The Effect of External Rhythmic Cues (Auditory and Visual) on Walking During a Functional Task in Homes of People With Parkinson’s Disease


      Rochester L, Hetherington V, Jones D, Nieuwboer A, Willems AM, Kwakkel G, Van Wegen E. The effect of external rhythmic cues (auditory and visual) on walking during a functional task in homes of people with Parkinson’s disease.


      To evaluate (1) the influence of rhythmic cues on gait interference during a functional activity and (2) the relationship of clinical symptoms to gait interference.


      Repeated-measures study.


      Participants’ homes.


      Twenty subjects with idiopathic Parkinson’s disease (PD) and a control group of 10 age-, sex-, and education-matched subjects.


      Subjects performed a simple functional task that included a walking component and a dual-motor task. The functional task was performed with and without external rhythmic (auditory and visual) cues.

      Main outcome measures

      Walking speed, mean step length, and step frequency were compared during trials of the tasks. In addition, tests of cognitive executive function (Hayling and Brixton tests), anxiety and depression (Hospital Anxiety and Depression Scale), and fatigue (Multidimensional Fatigue Inventory) were undertaken.


      The use of auditory cues during a dual task involving gait reduced the interference effect on the task; significant increases in step length were observed in PD subjects (P=.018), representing an increase of 19%.


      External auditory cues may be useful in reducing interference and maintaining gait performance during more complicated functional activities. Clinical symptoms, such as depression and fatigue, could influence the ability to focus attention and may increase gait interference during the performance of complex tasks, with subsequent implications for functional walking and safety.

