Background Self-efficacy, or an individual's belief in their ability to complete tasks, plays a critical role in mobility. Reduced gait efficacy can lead older adults to limit their walking and physical activities, despite their abilities. Limited information exists on the factors that contribute to gait efficacy among patients with Parkinson's disease (PD). Research question To identify motor and non-motor factors that are associated with gait efficacy in people with PD. Methods Gait efficacy was evaluated using the modified Gait Efficacy Scale (mGES) in 57 people with PD (30 women; mean age: 68.4 ± 7.2 yrs; disease duration: 5 ± 2.8 yrs; MDS-UPDRS part III: 24.7 ± 13.6). Potential contributing factors included age, sex, disease duration and severity, the Falls Efficacy Scale-International (FES-I), the Activities-specific Balance Confidence Scale (ABC), the 6-Minute Walk Test (6MWT), the Timed Up and Go test, and the Short Physical Performance Battery (SPPB). Results mGES was negatively correlated with disease duration, age, and FES-I and positively with ABC, SPPB, and 6MWT, but not with disease severity (p = 0.129). Regression analysis revealed a significant link between mGES and FES-I after adjusting for covariates (adjusted R²=0.687). FES-I was the strongest predictor (β=-0.731, p < 0.001). A model including 6MWT remained significant (p < 0.001, adjusted R²=0.708), with FES-I as the primary predictor (β=-0.653, p < 0.001). Stepwise regression identified ABC, FES-I, and age as significant predictors, explaining 81.5% of the variance in mGES. Significance Age, fear-of-falling, perceived balance, and mobility are related to gait efficacy in individuals with PD. Interventions to enhance gait efficacy in people with PD should address both psychological and physical factors.

Abstract Video annotation is the gold standard for assessing Freezing of Gait (FOG) in Parkinsonian disorders, but it is time-consuming. Deep learning (DL)-based assessment of FOG using inertial measurement units ameliorates this problem but poses challenges. Particularly, the large heterogeneity between patients and assessment methods potentially affects detection performance between independent cohorts. To evaluate heterogeneity effects, we developed a DL model on a local cohort (85 participants; 2043 trials) and validated it across six external cohorts (256 participants; 1058 trials). Model-expert agreement on the percentage-of-time-frozen was strong locally (ICC = 0.886 [0.79, 0.90]) but reduced in external cohorts (ICC = 0.562 ± 0.141). Fine-tuning the DL model with just 50 min of external cohort data improved the ICC to 0.732 ± 0.138, approaching the lower boundary of the inter-rater agreement between two clinical raters using video annotation (ICC = 0.73–0.99). Therefore, while unified standards are still being developed, we propose a human-in-the-loop workflow as an effective intermediary and present a proof-of-concept web-based platform for fine-tuning and expert review ( aidfog.be ).

ObjectiveTo assess the feasibility and, preliminarily, the effectiveness of long-term, personalized gait training using a digital wearable system (Gait Tutor) that provides real-time audio biofeedback to correct or reinforce gait behaviour.DesignOpen-label and non-controlled, with assessments before and after intervention.SettingReal-world.ParticipantsTwenty persons with Parkinson's disease.InterventionParticipants performed home-based gait training in their ON medication state for 30 minutes, 3 times per week, for 9 months using a Gait Tutor.Main measuresWe evaluated adherence (% of expected sessions), usability, and, preliminarily, efficacy by assessing the motor performance of the participants before and after the intervention.ResultsSeventeen participants (85%) completed the study, performing an average of 83 sessions. Adherence was higher for persons with an intermediate disease stage (80.5% of expected training sessions), compared to those with a more advanced disease stage (46.2%). All participants reported extremely positive scores on the questionnaire about ease of use and effectiveness (4.37 ± 0.42). The Movement Disorders Unified Parkinson's Disease Rating Scale motor scores remained stable after the training (mean 9 months). In people with an intermediate disease stage, clinical scores and physical capacity tended to improve.ConclusionsFor the first time, this study shows the feasibility of long-term real-world gait training for people with Parkinson's disease, providing preliminary evidence that personalized, technology-driven rehabilitation strategies can be sustained over extended periods and can assist clinicians in objectively assessing gait performance in the real world.

