Access Expert Help for Managing Freezing of Gait in Parkinson's Patients
Freezing of gait (FOG) is a troubling symptom common in Parkinson’s disease, often causing falls and affecting patients’ quality of life. Visual cueing has gained attention as an effective non-drug intervention to reduce FOG episodes and enhance mobility. This systematic review provides an in-depth analysis of existing research on visual cueing techniques and their impact on managing gait freezing in Parkinson’s patients. For students or researchers seeking comprehensive insights, this study also serves as a valuable resource for assignment writing help related to Parkinson’s disease interventions and clinical outcomes.
This is the first chapter of this research, which provides crucial information for research development. This study provides ideas about the effects of visual cueing for Parkinson’s disease. Reduced mobility is a common symptom of PD, and FOG is a specific presentation that is described by the patient’s inability to initiate a movement spontaneously. Among them, visual cueing, which means using visual cues to prompt movement, has been considered as a factor of FOG treatment. The following systematic review therefor,e aims at assessing the efficacy of visual cueing in the management of FOG among Parkinson’s patients. In this chapter rationale, background, aim and overview of the chapters is provided effectively for better understanding.
Freezing of gait (FOG) is an essential motor feature of Parkinson’s disease (PD) defined as the temporary inability to initiate or execute walking. This adversely affects mobility and rise in cases of falls, which in turn reduces the quality of life as well as independence. Former approaches to Parkinson’s management have included pharmacotherapy and deep brain stimulation, which are known to give very short improvement to FOG. Visual cueing is an intervention that entails the use of visual prompts in the training of practice that assist in motor performance and can consider the intervention strategy to handle FOG approach (Cosentino et al. 2023). The importance of visual cueing has been proposed in early studies of motor learning and rehabilitation where it was postulated that patients could overcome their motor dysfunction by using visual information. Early research done in the 1990s showed that simple changes to the environment such as four stripes or spots on the floor could enhance gait initiation and minimise freezing.
Figure 1: Freezing of Gait
Modern versions include a more precise hierarchical way of using the cueing devices, dynamic and computerised cueing like lighted cues and many more like this. It is monitored that all of these modern approaches can try to give more accurate and contextually relevant cueing, which may be of better use for the patients of Parkinson's. The evaluation of the use of visual cueing in the management of FOG requires a systematic review of these practices for practicality. This review aims to identify what has already been done in the past regarding the efficacy of particular visual cueing methods. The effects of those methods on gait parameters and the effects of those methods on the well-being of the patients (Rutz & Benninger, 2020). The findings are needed for patients with Parkinson’s disease to understand how to use visual cueing in patients’ everyday lives and to enhance the results of an individual treatment plan.
1.2.1. Visual cues
This can provide improvement from the issue of FOG and can reduce Parkinson’s disease effects.
1.2.2. Freezing of gait (FOG)
It is a symptom of Parkinson’s disease, which can cause people to become unable to move.
1.3.1. Aim
The main aim of this research is to focus on the effects of freezing cueing for Parkinson’s disease along with the information of freezing of gait. This research provides information about the systematic review for information of the previous researches of Perkinsons’s disease.
1.3.2. Objectives
The research rationale for the effectiveness assessment of VO on FOG in Parkinson’s patients base itself in the essential necessity of efficient non-drug treatments. Even with very recent improvements in PD treatment, FOG is still a troublesome symptom that typically does not respond to ordinary treatments. Therefore, owing to the theoretical background of motor learning, the techniques of the improved visual cueing have been found effective in the initial studies, but these techniques need more formal examination to determine the advantages and effectiveness for use (Miller et al. 2020). The findings of this study can help to determine the effectiveness or otherwise of various methods of visual cueing in the management of FOG and hence, contribute to the existing knowledge about this intervention. They could provide guidance to the systematic introduction of visual cueing into rehabilitation programs for improving the quality of life of persons with Parkinson’s disease. It is imperative that this research now forms the basis of targeting specific non-invasive management strategies which can address one of the worst aspects of Parkinson’s disease.
