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Gait disorders represent a therapeutic challenge in Parkinson’s disease (PD). This study investigated the efficacy of 4-week action observation training (AOT) on disease severity, freezing of gait and motor abilities in PD, and evaluated treatment-related brain functional changes. 25 PD patients with freezing of gait were randomized into two groups: AOT (action observation combined with practicing the observed actions) and “Landscape” (same physical training combined with landscape-videos observation). At baseline and 4-week, patients underwent clinical evaluation and fMRI. Clinical assessment was repeated at 8-week. At 4-week, both groups showed reduced freezing of gait severity, improved walking speed and quality of life. Moreover, AOT was associated with reduced motor disability and improved balance. AOT group showed a sustained positive effect on motor disability, walking speed, balance and quality of life at 8-week, with a trend toward a persisting reduced freezing of gait severity. At 4-week vs. baseline, AOT group showed increased recruitment of fronto-parietal areas during fMRI tasks, while the Landscape group showed a reduced fMRI activity of the left postcentral and inferior parietal gyri and right rolandic operculum and supramarginal gyrus. In AOT group, functional brain changes were associated with clinical improvements at 4-week and predicted clinical evolution at 8-week. AOT has a more lasting effect in improving motor function, gait and quality of life in PD patients relative to physical therapy alone. AOT-related performance gains are associated with an increased recruitment of motor regions and fronto-parietal mirror neuron and attentional control areas.

In patients with idiopathic normal-pressure hydrocephalus responsive to CSF drainage, shunting improved gait and balance at 3 months, but not cognition or incontinence, and was associated with some procedure-related risks.

Background The loss of gait automaticity is a key cause of motor deficits in Parkinson’s disease (PD) patients, even at the early stage of the disease. Action observation training (AOT) shows promise in enhancing gait automaticity. However, effective assessment methods are lacking. We aimed to propose a novel gait normalcy index based on dual task cost (NIDTC) and evaluate its validity and responsiveness for early-stage PD rehabilitation. Methods Thirty early-stage PD patients were recruited and randomly assigned to the AOT or active control (CON) group. The proposed NIDTC during straight walking and turning tasks and clinical scale scores were measured before and after 12 weeks of rehabilitation. The correlations between the NIDTCs and clinical scores were analyzed with Pearson correlation coefficient analysis to evaluate the construct validity. The rehabilitative changes were assessed using repeated-measures ANOVA, while the responsiveness of NIDTC was further compared by t tests. Results The turning-based NIDTC was significantly correlated with multiple clinical scales. Significant group-time interactions were observed for the turning-based NIDTC (F = 4.669, p = 0.042), BBS (F = 6.050, p = 0.022) and PDQ-39 (F = 7.772, p = 0.011) tests. The turning-based NIDTC reflected different rehabilitation effects between the AOT and CON groups, with the largest effect size (p = 0.020, Cohen’s d = 0.933). Conclusion The turning-based NIDTC exhibited the highest responsiveness for identifying gait automaticity improvement by providing a comprehensive representation of motor ability during dual tasks. It has great potential as a valid measure for early-stage PD diagnosis and rehabilitation assessment. Trial registration Chinese Clinical Trial Registry: ChiCTR2300067657