BACKGROUND:Wider step width and lower step-to-step variability are linked to improved gait stability and reduced fall risk. It is unclear if patients with spinocerebellar ataxia (SCA) can learn to adjust these aspects of gait to reduce fall risk. OBJECTIVES:The aims were to examine the possibility of using wearable step width haptic biofeedback to enhance gait stability and reduce fall risk in individuals with SCA. METHODS:Thirteen people with SCA type 3 performed step width training (single session) using real-time feedback. RESULTS:Step width increased post-training (19.3 cm, interquartile range [IQR] 16.3-20.2 cm) and at retention (16.6 cm, IQR 16.2-21.1 cm), compared to baseline (11.0 cm, IQR 5.2-15.2 cm; P < 0.001). Step width variability decreased during post-training (19.7%, IQR 17.4%-26.2%) and at retention (22.3%, IQR 18.6%-30.2%), compared to baseline (44.5%, IQR 28.5%-71.2%; P < 0.001). Crossover steps, another mark of instability, decreased after training (P < 0.031). CONCLUSIONS:These pilot results suggest that patients with SCA can use a novel, wearable biofeedback system to improve their gait stability. © 2025 International Parkinson and Movement Disorder Society.

Measuring ataxia severity is primarily conducted in-person using tests such as the Scale for the Assessment and Rating of Ataxia (SARA). However, given the motor and cognitive impairments of people with cerebellar ataxia (PwA), there are major limitations in ensuring the assessment is accessible and scalable. We aimed to develop and validate a novel test, enabling the remote assessment of ataxia severity, SARA-Le (SARA Live e-version). SARA-Le is a structured step-by-step test for administering the SARA through video conferencing. In two experiments, we administered SARA-Le to 106 PwA. In Experiment 1 (n = 23), we assessed concurrent validity by comparing SARA-Le and in-person SARA scores administered by an independent neurologist. In addition, we evaluated associations between nine gait measures and both SARA and SARA-Le scores. In Experiment 2 (n = 83), we assessed the efficacy, internal consistency, and correlations between SARA-Le and other related measures. First, we found a high correlation (r = 0.89, P = 0.001) between SARA-Le and in-person SARA scores, supporting convergent validity. Second, SARA-Le and SARA scores were both similarly associated with the nine gait measures, supporting construct validity. Third, SARA-Le’s Cronbach’s alpha was very high (0.831), supporting internal consistency. Fourth, SARA-Le scores exhibited a positive correlation with disease duration (r = 0.44, P < 0.001), and a negative correlation with MoCA scores (r = − 0.27, P = 0.007), supporting construct validity. SARA-Le can serve as a remote technology-based protocol, improving the accessibility and scalability of ataxia severity evaluation.

Step width is vital for gait stability, postural balance control, and fall risk reduction. However, estimating step width typically requires either fixed cameras or a full kinematic body suit of wearable inertial measurement units (IMUs), both of which are often too expensive and time-consuming for clinical application. We thus propose a novel data-augmented deep learning model for estimating step width in individuals with and without neurodegenerative disease using a minimal set of wearable IMUs. Twelve patients with neurodegenerative, clinically diagnosed Spinocerebellar ataxia type 3 (SCA3) performed over ground walking trials, and seventeen healthy individuals performed treadmill walking trials at various speeds and gait modifications while wearing IMUs on each shank and the pelvis. Results demonstrated step width mean absolute errors of 3.3 0.7 cm and 2.9 0.5 cm for the neurodegenerative and healthy groups, respectively, which were below the minimal clinically important difference of 6.0 cm. Step width variability mean absolute errors were 1.5 cm and 0.8 cm for neurodegenerative and healthy groups, respectively. Data augmentation significantly improved accuracy performance in the neurodegenerative group, likely because they exhibited larger variations in walking kinematics as compared with healthy subjects. These results could enable clinically meaningful and accurate portable step width monitoring for individuals with and without neurodegenerative disease, potentially enhancing rehabilitative training, assessment, and dynamic balance control in clinical and real-life settings.

