{"paper_id":"40a201d4-f1b0-4731-a2fe-918b5bcd4fba","body_text":"The Effect of Visual and Auditory Cueing Walker on Gait in İndividuals with Parkinson's Disease Experiencing Freezing of Gait | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effect of Visual and Auditory Cueing Walker on Gait in İndividuals with Parkinson's Disease Experiencing Freezing of Gait Neslihan Altuntaş YILMAZ, Muazzez Betigül ÇORBACIOĞLU, Ahmet Can YETİM, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4206782/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective The aim of this study was to investigate the effects of a visual and auditory cueing walker on freezing of gait during walking in patients with Parkinson's disease (PDF), compared to Parkinson patients without freezing of gait (PDNF). Design : Eighteen PDF and 12 PDNF were included in the study. Participants walked back and forth on a 7-meter walking path under two different conditions: without cues and with a walker providing visual and auditory cues. To assess the risk of falls in both groups, the \"Tinetti Balance and Gait Assessment\" was conducted. Additionally, the \"Dynamic Gait Index\" was used to evaluate the ability to adapt walking to varying task demands, and the Timed Up and Go Test (TUGT) was employed to determine walking speed. Results In the PDF group, visual and auditory cueing walker significantly decreased walking speed, but improved fall risk and walking adaptation. However, for the PDNF group, fall risk was unaffected, walking speed decreased, yet walking adaptation improved. When compared between the two groups, the visual and auditory cueing walker had a more positive effect on the PDF group. Conclusions This study suggests that a walker providing visual and auditory cues may improve daily walking in patients with Parkinson's disease with freezing of gait (PDF) and reduce the risk of falls in patients with Parkinson's disease without freezing of gait (PDNF) who exhibit hypokinetic gait patterns. Auditory and Visual cue Gait Parkinson's disease Walker Figures Figure 1 Introduction One of the most significant issues experienced by Parkinson's disease (PD) patients is gait disturbance 1 . This disturbance is characterized in various ways: (1) short and rapid stepping with dragging of the feet, (2) decreased swinging of the arms with the trunk flexed forward, (3) difficulty initiating or changing walking, freezing of gait 2 . As the disease progresses, walking speed gradually decreases 3 . Especially as the disease progresses, freezing of gait (FOG) can lead to injuries in Parkinson's patients 4 . Research on the pathophysiology and treatment of FOG has recently intensified. However, evaluating it is challenging due to its unpredictable and intermittent nature, making it very difficult to capture true spontaneous freezing. FOG most commonly occurs at home, during unobserved behaviors, and in response to specific environmental triggers, and rarely manifests in walking laboratories 5 . Typically, freezing of gait (FOG) lasts for a few seconds, but this transient episode can sometimes exceed 30 seconds 6 . In rare cases, the patient may be unable to take any effective steps for several minutes or longer until compensatory strategies such as cueing are provided 7 . FOG leads to significant falls in patients with Parkinson's disease (PD) 8 , which deeply diminishes their independence and mobility, significantly impairing their quality of life 9 . Recent studies have demonstrated that external stimuli such as visual or auditory cues reduce freezing of gait (FOG) in Parkinson's patients 10–12 . These approaches are based on teaching patients to shift their walking control from a \"habitual\" control to a \"goal-directed\" control in order to reduce and overcome FOG episodes 13 . It was found that visual cues improved the hypokinetic spatiotemporal walking pattern in individuals with Parkinson's disease (PH). Freezing of gait (FOG) attacks occur more frequently when step length is shortened 14 . Additionally, studies have indicated positive effects on reducing freezing when the frequency of auditory signals is reduced 15 . Despite these positive outcomes demonstrating the improvement of gait disturbances in Parkinson's patients with FOG using visual and auditory cues, we did not come across research comparing the effectiveness of combined visual and auditory cues in the \"freezing\" and \"non-freezing\" groups. Therefore, there is a need to compare the effectiveness of goal-directed visual and auditory cues between patients with Parkinson's disease with freezing of gait (PDF) and without freezing of gait (PDNF). The aim of this study is to compare the effects of a walker providing visual and auditory cues on PDNF with PDF. We quantitatively compared the risk of falls, walking speed, and the ability to adapt walking to varying task demands between PDF and PDNF. Methods Design This is an interventional, single-blinded study. Written informed consent was obtained from all participants before the procedures started. This study conforms to all CONSORT guidelines and reports the required information accordingly. Sample size was calculated to detect a difference of 0.37 m/sec on mean velocity, with a deviation of 0.3 m/sec, two-sided 5% significance level, and power of 90%. Considering the expected 10% dropout rate, twelve subjects were included. Researcher R1 determined whether the subject was eligible for inclusion in the trial and researcher R2 carried out the gait analysis. Both examiners were unaware of group allocation. An independent researcher (R3) performed the clinical evaluation before the procedures started. Participants Thirty Parkinson's patients were referred from the XXX Medical Center to the Parkinsonism and Other Movement Disorders Center of XX. The diagnosis of PH was established by three specialists from the Neurology Department based on the United Kingdom Parkinson's Disease Society Brain Bank criteria 16 . Patients with secondary parkinsonism, severe systemic diseases, psychiatric illness, cognitive impairment (Mini-Mental State Examination score < 24), hearing and vision loss, musculoskeletal problems, or symptoms suggestive of cerebellar dysfunction were excluded from the study. Patients with any abnormal signal changes or focal atrophy detected on brain magnetic resonance imaging were also excluded. Those with a Hoehn-Yahr classification between 2.5 and 4 were included in the study. The 30 PD patients consisted of 18 PDF (7 men, 11women; mean age, 62.7 ± 8.6 yrs) and 12 PDNF (7 men, 5women; mean age, 61.6 ± 5.8yrs). The diagnosis of FOG was based on patient history, responses on the FOG questionnaire 17 and scoring on the Unified Parkinson's Disease Rating Scale (UPDRS) part II 18 , and Hoehn & Yahr staging was also conducted for patients 19 . A levodopa equivalent dose was calculated as follows: levodopa equivalent dose = (standard levodopa dose × 1) + (slow-release levodopa dose × 0.75) + (bromocriptine dose × 10) + (ropinirole dose × 20) + (pergolide dose × 100) + (pramipexole dose × 100). If entacapone was used, the levodopa equivalent dose was the standard levodopa dose + (slow-release levodopa dose × 0.75). This study was approved by the ethics committee of our institute, and all subjects provided written informed consent. Interventions A visual and auditory sensor-equipped walker was designed. Sensors were placed on all four contact surfaces of the walker. When all four sensors come into contact with the ground, a simultaneous \"beep\" sound and a red light placed on the front of the walker illuminate. Therefore, participants were instructed to ensure that all four legs of the walker make contact with the ground. To reduce the gait disturbance and balance issues resulting from festinating gait (FG) characteristic of Parkinson's patients, where step width decreases (amplitude) and step frequency increases, four sensors were placed on all feet of the walker. Thus, participants were aimed to take steps with auditory and visual cues only after placing all feet of the walker on the ground (Fig. 1 ). All