The freezing of gait (FOG) is most probably one of the worst PD symptoms as it results in immobility and mostly interferes with the quality of life. General medical treatments such as medications and stereotactic electroencephalography do not give satisfactory outcomes in treating FOG. While non-pharmacological methods, one of which is visual cueing – the use of visible prompts to facilitate and support motion – have only been preliminarily assessed, the approach has been found to be promising (Delgado‐Alvarado et al. 2020). The issue is in the variability of the findings and limited evidence on the impact of various forms of visual cueing on the level of FOG and qualitative gait parameters. Such ambiguity hinders the extension of visual cueing into generally followed protocols on Parkinson’s disease. Hence, it is imperative there be a more systematic brief to measure the current use of visual cueing methods in the management of FOG. Solving this issue can assess the effectiveness of awareness, inform the approach toward the treatment, and possibly enhance the quality of life for those PD sufferers.
| Introduction | This is the first chapter that provides an introduction to the study. |
| Literature Review | In this second chapter, crucial information of previous research that has been conducted is provided for visual cueing and Parkinson's disease. |
| Manuscript | In this chapter, information on the publication of the journal is provided for Parkinson’s and FOG. |
| Critical Review | In this last chapter, all the crucial information of the research process is provided for better understanding. |
Therefore, in this way development of research becomes easier.
Freezing of Gait (FOG) is a disabling feature of Parkinson’s disease that negatively affects the patient’s functional status and quality of life. It presents itself as a brief and temporary loss of ability to initiate gait or continue walking again and this results in falls and subsequent injuries. Video-based instructions have been identified as one of the potential non-drug approaches for reducing FOG depending on external cues that would not go through the damaged neural circuits associated with motor control. This literature review will therefore seek to critically review published studies, which investigates the impact of different visual cueing techniques on decreasing of FOG episodes among PD patients. In accordance with the purpose of the review, by synthesising data from recent clinical trials and observational studies, the most effective visual cues will be revealed. This also comprehends the processes through which it happens and evaluates the sustainability concerning the consequences for the patient outcomes. The study’s results will have clinical implications as well as broader set of FOG interventional initiatives for Parkinson’s disease.
Parkinson’s disease (PD) which was recorded by James Parkinson in 1817 is a chronic movement disorder that is characterized by motor symptoms including tremors, slowness of movement or akinesia, rigidity and postural instability. However, one of the more difficult to treat syndromes in Parkinson’s patients comprises FOG which is a temporary dysfunction of gait in spite of the intention to do so. FOG is observed in the latter stages of PD, which is characterised by a higher fall risk, higher disability levels and poorer quality of life (Graham et al. 2023). The phenomenon of FOG in Parkinson’s disease was described at the beginning of the middle of the twentieth century, however too much remains unknown about FOG pathophysiology. FOG is attributed to a malfunction in the neural connections within the basal ganglia, impacting the motor control network. Initially, management strategies for FOG relied on different level of efficacy in pharmacological interventions. However, it became evident that symptoms influenced by metabolism could not be solely addressed through medication, prompting a search for alternative forms of treatment.
_68946324e28e7.webp "A scheme of the freezing of gait (FOG)")
Figure 1: A scheme of the freezing of gait (FOG)
Figure 1 shows the scheme of the freezing of gait or FOG. Graham et al. 2023 suggested that a non-drug approach to addressing FOG, though the approach was not popularized until the later decades of the 20th century. Further, various researches employed use of strips on the floor, changing diet and regular exercise helping patient to get out of a condition. These discoveries have laid a foundational framework for subsequent investigations within the field of visual cueing, critically examining its potential efficacy as a therapeutic intervention. However, to the development of visual cueing techniques different investigations are devoted, including, different types of cues and conditions of the most effective usage of them in detail. The process of evolving in the knowledge of visual cueing can be considered as a shift toward the individual treatment of PD. VCs can increase the engagement of defective motor pathways by directly retrieving the superior cortical regions. This makes it one of the potential approaches for enhancing the mobility as well as diminishing the frequency of FOG episodes of the patients with Parkinson’s disease.