BackgroundCueing can alleviate freezing of gait (FOG) in people with Parkinson's disease (PD), but using the same cues continuously in daily life may compromise effectiveness. Therefore, we developed the DeFOG-system to deliver personalized auditory cues on detection of a FOG episode.ObjectivesWe aimed to evaluate the effects of DeFOG during a FOG-provoking protocol: (1) after 4 weeks of DeFOG-use in daily life against an active control group; (2) after immediate DeFOG-use (within-group) in different medication states.MethodIn this randomized controlled trial, 63 people with PD and daily FOG were allocated to the DeFOG or active control group. Both groups received feedback on their daily living step counts using the device, but the DeFOG group also received on-demand cueing. Video-rated FOG severity was compared pre- and post-intervention through a FOG-provoking protocol administered at home off and on-medication, but without using DeFOG. Within-group effects were tested by comparing FOG during the protocol with and without DeFOG.ResultsDeFOG-use during the 4 weeks was similar between groups, but we found no between-group differences in FOG-severity. However, the within-group analysis showed that FOG was alleviated by DeFOG (effect size d = 0.57), regardless of medication state. Combining DeFOG and medication yielded an effect size of d = 0.67.ConclusionsDeFOG reduced FOG considerably in a population of severe freezers both off and on medication. Nonetheless, 4 weeks of DeFOG-use in daily life did not ameliorate FOG during the protocol unless DeFOG was worn. These findings suggest that on-demand cueing is only effective when used, similar to other walking aids. (c) 2024 International Parkinson and Movement Disorder Society. DeFOG is a wearable device that delivers on-demand auditory cueing. After 4-weeks of DeFOG-use in the home, freezing of gait (FOG) did not improve relative to a control group when tested without DeFOG. However, when DeFOG was used, FOG improved with a sizeable effect, especially when combined with medication. image

Background: Measurement of freezing of gait (FOG) relies on the sensitivity and reliability of tasks to provoke FOG. It is currently unclear which tasks provide the best outcomes and how medication state plays into this. Objective: To establish the sensitivity and test-retest reliability of various FOG-provoking tasks for presence and severity of FOG, with (ON) and without (OFF) dopaminergic medication. Methods: FOG-presence and percentage time frozen (% TF) were derived from video annotations of a home-based FOG-provoking protocol performed in OFF and ON. This included: the four meter walk (4MW), Timed Up and Go (TUG) single (ST) and dual task (DT), 360° turns in ST and DT, a doorway condition, and a personalized condition. Sensitivity was tested at baseline in 63 definite freezers. Test-retest reliability was evaluated over 5 weeks in 26 freezers. Results: Sensitivity and test-retest reliability were highest for 360° turns and higher in OFF than ON. Test-retest intra-class correlation coefficients of % TF varied between 0.63–0.90 in OFF and 0.18–0.87 in ON, and minimal detectable changes (MDCs) were high. The optimal protocol included TUG ST, 360° turns ST, 360° turns DT and a doorway condition, provoking FOG in all freezers in OFF and 91.9% in ON and this could be done reliably in 95.8% (OFF) and 84.0% (ON) of the sample. Combining OFF and ON further improved outcomes. Conclusions: The highest sensitivity and reliability was achieved with a multi-trigger protocol performed in OFF + ON. However, the high MDCs for % TF underscore the need for further optimization of FOG measurement.

Background This study aimed to explore the acceptability of a wearable device for remotely measuring mobility in the Mobilise-D technical validation study (TVS), and to explore the acceptability of using digital tools to monitor health. Methods Participants ( N = 106) in the TVS wore a waist-worn device (McRoberts Dynaport MM + ) for one week. Following this, acceptability of the device was measured using two questionnaires: The Comfort Rating Scale (CRS) and a previously validated questionnaire. A subset of participants ( n = 36) also completed semi-structured interviews to further determine device acceptability and to explore their opinions of the use of digital tools to monitor their health. Questionnaire results were analysed descriptively and interviews using a content analysis. Results The device was considered both comfortable (median CRS (IQR; min-max) = 0.0 (0.0; 0–20) on a scale from 0–20 where lower scores signify better comfort) and acceptable (5.0 (0.5; 3.0–5.0) on a scale from 1–5 where higher scores signify better acceptability). Interviews showed it was easy to use, did not interfere with daily activities, and was comfortable. The following themes emerged from participants’ as being important to digital technology: altered expectations for themselves, the use of technology, trust, and communication with healthcare professionals. Conclusions Digital tools may bridge existing communication gaps between patients and clinicians and participants are open to this. This work indicates that waist-worn devices are supported, but further work with patient advisors should be undertaken to understand some of the key issues highlighted. This will form part of the ongoing work of the Mobilise-D consortium.

