters use of the ankle and hip strategies to manage postural sway. Coherence of acceleration between the trunk and legs was evaluated with accelerometers placed on the sacrum and lower leg. Thirty-six PwMS and 20 healthy control subjects performed quiet standing with eyes open and closed while center of pressure (CoP) and acceleration of postural sway was measured. Acceleration frequencies were divided into lower frequencies (≤1.0 Hz) and higher frequencies (>1.0 Hz) to categorize sway characteristics. With eyes open, coherence was significantly lower in PwMS compared to controls at lower frequencies only. With eyes closed, coherence was significantly lower in PwMS compared to controls, who use an ankle strategy at lower frequencies only, at both lower and higher frequencies. Both groups showed decreased coherence with increasing frequency when eyes were open and closed. Coherence was significantly correlated with CoP sway area in PwMS during the eyes closed condition only. The reduced coherence in PwMS during both lower and higher frequency sway indicates PwMS utilize a mixed ankle-hip sway strategy regardless of sway frequency. This is in contrast to sway in healthy subjects which utilizes an ankle strategy at lower frequencies and a mixed strategy at higher frequencies. Lack of adaptability in segmental control strategy likely contributes to abnormal postural control, as reflected by CoP sway patterns, in PwMS.

To determine whether spatial auditory cues provided by cochlear implants can improve postural balance in adults with severe deafness.In the presence of spatial white noise, 13 adult cochlear implantees wore head and lumbar-mounted inertial sensors while standing in the dark for 30 seconds in two auditory conditions: hearing assistive devices on and off.Stability was improved with implants on (aided condition) compared to off (unaided condition) with respect to differences in mean head velocity (Cohen's d = 0.912, P = 0.006) as well as to root mean square (RMS) acceleration (Cohen's d = 0.456, P = 0.048). This was particularly evident in measures of anteroposterior accelerations (mean difference = 0.034 m/sThe decrease in RMS head acceleration and velocity while wearing cochlear implants suggests that they could be recognized as balance implants in addition to auditory implants. The clinical importance of this finding in various patient populations remains to be determined.4. Laryngoscope, 128:1676-1680, 2018.

BACKGROUND: The goal of this study was to validate an objective method of measuring levodopa induced dyskinesia in Parkinson's disease (PD). METHODS: To characterize agreement between the clinician‐based measure and a force plate, we assessed dyskinesia in PD subjects participating in a randomized and blinded clinical trial of an adenosine A2A anatagonist. Convergent validity and intra‐class correlations were evaluated between the objective force plate measure and clinician assessments. RESULTS: All measures correlated across time and detected differences in treatments. CONCLUSION: Our results indicate that objective measure from a force plate is in scale agreement with clinical ratings of dyskinesia severity, indicating it as a reliable method to measure LID objectively but with greater resolution to detect changes in LID.

Made available in DSpace on 2018-12-11T17:32:29Z (GMT). No. of bitstreams: 0 Previous issue date: 2017-07-01 National Institutes of Health Freezing of gait (FoG) is associated with less automatic gait and more impaired cognition, balance and postural transitions compared to people with PD who do not have FoG. However, it is unknown whether dual-task cost during postural sway, postural transitions (such as gait initiation and turning), and gait are more in subjects with Parkinson's disease (PD) who have freezing of gait (FoG+) compared to those who do not have FoG (FoG−). Here, we hypothesized that the effects of a cognitive dual task on postural sway, postural transitions and gait would be larger in FoG+ than FoG−. Thirty FoG− and 24 FoG+ performed an Instrumented Stand and Walk test in OFF medication state, with and without a secondary cognitive task (serial subtraction by 3s). Measures of postural sway, gait initiation, turning, and walking were extracted using body-worn inertial sensors. FoG+ showed significantly larger dual task cost than FoG− for several gait metrics, but not during postural sway or postural transitions. During walking, FoG+ exhibited a larger dual task cost than FoG− resulting in shorter stride length and slower stride velocity. During standing, FoG+ showed a larger postural sway compared to FoG− and during gait initiation, FoG+, but not FoG−, showed a longer first step duration during the dual-task condition compared to single-task condition (interaction effect, p = 0.04). During turning, both groups showed a slower turn peak speed in the dual-task condition compared to single task condition. These findings partly support our hypothesis that dual task cost on walking is greater in FoG+ than FoG−. Bioscience Institute São Paulo State University (UNESP) Department of Neurology School of Medicine Oregon Health & Science University, 3181 Sam Jackson Park Road Department of Research Portland VA Medical Center, 3710 SW US Veterans Hospital Rd Department of Physiotherapy São Paulo State University (UNESP) Department of Physical Education São Paulo State University (UNESP) Bioscience Institute São Paulo State University (UNESP) Department of Physiotherapy São Paulo State University (UNESP) Department of Physical Education São Paulo State University (UNESP) National Institutes of Health: 2R01 AG006457