subjects completed gait cycles defined as walking back-and-forth once between two points spaced 7 meters apart. This was performed under two different conditions: initially without cues, and then with a walker providing visual and auditory cues. Before the test, subjects were given the opportunity to experience each condition. In each condition, the total duration per cycle was recorded by the researcher 20 . All patients were on stable medication use and were tested during the \"off\" phase of medication cycles because higher frequency of freezing in open spaces in PD patients was reported during the \"off\" phase 21 . Evaluation All subjects underwent the \"Tinetti Balance and Gait Assessment\" (TBGA) to measure the risk of falls for both conditions 22 . Additionally, the \" Functional Gait Assessment” (FGA) was used to evaluate the ability to adapt walking to varying task demands 23 , and the “Timed Up and Go Test” (TUGT) was conducted to determine walking speed 23 . TBGA; this scale consists of two sections assessing gait and balance. The first nine questions concern balance, and the following seven concern gait. The total possible score is 28 with 12 points in the gait scale and 16 in the balance scale. Low scores are predictive of balance and gait disorders and an associated risk of falls 24 . FGA was used to assess gait. The FGA consists of 10 items in which the patient walks under increasingly difficult conditions, such as pivoting or walking with eyes closed. Each item is scored from zero to 3, in which a score of zero indicates an inability to perform the task, while 3 is normal. According to the FGA, the best score is the maximum of 30 25 . TUGT is conducted as follows: Let the patient seated in a chair with armrests stand up independently, walk forward 3 m, walk back to the chair, and sit down, while being timed. A total of 3 tests are conducted at an interval of 1 min, and the mean time is used. The test is done independently under guardianship. Guardians do not make any physical contact with the patient to avoid giving any practical assistance. In 2013, a systematic review 26 indicated that the TUGT is a sensitive assessment for gait and balance evaluation. A previous study also found that the TUGT had high reliability (ICC > 0.87) for assessing balance in people with PD 27 . Statistical Analysis The data obtained were analyzed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, United States) software, version 21.0. The Mean, standard deviation, median, maximum, and minimum values were calculated for all parameters. The Shapiro-Wilk test was first applied to analyze the normality of the distribution between the two groups. Nonparametric data was analyzed with using the Wilcoxon signed-rank test to investigate difference within the groups, and the paired sample t-test was used to compare intragroup changes in normally-distributed variables. Two independent t-tests were used to compare the means between the groups for the normally-distributed data. The nonparametric Mann-Whitney U test was used to investigate potential differences between the groups regarding nonparametric variables without normal distribution. The results were evaluated using a 95% confidence interval and values of p < 0.05 were considered statistically significant. Results Thirty subjects from two groups (18 PDF, 12 PDNF) completed the walking cycle under two different conditions: without the device, and with the visual and auditory cueing walker. There was a difference between the two groups in terms of Levodopa dose (mg) and freezing scores (P < 0.001), while no difference was found in other initial evaluation parameters (P > 0.05) (Table 1 ). Table 1 Shows the demographic characteristics of all subjects. PDF (n = 18) PDNF (n = 12) P Age ,yrs 63.7 ± 7.8 61.9 ± 4.5 0.213 Sex, M/F 12:6 8:4 0.348 Height, cm 168.2 ± 4.1 163.8 ± 3.7 0.548 Weight, kg 66.8 ± 5.8 64.7 ± 4.2 0.476 Hoehn and Yahr Grade 3.98 ± 0.79 2.77 ± 0.69 0.248 Disease duration, yrs 8.2 ± 2.5 4.2 ± 3.2 0.076 UPDRS II score 13.7 ± 3.8 5.7 ± 3.6 0.006 UPDRS III score 18.6 ± 7.4 16.8 ± 7.2 0.589 Levodopa dose,mg 576.4 ± 184.7 245.0 ± 186.4 ˂0.001 Freezing score 11.7 ± 4.5 2.7 ± 1.2 ˂0.001 Value are expressed as mean ± SD, PDF, Parkinson disease with freezing of gait ; PDNF, Parkinson disease wirhout freezing of gait; UPDRS, Unified Parkinson Disease Rating Scale. The evaluation conducted with the visual and auditory cueing walker revealed significant differences in fall risk, walking adaptation, and walking speed in the PDF group (p < 0.05), while significant increases were found in walking speed and walking adaptation in the PDNF group (p < 0.05). When comparing the scores of both groups in assessments with and without the walker, only the PDF group showed favorable results in terms of fall risk (Table 2 ). Table 2 Comparisons of results between the 2 groups (mean ± SD). PDF (n = 18) PDNF (n = 12) P TBGA Walker with 20.31 ± 1.02 22.23 ± 2.30 0.031 b Without walker 23.44 ± 2.03 23.70 ± 2.14 P 0.031 a 0.064 a TUGT Walker with 24.11 ± 5.12 22.07 ± 3.16 0.487 b Without walker 28.64 ± 4.02 26.37 ± 4.11 P 0.021 a 0.041 a FGA Walker with 15.68 ± 2.63 17.35 ± 3.42 0.151 b Without walker 21.31 ± 4.12 19.21 ± 2.54 P 0.011 a 0.037 a a : Wilcoxon signed-rank test ; b :Mann-Whitney U test. TBGA– Tinetti Balance and Gait Assessment; TUGT – Timed ‘Up and Go’ Test; FGA; Functional Gait Assessment Discussion This study demonstrated that the visual and auditory sensor-equipped walker designed for patients with Parkinson's disease freezing of gait (PDF) improved walking and balance. The results showed improvement in the Tinetti Balance and Gait Assessment (TBGA) score and Functional Gait Assessment (FGA) score in the FOG group, while there was an increase in the Timed Up and Go Test (TUGT) time. In Parkinson's disease patients without freezing of gait (PDNF), improvement in the Functional Gait Assessment (FGA) score was observed, accompanied by an increase in walking time in this group. The existing studies have separately evaluated auditory and visual stimuli in the PDF group, finding that both stimuli contribute to improving walking levels 28–31 . Taking these studies into consideration, we have developed a walker for PH that provides these two stimuli and also reduces the risk of falling in daily life. Technological advancements provide opportunities not only to change the way cues are delivered but also to adapt the content of cues. There is a study reporting that auditory cues are ineffective in individuals with Parkinson's disease experiencing freezing of gait if they do not mimic real walking sounds 32 . Therefore, we aimed to provide both In a study conducted with wearable sensor-equipped garments (smart verbal cues), it has been tested on patients with freezing episodes, indicating that these patients showed less gait deviation 33 . However, it has been reported that patients do not particularly prefer to use this smart verbal cue system. Especially, it has been reported that the smart verbal cue system causes fatigue in patients 34 . Similarly, in our study, although the cue was found to reduce the risk of falls in patients and increase their ability to adapt to different movements along with walking, it may have caused patients to slow down their walking speed, which could be a reason for them not to use this developed walker. Postural control and balance 35 were affected more significantly in PD patients with FOG compared with non-FOG group. FOG often occurs when turning also suggests that the postural control impairment probably contributes to freezing. However, whether balance impairment is an accompanying symptom of FOG or a risk factor of FOG remains unclear. We found that the walker we developed reduced the risk of falls in both PDF and PDNF patients, where the risk of falling is a concern. Janssen et al. (2020) reported that visual stimuli provided through virtual reality did not affect patients' freezing of gait (FOG) and even prolonged turning duration 36 . Our study similarly found that walking speed decreased in all Parkinson's patients, supporting