      Key words

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        • Morris M.E.
        • Iansek R.
        • Matyas T.A.
        • Summers J.L.
        The pathogenesis of gait hypokinesia in Parkinson’s disease.
        Brain. 1994; 117: 1169-1181
        • Morris M.E.
        • Iansek R.
        • Matyas T.A.
        • Summers J.L.
        Stride length regulation in Parkinson’s disease. Normalization strategies and underlying mechanisms.
        Brain. 1996; 119: 551-568
        • Thaut M.
        • McIntosh G.C.
        • Rice R.R.
        • Miller R.A.
        • Rathbun J.
        • Brault J.M.
        Rhythmic auditory stimulation in gait training for Parkinson’s disease patients.
        Mov Disord. 1996; 11: 193-200
        • Lewis G.
        • Byblow W.D.
        • Walt S.
        Stride length regulation in Parkinson’s disease.
        Brain. 2000; 123: 2077-2090
        • Bond J.
        • Morris M.E.
        Goal-directed secondary motor tasks.
        Arch Phys Med Rehabil. 2000; 81: 110-116
        • O’Shea S.
        • Morris M.E.
        • Iansek R.
        Dual task interference during gait in people with Parkinson’s disease.
        Phys Ther. 2002; 82: 888-897
        • Rochester L.
        • Hetherington V.
        • Jones D.
        • et al.
        Attending to the task.
        Arch Phys Med Rehabil. 2004; 85: 1578-1585
        • Iansek R.
        • Bradshaw J.
        • Phillips J.
        • et al.
        Interaction of the basal ganglia and supplementary motor area in the elaboration of movement.
        in: Glencross D. Piek J.P. Motor control and sensory-motor integration issues and directions. Elsevier Science, Amsterdam1995: 37-59
        • Lou J.
        • Kearns G.
        • Oken B.
        • Sexton G.
        • Nutt J.
        Exacerbated physical fatigue and mental fatigue in Parkinson’s disease.
        Mov Disord. 2001; 16: 190-196
        • Dalrymple J.
        • Kalders A.
        • Jones R.
        • Watson R.
        A central executive deficit in patients with Parkinson’s disease.
        J Neurol Neurosurg Psychiatry. 1994; 57: 360-367
        • Wertman E.
        • Speedie L.
        • Shemesh Z.
        • Gilon D.
        • Raphael M.
        • Stessman J.
        Cognitive disturbances in Parkinsonian patients with depression.
        Neuropsychiatry Neuropsychol Behav Neurol. 1993; 6: 31-37
        • Cooper J.A.
        • Sagar H.J.
        • Jordan N.
        • Harvey N.S.
        • Sullivan E.V.
        Cognitive impairment in early, untreated Parkinson’s disease and its relationship to motor disability.
        Brain. 1991; 114: 2095-2122
        • Litvan I.
        Extrapyramidal disorders and frontal lobe function.
        in: Miller B.L. Cummings J.C. The human frontal lobes functions and disorders. Guilford Pr, New York1999: 402-421
        • Stam C.J.
        • Visser S.L.
        • Op de Coul A.A.
        • et al.
        Disturbed frontal regulation of attention in Parkinson’s disease.
        Brain. 1993; 116: 1139-1158
        • van der Linden D.
        • Frese M.
        • Meijman T.F.
        Mental fatigue and the control of cognitive processes.
        Acta Psychol. 2003; 113: 45-65
        • Reischies F.M.
        • Neu P.
        Comorbidity of mild cognitive disorder and depression—a neuropsychological analysis.
        Eur Arch Clin Neurosci. 2000; 250: 186-193
        • Bloem B.
        • Valkenburg V.V.
        • Slabbekoorn M.
        • van Dijk J.G.
        The multiple tasks test. Strategies in Parkinson’s disease.
        Exp Brain Res. 2001; 137: 478-486
        • Hoehn H.
        • Yahr M.
        Neurology. 1967; 17: 427-442
        • Folstein M.
        • Folstein S.
        “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Goetz C.
        • Stebbins G.T.
        • Shale H.M.
        • et al.
        Utility of an objective dyskinesia rating scale for Parkinson’s disease.
        Mov Disord. 1994; 9: 390-394
        • Fahn S.
        • Elton R.
        • members of UPDRS Committee
        Unified Parkinson’s disease rating scale.
        in: Fahn S. Marsden C.D. Goldstein M. Calne D.B. Recent developments in Parkinson’s disease. MacMillan, New York1987: 153-163
        • Crawford J.
        • Allan K.
        • Cochrane R.
        • Parker D.
        Assessing the validity of NART estimated premorbid IQs in the individual case.
        B J Clin Psychol. 1990; 29: 435-436
        • Burgess P.T.
        The Hayling and Brixton tests.
        Thames Valley Test Co, Bury St Edmonds1997
        • Zigmund A.S.
        • Snaith R.P.
        The Hospital Anxiety and Depression Scale.
        Acta Psychiatr Scand. 1983; 67: 361-370
        • Smets E.
        • Garssen B.
        • Bonke B.
        • De Haes J.C.
        The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue.
        J Psychosom Res. 1995; 39: 315-325
        • Bussman H.
        • Tulen J.
        • Herel van E.
        • Stam H.
        Quantification of physical activities by means of ambulatory accelerometry.
        Psychophysiology. 1998; 35: 488-496
        • Behrman A.
        • Teitelbaum P.
        • Cauraugh J.H.
        Verbal instructional sets to normalise the temporal and spatial gait variables in Parkinson’s disease.
        J Neurol Neurosurg Psychiatry. 1998; 65: 580-582
        • McIntosh G.
        • Brown S.H.
        • Rice R.R.
        • Thaut M.H.
        Rhythmic auditory-motor facilitation of gait patterns in patients with Parkinson’s disease.
        J Neurol Neurosurg Psychiatry. 1997; 62: 22-26
        • Howe T.E.
        • Lovgreen B.
        • Cody F.W.
        • Ashton V.J.
        • Oldham J.A.
        Auditory cues can modify the gait of persons with early-stage Parkinson’s disease.
        Clin Rehabil. 2003; 17: 363-367
        • Gueye L.
        • Viallet F.
        • Legallet E.
        • Trouche E.
        The use of advance information for motor preparation in Parkinson’s disease.
        Brain Cogn. 1998; 38: 66-86
        • Knoke D.
        • Taylor A.E.
        • Saint-Cyr J.A.
        The differential effects of cueing on recall in Parkinson’s disease and normal subjects.
        Brain Cogn. 1998; 38: 261-274
        • Brown R.
        • Marsden C.
        Internal versus external cues and the control of attention in Parkinson’s disease.
        Brain. 1988; 111: 323-345
        • Kritikos A.
        • Leahy C.
        • Bradshaw J.L.
        • Iansek R.
        • Phillips J.G.
        • Bradshaw J.A.
        Contingent and non-contingent auditory cueing in Parkinson’s disease.
        Neuropsychologia. 1995; 33: 1193-1203
        • Cools R.
        • Barker R.A.
        • Sahakian B.J.
        • Robbins T.W.
        Mechanisms of cognitive set flexibility in Parkinson’s disease.
        Brain. 2001; 124: 2503-2512