BACKGROUND:The performance of an attention-demanding task while walking, i.e., dual-tasking, leads to dual-task costs (e.g., reduced gait speed) in older adults. Previous studies have shown that dual-task costs in gait are associated with future falls and cognitive decline. According to the communication through coherence hypothesis, transcranial alternating current stimulation (tACS) might help alleviate this problem. OBJECTIVE:The aim of this study was to examine the effects of a single session of theta-tACS targeting the left fronto-parietal network (L-FPN) on dual-task walking and cognitive function compared to sham stimulation and transcranial direct current stimulation (tDCS) targeting the left dorsolateral prefrontal cortex, a node within the L-FPN. METHODS:Twenty older adults completed a four-visit, double-blinded, within-subject, cross-over study in which usual-walking, dual-task walking, and cognitive function were evaluated before and immediately after 20 min of tACS, tDCS, or sham (order randomized) stimulation. Dual-task costs to gait speed (primary outcome) and other measures were analyzed. RESULTS:The dual-task cost to gait speed tended to be lower (i.e., better) after tACS (p = 0.067, Cohen's d = 0.433∼small); tDCS significantly reduced this dual-task cost (p = 0.012, Cohen's d = 0.618∼medium), and sham stimulation had no effect (p = 0.467). tACS significantly reduced the dual-task cost to step length (p = 0.037, Cohen's d = 0.502∼medium); a trend was seen after tDCS (p = 0.069, Cohen's d = 0.443∼small). No statistical differences were found for other measures of gait or cognitive function. CONCLUSIONS:The positive effects of tACS on dual-task gait speed and step length were roughly similar to those seen with tDCS. These results suggest that tACS affects the fronto-parietal network and, similar to tDCS, tACS may improve dual-tasking. Nonetheless, to achieve larger benefits and differentiate the effects of tACS and tDCS on brain function and dual-task walking in older adults, other stimulation montages and protocols should be tested.

OBJECTIVES:There has been recent interest in the administration of transcranial electrical stimulation (tES) by a caregiver, family member, or patient themselves while in their own homes (HB-tES). The need to properly train individuals in the administration of HB-tES is essential, and the lack of a uniform training approach across studies has come to light. The primary aim of this paper is to present the HB-tES training and supervision program, a tele-supervised, instructional, and evaluation program to teach laypersons how to administer HB-tES to a participant and to provide a standardized framework for remote monitoring of participants by teaching staff. The secondary aim is to present early pilot data on the feasibility and effectiveness of the training portion of the program based on its implementation in 379 sessions between two pilot clinical trials. MATERIALS AND METHODS:The program includes instructional materials, standardized tele-supervised hands-on practice sessions, and a system for remote supervision of participants by teaching staff. Nine laypersons completed the training program. Data on the feasibility and effectiveness of the program were collected. RESULTS:No adverse events were reported during the training or any of the HB-tES sessions after the training. All laypersons successfully completed the training. The nine laypersons reported being satisfied with the training program and confident in their tES administration capabilities. This was consistent with laypersons requiring technical assistance from teaching staff very infrequently during the 379 completed sessions. The average adherence rate between all administrators was >98%, with seven of nine administrators having 100% adherence to the scheduled sessions. CONCLUSIONS:These findings indicate that the HB-tES program is effective and is associated with participant satisfaction. SIGNIFICANCE:We hope that the remote nature of this training program will facilitate increased accessibility to HB-tES research for participants of different demographics and locations. This program, designed for easy adaptation to different HB-tES research applications and devices, also is accessible online. The adoption of this program is expected to facilitate uniformity of study methods among future HB-tES studies and thereby accelerate the pace of tES intervention discovery.

