Medical Studies

Direct feedback to improve mobility and posture with optional physical activity monitoring logging

C.J.T. de Goede MSc – Physical Therapist, movement scientist ctj.degoede@vumc.nl
E. van Wegen PhD – Research coordinator, movement scientist e.vanwegen@vumc.nl
Department of Rehabilitation, VU University Medical Center, Amsterdam, the Netherlands

Stooped posture, a forward bent position of the trunk and head, is one of the characteristicmotor symptoms of patients with Parkinson’s disease (Selby G., 1968). Data regarding the prevalence of stooped posture is lacking, but recent studies indicate that 30-35% of Parkinson patients have pronounced stooped posture.(Muslimovic et al., 2008,Nieuwboer et al., 2007,Post et al., 2007).
This postural deficit is less susceptible to drug therapy and can impair the patients’ ability to walk and perform other daily activities, hereby significantly impacting quality of life (Bartolo et al., 2010); (Benatru et al., 2008)
One of the disadvantages of existing rehabilitative therapy programs is that they are mostly applied and evaluated in an outpatient clinical setting. However in the home environment, patients are not often aware of their stooped posture and there is a lack of feedback. Trying to solve this problem 2M Engineering Ltd and VUmc developed an ambulatory feedback device, which can be used in the home situation. The device monitors the postural (trunk) angle and gives immediate feedback with a sensory cue when the trunk angle exceeds a threshold value.
This vibration cue triggers attention and the patient can actively correct his stooped posture. The main objective is of this pilot study was to test the efficacy, practical utility and user-friendliness of a trunk angle sensor and feedback device UPRIGHT, 2M Engineering Ltd) in the home setting of patients with Parkinson’s disease with a stooped posture. Ultimately, the aim is to use the device in a regular therapeutic setting.

Study population

Sixteen patients with idiopathic PD were recruited from the neurology outpatient clinic of the VU University medical center (VUmc), Amsterdam, the Netherlands. All patients gave their written consent to participate and met the following inclusion criteria: (a) diagnosed with idiopathic PD; (b) Hoehn & Yahr stage 1-3; (c) stooped posture as major motor symptom, indicated in item 28 ≥ 2 from the Unified Parkinson’s Disease Rating Scale (UPDRS); (d) postural abnormality which can be actively corrected; (e) sufficient cognitive function, confirmed by a neurologist; (f) absence of relevant co morbidities; (g) stable medication use.

Study design

The STOPA project is an experimental pilot study: a repeated measurements single subject design (AB) with assessments before and after a baseline period (A) and intervention period (B), where the participants serve as their own control. The efficacy, practical utility and user-friendliness of the UPRIGHT were investigated during a period of two weeks (baseline period: week 1; intervention period: week 2) in the patient’s home situation. All measurements (M1, M2, M3) were performed in the home as well.
In the intervention period (week 2) the device gave a sensory cue in the form of a vibration feedback signal to the patient, if the trunk angle exceeded a predetermined threshold value. The threshold angle (10°-20°) was determined specific to each patient, depending on the their abilities to correct the posture and react to the feedback signal. The assessors instructed the patients a how they could consciously correct the posture in response to the feedback signal.

Results

15 patients completed the protocol, 13 males, mean age 70.1 ( ±8.7) years, median H&Y stage 2.5, with mean disease duration of 8.6 ( ±4.8) years. Mean UPDRS motor score was 25.8 (±10.4) and mean UPDRS Posture score (item 28) 2.1 ( ±0.43). 3.3. Patient satisfaction measured with VAS scores for comfort, ease of use etc, ranged from 5.6 to 7.7 (0 =worst, 10 = best).
An overall statistically significant decrease in sagittal trunk angle of -5.4 degrees was observed from the baseline week to the intervention week (p < 0.01). 13 out of 15 patients (87%) showed a decrease in trunk angle ranging from -0.8 to -12.8 degrees (mean -6.7 degrees), while 2 patients (13%) had an increase in trunk angle with a range of 1.7 to 1.09 degrees (mean 1.8 degrees). All therapists responded very positively in the internet survey about using the UPRIGHT as an additional aid for their patients. Specifically, 100% of the respondents would advise patients to use the UPRIGHT.
14 out of 15 patients (93%) reported that they would use the device minimally 1-2 days per week. On ’acceptable price of the device in Euro’s’ 13 out of 15 patients (87%) reported they would be willing to pay for the device if it was available in stores. Wearing and using the device: In general the wearing comfort was scored sufficient, though about half of the patients noticed
at least some discomfort during activities and some patients complained about the strap. The new design of the device may eliminate these complaints. Almost all patients could easily use the device and the charger. One third of the patients thought the device too eye-catching, therefore the new design was made more neutral and smaller so that it is easier to wear under clothes.
Feedback signal: Altogether we conclude that there are clear indications that using the feedback has a positive effect the stooped posture of Parkinson patients and that the approach is in principle feasible for use in patients with Parkinson’s Disease.

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

A Nieuwboer, G Kwakkel, L Rochester, D Jones, E van Wegen, A M Willems, F Chavret,
V Hetherington, K Baker, I Lim, J Neurol Neurosurg Psychiatry 2007;78:134–140. doi: 10.1136/jnnp.200X.097923

Objectives

Gait and mobility problems are difficult to treat in people with Parkinson’s disease. The Rehabilitation in Parkinson’s Disease:
Strategies for Cueing (RESCUE) trial investigated the effects of a home physiotherapy programme based on rhythmical cueing on gait
and gait-related activity.

Methods

A single-blind randomised crossover trial was set up, including 153 patients with Parkinson’s disease aged between 41 and 80
years and in Hoehn and Yahr stage II–IV. Subjects allocated to early intervention (n = 76) received a 3-week home cueing programme
using a prototype cueing device, followed by 3 weeks without training. Patients allocated to late intervention (n = 77) underwent the same
intervention and control period in reverse order. After the initial 6 weeks, both groups had a 6-week follow-up without training. Posture
and gait scores (PG scores) measured at 3, 6 and 12 weeks by blinded testers were the primary outcome measure. Secondary outcomes
included specific measures on gait, freezing and balance, functional activities, quality of life and carer strain.

Results

Small but significant improvements were found after intervention of 4.2% on the PG scores (p = 0.005). Severity of freezing was
reduced by 5.5% in freezers only (p = 0.007). Gait speed (p = 0.005), step length (p,0.001) and timed balance tests (p = 0.003) improved
in the full cohort. Other than a greater confidence to carry out functional activities (Falls Efficacy Scale, p = 0.04), no carry-over effects
were observed in functional and quality of life domains. Effects of intervention had reduced considerably at 6-week follow-up.
Conclusions: Cueing training in the home has specific effects on gait, freezing and balance. The decline in effectiveness of intervention
effects underscores the need for permanent cueing devices and follow-up treatment. Cueing training may be a useful therapeutic adjunct
to the overall management of gait disturbance in Parkinson’s disease.