A protocol to examine vision and gait in Parkinson’s disease: impact of cognition and response to visual cues

Background Cognitive and visual impairments are common in Parkinson's disease (PD) and contribute to gait deficit and falls. To date, cognition and vision in gait in PD have been assessed separately. Impact of both functions (which we term 'visuo-cognition') on gait however is likely interactive and can be tested using visual sampling (specifically saccadic eye movements) to provide an online behavioural measure of performance. Although experiments using static paradigms show saccadic impairment in PD, few studies have quantified visual sampling during dynamic motor tasks such as gait. This article describes a protocol developed for testing visuo-cognition during gait in order to examine the: 1) independent roles of cognition and vision in gait in PD, 2) interaction between both functions, and 3) role of visuo-cognition in gait in PD. Methods Two groups of older adults (≥50 years old) were recruited; non-demented people with PD (n=60) and age-matched controls (n=40). Participants attended one session and a sub-group (n=25) attended two further sessions in order to establish mobile eye-tracker reliability. Participants walked in a gait laboratory under different attentional (single and dual task), environmental (walk straight, through a door and turning), and cueing (no visual cues and visual cues) conditions. Visual sampling was recorded using synchronised mobile eye-tracker and electrooculography systems, and gait was measured using 3D motion analysis. Discussion This exploratory study examined visuo-cognitive processes and their impact on gait in PD. Improved understanding of the influence of cognitive and visual functions on visual sampling during gait and gait in PD will assist in development of interventions to improve gait and reduce falls risk. This study will also help establish robust mobile eye-tracking methods in older adults and people with PD

Saccade frequency response to visual cues during gait in Parkinson's disease: the selective role of attention

Gait impairment is a core feature of Parkinson's disease (PD) with implications for falls risk. Visual cues improve gait in PD, but the underlying mechanisms are unclear. Evidence suggests that attention and vision play an important role; however, the relative contribution from each is unclear. Measurement of visual exploration (specifically saccade frequency) during gait allows for real-time measurement of attention and vision. Understanding how visual cues influence visual exploration may allow inferences of the underlying mechanisms to response which could help to develop effective therapeutics. This study aimed to examine saccade frequency during gait in response to a visual cue in PD and older adults and investigate the roles of attention and vision in visual cue response in PD. A mobile eye-tracker measured saccade frequency during gait in 55 people with PD and 32 age-matched controls. Participants walked in a straight line with and without a visual cue (50 cm transverse lines) presented under single task and dual-task (concurrent digit span recall). Saccade frequency was reduced when walking in PD compared to controls; however, visual cues ameliorated saccadic deficit. Visual cues significantly increased saccade frequency in both PD and controls under both single task and dual-task. Attention rather than visual function was central to saccade frequency and gait response to visual cues in PD. In conclusion, this study highlights the impact of visual cues on visual exploration when walking and the important role of attention in PD. Understanding these complex features will help inform intervention development

A protocol to examine vision and gait in Parkinson’s disease: impact of cognition and response to visual cues

Background Cognitive and visual impairments are common in Parkinson's disease (PD) and contribute to gait deficit and falls. To date, cognition and vision in gait in PD have been assessed separately. Impact of both functions (which we term 'visuo-cognition') on gait however is likely interactive and can be tested using visual sampling (specifically saccadic eye movements) to provide an online behavioural measure of performance. Although experiments using static paradigms show saccadic impairment in PD, few studies have quantified visual sampling during dynamic motor tasks such as gait. This article describes a protocol developed for testing visuo-cognition during gait in order to examine the: 1) independent roles of cognition and vision in gait in PD, 2) interaction between both functions, and 3) role of visuo-cognition in gait in PD. Methods Two groups of older adults (≥50 years old) were recruited; non-demented people with PD (n=60) and age-matched controls (n=40). Participants attended one session and a sub-group (n=25) attended two further sessions in order to establish mobile eye-tracker reliability. Participants walked in a gait laboratory under different attentional (single and dual task), environmental (walk straight, through a door and turning), and cueing (no visual cues and visual cues) conditions. Visual sampling was recorded using synchronised mobile eye-tracker and electrooculography systems, and gait was measured using 3D motion analysis. Discussion This exploratory study examined visuo-cognitive processes and their impact on gait in PD. Improved understanding of the influence of cognitive and visual functions on visual sampling during gait and gait in PD will assist in development of interventions to improve gait and reduce falls risk. This study will also help establish robust mobile eye-tracking methods in older adults and people with PD