Balance assessment is an integral component of concussion evaluation and management. Although the modified balance error scoring system (mBESS) is the conventional clinical tool, objective metrics derived from wearable inertial sensors during the mBESS may increase sensitivity in detecting subtle balance deficits post-concussion. The aim of this study was to identify which stance condition and postural sway metrics obtained from an inertial sensor placed on the lumbar spine during the mBESS best discriminate athletes with acute concussion. Fifty-two college athletes in the acute phase of concussion and seventy-six controls participated in this study. Inertial sensor-based measures objectively detected group differences in the acutely concussed group of athletes while the clinical mBESS did not (p

Introduction Optimal balance control requires a complex integration of sensory information from the visual, vestibular, and proprioceptive systems. The goal of this study is to determine if the instrumented modified Clinical Test of Sensory Integration and Balance (mCTSIB) was impaired acutely after mild traumatic brain injury (mTBI) when postural sway under varying sensory conditions was measured with a wearable inertial sensor. Materials and Methods Postural sway was assessed in athletes who had sustained a mTBI within the past 2-3 d (n = 38) and control athletes (n = 81). Postural sway was quantified with a wearable inertial sensor (Opal; APDM, Inc.) during four varying sensory conditions of quiet stance: (1) eyes open (EO) firm surface, (2) eyes closed (EC) firm surface, (3) eyes open (EO) foam surface, and (4) eyes closed (EC) foam surface. Sensory reweighting deficits were computed by comparing the postural sway area in eyes closed versus eyes open conditions for firm and foam condition. Results Postural sway was higher for mTBI compared with the control group during three of the four conditions of instrumented mCTSIB (EO firm, EC firm, and EC foam; p < 0.05). Sensory reweighting deficits were evident for mTBI individuals compared with control group on foam surface (EC firm vs EO firm; p < 0.05) and not on firm surface (EC firm vs EO firm; p = 0.63). Conclusions The results from this study highlight the importance of detecting postural sway deficits during sensorimotor integration in mild TBI individuals.

Introduction Progressive supranuclear palsy (PSP) is characterized by early postural instability and backward falls. The mechanisms underlying backward postural instability in PSP are not understood. The aim of this study was to test the hypothesis that postural instability in PSP is a result of dysfunction in the perception of postural verticality. Methods We gathered posturography data on 12 subjects with PSP to compare with 12 subjects with idiopathic Parkinson’s Disease (PD) and 12 healthy subjects. Objective tests of postural impairment included: dynamic sensory perception tests of gravity and of surface oscillations, postural responses to surface perturbations, the sensory organization test of postural sway under altered sensory conditions and limits of stability in stance. Results Perception of toes up (but not toes down) surface tilt was reduced in subjects with PSP compared to both control subjects (p≤0.001 standing, p≤0.007 seated) and subjects with PD (p≤0.03 standing, p≤0.04 seated). Subjects with PSP, PD and normal controls accurately perceived the direction of gravity when standing on a tilting surface. Unlike PD and control subjects, subjects with PSP exerted less postural corrective torque in response to toes up surface tilts. Discussion Difficulty perceiving backward tilt of the surface or body may account for backward falls and postural impairments in patients with PSP. These observations suggest that abnormal central integration of sensory inputs for perception of body and surface orientation contributes to the pathophysiology of postural instability in PSP.