Introduction People with Parkinson’s Disease (PD) show abnormal gait patterns compromising their independence and quality of life. Among all gait alterations due to PD, reduced step length, increased cadence, and decreased ground-reaction force during the loading response and push-off phases are the most common. Wearable biofeedback technologies offer the possibility to provide correlated single or multi-modal stimuli associated with specific gait events or gait performance, hence promoting subjects’ awareness of their gait disturbances. Moreover, the portability and applicability in clinical and home settings for gait rehabilitation increase the efficiency in the management of PD. The Wearable Vibrotactile Bidirectional Interface (BI) is a biofeedback device designed to extract gait features in real-time and deliver a customized vibrotactile stimulus at the waist of PD subjects synchronously with specific gait phases. The aims of this study were to measure the effect of the BI on gait parameters usually compromised by the typical bradykinetic gait and to assess its usability and safety in clinical practice. Methods In this case series, seven subjects (age: 70.4 ± 8.1 years; H&Y: 2.7 ± 0.3) used the BI and performed a test on a 10-meter walkway (10mWT) and a two-minute walk test (2MWT) as pre-training (Pre-trn) and post-training (Post-trn) assessments. Gait tests were executed in random order with (Bf) and without (No-Bf) the activation of the biofeedback stimulus. All subjects performed three training sessions of 40 min to familiarize themselves with the BI during walking activities. A descriptive analysis of gait parameters (i.e., gait speed, step length, cadence, walking distance, double-support phase) was carried out. The 2-sided Wilcoxon sign-test was used to assess differences between Bf and No-Bf assessments ( p  < 0.05). Results After training subjects improved gait speed (Pre-trn_No-Bf: 0.72(0.59,0.72) m/sec; Post-trn_Bf: 0.95(0.69,0.98) m/sec; p  = 0.043) and step length (Pre-trn_No-Bf: 0.87(0.81,0.96) meters; Post-trn_Bf: 1.05(0.96,1.14) meters; p  = 0.023) using the biofeedback during the 10mWT. Similarly, subjects’ walking distance improved (Pre-trn_No-Bf: 97.5 (80.3,110.8) meters; Post-trn_Bf: 118.5(99.3,129.3) meters; p  = 0.028) and the duration of the double-support phase decreased (Pre-trn_No-Bf: 29.7(26.8,31.7) %; Post-trn_Bf: 27.2(24.6,28.7) %; p  = 0.018) during the 2MWT. An immediate effect of the BI was detected in cadence (Pre-trn_No-Bf: 108(103.8,116.7) step/min; Pre-trn_Bf: 101.4(96.3,111.4) step/min; p  = 0.028) at Pre-trn, and in walking distance at Post-trn (Post-trn_No-Bf: 112.5(97.5,124.5) meters; Post-trn_Bf: 118.5(99.3,129.3) meters; p  = 0.043). SUS scores were 77.5 in five subjects and 80.3 in two subjects. In terms of safety, all subjects completed the protocol without any adverse events. Conclusion The BI seems to be usable and safe for PD users. Temporal gait parameters have been measured during clinical walking tests providing detailed outcomes. A short period of training with the BI suggests improvements in the gait patterns of people with PD. This research serves as preliminary support for future integration of the BI as an instrument for clinical assessment and rehabilitation in people with PD, both in hospital and remote environments. Trial registration The study protocol was registered (DGDMF.VI/P/I.5.i.m.2/2019/1297) and approved by the General Directorate of Medical Devices and Pharmaceutical Service of the Italian Ministry of Health and by the ethics committee of the Lombardy region (Milan, Italy).

Objectives To investigate changes in external moments in medial meniscus posterior root tear (MMPRT) patients, and the effect of medial meniscus posterior root repair (MMPRR) in restoring normal kinetics. Methods We present preliminary findings from six subjects with MMPRT, four with MMPRR, and three healthy age-matched control participants (CON). Participants walked on level ground at a self-selected gait speed. Data were collected using high-speed cameras and ground-embedded force plates. Peak knee moments for flexion-extension (KFM and KEM), abduction-adduction (KAbM, KAdM), and internal-external rotation (KERM, KIRM) were calculated using inverse dynamics during the stance phase of gait, and normalized to body mass and height. Group comparisons were conducted using the Kruskal-Wallis and Dunn test with Bonferroni correction. Results were considered statistically significant if p-values were less than 0.05. Results Both MMPRT and MMPRR groups exhibited significantly lower KFM relative to the CON group, suggesting a strategy to reduce quadriceps activation in both patient groups, which may persist after surgery. MMPRT patients showed significantly diminished KEM relative to both MMR and CON groups, indicating a strategy to reduce external knee forces following injury. MMPRR patients presented KEM that resembled the healthy control group, showing that repair surgery could potentially restore this gait variable. KAbM was statistically higher in the MMPRR and CON groups relative to MMPRT patients, which presented lower KAM than the other groups, suggesting a protective strategy to offload the medial compartment. KERM were significantly higher in the CON group compared to the MMT group, suggesting a protective strategy to avoid excessive external rotation by the MMT group. No significant differences were observed in KIRM across the three groups. Conclusion MMPRT leads to alterations in gait kinetics, compatible with a protective strategy to unload the knee and compensate for increased medial compartment contact pressures, which are partially restored following root repair.

Background Stroke is a leading cause of long-term disability, with lower limb dysfunction being a common sequela that significantly impacts patients' mobility and quality of life. Robotic-assisted training has emerged as a promising intervention for gait rehabilitation post-stroke. This study aims to compare the effects of active and passive lower limb robotic training on gait recovery in stroke patients. Methods This randomized controlled trial included 45 stroke patients who were divided into three groups: active mode group, passive mode group, and control group. All participants received standard rehabilitation therapy, while the intervention groups additionally received 20 min of robotic training (active or passive mode) daily for 10 sessions over two weeks. Outcome measures included the Fugl-Meyer Assessment (FMA) for motor function, motor evoked potentials (MEP) for neurophysiological assessment, and functional near-infrared spectroscopy (fNIRS) for brain imaging. Results Both active and passive groups showed significant improvements in FMA scores and MEP measures compared to pre-treatment baselines ( P  < 0.01). The active group exhibited significantly greater FMA score improvements ( P  = 0.02) and MEP amplitudes ( P  < 0.01) than the passive group. Additionally, fNIRS results indicated significantly enhanced brain activation in the affected motor cortex in the active group post-treatment ( F  = 5.82, P  = 0.026), a change not observed in the passive group. These findings underscore the clinical superiority of active robotic training in enhancing motor recovery post-stroke. Conclusion Active mode robotic training is more effective than passive mode training in improving motor function and neurophysiological outcomes in stroke patients. These findings support the preferential use of active mode robotic training in clinical rehabilitation settings for enhancing gait recovery post-stroke. Further research with larger sample sizes and longer follow-up periods is warranted to confirm these results and explore long-term benefits.