What Can Quantitative Gait Analysis Tell Us about Dementia and Its Subtypes? A Structured Review

Distinguishing dementia subtypes can be difficult due to similarities in clinical presentation. There is increasing interest in discrete gait characteristics as markers to aid diagnostic algorithms in dementia. This structured review explores the differences in quantitative gait characteristics between dementia and healthy controls, and between four dementia subtypes under single-task conditions: Alzheimer’s disease (AD), dementia with Lewy bodies and Parkinson’s disease dementia, and vascular dementia. Twenty-six papers out of an initial 5,211 were reviewed and interpreted using a validated model of gait. Dementia was associated with gait characteristics grouped by slower pace, impaired rhythm, and increased variability compared to normal aging. Only four studies compared two or more dementia subtypes. People with AD are less impaired in pace, rhythm, and variability domains of gait compared to non-AD dementias. Results demonstrate the potential of gait as a clinical marker to discriminate between dementia subtypes. Larger studies using a more comprehensive battery of gait characteristics and better characterized dementia sub-types are required

Natural history of falls in an incident cohort of Parkinson’s disease: early evolution, risk and protective features

The natural history of falls in early Parkinson’s disease (PD) is poorly understood despite the profound effect of falls on outcome. The primary aim of this study was to describe the natural history of falls, and characterise fallers over 54 months in 99 newly diagnosed people with PD. Seventy-nine (79.7%) participants fell over 54 months and 20 (20.3%) remained falls-naïve. Twenty six (26.2%) reported retrospective falls at baseline. Gait outcomes, disease severity and self-efficacy significantly discriminated across groups. Subjective cognitive complaints emerged as the only significant cognitive predictor. Without exception, outcomes were better for non-fallers compared with fallers at any time point. Between group differences for 54 month fallers and non-fallers were influenced by the inclusion of retrospective fallers and showed a broader range of discriminant characteristics, notably stance time variability and balance self-efficacy. Single fallers (n = 7) were significantly younger than recurrent fallers (n = 58) by almost 15 years (P = 0.013). Baseline performance in early PD discriminates fallers over 54 months, thereby identifying those at risk of falls. Clinical profiles for established and emergent fallers are to some extent distinct. These results reiterate the need for timely interventions to improve postural control and gait

Natural history of falls in an incident cohort of Parkinson’s disease: early evolution, risk and protective features

The natural history of falls in early Parkinson’s disease (PD) is poorly understood despite the profound effect of falls on outcome. The primary aim of this study was to describe the natural history of falls, and characterise fallers over 54 months in 99 newly diagnosed people with PD. Seventy-nine (79.7%) participants fell over 54 months and 20 (20.3%) remained falls-naïve. Twenty six (26.2%) reported retrospective falls at baseline. Gait outcomes, disease severity and self-efficacy significantly discriminated across groups. Subjective cognitive complaints emerged as the only significant cognitive predictor. Without exception, outcomes were better for non-fallers compared with fallers at any time point. Between group differences for 54 month fallers and non-fallers were influenced by the inclusion of retrospective fallers and showed a broader range of discriminant characteristics, notably stance time variability and balance self-efficacy. Single fallers (n = 7) were significantly younger than recurrent fallers (n = 58) by almost 15 years (P = 0.013). Baseline performance in early PD discriminates fallers over 54 months, thereby identifying those at risk of falls. Clinical profiles for established and emergent fallers are to some extent distinct. These results reiterate the need for timely interventions to improve postural control and gait

A multi-resolution investigation for postural transition detection and quantification using a single wearable