2.3.1. Types of Visual cueing
According to Cosentino et al. 2023, visual cueing has turned out to be perhaps the most important non-pharmacological approach for managing Freezing of Gait (FOG) in Parkinson’s disease (PD). First, non-moving visual signals which include rope or colored lines on the floor, for example, red conveyer began in the early 1990s. Initial studies indicated that all these prompts reduced FOG episodes by at least 50% by merely giving the individual a clear object to step over. This was therefore a direct approach, but it was efficient, making this approach popular in clinical practice. Progressing with technological development, different dynamic stimuli, such as moving patterns and projected lines, appeared. These dynamic cues were beneficial to some patients and their effectiveness stemmed from the continuous video-reflection that was given to the patients to keep the pace as they walked. Laser shoes introduced have increased the feasibility of visual cueing and consequently patients can use such interventions while walking in their daily activities.
Latest innovations have made use of virtual and augmented reality cues also known as VR/AR cues. Research such as that showed that VR environments could give personalised and realistic visual cues for a significant enhancement in gait and FOG. The use of lines as static cues have changed gradually to more complex systems such as the virtual reality systems showing the progress of these interventions. Investigations into the effect of visual cues, whatever the level of complexity, highlight that gaze relies on intact circuits hence providing a promising strategy to managing FOG and improving the well-being of patients with PD. Therefore, all these various types can provide effective outcomes for PD.
2.3.2. Different findings on research
According to Rutz et al. 2020, the first form of cueing included use of static cues that include the use of red tape or stripes on the floor. These cues were used as external prompts of visual nature to help the patients keep on moving and minimize the incidences of FOG. Scientists are considered among the pioneers in using these basic prompts in establishing their efficiency. Using their results, it was observed that patients were able to have a significant decrease in FOG episodes while walking over the lines as compared to walking without the lines. Due to the ease and success of this technique, it became common to use in the clinical settings and was the foundation for the further development of more complex cueing strategies.
_689463953b85c.webp "Tactile cueing for freezing of gait")
Figure 2: Tactile cueing for freezing of gait
Following the further development of the previous static stimuli, the scientists began to use dynamic stimuli such as moving patterns or projection. These cues are more subtle, and are based on calling to senses, it is also more aware of the environment. For instance, there was evidence that projection of more lines onto a surface that one intends to walk on can assist such patients to walk more probably (Zhang et al. 2023). These lines establish continuous and assumptive visual signs which facilitate patients to go from one transition to another in a seamless manner. The study comparatively and significantly found that Dynamic visible cues are more within the advantageous range for those patients who respond poorly or fairly to Static cues and thereby extends the applicability of the Visual cueing as a tool in managing FOG.
According to Bansal et al. 2023, with time, necessity and availability of technology called for more sophisticated visual cues and the new idea of portable or wearable devices came in. This research used Purdue satisfying existing attachments of laser light devices on shoes of the patients where a line was projected on the floor, while the patient was walking. This portable cue permitted its use in the course of the day and in various places, making it a better tool for everyday use. Mobile cues were reported to be helpful in minimizing FOG in various settings, which encourages the patients’ mobility within the community and in home settings besides clinic environments. Such findings were influential to the main patterns of FOG treatment as it showed that uninterrupted visual cuing could be feasibly employed in patients’ daily life.
The latest developments of visual cueing are connected with virtual and augmented reality (VR/AR). These techniques produce environments within which the patients engage virtual stimuli aimed at promoting the process of walking. A research found how the application of VR can help in projecting stepping stones on the patients as they move (Cui et al. 2021). The results revealed that VR cues are not only effective in decreasing FOG but also enhance the general gait quality, because the presented visual environment stimulates and can be adjusted very well. VR & AR as a technique is a major advancement in the field of visual cueing technology and holds the possibility of personalized therapeutic approach that can be designed for every person.