People with Parkinson’s disease (PD) typically demonstrate impaired anticipatory postural adjustments (APAs) that shift the body center of mass forward (imbalance) and over the stance leg (unloading) prior to gait initiation. APAs are known to be smallest when people with PD are in their OFF-medication state compared to ON-medication or healthy controls. The aim of this pilot study is to validate a previously developed method for the assessment of gait initiation on PD patients in OFF state with body-worn, inertial sensors. Ten subjects with mild-to-moderate idiopathic PD and twelve healthy controls of similar age performed three gait initiation trials. The spatio-temporal parameters of APAs were extracted from three wearable sensors, placed on the shins and on the lower back, and validated with two force plates. Temporal parameters extracted from sensors and force plates, as well as the trunk medio-lateral acceleration and the correspondent displacement of the center of pressure, were significantly correlated. Subjects with PD showed hypometric adjustments in the medio-lateral direction (p-value < 0.003) and increased duration of the unloading phase (p-value = 0.04). The unloading phase was significantly longer than the imbalance (p-value = 0.003) only in subjects with PD. The validity of the method of quantifying APAs from inertial sensors was confirmed in PD subjects by comparison with force plates. Sensitivity in discriminating PD patients from healthy controls was proven by both spatial and temporal parameters. Objective measures of gait initiation deficits with wearable technology provides valuable instrument for the assessment of gait initiation in clinical environments.

Background Freezing of gait in people with Parkinson9s disease (PD) is likely related to attentional control (ie, ability to divide and switch attention). However, the neural pathophysiology of altered attentional control in individuals with PD who freeze is unknown. Structural connectivity of the pedunculopontine nucleus has been related to freezing and may play a role in altered attentional control; however, this relationship has not been investigated. We measured whether dual-task interference, defined as the reduction in gait performance during dual-task walking, is more pronounced in individuals with PD who freeze, and whether dual-task interference is associated with structural connectivity and/or executive function in this population. Methods We measured stride length in 13 people with PD with and 12 without freezing of gait during normal and dual-task walking. We also assessed asymmetry of pedunculopontine nucleus structural connectivity via diffusion tensor imaging and performance on cognitive tests assessing inhibition and set-shifting, cognitive domains related to freezing. Results Although stride length was not different across groups, change in stride length between normal and dual-task gait (ie, dual-task interference) was more pronounced in people with PD who freeze compared to non-freezers. Further, in people with PD who freeze, dual-task interference was correlated with asymmetry of pedunculopontine nucleus structural connectivity, Go-NoGo target accuracy (ability to release a response) and simple reaction time. Conclusions These results support the hypothesis that freezing is related to altered attentional control during gait, and suggest that differences in pedunculopontine nucleus connectivity contribute to poorer attentional control in people with PD who freeze.

Gait and balance deficits are a frequent complaint in MS but poorly captured by stopwatch-timed tests or rating scales. Body-worn accelerometers and gyroscopes are able to detect gait and balance abnormalities in people with MS who have normal walking speeds. Few longitudinal studies exist using this technology to study the evolution of mobility deficits. The purpose of this study was to determine if body-worn sensors detected any decline in gait and balance measures in people with MS over time. Twenty-seven people with MS (13 mildly disabled, Self-Rated Expanded Disability Status Scale 0 - 3.5; 14 moderately disabled, SR-EDSS 4.0 -5.5) who had normal walking speeds and 18 matched control subjects underwent gait and balance testing using body-worn sensors every 6 months for 18 months. While no parameter worsened over time, the moderately disabled MS cohort performed more poorly than the mildly disabled MS cohort who, in turn, were worse than control subjects for both objective and subjective walking and balance measures. Furthermore, the moderately disabled MS cohort demonstrated greater variation in between-visit performance than did the less disabled MS cohort or controls (Bonferroni-corrected p < 0.05). Variability may be a key indicator of worsening gait and balance disability in MS.