this finding. The effect of walking cues in patients with Parkinson's disease has been evaluated in the literature. However, there are few studies that assess the combined effect of both cues. One such study conducted by Suteerawattananon et al. (2004) reported that cues improved walking in Parkinson's disease patients, with visual cues alone improving step length, auditory cues alone improving walking pace, and the combination of both cues being much more effective than cues given individually 1 . However, this study was not conducted in patients with freezing. Another study conducted in patients with freezing 37 evaluated walking by stimulating patients' feet with mechanical pressure applied to the sole, resulting in sensory feedback upon contact with the ground. This study indicated that peripheral stimulation improved walking parameters in patients with freezing. Conclusions It has been determined that the visual and auditory sensor-equipped walker designed for Parkinson's patients has a positive effect on reducing the risk of falls and the ability to adapt to different tasks during walking, but it reduces walking speed. In patients with PD, we found that the visual and auditory cueing walker reduced the risk of falls, improved walking adaptation, but decreased walking speed, indicating an increase in walking duration. However, in patients with PDNF, we determined that this cueing walker had no effect on fall risk, only benefiting walking adaptation, but increasing walking duration. The first limitation of this study is that participants were not selected based on known cue sensitivity. The fact that our participants may not be accustomed to using cues could be due to their unfamiliarity with cues, and it may also be related to a resistance they have previously experienced to cue effects. Selecting only those patients with a recognized response to cues would increase the potency of experimental cues, but reduce generalizability of the results to patients with an unknown response to cues. A second limitation to this study is the relatively small sample size. The impact size of Walker's visual and auditory cues may be smaller than anticipated and may require a larger sample size to detect statistically significant differences. This study found that providing goal-oriented visual and auditory cues together is beneficial for walking safety in freezing of gait (FOG) patients. However, it may influence patient preference due to its effect of slowing down walking speed. Nevertheless, especially in patients with Hoehn & Yahr stages 4 and above, the use of a walker designed for safety should be recommended. Declarations Ethics approval and consent to participate This study was conducted in accordance with the rules of the Helsinki Declaration (1964), approved by the Medical Ethics Committee (Necmettin Erbakan University-Health Sciences Scientific Research Ethics Committee), and registered in the research registry (2022/339: ID 12168). Written informed consent was obtained from all participants before they were included in the study. Consent for publication Not applicable Availability of data and materials The data presented in this study are available on appropriate request from the corresponding author. The data are not publicly available as the privacy of the human subjects must be ensured. Competing interests The authors have no conficts of interest. Funding We would like to thank the Publikationsfond of the Turkish Scientific and Technological Research Council for funding the publication of this paper. Authors' contributions NAY and MBÇ were involved in the conception and design of the study, the acquisition, analysis, and interpretation of the data, writing of the manuscript, and editing of the final manuscript for submission. ACY, ATA, İK were involved in the design and building of the walker. NAY, İR were involved in the analysis of the data and critical appraisal of the manuscript. MBÇ critically appraised the manuscript. NAY and İK were involved in the conceptual design and setup of this study, the analysis and interpretation of the data, critical revision of the manuscript, and supervision over the study. All authors read and approved the final manuscript. Acknowledgments We would like to individually thank all our participants, and we also extend our gratitude to the Hospital administration for their support in this study. We thank TÜBİTAK (The Scientific and Technological Research Council of Turkey) for their funding support in the design of the walker. References Suteerawattananon M, Morris GS, Etnyre BR, Jankovic J, Protas EJ. Effects of visual and auditory cues on gait in individuals with Parkinson's disease. Journal of the Neurological E. 2004; 15;219(1–2):63 − 9. doi: 10.1016/j.jns.2003.12.007. Ruzicka M, Hallett J, Jankovic (Eds.). Classification, diagnosis and etiology of gait disorders. Gait disorders, Adv. 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Hindawi Parkinson’s Disease Volume 2020, Article ID 4104712, 3 pages. https://doi.org/10.1155/2020/4104712 Camila P, Aline P, Kleiner R, Francisca A, Marchese, Redivo R; Paula S; Carlos R, Manuela G. Automated Mechanical Peripheral Stimulation Improves Gait Parameters in Subjects With Parkinson Disease and Freezing of Gait A Randomized Clinical Trial. American Journal of Physical Medicine & Rehabilitation 97(6):p 383–389, June 2018. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-4206782\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":288484366,\"identity\":\"206f8e76-0f76-42cd-b57e-676d72e6577b\",\"order_by\":0,\"name\":\"Neslihan Altuntaş YILMAZ\",\"email\":\"data:image/png;base64,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\",\"orcid\":\"\",\"institution\":\"Necmettin Erbakan University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Neslihan\",\"middleName\":\"Altuntaş\",\"lastName\":\"YILMAZ\",\"suffix\":\"\"},{\"id\":288484367,\"identity\":\"037fe144-5233-4ebd-95b3-0e061dfd032a\",\"order_by\":1,\"name\":\"Muazzez Betigül ÇORBACIOĞLU\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Necmettin Erbakan University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Muazzez\",\"middleName\":\"Betigül\",\"lastName\":\"ÇORBACIOĞLU\",\"suffix\":\"\"},{\"id\":288484368,\"identity\":\"7b0b1a6c-7c08-42a7-b4f3-e0ce7e51720b\",\"order_by\":2,\"name\":\"Ahmet Can YETİM\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Necmettin Erbakan University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ahmet\",\"middleName\":\"Can\",\"lastName\":\"YETİM\",\"suffix\":\"\"},{\"id\":288484369,\"identity\":\"60c2efd5-1fa2-47f3-8391-618bd2e19a45\",\"order_by\":3,\"name\":\"Abdurrahman Talat ARSLAN\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Necmettin Erbakan University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Abdurrahman\",\"middleName\":\"Talat\",\"lastName\":\"ARSLAN\",\"suffix\":\"\"},{\"id\":288484370,\"identity\":\"c5204058-370f-4401-90fd-c9877bc93fa9\",\"order_by\":4,\"name\":\"İrem KARAKÜLAH\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Necmettin Erbakan University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"İrem\",\"middleName\":\"\",\"lastName\":\"KARAKÜLAH\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-04-02 12:48:05\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-4206782/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-4206782/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":54371635,\"identity\":\"ae2652f9-a1f3-4fc7-ac21-21e063125611\",\"added_by\":\"auto\",\"created_at\":\"2024-04-09 13:15:56\",\"extension\":\"jpeg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":372800,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eA. 4 contact-sensitive sensors. B. Placement of sensors on the walker. C. Representation of the buzzer sound circuit, power source, and the light on the front panel.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4206782/v1/6cfbbcec6fdd071f0ae3c112.jpeg\"},{\"id\":55265026,\"identity\":\"02f1a9c1-6c65-4dbb-9d6e-06fbbf92e7c6\",\"added_by\":\"auto\",\"created_at\":\"2024-04-25 01:53:56\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":495125,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4206782/v1/61ff3416-7751-4368-b928-c0d9d4504a71.