From the common finding of all these types of visual cues is that the use of cue improves gait and decreases the FOG episodes among PD patients. Such work added to the knowledge on how and through which processes visual stimuli impact attentional processes and the ability to bypass damaged motor circuitry. Furthermore, these studies emphasized the need for identifying the nature of the cue to be appropriate to that individual patient and the nature of the episodes of FOG. An assessment of the various cueing techniques from the initial basic strip lines up to today’s virtual reality environment support the invention and innovation of this intervention. Although the initial investigations that demonstrated the efficacy of visual cues can be considered to be the starting point for this area of knowledge, subsequent investigations have raised the visibility of these cues to a further level (Delgado‐Alvarado et al. 2002). This makes them more versatile, as well as more comprehensible to patients. Not only has the development and application of progressive understanding and implementation of visual cueing techniques enhanced FOG management. However, this has also added valuable information to the general field of PD rehabilitation as a non-invasive, cost-effective, and easily generalizable technique.
2.3.3. Impact of different studies on FOG management
Previous research work on visual cueing to reduce Freezing of Gait (FOG) in Parkinson’s disease (PD) has informed improved clinical interventions and patient experience. Their initial endeavours showed that a few features that include floor stripes could effectively be used to prevent onset of FOG episodes. This early research helped to set up visual cueing as an acceptable non-pharmacological approach and consequently it is effectively used in practice. Subsequent investigations complemented these initial researches in a way concentrating on dynamic visual cues. This further demonstrated that geometric patterns and projected straight lines could serve as continuous stimuli which yielded superior results of gait smoothing and reduction of FOG over static patterns (Magdi et al. 2021). This research has also demonstrated a need to use dynamic cues for some patients since certain patients yielded tangible benefits from such procedures, affirming the proposition that patients should be treated based on their specific need.
Technological advances like portable devices exemplified by laser shoes employed by patients who are studied by presented a way through which clinicians could include the visual cueing system in the daily lives of their patients while promoting their independent mobility. These discoveries have helped to change the FOG management as the effective treatments got more possibilities and applicability outside the clinical settings. Cues continue to be explored in more recent works especially in virtual and augmented reality by authors (Razmkon et al. 2023). Where it is seen that the utilization of visual cues from more advanced customizable artificial environments can have even better implications for better control on FOG. Such developments demonstrate that VR/AR technology has the potential of being the future of non-pharmacological treatments for PD. Altogether, these studies in aggregate point towards the centrality of visual cueing when addressing FOG and all add to the development and maturation of therapies. The synthesizing of this knowledge is a direct pathway of increased personalized and intercessions for PD. Thus indicating that there is hope for enhanced mobility and quality of life in such patients.
The variability of the methods of using visual cues demonstrates the ongoing research for the best approach to the management of FOG in PD. Although static cues do not become irrelevant, the shift towards dynamic, portable and virtual cues reveal the need for person and context dependent interventions. The studies’ findings also imply that visual cueing is a useful approach because its development shows a gradual improvement and the possibility of using it in practical and therapeutic contexts (Monaghan et al. 2023). Future research to be conducted in this area is expected to advance the efficiency of visual cueing steadily thus enabling patients with Parkinson’s disease to have a better life.
Figure 3: Cueing for people with Parkinson's disease
Freezing of Gait (FOG) is considered to be the most troubling symptom of Parkinson’s disease (PD) since it increases the risk of falls and has a greatly adverse effect on the patient’s quality of life. In this section, other non-pharmacological treatments also with an emphasis on conventional and auditory cueing have been discussed. This section compares and contrasts visual cueing with those other interventions, synthesizes their results, and determines their efficacy.
According to Xie et al. 2020, historically the management of FOG in PD has been mainly centered on pharmacological management and physical therapy. Levodopa and dopamine agonists are amongst the drugs used in treating motor manifestations of PD such as FOG. However, the studies indicate that they have a moderate performance in handling FOG. Research like that indicates that, while medicines may decrease the number of FOG episodes, the phenomenon remains present to some extent, and patients’ response to the medications declines over time due to disease progression and the appearance of motor complications. The other traditional method of treatment is physical therapy where the patients are subjected to gait training, balance training as well as strength training training in an effort to enhance their mobility. However, it is helpful and has to be consistently practiced, it cannot be utilized for an immediate negative symptom relief during FOG episodes. FOG is said to be improved by PT (physical therapy) and undertake changes in gait mechanics but the outcome lasts for a short time and depends on the extent to which the patient complies with the treatment schedule.