OBJECTIVE: To determine whether alterations to the Balance Error Scoring System (BESS), such as modified conditions and/or instrumentation, would improve the ability to correctly classify TBI status in patients with mild TBI with persistent self-reported balance complaints. DESIGN: A cross-sectional study. SETTING: An outpatient clinic in the Department of Rehabilitation Services at Oregon Health & Sciences University (OHSU). SUBJECTS: Thirteen subjects (age 16.3 ±2) with a recent history of concussion (mTBI group) and 13 demographically matched control subjects (age 16.7 ±2) (control group). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Outcome measures included the BESS, Modified BESS (Mod. BESS), Instrumented BESS (Instr. BESS), and Instrumented Modified BESS (Instr. Mod. BESS). All subjects were tested on the non-instrumented BESS and Mod. BESS, scored by visual observation of instability in six and three stance conditions, respectively. Instrumentation of these 2 tests utilized one inertial sensor (APDM-3D), with an accelerometer and gyroscope to quantify bi-directional body sway. RESULTS: Scores from the BESS and the Mod. BESS tests were similar between groups. However, results from the instrumented measures using the inertial sensor() were significantly different between groups. The Instr. Mod. BESS had superior diagnostic classification and the largest Area Under the Curve (AUC) when compared to the other balance measures. CONCLUSIONS: A concussion may disrupt the sensory processing required for optimal postural control, measured by sway during quiet stance. These results suggest that the use of portable inertial sensors() may be useful in the move towards more objective and sensitive measures of balance control post-concussion but more work is needed to increase sensitivity.

Objective: Gait provides a sensitive measurement for signs of aging and neurodegenerative conditions. Measurement of gait is transitioning from the laboratory environment to the clinic with the use of inertial measurement units, providing a simple and cost-effective assessment tool. However, such assessments first need validation against reference systems. The aim of this study was to validate the APDM Mobility Lab (ML) system (version 2) against a pressure sensor walkway in younger adults (n = 18), older adults (n = 18) and people with mild Parkinson's disease (n = 21) in the laboratory. Approach: Participants completed a two-minute walk over a pressure sensor walkway whilst wearing three sensors (strapped to the lumbar spine and both feet). Comparison of output from the systems was then performed. Main results: Overall, we identified that ML provided good to excellent agreement (ICC > 0.75) for gait velocity, stride length, stride length SD, cadence, stride time and stride time SD. Measures of double support time, single support time and swing time had moderate to poor agreement (ICC 0.213–0.725), particularly for younger adults and PD. Significance: Overall, Mobility Lab provides a valid system for gait data collection for clinical and research application.

Balance and gait impairments characterize the progression of Parkinson's disease (PD), predict the risk of falling, and are important contributors to reduced quality of life. Advances in technology of small, body-worn, inertial sensors have made it possible to develop quick, objective measures of balance and gait impairments in the clinic for research trials and clinical practice. Objective balance and gait metrics may eventually provide useful biomarkers for PD. In fact, objective balance and gait measures are already being used as surrogate endpoints for demonstrating clinical efficacy of new treatments, in place of counting falls from diaries, using stop-watch measures of gait speed, or clinical balance rating scales. This review summarizes the types of objective measures available from body-worn sensors. The metrics are organized based on the neural control system for mobility affected by PD: postural stability in stance, postural responses, gait initiation, gait (temporal-spatial lower and upper body coordination and dynamic equilibrium), postural transitions, and freezing of gait. However, the explosion of metrics derived by wearable sensors during prescribed balance and gait tasks, which are abnormal in individuals with PD, do not yet qualify as behavioral biomarkers, because many balance and gait impairments observed in PD are not specific to the disease, nor have they been related to specific pathophysiologic biomarkers. In the future, the most useful balance and gait biomarkers for PD will be those that are sensitive and specific for early PD and are related to the underlying disease process.