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"The Effect of Visual and Auditory Cueing Walker on Gait in İndividuals with Parkinson's Disease Experiencing Freezing of Gait\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eOne of the most significant issues experienced by Parkinson's disease (PD) patients is gait disturbance\\u003csup\\u003e1\\u003c/sup\\u003e. This disturbance is characterized in various ways: (1) short and rapid stepping with dragging of the feet, (2) decreased swinging of the arms with the trunk flexed forward, (3) difficulty initiating or changing walking, freezing of gait\\u003csup\\u003e2\\u003c/sup\\u003e. As the disease progresses, walking speed gradually decreases \\u003csup\\u003e3\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eEspecially as the disease progresses, freezing of gait (FOG) can lead to injuries in Parkinson's patients\\u003csup\\u003e4\\u003c/sup\\u003e. Research on the pathophysiology and treatment of FOG has recently intensified. However, evaluating it is challenging due to its unpredictable and intermittent nature, making it very difficult to capture true spontaneous freezing. FOG most commonly occurs at home, during unobserved behaviors, and in response to specific environmental triggers, and rarely manifests in walking laboratories \\u003csup\\u003e5\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eTypically, freezing of gait (FOG) lasts for a few seconds, but this transient episode can sometimes exceed 30 seconds\\u003csup\\u003e6\\u003c/sup\\u003e. In rare cases, the patient may be unable to take any effective steps for several minutes or longer until compensatory strategies such as cueing are provided \\u003csup\\u003e7\\u003c/sup\\u003e. FOG leads to significant falls in patients with Parkinson's disease (PD)\\u003csup\\u003e8\\u003c/sup\\u003e, which deeply diminishes their independence and mobility, significantly impairing their quality of life \\u003csup\\u003e9\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eRecent studies have demonstrated that external stimuli such as visual or auditory cues reduce freezing of gait (FOG) in Parkinson's patients \\u003csup\\u003e10\\u0026ndash;12\\u003c/sup\\u003e. These approaches are based on teaching patients to shift their walking control from a \\\"habitual\\\" control to a \\\"goal-directed\\\" control in order to reduce and overcome FOG episodes \\u003csup\\u003e13\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eIt was found that visual cues improved the hypokinetic spatiotemporal walking pattern in individuals with Parkinson's disease (PH). Freezing of gait (FOG) attacks occur more frequently when step length is shortened \\u003csup\\u003e14\\u003c/sup\\u003e. Additionally, studies have indicated positive effects on reducing freezing when the frequency of auditory signals is reduced \\u003csup\\u003e15\\u003c/sup\\u003e. Despite these positive outcomes demonstrating the improvement of gait disturbances in Parkinson's patients with FOG using visual and auditory cues, we did not come across research comparing the effectiveness of combined visual and auditory cues in the \\\"freezing\\\" and \\\"non-freezing\\\" groups. Therefore, there is a need to compare the effectiveness of goal-directed visual and auditory cues between patients with Parkinson's disease with freezing of gait (PDF) and without freezing of gait (PDNF).\\u003c/p\\u003e \\u003cp\\u003eThe aim of this study is to compare the effects of a walker providing visual and auditory cues on PDNF with PDF. We quantitatively compared the risk of falls, walking speed, and the ability to adapt walking to varying task demands between PDF and PDNF.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eDesign\\u003c/h2\\u003e \\u003cp\\u003eThis is an interventional, single-blinded study. Written informed consent was obtained from all participants before the procedures started. This study conforms to all CONSORT guidelines and reports the required information accordingly. Sample size was calculated to detect a difference of 0.37 m/sec on mean velocity, with a deviation of 0.3 m/sec, two-sided 5% significance level, and power of 90%. Considering the expected 10% dropout rate, twelve subjects were included.\\u003c/p\\u003e \\u003cp\\u003eResearcher R1 determined whether the subject was eligible for inclusion in the trial and researcher R2 carried out the gait analysis. Both examiners were unaware of group allocation. An independent researcher (R3) performed the clinical evaluation before the procedures started.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eParticipants\\u003c/h2\\u003e \\u003cp\\u003eThirty Parkinson's patients were referred from the XXX Medical Center to the Parkinsonism and Other Movement Disorders Center of XX. The diagnosis of PH was established by three specialists from the Neurology Department based on the United Kingdom Parkinson's Disease Society Brain Bank criteria\\u003csup\\u003e16\\u003c/sup\\u003e. Patients with secondary parkinsonism, severe systemic diseases, psychiatric illness, cognitive impairment (Mini-Mental State Examination score\\u0026thinsp;\\u0026lt;\\u0026thinsp;24), hearing and vision loss, musculoskeletal problems, or symptoms suggestive of cerebellar dysfunction were excluded from the study. Patients with any abnormal signal changes or focal atrophy detected on brain magnetic resonance imaging were also excluded. Those with a Hoehn-Yahr classification between 2.5 and 4 were included in the study.\\u003c/p\\u003e \\u003cp\\u003eThe 30 PD patients consisted of 18 PDF (7 men, 11women; mean age, 62.7\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;8.6 yrs) and 12 PDNF (7 men, 5women; mean age, 61.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;5.8yrs). The diagnosis of FOG was based on patient history, responses on the FOG questionnaire \\u003csup\\u003e17\\u003c/sup\\u003e and scoring on the Unified Parkinson's Disease Rating Scale (UPDRS) part II \\u003csup\\u003e18\\u003c/sup\\u003e, and Hoehn \\u0026amp; Yahr staging was also conducted for patients\\u003csup\\u003e19\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eA levodopa equivalent dose was calculated as follows: levodopa equivalent dose = (standard levodopa dose \\u0026times; 1) + (slow-release levodopa dose \\u0026times; 0.75) + (bromocriptine dose \\u0026times; 10) + (ropinirole dose \\u0026times; 20) + (pergolide dose \\u0026times; 100) + (pramipexole dose \\u0026times; 100). If entacapone was used, the levodopa equivalent dose was the standard levodopa dose + (slow-release levodopa dose \\u0026times; 0.75). This study was approved by the ethics committee of our institute, and all subjects provided written informed consent.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec5\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eInterventions\\u003c/h2\\u003e \\u003cp\\u003eA visual and auditory sensor-equipped walker was designed. Sensors were placed on all four contact surfaces of the walker. When all four sensors come into contact with the ground, a simultaneous \\\"beep\\\" sound and a red light placed on the front of the walker illuminate. Therefore, participants were instructed to ensure that all four legs of the walker make contact with the ground. To reduce the gait disturbance and balance issues resulting from festinating gait (FG) characteristic of Parkinson's patients, where step width decreases (amplitude) and step frequency increases, four sensors were placed on all feet of the walker. Thus, participants were aimed to take steps with auditory and visual cues only after placing all feet of the walker on the ground (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eAll subjects completed gait cycles defined as walking back-and-forth once between two points spaced 7 meters apart. This was performed under two different conditions: initially without cues, and then with a walker providing visual and auditory cues.