Motor and cognitive impairments impact the everyday functioning of people with MS (pwMS). The present randomized controlled trial (RCT) evaluated the benefits of a combined motor–cognitive virtual reality training program on key motor and cognitive symptoms and related outcomes in pwMS. In a single-blinded, two-arm RCT, 124 pwMS were randomized into a treadmill training with virtual reality (TT + VR) group or a treadmill training alone (TT) (active-control) group. Both groups received three training sessions per week for 6 weeks. Dual-tasking gait speed and cognitive processing speed (Symbol Digit Modalities Test, SDMT, score) were the primary outcomes. Secondary outcomes included additional tests of cognitive function, mobility, and patient-reported questionnaires. These were measured before, after, and 3 months after training. Gait speed improved (p < 0.005) in both groups, similarly, by about 10 cm/s. The TT + VR group (n = 53 analyzed per-protocol) showed a clinically meaningful improvement of 4.4 points (95% CI 1.9–6.8, p = 0.001) in SDMT, compared to an improvement of only 0.8 points in the TT (n = 51 analyzed per-protocol) group (95% CI 0.9–2.5 points, p = 0.358) (group X time interaction effect p = 0.027). Furthermore, TT + VR group-specific improvements were seen in depressive symptoms (lowered by 31%, p = 0.003), attention (17%, p < 0.001), and verbal fluency (11.6% increase, p = 0.002). These findings suggest that both TT and TT + VR improve usual and dual-task gait in pwMS. Nonetheless, a multi-modal approach based on VR positively impacts multiple aspects of cognitive function and mental health, more than seen after treadmill-treading alone. Trial registered at ClinicalTrials.Gov NCT02427997.

Objective Freezing of gait (FOG) is an episodic, debilitating phenomenon that is common among people with Parkinson disease. Multiple approaches have been used to quantify FOG, but the relationships among them have not been well studied. In this cross-sectional study, we evaluated the associations among FOG measured during unsupervised daily-living monitoring, structured in-home FOG-provoking tests, and self-report. Methods Twenty-eight people with Parkinson disease and FOG were assessed using self-report questionnaires, percentage of time spent frozen (%TF) during supervised FOG-provoking tasks in the home while off and on dopaminergic medication, and %TF evaluated using wearable sensors during 1 week of unsupervised daily-living monitoring. Correlations between those 3 assessment approaches were analyzed to quantify associations. Further, based on the %TF difference between in-home off-medication testing and in-home on-medication testing, the participants were divided into those responding to Parkinson disease medication (responders) and those not responding to Parkinson disease medication (nonresponders) in order to evaluate the differences in the other FOG measures. Results The %TF during unsupervised daily living was mild to moderately correlated with the %TF during a subset of the tasks of the in-home off-medication testing but not the on-medication testing or self-report. Responders and nonresponders differed in the %TF during the personal "hot spot" task of the provoking protocol while off medication (but not while on medication) but not in the total scores of the self-report questionnaires or the measures of FOG evaluated during unsupervised daily living. Conclusion The %TF during daily living was moderately related to FOG during certain in-home FOG-provoking tests in the off-medication state. However, this measure of FOG was not associated with self-report or FOG provoked in the on-medication state. These findings suggest that to fully capture FOG severity, it is best to assess FOG using a combination of all 3 approaches. Impact These findings suggest that several complementary approaches are needed to provide a complete assessment of FOG severity.

ObjectiveAmong older adults, the ability to stand or walk while performing cognitive tasks (ie, dual‐tasking) requires coordinated activation of several brain networks. In this multicenter, double‐blinded, randomized, and sham‐controlled study, we examined the effects of modulating the excitability of the left dorsolateral prefrontal cortex (L‐DLPFC) and the primary sensorimotor cortex (SM1) on dual‐task performance “costs” to standing and walking.MethodsFifty‐seven older adults without overt illness or disease completed 4 separate study visits during which they received 20 minutes of transcranial direct current stimulation (tDCS) optimized to facilitate the excitability of the L‐DLPFC and SM1 simultaneously, or each region separately, or neither region (sham). Before and immediately after stimulation, participants completed a dual‐task paradigm in which they were asked to stand and walk with and without concurrent performance of a serial‐subtraction task.ResultstDCS simultaneously targeting the L‐DLPFC and SM1, as well as tDCS targeting the L‐DLPFC alone, mitigated dual‐task costs to standing and walking to a greater extent than tDCS targeting SM1 alone or sham (p < 0.02). Blinding efficacy was excellent and participant subjective belief in the type of stimulation received (real or sham) did not contribute to the observed functional benefits of tDCS.InterpretationThese results demonstrate that in older adults, dual‐task decrements may be amenable to change and implicate L‐DPFC excitability as a modifiable component of the control system that enables dual‐task standing and walking. tDCS may be used to improve resilience and the ability of older results to walk and stand under challenging conditions, potentially enhancing everyday functioning and reducing fall risks. ANN NEUROL 2021;90:428–439