People with Parkinson's disease (PD) suffer from progressive impairment in their mobility. Locomotor and balance dysfunction that impairs mobility in PD is an important cause of physical and psychosocial disability. The recognition and evaluation of balance dysfunction by the clinician are an essential component of managing PD. In this review, we describe a framework for understanding balance dysfunction in PD to help clinicians recognize patients who are at risk for falling and impaired mobility.

Freezing of gait is one of the most debilitating symptoms in Parkinson’s disease as it causes falls and reduces mobility and quality of life. The pedunculopontine nucleus is one of the major nuclei of the mesencephalic locomotor region and has neurons related to anticipatory postural adjustments preceding step initiation as well as to the step itself, thus it may be critical for coupling posture and gait to avoid freezing. Because freezing of gait and postural impairments have been related to frontal lesions and frontal dysfunction such as executive function, we hypothesized that freezing is associated with disrupted connectivity between midbrain locomotor regions and medial frontal cortex. We used diffusion tensor imaging to quantify structural connectivity of the pedunculopontine nucleus in patients with Parkinson’s disease with freezing of gait, without freezing, and healthy age-matched controls. We also included behavioural tasks to gauge severity of freezing of gait, quantify gait metrics, and assess executive cognitive functions to determine whether between-group differences in executive dysfunction were related to pedunculopontine nucleus structural network connectivity. Using seed regions from the pedunculopontine nucleus, we were able to delineate white matter connections between the spinal cord, cerebellum, pedunculopontine nucleus, subcortical and frontal/prefrontal cortical regions. The current study is the first to demonstrate differences in structural connectivity of the identified locomotor pathway in patients with freezing of gait. We report reduced connectivity of the pedunculopontine nucleus with the cerebellum, thalamus and multiple regions of the frontal cortex. Moreover, these structural differences were observed solely in the right hemisphere of patients with freezing of gait. Finally, we show that the more left hemisphere-lateralized the pedunculopontine nucleus tract volume, the poorer the performance on cognitive tasks requiring the initiation of appropriate actions and/or the inhibition of inappropriate actions, specifically within patients with freezing. These results support the notion that freezing of gait is strongly related to structural deficits in the right hemisphere’s locomotor network involving prefrontal cortical areas involved in executive inhibition function.

Background. It is widely believed that exercise improves mobility in people with Parkinson’s disease (PD). However, it is difficult to determine whether a specific type of exercise is the most effective. The purpose of this study was to determine which outcome measures were sensitive to exercise intervention and to explore the effects of two different exercise programs for improving mobility in patients with PD.Methods. Participants were randomized into either the Agility Boot Camp (ABC) or treadmill training; 4x/week for 4 weeks. Outcome measures were grouped by the International Classification of Function/Disability (ICF). To determine the responsiveness to exercise, we calculated the standardized response means.t-tests were used to compare the relative benefits of each exercise program.Results. Four of five variables at the structure/function level changed after exercise: turn duration (P=0.03), stride velocity (P=0.001), peak arm speed (P=0.001), and horizontal trunk ROM during gait (P=0.02). Most measures improved similarly for both interventions. The only variable that detected a difference between groups was postural sway in ABC group (F=4.95;P=0.03).Conclusion. Outcome measures at ICF body structure/function level were most effective at detecting change after exercise and revealing differences in improvement between interventions.

