Metronome Cueing of Walking Reduces Gait Variability after a Cerebellar Stroke

Well shit, a stroke protocol should have been written up 3 years ago.

Home-Based Auditory Stimulation Training for Gait Rehabilitation of Chronic Stroke Patients  Jan. 2013 

Effects of Interactive Metronome Therapy on Cognitive Functioning After Blast-Related Brain Injury: A Randomized Controlled Pilot Trial  Sept. 2013 

Stepping to the Beat Improves Spatiotemporal Characteristics of Gait in Stroke Patients with Hemiparesis: A Proof of Concept Case Study of a Home-based Training Intervention  April, 2014 

And how is metronome different than Rhythmic Auditory Cueing?

Rhythmic Auditory Cueing in Motor Rehabilitation for Stroke Patients: Systematic Review and Meta-Analysis  April, 2016

 

The latest here:

Metronome Cueing of Walking Reduces Gait Variability after a Cerebellar Stroke

Rachel L. Wright^1,2*, Joseph W. Bevins³, David Pratt⁴, Catherine M. Sackley⁵ and Alan M. Wing²

• ¹School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, UK
• ²School of Psychology, University of Birmingham, Birmingham, UK
• ³Institute of Sport and Exercise Science, University of Worcester, Worcester, UK
• ⁴West Midlands Rehabilitation Centre, Birmingham Community Healthcare Trust, Birmingham, UK
• ⁵Faculty of Life Sciences & Medicine, King’s College London, London, UK

Cerebellar stroke typically results in increased variability during walking. Previous research has suggested that auditory cueing reduces excessive variability in conditions such as Parkinson’s disease and post-stroke hemiparesis. The aim of this case report was to investigate whether the use of a metronome cue during walking could reduce excessive variability in gait parameters after a cerebellar stroke. An elderly female with a history of cerebellar stroke and recurrent falling undertook three standard gait trials and three gait trials with an auditory metronome. A Vicon system was used to collect 3-D marker trajectory data. The coefficient of variation was calculated for temporal and spatial gait parameters. SDs of the joint angles were calculated and used to give a measure of joint kinematic variability. Step time, stance time, and double support time variability were reduced with metronome cueing. Variability in the sagittal hip, knee, and ankle angles were reduced to normal values when walking to the metronome. In summary, metronome cueing resulted in a decrease in variability for step, stance, and double support times and joint kinematics. Further research is needed to establish whether a metronome may be useful in gait rehabilitation after cerebellar stroke and whether this leads to a decreased risk of falling.

Introduction

Cerebellar infarction accounts for ~3% of strokes, resulting in an incidence of ~20,000 cases per year in the USA (1). Gait instability and gait ataxia are reported in over half of those who experience an infarct in the cerebellum (2). Gait ataxia is associated with increased variability in both step time and step length (3), and although similar range of motion patterns were observed at the hip, knee, and ankle, the variability of these patterns were significantly higher for hip and knee motion compared to controls (4). These increases in variability are likely to be caused by the interaction between the stroke-induced deficits in balance control, limb control and coordination, and the resultant adjustments needed to respond to these deficits (5).

Any increase in the variability of gait parameters is of concern as a small increase in stride time variability is associated with a risk of future falls in community-dwelling older adults (6). Stance and swing time variability distinguishes between fallers and non-fallers (7), and greater stance time variability is associated with future mobility disability (8). Greater variability in step length and double support time is linearly associated with increased risk of multiple falls in older adults, with a non-linear association for step time variability (9). Both increased stride time and length variability are also associated with falls in cerebellar ataxia (10). The occurrence of falls can lead to an associated fear of falling, which can result in a reduction in activity and community involvement (11). Additionally, a high fear of falling also appears to place an individual at an increased risk of experiencing future falls (12). Therefore, reducing excessive gait variability resulting from a cerebellar stroke is an important concern for health-care professionals.

Temporal and spatial parameters, although providing useful information, only provide global measures of gait function. They do not provide information about potential changes at the hip, knee, and ankle joints. The variability of these joint kinematics are only infrequently reported; however, increased variability has been previously reported for individuals with multiple sclerosis (13) and Parkinson’s disease (14), as well as in gait ataxia (4). Therefore, the inclusion of joint angle variability in an assessment of gait variability will provide further information of gait function than by temporal and spatial parameters alone.

Research has shown that auditory rhythm and music can produce an effect on the motor system. Musical rhythms and auditory cues can facilitate muscle activation through the audio-motor pathways at the reticulospinal level (15), and studies have demonstrated the ability to synchronize lower limb movements to auditory cues (16, 17). Tapping studies have identified that a complex circuit involving different cortical areas, cerebellum and basal ganglia, are associated with timing and rhythmic processing (18). The posterior superior temporal gyrus and premotor cortex have been shown to be involved in the entrainment of movement to auditory cues (19). It has been suggested that although cerebellar damage may impair the conscious detection of rhythmic variation, it does not appear to effect motor entrainment to rhythmic stimuli (18). Therefore, the use of rhythmic stimuli for cueing movement may be a useful tool in the rehabilitation of movement deficits following a cerebellar stroke.

The use of an auditory cue for walking, such as a metronome, has been used for a variety of patient groups, such as those with Parkinson’s disease (20–22), post-stroke hemiparesis (23–26), and Huntingdon’s disease (27). For individuals with Parkinson’s disease, the use of a metronome reduced stride time and swing time variability, but only when the metronome was set to 10% higher than the preferred cadence, with the improvements still present 15 min later (21). For individuals with post-stroke hemiparesis, the use of a metronome set to each participant’s preferred cadence reduced paretic step time variability when stepping in place (28).

These studies indicate that the use of a metronome to cue gait can be a useful tool in reducing excessive gait variability; however, no study has investigated the use of a metronome with someone after a cerebellar stroke. Therefore, the aim of this case report was to investigate whether metronome cueing of gait produces an immediate effect on gait variability after a cerebellar stroke.

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