\\u003c/p\\u003e \\u003cp\\u003eBefore the test, subjects were given the opportunity to experience each condition. In each condition, the total duration per cycle was recorded by the researcher\\u003csup\\u003e20\\u003c/sup\\u003e. All patients were on stable medication use and were tested during the \\\"off\\\" phase of medication cycles because higher frequency of freezing in open spaces in PD patients was reported during the \\\"off\\\" phase\\u003csup\\u003e21\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eEvaluation\\u003c/h2\\u003e \\u003cp\\u003eAll subjects underwent the \\\"Tinetti Balance and Gait Assessment\\\" (TBGA) to measure the risk of falls for both conditions\\u003csup\\u003e22\\u003c/sup\\u003e. Additionally, the \\\" Functional Gait Assessment\\u0026rdquo; (FGA) was used to evaluate the ability to adapt walking to varying task demands \\u003csup\\u003e23\\u003c/sup\\u003e, and the \\u0026ldquo;Timed Up and Go Test\\u0026rdquo; (TUGT) was conducted to determine walking speed \\u003csup\\u003e23\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eTBGA; this scale consists of two sections assessing gait and balance. The first nine questions concern balance, and the following seven concern gait. The total possible score is 28 with 12 points in the gait scale and 16 in the balance scale. Low scores are predictive of balance and gait disorders and an associated risk of falls \\u003csup\\u003e24\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eFGA was used to assess gait. The FGA consists of 10 items in which the patient walks under increasingly difficult conditions, such as pivoting or walking with eyes closed. Each item is scored from zero to 3, in which a score of zero indicates an inability to perform the task, while 3 is normal. According to the FGA, the best score is the maximum of 30 \\u003csup\\u003e25\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eTUGT is conducted as follows: Let the patient seated in a chair with armrests stand up independently, walk forward 3 m, walk back to the chair, and sit down, while being timed. A total of 3 tests are conducted at an interval of 1 min, and the mean time is used. The test is done independently under guardianship. Guardians do not make any physical contact with the patient to avoid giving any practical assistance. In 2013, a systematic review\\u003csup\\u003e26\\u003c/sup\\u003e indicated that the TUGT is a sensitive assessment for gait and balance evaluation. A previous study also found that the TUGT had high reliability (ICC\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.87) for assessing balance in people with PD \\u003csup\\u003e27\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStatistical Analysis\\u003c/h2\\u003e \\u003cp\\u003eThe data obtained were analyzed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, United States) software, version 21.0. The Mean, standard deviation, median, maximum, and minimum values were calculated for all parameters. The Shapiro-Wilk test was first applied to analyze the normality of the distribution between the two groups. Nonparametric data was analyzed with using the Wilcoxon signed-rank test to investigate difference within the groups, and the paired sample t-test was used to compare intragroup changes in normally-distributed variables. Two independent t-tests were used to compare the means between the groups for the normally-distributed data. The nonparametric Mann-Whitney U test was used to investigate potential differences between the groups regarding nonparametric variables without normal distribution. The results were evaluated using a 95% confidence interval and values of p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05 were considered statistically significant.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eThirty subjects from two groups (18 PDF, 12 PDNF) completed the walking cycle under two different conditions: without the device, and with the visual and auditory cueing walker. There was a difference between the two groups in terms of Levodopa dose (mg) and freezing scores (P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), while no difference was found in other initial evaluation parameters (P\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05) (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eShows the demographic characteristics of all subjects.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePDF (n\\u0026thinsp;=\\u0026thinsp;18)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePDNF (n\\u0026thinsp;=\\u0026thinsp;12)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eP\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eAge ,yrs\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e63.7\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;7.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e61.9\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.213\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eSex, M/F\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e12:6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8:4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.348\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eHeight, cm\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e168.2\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e163.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.548\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eWeight, kg\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e66.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;5.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e64.7\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.476\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eHoehn and Yahr Grade\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3.98\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.79\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2.77\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.69\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.248\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eDisease duration, yrs\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8.2\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.2\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.076\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eUPDRS II score\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e13.7\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5.7\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.006\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eUPDRS III score\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e18.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;7.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e16.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;7.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.589\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eLevodopa dose,mg\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e576.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;184.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e245.0\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;186.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e˂0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eFreezing score\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e11.7\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2.7\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e˂0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eValue are expressed as mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD, PDF, Parkinson disease with freezing of gait ; PDNF, Parkinson disease wirhout freezing of gait; UPDRS, Unified Parkinson Disease Rating Scale.