In this feasibility study, we present a novel, wearable prototype of tactile biofeedback to alleviate gait disturbances, such as freezing of gait in Parkinson's disease. We designed and tested a phase-dependent tactile biofeedback system that can be easily worn on the feet, with a simple switch to turn it on or off. Preliminary validation was performed in 8 subjects with Parkinson's disease who show freezing during a turning in place test. A metronome, control condition was used to compare effectiveness in alleviating freezing. Promising results were obtained, both in term of acceptability of the device, and improving motor performance.

Objective\ud 1) To identify patient barriers to help-seeking for non-motor symptoms (NMS) from their Parkinson’s healthcare provider,\ud 2) To determine whether barriers are symptom specific (e.g. embarrassment disclosing sexual problems) or patient specific (e.g. misattribution of a range of NMS to old age).\ud \ud Background\ud NMS are common in Parkinson’s disease (PD) and cause significant distress and decreased quality of life. A high rate of non-declaration of NMS by patients to healthcare providers means that many NMS remain unrecognized and untreated, even in specialist clinical services. Current understanding of the factors preventing disclosure of NMS to healthcare professions is limited.\ud \ud Method\ud 358 PD patients completed the Non-motor Symptom Questionnaire and a barriers to help-seeking for NMS questionnaire developed from previous qualitative work. A Generalised Estimating Equation was used to determine whether barriers were symptom or individual specific.\ud \ud Results\ud The sample had a mean age of 66.3 years, mean disease duration of 5.9 years and were 52.5% male. Urinary urgency was the most common NMS (65%) and sexual dysfunction was the symptom most frequently not disclosed (52%). Barriers to symptom disclosure varied dependent on symptom type. Pain and sleep problems were commonly not thought to be symptoms of PD. Bowel and bladder symptoms were often simply accepted as part of daily life and participants were unsure about the availability of effective treatments. Patients experienced embarrassment discussing sexual dysfunction.\ud \ud Conclusion\ud Our results highlight the barriers which prevent PD patients reporting NMS to their Parkinson’s clinical team and the diversity of these barriers between different NMS. Strategies to improve rates of reporting must target individual NMS. For example, effective interventions might provide information regarding treatment efficacy for bowel and bladder symptoms or develop communication skills and normalising information for sexual dysfunction. The study provides the information needed to develop such individualised interventions. Increasing rates of disclosure of NMS by patients to their Parkinson’s healthcare providers will ensure patients receive appropriate clinical care which may increase quality of life and well-being.

none 7 si Published online: 27 December 2013 Difficulty with turning is a major contributor to mobility disability and falls in people with movement disorders, such as Parkinson's disease (PD). Turning often results in freezing and/or falling in patients with PD. However, asking a patient to execute a turn in the clinic often does not reveal their impairments. Continuous monitoring of turning with wearable sensors during spontaneous daily activities may help clinicians and patients determine who is at risk of falls and could benefit from preventative interventions. In this study, we show that continuous monitoring of natural turning with wearable sensors during daily activities inside and outside the home is feasible for people with PD and elderly people. We developed an algorithm to detect and characterize turns during gait, using wearable inertial sensors. First, we validate the turning algorithm in the laboratory against a Motion Analysis system and against a video analysis of 21 PD patients and 19 control (CT) subjects wearing an inertial sensor on the pelvis. Compared to Motion Analysis and video, the algorithm maintained a sensitivity of 0.90 and 0.76 and a specificity of 0.75 and 0.65, respectively. Second, we apply the turning algorithm to data collected in the home from 12 PD and 18 CT subjects. The algorithm successfully detects turn characteristics, and the results show that, compared to controls, PD subjects tend to take shorter turns with smaller turn angles and more steps. Furthermore, PD subjects show more variability in all turn metrics throughout the day and the week. © 2013 by the authors; licensee MDPI, Basel, Switzerland. open Mahmoud El-Gohary; Sean Pearson; James McNames; Martina Mancini; Fay Horak; Sabato Mellone; Lorenzo Chiari Mahmoud El-Gohary; Sean Pearson; James McNames; Martina Mancini; Fay Horak; Sabato Mellone; Lorenzo Chiari