Freezing of Gait (FOG) is one of the most debilitating gait impairments in Parkinson’s disease (PD), leading to increased fall risk and reduced health-related quality of life. The utility of parkinsonian medications is often limited in the case of FOG and it frequently becomes dopamine resistant. Recent studies have suggested that pre-frontal cortex (PFC) dysfunction contributes to FOG; however, most previous findings provide only indirect evidence. To better understand the role of the PFC, we aimed to investigate the impact of high frequency, deep, repetitive transcranial magnetic stimulation (drTMS) of the medial PFC on FOG and its mediators. Nine patients with advanced PD participated in a randomized, cross-over exploratory study. We applied drTMS over the medial PFC for 16 weeks, with real and sham conditions; each condition included an intensive (i.e., 3 times a week) phase and a maintenance (once a week) phase. Scores on a FOG-provoking test, the motor part of the Unified Parkinson’s Disease Rating Scale, and gait variability significantly improved after real drTMS, but not after the sham condition. Self-report of FOG severity and cognitive scores did not improve. Due to discomfort and pain during treatment, two patients dropped out and the study was halted. These initial findings support the cause-and-effect role of the pre-frontal cortex in FOG among patients with PD. Due to the small sample size, findings should be interpreted cautiously. Further studies are needed to more fully assess the role of the medial PFC in the underlying mechanism of FOG and the possibility of using non-invasive brain stimulation to modify FOG.

Background Biomechanical gait impairments, such as reduced paretic propulsion, are common post-stroke. Studies have used biofeedback to increase paretic propulsion and reduce propulsion asymmetry, but it is unclear if these changes impact overall gait asymmetry. There is an implicit assumption that reducing propulsion asymmetry will improve overall gait symmetry, as paretic propulsion has been related to numerous biomechanical impairments. However, no work has investigated the impact of reducing propulsion asymmetry on overall gait asymmetry. We aimed to understand how within-session changes in propulsion asymmetry affect overall gait asymmetry in individuals post-stroke, operationalized as the combined gait asymmetry metric (CGAM). We hypothesized that decreasing propulsion asymmetry would reduce CGAM. Methods. Participants completed twenty minutes of biofeedback training designed to increase paretic propulsion. We calculated the change in propulsion asymmetry magnitude (Δ|PA|) and the change in CGAM (ΔCGAM) during biofeedback relative to baseline. Then, we fit a robust linear mixed-effects model with ΔCGAM as the outcome and a fixed effect for Δ|PA|. Results. We found a positive association between Δ|PA| and ΔCGAM (β = 2.6, p = 0.002). The average Δ|PA| was -0.09, suggesting that, on average, we would expect a CGAM change of 0.2, which is 0.5% of the average baseline CGAM value. Conclusions. Reducing propulsive asymmetry using biofeedback is unlikely to produce substantial reductions in overall gait asymmetry, suggesting that biofeedback-based approaches to reduce propulsion asymmetry may need to be combined with other interventions to improve overall gait asymmetry. Clinical Trial Registration . NCT04411303.

Innovative technology allows for personalization of stimulation frequency in dual-site deep brain stimulation (DBS), offering promise for challenging symptoms in advanced Parkinson’s disease (PD), particularly freezing of gait (FoG). Early results suggest that combining standard subthalamic nucleus (STN) stimulation with substantia nigra pars reticulata (SNr) stimulation may improve FoG outcomes. However, patient response and the optimal SNr stimulation frequency vary. Our randomized controlled trial studied patients with advanced PD and persistent FoG, while recording gait kinematics through wearable inertial sensors, along with clinical assessments and patient-reported outcomes. In a with-subjects design, we compared a no-stimulation control with four stimulation conditions: Mono-site STN stimulation at 119 Hz and three dual-site protocols (STN + SNr) with SNr stimulation at 119 Hz, 71 Hz, or 30 Hz, keeping total electrical energy delivered (TEED) constant between SNr conditions. Significant interindividual variability was observed for the optimal stimulation protocol, with comparable proportions favoring STN, STN + SNr119, and STN + SNr71. Changes in spatial and temporal gait parameters, such as stride length and swing time, correlated significantly with FoG clinical improvements, with high correlation coefficients (> 0.8). Optimized stimulation parameters also led to improvements in patient-reported outcomes, highlighting the potential of digital biomarkers in tailoring DBS protocols for individualized outcomes.