Background: Multi-resolution analyses involving wavelets are commonly applied to data derived from accelerometer-based wearable technologies (wearables) to identify and quantify postural transitions (PTs). Previous studies fail to provide rationale to inform their choice of wavelet and scale approximation when utilising discrete wavelet transforms. This study examines varying combinations of those parameters to identify best practice recommendations for detecting and quantifying sit-to-stand (SiSt) and stand-to-sit (StSi) PTs. Methods: 39 young and 37 older participants completed three SiSt and StSi PTs on supported and unsupported chair types while wearing a single tri-axial accelerometer-based wearable on the lower back. Transition detection and duration were calculated through peak detection within the signal vector magnitude for a range of wavelets and scale approximations. A laboratory reference measure (2D video) was used for comparative analysis. Results: Detection accuracy of wavelet and scale combinations for the transitions was excellent for both SiSt (87–97%) and StSi (82–86%) PT-types. The duration of PTs derived from the wearable showed considerable bias and poor agreement compared with the reference videos. No differences were observed between chair types and age groups respectively. Conclusions: Improved detection of PTs could be achieved through the incorporation of different wavelet and scale combinations for the assessment of specific PT types in clinical and free-living settings. An upper threshold of 5th scale approximations is advocated for improved detection of multiple PT-types. However, care should be taken estimating the duration of PTs using wearables

Free-living gait characteristics in ageing and Parkinson’s disease: impact of environment and ambulatory bout length

Background - Gait is emerging as a powerful diagnostic and prognostic tool, and as a surrogate marker of disease progression for Parkinson’s disease (PD). Accelerometer-based body worn monitors (BWMs) facilitate the measurement of gait in clinical environments. Moreover they have the potential to provide a more accurate reflection of gait in the home during habitual behaviours. Emerging research suggests that measurement of gait using BWMs is feasible but this has not been investigated in depth. The aims of this study were to explore (i) the impact of environment and (ii) ambulatory bout (AB) length on gait characteristics for discriminating between people with PD and age-matched controls. Methods - Fourteen clinically relevant gait characteristics organised in five domains (pace, variability, rhythm, asymmetry, postural control) were quantified using laboratory based and free-living data collected over 7 days using a BWM placed on the lower back in 47 PD participants and 50 controls. Results - Free-living data showed that both groups walked with decreased pace and increased variability, rhythm and asymmetry compared to walking in the laboratory setting. Four of the 14 gait characteristics measured in free-living conditions were significantly different between controls and people with PD compared to two measured in the laboratory. Between group differences depended on bout length and were more apparent during longer ABs. ABs ≤ 10s did not discriminate between groups. Medium to long ABs highlighted between-group significant differences for pace, rhythm and asymmetry. Longer ABs should therefore be taken into account when evaluating gait characteristics in free-living conditions. Conclusion -This study provides encouraging results to support the use of a single BWM for free-living gait evaluation in people with PD with potential for research and clinical application

Viewing 3D TV over two months produces no discernible effects on balance, coordination or eyesight

With the rise in stereoscopic 3D media, there has been concern that viewing stereoscopic 3D (S3D) content could have long-term adverse effects, but little data are available. In the first study to address this, 28 households who did not currently own a 3D TV were given a new TV set, either S3D or 2D. The 116 members of these households all underwent tests of balance, coordination and eyesight, both before they received their new TV set, and after they had owned it for 2 months. We did not detect any changes which appeared to be associated with viewing 3D TV. We conclude that viewing 3D TV does not produce detectable effects on balance, coordination or eyesight over the timescale studied. Practitioner Summary: Concern has been expressed over possible long-term effects of stereoscopic 3D (S3D). We looked for any changes in vision, balance and coordination associated with normal home S3D TV viewing in the 2 months after first acquiring a 3D TV. We find no evidence of any changes over this timescale

Time-dependent changes in postural control in early Parkinson’s disease: what are we missing?

Impaired postural control (PC) is an important feature of Parkinson’s disease (PD), but optimal testing protocols are yet to be established. Accelerometer-based monitors provide objective measures of PC. We characterised time-dependent changes in PC in people with PD and controls during standing, and identified outcomes most sensitive to pathology. Thirty-one controls and 26 PD patients were recruited: PC was measured with an accelerometer on the lower back for 2 minutes (mins). Preliminary analysis (autocorrelation) that showed 2 seconds (s) was the shortest duration sensitive to changes in the signal; time series analysis of a range of PC outcomes was undertaken using consecutive 2-s windows over the test. Piecewise linear regression was used to fit the time series data during the first 30 s and the subsequent 90 s of the trial. PC outcomes changed over the 2 mins, with the greatest change observed during the first 30 s after which PC stabilised. Changes in PC were reduced in PD compared to controls, and Jerk was found to be discriminative of pathology. Previous studies focusing on average performance over the duration of a test may miss time-dependent differences. Evaluation of time-dependent change may provide useful insights into PC in PD and effectiveness of intervention