Effect of rhythmic auditory cueing on parkinsonian gait: A systematic review and meta-analysis

The use of rhythmic auditory cueing to enhance gait performance in parkinsonian patients’ is an emerging area of interest. Different theories and underlying neurophysiological mechanisms have been suggested for ascertaining the enhancement in motor performance. However, a consensus as to its effects based on characteristics of effective stimuli, and training dosage is still not reached. A systematic review and meta-analysis was carried out to analyze the effects of different auditory feedbacks on gait and postural performance in patients affected by Parkinson’s disease. Systematic identification of published literature was performed adhering to PRISMA guidelines, from inception until May 2017, on online databases; Web of science, PEDro, EBSCO, MEDLINE, Cochrane, EMBASE and PROQUEST. Of 4204 records, 50 studies, involving 1892 participants met our inclusion criteria. The analysis revealed an overall positive effect on gait velocity, stride length, and a negative effect on cadence with application of auditory cueing. Neurophysiological mechanisms, training dosage, effects of higher information processing constraints, and use of cueing as an adjunct with medications are thoroughly discussed. This present review bridges the gaps in literature by suggesting application of rhythmic auditory cueing in conventional rehabilitation approaches to enhance motor performance and quality of life in the parkinsonian community.

Significant enhancement in cadence and coefficient of variation for inter stride interval after rhythmic auditory cueing in all conditions for both Exp and Ct. Significant effect of rhythmic auditory cueing that was amplitude modulated for biological variability as compared to isosynchronous metronome cueing on short-long term correlation for term series of interresponse-interval correlations in both Exp and Ct. Enhanced synchronization, but reduced short-long term correlation for term series of inter-responseinterval correlations during metronome based isosynchronous cueing as compared to cueing with amplitude modulated for biological variability in both Exp and Ct. Dalla Bella,et al. 93 Effects of auditory cueing on gait in patients affected from Parkinsonism Significant enhancement in gait speed in both Exp and Ct after training and with follow-up. Significant reduction in stride time variability after training, however, effect not seen at follow-up. Significantly shorter inter-step interval with -10% input as compared to +10%, however synchronization variability significantly increased with +10%. No effects on synchronization accuracy. Significantly reduced synchronization variability in hand tapping task with auditory input. Significant enhancement in adaptation index, and phase correction relative to group average was reported. Chen,et al. 87 Effects of auditory cueing on walking turns in patients affected from Parkinsonism Rhythmic auditory cueing at -10% or +10% of preferred cadence Significant enhancement in gait velocity, freezing of gait score with auditory cueing in both single and dual task conditions. Significant enhancement in gait velocity (dual-task only), step length, cadence and freezing of gait score in audio-visual condition in both single and dual task conditions. Significant enhancement in step length, gait speed, cadence, swing phase % after 5 weeks of supervised training and 17 weeks of home training with rhythmic auditory cueing as compared to baseline. Significant enhancement in step width after 17 weeks of training with rhythmic auditory cueing as compared to baseline and 5-week training. Significant reduction in stance phase % (5-week only) and double support % after 5 weeks of supervised training and 17 weeks of home training with rhythmic auditory cueing as compared to baseline. Significant reduction in gait profile score, gait variable score (hip flexion-extension) after 17 weeks of training with rhythmic auditory cueing as compared to baseline and 5-week training. Significant enhancement in gait variable score for (ankle dorsiplantarflexion) after 17 weeks of training with rhythmic auditory cueing as compared to baseline and 5-week training. Significant enhancement in dynamic range of motion at hip flexion-extension (17-week> 5-week), knee flexion-extension after 5 weeks of supervised training and 17 weeks of home training with rhythmic auditory cueing as compared to baseline. Zhao,et al. 198 Effect Patients performed gait with/without rhythmic auditory cueing at -10%, +10% of preferred cadence alone or with additional cueing strategy "think about larger strides" with/without -10% and +10% of auditory inputs tone, with/without dual-task "word generation task" Metronomic cueing at -10% or +10% of preferred cadence.
Significantly enhanced gait velocity and stride length in Exp within combined condition of additional cues and auditory inputs. Significant increase in stride length in the dual-task setting wit auditory input and additional cues. Modulated auditory input affected gait parameters of Ct. Ford,et al. 141 Effects of auditory cueing on gait and treadmill With different instructions "step in beat time", "take big step in beat time" Rhythmic beep cueing at preferred cadence Significant enhancement in gait speed, stride amplitude with walking instructions "big step in beat time" and auditory input in both single and dual task conditions. The enhancements were higher for single task as compared to dual task setting. Reduced coefficient of variation of step time and coefficient of variation of double limb support time with auditory input, single/dual task, and additional instructions. Higher reduction for "big steps in beat time". Enhanced cadence for auditory input in both single and dual task conditions. Bryant,et al. 108 Effects Significant effect of auditory cueing and attentional cue "big steps with beat" on step frequency in gait on gait in Ct: 7F, 4M frequency auditory cueing -10% of speed, step amplitude, step frequency (dual task only) patients (71.5±2.5) preferred cadence, attentional in Exp in both single and dual task conditions. affected from cue instructions "try to take Significant effect of auditory cueing and attentional Parkinson's big steps", together "take a big cue "big steps with beat" on step frequency in gait disease step with the beat", and speed (single task only), step amplitude, step with/without a dual task (a frequency in Ct in both single and dual task tray with 2 cups of water on conditions. top), post-test Non-significant effects on gait speed, step amplitude and step frequency with auditory cueing only. Step length, step frequency, walking speed, time duration and cadence Complex functional walking and sitting task under single and dual-motor task (carrying a tray) condition Rhythmic auditory cueing generated according to preferred speed of patients.
Significant enhancement in step length of dual-motor task with auditory cueing as compared to Ct group.
Enhancement in walking speed for patients in dualmotor task with auditory cueing.
No difference in step length and walking speed in single task conditions.
No difference in step frequency, time duration and cadence in both single and dual-motor conditions. Significantly enhanced synchronization in Ct, but synchronization not evident in both Exp groups.
Significant enhancement in gait velocity, stride length and cadence in Exp.
Re-production of performance parameters evident after training in absence of auditory stimuli.
Significant reduction in electromyogram amplitude variability of tibialis anterior and vastus medialis muscle.
Exp: experimental group, Ct: Control group