\\u003c/p\\u003e \\u003cp\\u003eThe evaluation conducted with the visual and auditory cueing walker revealed significant differences in fall risk, walking adaptation, and walking speed in the PDF group (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05), while significant increases were found in walking speed and walking adaptation in the PDNF group (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05). When comparing the scores of both groups in assessments with and without the walker, only the PDF group showed favorable results in terms of fall risk (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eComparisons of results between the 2 groups (mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD).\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePDF (n\\u0026thinsp;=\\u0026thinsp;18)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePDNF (n\\u0026thinsp;=\\u0026thinsp;12)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eP\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eTBGA\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eWalker with\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e20.31\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.02\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e22.23\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.30\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.031\\u003c/b\\u003e\\u003csup\\u003e\\u003cb\\u003eb\\u003c/b\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eWithout walker\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e23.44\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.03\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e23.70\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.14\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eP\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.031\\u003c/b\\u003e\\u003csup\\u003e\\u003cb\\u003ea\\u003c/b\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.064\\u003csup\\u003ea\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eTUGT\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eWalker with\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e24.11\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;5.12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e22.07\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003e0.487\\u003csup\\u003eb\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eWithout walker\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e28.64\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.02\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e26.37\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.11\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eP\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.021\\u003c/b\\u003e\\u003csup\\u003e\\u003cb\\u003ea\\u003c/b\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.041\\u003c/b\\u003e\\u003csup\\u003e\\u003cb\\u003ea\\u003c/b\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eFGA\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eWalker with\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e15.68\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.63\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e17.35\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.42\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003e0.151\\u003csup\\u003eb\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eWithout walker\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e21.31\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e19.21\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.54\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eP\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.011\\u003c/b\\u003e\\u003csup\\u003e\\u003cb\\u003ea\\u003c/b\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.037\\u003c/b\\u003e\\u003csup\\u003e\\u003cb\\u003ea\\u003c/b\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"5\\\"\\u003e\\u003csup\\u003ea\\u003c/sup\\u003e: Wilcoxon signed-rank test\\u003csup\\u003e; b\\u003c/sup\\u003e:Mann-Whitney U test. TBGA\\u0026ndash; Tinetti Balance and Gait Assessment; TUGT \\u0026ndash; Timed \\u0026lsquo;Up and Go\\u0026rsquo; Test; FGA; Functional Gait Assessment\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study demonstrated that the visual and auditory sensor-equipped walker designed for patients with Parkinson's disease freezing of gait (PDF) improved walking and balance. The results showed improvement in the Tinetti Balance and Gait Assessment (TBGA) score and Functional Gait Assessment (FGA) score in the FOG group, while there was an increase in the Timed Up and Go Test (TUGT) time. In Parkinson's disease patients without freezing of gait (PDNF), improvement in the Functional Gait Assessment (FGA) score was observed, accompanied by an increase in walking time in this group.\\u003c/p\\u003e \\u003cp\\u003eThe existing studies have separately evaluated auditory and visual stimuli in the PDF group, finding that both stimuli contribute to improving walking levels \\u003csup\\u003e28\\u0026ndash;31\\u003c/sup\\u003e. Taking these studies into consideration, we have developed a walker for PH that provides these two stimuli and also reduces the risk of falling in daily life.\\u003c/p\\u003e \\u003cp\\u003eTechnological advancements provide opportunities not only to change the way cues are delivered but also to adapt the content of cues. There is a study reporting that auditory cues are ineffective in individuals with Parkinson's disease experiencing freezing of gait if they do not mimic real walking sounds \\u003csup\\u003e32\\u003c/sup\\u003e. Therefore, we aimed to provide both\\u003c/p\\u003e \\u003cp\\u003eIn a study conducted with wearable sensor-equipped garments (smart verbal cues), it has been tested on patients with freezing episodes, indicating that these patients showed less gait deviation \\u003csup\\u003e33\\u003c/sup\\u003e. However, it has been reported that patients do not particularly prefer to use this smart verbal cue system. Especially, it has been reported that the smart verbal cue system causes fatigue in patients \\u003csup\\u003e34\\u003c/sup\\u003e. Similarly, in our study, although the cue was found to reduce the risk of falls in patients and increase their ability to adapt to different movements along with walking, it may have caused patients to slow down their walking speed, which could be a reason for them not to use this developed walker.\\u003c/p\\u003e \\u003cp\\u003ePostural control and balance \\u003csup\\u003e35\\u003c/sup\\u003e were affected more significantly in PD patients with FOG compared with non-FOG group. FOG often occurs when turning also suggests that the postural control impairment probably contributes to freezing. However, whether balance impairment is an accompanying symptom of FOG or a risk factor of FOG remains unclear. We found that the walker we developed reduced the risk of falls in both PDF and PDNF patients, where the risk of falling is a concern.\\u003c/p\\u003e \\u003cp\\u003eJanssen et al. (2020) reported that visual stimuli provided through virtual reality did not affect patients' freezing of gait (FOG) and even prolonged turning duration\\u003csup\\u003e36\\u003c/sup\\u003e. Our study similarly found that walking speed decreased in all Parkinson's patients, supporting this finding.\\u003c/p\\u003e \\u003cp\\u003eThe effect of walking cues in patients with Parkinson's disease has been evaluated in the literature. However, there are few studies that assess the combined effect of both cues. One such study conducted by Suteerawattananon et al. (2004) reported that cues improved walking in Parkinson's disease patients, with visual cues alone improving step length, auditory cues alone improving walking pace, and the combination of both cues being much more effective than cues given individually\\u003csup\\u003e1\\u003c/sup\\u003e. However, this study was not conducted in patients with freezing. Another study conducted in patients with freezing\\u003csup\\u003e37\\u003c/sup\\u003e evaluated walking by stimulating patients' feet with mechanical pressure applied to the sole, resulting in sensory feedback upon contact with the ground. This study indicated that peripheral stimulation improved walking parameters in patients with freezing.