Computerized Dual-Task Testing of Gait Visuomotor and Cognitive Functions in Parkinson's Disease: Test-Retest Reliability and Validity.

BACKGROUND: Mobility and cognitive impairments in Parkinson's disease (PD) often coexist and are prognostic of adverse health events. Consequently, assessment and training that simultaneously address both gait function and cognition are important to consider in rehabilitation and promotion of healthy aging. For this purpose, a computer game-based rehabilitation treadmill platform (GRP) was developed for dual-task (DT) assessment and training. OBJECTIVE: The first objective was to establish the test-retest reliability of the GRP assessment protocol for DT gait, visuomotor and executive cognitive function in PD patients. The second objective was to examine the effect of task condition [single task (ST) vs. DT] and disease severity (stage 2 vs. stage 3) on gait, visuomotor and cognitive function. METHODS: Thirty individuals aged 55 to 70 years, diagnosed with PD; 15 each at Hoehn and Yahr scale stage 2 (PD-2) and 3 (PD-3) performed a series of computerized visuomotor and cognitive game tasks while sitting (ST) and during treadmill walking (DT). A treadmill instrumented with a pressure mat was used to record center of foot pressure and compute the average and coefficient of variation (COV) of step time, step length, and drift during 1-min, speed-controlled intervals. Visuomotor and cognitive game performance measures were quantified using custom software. Testing was conducted on two occasions, 1 week apart. RESULTS: With few exceptions, the assessment protocol showed moderate to high intraclass correlation coefficient (ICC) values under both ST and DT conditions for the spatio-temporal gait measures (average and COV), as well as the visuomotor tracking and cognitive game performance measures. A significant decline in gait, visuomotor, and cognitive game performance measures was observed during DT compared to ST conditions, and in the PD-3 compared to PD-2 groups. CONCLUSION: The high to moderate ICC values along with the lack of systematic errors in the measures indicate that this tool has the ability to repeatedly record reliable DT interference (DTI) effects over time. The use of interactive digital media provides a flexible method to produce and evaluate DTI for a wide range of executive cognitive activities. This also proves to be a sensitive tool for tracking disease progression. CLINICAL TRIAL REGISTRATION: www.ClinicalTrials.gov, identifier NCT03232996.

Changes in Metabolic Activity and Gait Function by Dual-Task Cognitive Game-Based Treadmill System in Parkinson's Disease: Protocol of a Randomized Controlled Trial.

Balance and gait impairments, and consequently, mobility restrictions and falls are common in Parkinson's disease (PD). Various cognitive deficits are also common in PD and are associated with increased fall risk. These mobility and cognitive deficits are limiting factors in a person's health, ability to perform activities of daily living, and overall quality of life. Community ambulation involves many dual-task (DT) conditions that require processing of several cognitive tasks while managing or reacting to sudden or unexpected balance challenges. DT training programs that can simultaneously target balance, gait, visuomotor, and cognitive functions are important to consider in rehabilitation and promotion of healthy active lives. In the proposed multi-center, randomized controlled trial (RCT), novel behavioral positron emission tomography (PET) brain imaging methods are used to evaluate the molecular basis and neural underpinnings of: (a) the decline of mobility function in PD, specifically, balance, gait, visuomotor, and cognitive function, and (b) the effects of an engaging, game-based DT treadmill walking program on mobility and cognitive functions. Both the interactive cognitive game tasks and treadmill walking require continuous visual attention, and share spatial processing functions, notably to minimize any balance disturbance or gait deviation/stumble. The ability to "walk and talk" normally includes activation of specific regions of the prefrontal cortex (PFC) and the basal ganglia (site of degeneration in PD). The PET imaging analysis and comparison with healthy age-matched controls will allow us to identify areas of abnormal, reduced activity levels, as well as areas of excessive activity (increased attentional resources) during DT-walking. We will then be able to identify areas of brain plasticity associated with improvements in mobility functions (balance, gait, and cognition) after intervention. We expect the gait-cognitive training effect to involve re-organization of PFC activity among other, yet to be identified brain regions. The DT mobility-training platform and behavioral PET brain imaging methods are directly applicable to other diseases that affect gait and cognition, e.g., cognitive vascular impairment, Alzheimer's disease, as well as in aging.

Evaluation of a Game Based Tele Rehabilitation Platform for In-Home Therapy of Hand-Arm Function Post Stroke: Feasibility Study.

BACKGROUND: There is a need for innovation to improve compliance and accessibility of rehabilitation programs for individuals with acquired brain injuries. A computer game-assisted tele-rehabilitation platform (GTP) has been developed to address this need. With the novel application of a miniature inertial computer mouse and taking advantage of the wide variety of computer games, the GTP can provide engaging exercises for rehabilitation of upper extremity motor skills. OBJECTIVE: To determine the feasibility and acceptability of the game-assisted home exercise program for upper extremity rehabilitation for people with stroke. The treatment effect was also measured after 16 weeks of intervention. DESIGN: A feasibility study. SETTING: College of Rehabilitation Science, University of Manitoba. PARTICIPANTS: Ten stroke clients. INTERVENTION: Participants received three to four initial clinically supervised therapy sessions for training with the game assisted therapy program. Once trained, participants continued the program at the home for 16 weeks, four times per week. MAIN OUTCOME MEASURES: Feasibility was evaluated based on retention rate and compliance. Semistructured interviews after the completion of the program were done to assess acceptability of the program. Quantitative analysis included (1) the Wolf Motor Function Test A and B and (2) a computerized performance-based assessment of specific object manipulation tasks that required a combination of finger, wrist, elbow and shoulder motion. RESULTS: Findings demonstrated the feasibility and acceptability of the home tele-rehab program. Eight of the 10 participants fully complied with the 16-week exercise program. Two participants had difficulty with computer operations and did not complete the program. For the eight participants who completed the program, there was a substantial improvement from pre- to postintervention. CONCLUSION: Although some difficulties with the technology were reported, the findings demonstrate feasible trial procedures, acceptable game-assisted task-oriented home training with a high compliance rate and positive outcomes. These findings and the theoretical evidence direct the next phase of a full-scale randomized controlled trial.

Imaging Cerebral Glucose Metabolism during Dual-Task Walking in Patients with Parkinson's disease.

BACKGROUND AND PURPOSE: Gait impairment is a hallmark of Parkinson's disease (PD). Natural walking involves more cognitive demand than treadmill walking or in-laboratory walking tests because patients have to actively work on navigation and top-down cognitive control which taxes cognitive reserve in the prefrontal cortex. To mimic the prefrontal engagement occurring with natural walking in a controlled and safe environment, dual-task (DT) treadmill walking has been developed. In this study, we tested the feasibility of imaging DT walking-related changes in brain glucose metabolism in patients with PD. METHODS: Fifteen patients with PD were scanned with fluorodeoxyglucose (FDG) positron emission tomography. Five patients performed DT walking, and 10 patients were rested during the FDG uptake period. First, the images were contrasted between the groups. Second, the walking-related brain glucose metabolism was inspected at the individual level. RESULTS: Consistently increased glucose metabolism was identified in DT walking versus rest in the primary visual/sensorimotor areas, thalamus, superior colliculus, and cerebellum. In individual level analysis, patients with less progressed disease (n = 3) showed prefrontal activity during DT walking while patients with more progressed disease (n = 2) did not. CONCLUSION: This study confirms the feasibility of imaging glucose metabolism during DT walking in patients with PD. We also report that during DT walking, there is a lesser degree of prefrontal engagement in the patients with more progressed disease compared to those with less progressed disease, implying increased degrees of frontal dysfunction with PD progression.