Background
Parkinson’s disease (PD) is a common neurodegenerative disease, whose prevalence rises rapidly with age [
1]. The cardinal motor manifestations of PD include bradykinesia, rigidity, rest tremor, and gait impairment [
2]. Gait disturbance runs through the course of PD and greatly affects their quality of life [
3].
The characteristics of gait impairment in PD patients vary widely, including decreased speed, reduced stride length, reduced arm swing amplitude, increased interlimb asymmetry, larger gait variability, impaired complex locomotor tasks, reduced axial rotation, stooped posture, impaired motor automaticity, freezing of gait (FOG), and increased risk of falling [
3‐
5]. It has been believed that gait impairment in PD patients is not only related to deficit of motor activity, but also closely related to higher-level cognitive impairments such as executive dysfunction [
6,
7]. Accurate assessment and treatment of gait impairment in PD patients is very important.
Several observational and quantitative scales such as Movement Disorder Society Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) [
8], Freezing of Gait Questionnaire [
9], Timed Up-and-Go [
10], and 6-min walk test [
11] have been widely used to assess PD gait. However, these methods obtain relatively simple metrics and are susceptible to tester bias [
3,
12]. Sensor-based wearable electronic devices enable gait measures more detailed and can be performed in home and community settings.
Similar to bradykinesia, tremor, and rigidity, gait impairment in PD can be clearly relieved by dopaminergic drugs, especially in the early stage. However, these drugs are not always effective and might lead to sedation, orthostatic hypotension, behavioral and psychiatric symptoms [
13,
14]. Motor fluctuation and dyskinesia associated with long-term use of levodopa can even lead to worsening of gait [
15]. Therefore, non-pharmacological interventions to treat PD gait are receiving increasing attention. Numerous studies have shown that various aspects of gait in PD patients can be improved by different rhythmical visual and auditory cues [
16‐
20]. A previous study showed that public space floors with visual cues can improve gait in PD patients [
21].
In this study, we designed carpets with visual cues, and aimed to explore whether they could improve gait in PD patients using wearable electronic device. We also want to test if executive dysfunction affects the gait improvement.
Discussion
Gait impairment is very common and heterogeneous in PD patients. In this study, we designed two kinds of carpets with visual cues (chessboard pattern and stripe pattern), and found that carpets with the two patterns are effective in improving gait in PD patients without FOG. Further analysis suggested that this improvement may be independent of executive function.
Gait impairment is a major concern for PD patients, causing falls and recurrent falls in 68.3% and 39% of the patients [
30‐
32]. Treatment for PD gait impairment is diverse. Although their therapeutic targets are different, levodopa, dopamine agonists, inhibitors of amine oxidase B, and acetylcholinesterase inhibitors have all been reported to be effective in improving PD gait [
13,
33‐
36]. However, the side effects of long-term use and the uncertainty of efficacy are their limitations [
13]. Non-pharmacological interventions make up for these deficiencies and bring additional benefits. Compensation strategies developed spontaneously or trained by doctors can alleviate PD gait impairment by bypassing the basal ganglia pathway, among which, external cues are known to be the most widely applied strategy [
37,
38]. External cues refer to a series of rhythmically visual, auditory, or proprioceptive stimuli that provide a gait reference. To better apply visual cue strategies to home and community settings, we designed carpets with chessboard and striped cues in the current study. Based on wearable device recordings and subsequent analysis, our results showed that the two patterned carpets can improve stride length, gait speed and fall risk in PD patients. A previous study designed a chessboard floor and tested it in 32 PD patients with FOG. The results showed that it can improve several parameters of gait [
21]. Our study, with a larger sample size, showed that even PD patients without FOG would benefit from carpets with visual cues.
The underlying mechanism of gait impairments in PD patients is not clear. Relevant studies are mainly carried out in cross-sectional studies, focusing on brain functional MRI, risk factors, and neurotransmitters. In addition to the nigrostriatal dopamine system, non-motor symptoms, non-dopaminergic systems, and frontal-striatal connections have also been shown to be associated with gait impairment in PD [
39‐
41]. Executive dysfunction plays an important role in gait impairment [
7]. A previous study showed that both mild and marked executive dysfunctions are independent risk factors for falls in PD patients [
25]. What’s more, rivastigmine and donepezil, which are used to improve executive function, have been shown to be effective in improving PD gait [
35,
36].
Highlighted should be that we firstly evaluated the gait improvement by visual cues in PD patients with or without executive dysfunction respectively. The results showed that the benefits in stride length and gait speed are significant in those without executive dysfunction. However, further analysis showed that this improvement was not significantly different between the patients with and without executive dysfunction. It may be due to the fact that executive dysfunction is not extremely severe in our cohort, as we have excluded those who could not follow the instructions when recruiting patients. Our results suggest that the gait-improving effect of visual cues is also valuable in PD patients with mild executive dysfunction.
It is worth noting that a short walk (in the absence of habituation) on a patterned carpet may raise attention, and further boost the gait performance. The habits of walking on such patterns may induce habituation, lower attention and eventually lose the benefit observed on gait in such a research setting. Therefore, whether such patterned carpets can permanently improve PD gait needs further study. Meanwhile, we have to acknowledge certain limitations. The turns, narrow spaces and obstacles that exist in real home and community settings are not reflected in our research. In addition, our study has a relatively small sample size and lacks longitudinal observation, the presence of which would otherwise enhance the reliability of the conclusions.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit
http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (
http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.