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eIt has been determined that the visual and auditory sensor-equipped walker designed for Parkinson's patients has a positive effect on reducing the risk of falls and the ability to adapt to different tasks during walking, but it reduces walking speed.\\u003c/p\\u003e \\u003cp\\u003eIn patients with PD, we found that the visual and auditory cueing walker reduced the risk of falls, improved walking adaptation, but decreased walking speed, indicating an increase in walking duration. However, in patients with PDNF, we determined that this cueing walker had no effect on fall risk, only benefiting walking adaptation, but increasing walking duration.\\u003c/p\\u003e \\u003cp\\u003e The first limitation of this study is that participants were not selected based on known cue sensitivity. The fact that our participants may not be accustomed to using cues could be due to their unfamiliarity with cues, and it may also be related to a resistance they have previously experienced to cue effects. Selecting only those patients with a recognized response to cues would increase the potency of experimental cues, but reduce generalizability of the results to patients with an unknown response to cues. A second limitation to this study is the relatively small sample size. The impact size of Walker's visual and auditory cues may be smaller than anticipated and may require a larger sample size to detect statistically significant differences.\\u003c/p\\u003e \\u003cp\\u003eThis study found that providing goal-oriented visual and auditory cues together is beneficial for walking safety in freezing of gait (FOG) patients. However, it may influence patient preference due to its effect of slowing down walking speed. Nevertheless, especially in patients with Hoehn \\u0026amp; Yahr stages 4 and above, the use of a walker designed for safety should be recommended.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was conducted in accordance with the rules of the Helsinki Declaration (1964), approved by the Medical Ethics Committee (Necmettin Erbakan University-Health Sciences Scientific Research Ethics Committee), and registered in the research registry (2022/339: ID 12168). Written informed consent was obtained from all participants before they were included in the study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe data presented in this study are available on appropriate request from the corresponding author. The data are not publicly available as the privacy of the human subjects must be ensured.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors have no conficts of interest.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe would like to thank the Publikationsfond of the Turkish Scientific and Technological Research Council for funding the publication of this paper.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026apos; contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNAY and MB\\u0026Ccedil; were involved in the conception and design of the study, the acquisition, analysis, and interpretation of the data, writing of the manuscript, and editing of the final manuscript for submission. ACY, ATA, İK were involved in the design and building of the walker. NAY, İR were involved in the analysis of the data and critical appraisal of the manuscript. MB\\u0026Ccedil; critically appraised the manuscript. NAY and İK were involved in the conceptual design and setup of this study, the analysis and interpretation of the data, critical revision of the manuscript, and supervision over the study. All authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgments\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe would like to individually thank all our participants, and we also extend our gratitude to the Hospital administration for their support in this study. We thank T\\u0026Uuml;BİTAK (The Scientific and Technological Research Council of Turkey) \\u0026nbsp; for their funding support in the design of the walker.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003eSuteerawattananon M, Morris GS, Etnyre BR, Jankovic J, Protas EJ. Effects of visual and auditory cues on gait in individuals with Parkinson\\u0026apos;s disease. Journal of the Neurological E. 2004; 15;219(1\\u0026ndash;2):63\\u0026thinsp;\\u0026minus;\\u0026thinsp;9. doi: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/j.jns.2003.12.007.\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eRuzicka M, Hallett J, Jankovic (Eds.). Classification, diagnosis and etiology of gait disorders. Gait disorders, Adv. Neurol., vol. 87, Lippincott Williams and Wilkins, Philadelphia, PA; 2001, pp. 119\\u0026ndash;134.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eMorris ME, Iansek R, Matyas TA, Summers JJ. Stride length regulation in Parkinson\\u0026apos;s disease: normalization strategies and underlying mechanism. Brain, 119; 1996, pp. 551\\u0026ndash;568.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eOkuma Y. 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J Neurol Neurosurg Psychiatry 2007; 78: 134\\u0026ndash;40.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eAshburn A, Pickering R, McIntosh E, Hulbert S, Rochester L, Roberts HC, Nieuwboer A, Kunkel D, Goodwin VA, Lamb SE, Ballinger C, Seymour KC. Exercise- and strategy-based physiotherapy-delivered intervention for preventing repeat falls in people with Parkinson\\u0026apos;s: the PDSAFE RCT. Health Technol Assess. 2019 Jul;23(36):1-150. doi: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3310/hta23360\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eCosentino C, Baccini M, Putzolu M, Ristori D, Avanzino L, Pelosin E. Effectiveness of Physiotherapy on Freezing of Gait in Parkinson\\u0026apos;s Disease: A Systematic Review and Meta-Analyses. Mov Disord. 2020 Apr;35(4):523\\u0026ndash;536. doi: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1002/mds.27936\\u003c/span\\u003e\\u003c/span\\u003e. Epub 2019 Dec 4.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eRedgrave P, Rodriguez M, Smith Y, et al. Goal-directed and habitual control in the basal ganglia: implications for Parkinson\\u0026apos;s disease. Nat Rev Neurosci 2010; 11: 760\\u0026ndash;762.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eLewis GN, Byblow WD, Walt SE: Stride length regulation in Parkinson\\u0026rsquo;s disease: The use of extrinsic, visual cues. Brain 2000; 123 (pt 10): 2077\\u0026ndash;90\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eWillems AM, Nieuwboer A, Chavret F, Desloovere K, Dom R, Rochester L, et al.: The use of rhythmic auditory cues to influence gait in patients with Parkinson\\u0026rsquo;s disease, the differential effect for freezers and non-freezers, an explorative study. Disabil Rehabil 2006; 28: 721\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eHughes AJ, Daniel SE, Kilford L, Lees AJ: Accuracy of clinical diagnosis of idiopathic Parkinson\\u0026rsquo;s disease: A clinico-pathological study of 100 cases. J Neurol Neurosurg Psychiatry 1992; 55: 181\\u0026ndash;4.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eGiladi N, Shabtai H, Simon ES, Biran S, Tal J, Korczyn AD: Construction of freezing of gait questionnaire for patients with Parkinsonism. Parkinsonism Relat Disord 2000; 6: 165\\u0026ndash;70\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eGoetz CG, Fahn S, Martinez-Martin P, Poewe W, Sampaio C, Stebbins GT, et al.: Movement Disorder Society-sponsored revision of the Unified Parkinson\\u0026rsquo;s Disease Rating Scale (MDS-UPDRS): Process, format, and clinimetric testing plan. Mov Disord 2007; 22: 41\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eHoehn MM, Yahr MD: Parkinsonism: Onset, progression and mortality. Neurology 1967; 17: 427\\u0026ndash;42.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eLee, SJ; Yoo JY, Ryu JS; Park HK; Chung SJ. The Effects of Visual and Auditory Cues on Freezing of Gait in Patients with Parkinson Disease. American Journal of Physical Medicine \\u0026amp; Rehabilitation 2012; 91(1):p 2\\u0026ndash;11. DOI: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1097/PHM.0b013e31823c7507\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eSchaafsma JD, Balash Y, Gurevich T, Bartels AL, Hausdorff JM, Giladi N. Characterization of freezing of gait subtypes and the response of each to levodopa in Parkinson\\u0026rsquo;s disease. Eur J Neurol 2003; 10: 391\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eOpara J, Malecki A, Malecka E, Socha T. Motor assessment in Parkinson`s disease. Ann Agric Environ Med. 2017 Sep 21;24(3):411\\u0026ndash;415. doi: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.5604/12321966.1232774\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eBloem B, Marinus J, Almeida Q, Dibble L, Nieuwboer A, Post B, Ruzicka E, Goetz C, Stebbins G, Pablo M, Schrag A. Measurement instruments to assess posture, gait, and balance in Parkinson\\u0026apos;s disease: Critique and recommendations. Mov Disord. 2016 Sep;31(9):1342-55. doi: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1002/mds.26572\\u003c/span\\u003e\\u003c/span\\u003e. Epub 2016 Mar 4.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eTinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc 1986;34(02):119\\u0026ndash;126\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eWrisley DM, Marchetti GF, Kuharsky DK et al: Reliability, internal consistency, and validity of data obtained with the functional gait assessment.Phys Ther, 2004; 84: 906\\u0026ndash;18.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eSchoene D, Wu SM, Mikolaizak AS et al: Discriminative ability and predictive validity of the timed up and go test in identifying older people who fall: Systematic review and meta-analysis. J Am Geriatr Soc, 2013; 61: 202\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eMorris S, Morris ME, Iansek R: Reliability of measurements obtained with the Timed \\u0026ldquo;Up \\u0026amp; Go\\u0026rdquo; test in people with Parkinson disease. Phys Ther, 2001; 81: 810\\u0026ndash;18.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eGinis P, Nackaerts E, Nieuwboer A, Heremans E. Cueing for people with Parkinson\\u0026apos;s disease with freezing of gait: A narrative review of the state-of-the-art and novel perspectives. Annals of Physical and Rehabilitation Medicine. Volume 61, Issue 6, November 2018, Pages 407\\u0026ndash;413\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eG\\u0026oacute;mez-Gonz\\u0026aacute;lez J, Mart\\u0026iacute;n-Casas P., Cano-de-la-Cuerda R. Effects of auditory cues on gait initiation and turning in patients with Parkinson\\u0026apos;s diseaseEfectos de los est\\u0026iacute;mulos auditivos en la fase de iniciaci\\u0026oacute;n de la marcha y de giro en pacientes con enfermedad de Parkinson. Neurolog\\u0026iacute;a (English Edition) Volume 34, Issue 6, July\\u0026ndash;August 2019, Pages 396\\u0026ndash;407.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eChiahao L, Huffmaster S, Tuite P, VachonJ, MacKinnon C. Effect of Cue Timing and Modality on Gait Initiation in Parkinson Disease With Freezing of Gait. Archives of Physical Medicine and Rehabilitation. Volume 98, Issue 7, July 2017, Pages 1291\\u0026ndash;1299.e1\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eJanssen S, Steveninck J, Salim H, Cockx H, Bloem B, Heida T,Wezel R. The Effects of Augmented Reality Visual Cues on Turning in Place in Parkinson\\u0026apos;s Disease Patients With Freezing of Gait, Front Neurol. 2020; 11: 185. Published online 2020 Mar 24. doi: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3389/fneur.2020.00185\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eYoung WR, Shreve L., Quinn EJ, Craig C., Bronte-Stewart H. Auditory cueing in Parkinson\\u0026apos;s patients with freezing of gait. What matters most: action-relevance or cue-continuity? Neuropsychologia, 87 (2016), pp. 54\\u0026ndash;62\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eGinis P, Heremans E, Ferrari A, Dockx K, Canning CG, Nieuwboer A. Prolonged walking with a wearable system providing intelligent auditory input in people with Parkinson\\u0026apos;s disease. Front Neurol, 8 (2017), p. 128.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eGinis P, Nieuwboer A, Dorfman M, Ferrari A, Gazit E, Canning CG, et al. Feasibility and effects of home-based smartphone-delivered automated feedback training for gait in people with Parkinson\\u0026apos;s disease: a pilot randomized controlled trial. Parkinsonism Relat Disord, 22 (2016), pp. 28\\u0026ndash;34\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eDuncan RP, Leddy AL, Cavanaugh JT, Dibble LE, Ellis TD, Ford MP, Foreman KB, Earhart GM. Balance differences in people with Parkinson disease with and without freezing of gait. Gait Posture. 2015;42(3):306\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eJanssen S, Steveninck J, Salim H, Bloem B, Heida T, Wezel R. The Beneficial Effects of Conventional Visual Cues Are Retained When Augmented Reality Glasses Are Worn. Hindawi Parkinson\\u0026rsquo;s Disease Volume 2020, Article ID 4104712, 3 pages. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1155/2020/4104712\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eCamila P, Aline P, Kleiner R, Francisca A, Marchese, Redivo R; Paula S; Carlos R, Manuela G. Automated Mechanical Peripheral Stimulation Improves Gait Parameters in Subjects With Parkinson Disease and Freezing of Gait A Randomized Clinical Trial. American Journal of Physical Medicine \\u0026amp; Rehabilitation 97(6):p 383\\u0026ndash;389, June 2018.\\u003c/span\\u003e\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Auditory and Visual cue, Gait, Parkinson's disease, Walker\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-4206782/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-4206782/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eObjective\\u003c/h2\\u003e \\u003cp\\u003eThe aim of this study was to investigate the effects of a visual and auditory cueing walker on freezing of gait during walking in patients with Parkinson's disease (PDF), compared to Parkinson patients without freezing of gait (PDNF). \\u003cb\\u003eDesign\\u003c/b\\u003e: Eighteen PDF and 12 PDNF were included in the study. Participants walked back and forth on a 7-meter walking path under two different conditions: without cues and with a walker providing visual and auditory cues. To assess the risk of falls in both groups, the \\\"Tinetti Balance and Gait Assessment\\\" was conducted. Additionally, the \\\"Dynamic Gait Index\\\" was used to evaluate the ability to adapt walking to varying task demands, and the Timed Up and Go Test (TUGT) was employed to determine walking speed.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eIn the PDF group, visual and auditory cueing walker significantly decreased walking speed, but improved fall risk and walking adaptation. However, for the PDNF group, fall risk was unaffected, walking speed decreased, yet walking adaptation improved. When compared between the two groups, the visual and auditory cueing walker had a more positive effect on the PDF group.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eThis study suggests that a walker providing visual and auditory cues may improve daily walking in patients with Parkinson's disease with freezing of gait (PDF) and reduce the risk of falls in patients with Parkinson's disease without freezing of gait (PDNF) who exhibit hypokinetic gait patterns.\\u003c/p\\u003e\",\"manuscriptTitle\":\"The Effect of Visual and Auditory Cueing Walker on Gait in İndividuals with Parkinson's Disease Experiencing Freezing of Gait\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-04-09 13:15:36\",\"doi\":\"10.21203/rs.3.rs-4206782/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"cee60dd2-f798-432f-a116-11c2c15dced2\",\"owner\":[],\"postedDate\":\"April 9th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2024-04-26T05:11:17+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2024-04-09 13:15:36\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-4206782\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-4206782\",\"identity\":\"rs-4206782\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}