According to Hvingelby et al. 2022, another non-pharmacological method for treating FOG in PD is called auditory cueing. Motor control is achieved through synchronized sound frequencies including the use of stopwatch in the management of the rate of taking steps. Studied substantiated that the provided prompt could increase gait velocity and step measure and decrease FOG in patients with PD. The reason for the use of auditory cues is because of their ability to establish a rhythm that in turn facilitates motor output to enable the patient to start and maintain walking. The efficiency of the auditory cueing depends on the personality of a child. This research gave evidence that only some of the patients were able to benefit from the auditory prompt. While others only registered few improvements or none at all in certain conditions and specifically during situations that involved task complications and dynamics. This variability means that auditory cueing could be more effective in treating particular subpopulations of PD patients, namely those who have issues with the timing and tempo in walking.
Several disparities can be pointed out when comparing visual cueing to conventional treatments and to auditory cueing. Hence, visual cueing as indicated by such studies as those compares favourably to a more direct and immediate form of intervention for FOG. This makes it possible to give a visual target or stimulus, and therefore even if the motor circuits in the brain are defective, the patients are given a chance to regain control of their body movements almost immediately. This is unlike the pharmacological treatments with shown delayed or rather inconsistent response where the effectiveness varies with the time of administration of the drugs, and the advancement in the disease (Hvingelby et al. 2022). In this regard, it is significant that the use of visual cueing is a location-oriented method compared to the use of auditory cueing. Visual triggers like lines on the floor or even drawings, wooden tiles, or bubbles on the surface of the screen help the patient to have physical touches rather than internal images for handling a FOG episode.
Such findings as those indicate that information presented in the form of visual cues is especially useful in situations when the use of auditory cues is likely to be impaired by extraneous noise or when the temporal synchronization of stimuli and responses is less vital. Furthermore, the flexibility of visual cueing technique from simple lines and up to the latest actual VR is another advantage. This makes these techniques more superior and could be efficient in different facilities and varieties of patients. Nevertheless, the use of auditory cueing does have its benefits in certain situations. For example, it is very mobile and may be implemented into the everyday life of a patient like the use of the metronome application in the smartphone. Also for those patients that have shown improvement regarding rhythmic stimuli auditory cueing can be a simple and less invasive way of handling FOG. Especially when visual cues cannot be used due to congested environments or other cluttered surroundings.
The contingent cueing and independent cueing both types of the cueing strategy can be used separately or together with other strategies with equal success. Comparing visual cueing to the traditional treatment modalities as well as auditory cueing it is notable that although there are definite benefits in therapy use of visual cueing are not independent from the other two methods. Consequently, it was provided that, integrating auditory and visual cueing for successfully in FOG management may increase its total effectiveness (Conde et al. 2023). For instance, walking with target stimuli and synchronous rhythmic auditory signals may be beneficial. As they may include both visual and auditory cues that may support the initiation and continuation of walking especially in difficult terrains. The approach highlighted above can therefore work as an enhanced and more holistic solution to the identified methods for varied patient needs.
Figure 4: Therapeutic Strategies development
It has been found that visual cueing can be effective in reducing FOG in PD, and provides more benefits than regular treatments and sometimes even superior to auditory cueing. Therefore, because it offers real time, location sensitive feedback, it is especially useful in retraining patients who have FOG in a variety of contexts. Nevertheless, the use of auditory cueing is still functional for people who tend to react to rhythmic signals or for people who need a mobile solution. Thus, it may be hypothesized that the optimal management of FOG can be based on individual use of visual and auditory signals. Integrating these approaches, healthcare providers can provide patients with a more complex and versatile treatment plan that would help patients achieve the best results and have a better quality of life in case of Parkinson’s disease.
The theories have been developing a lot with time as they can improve the treatment process more effectively. The development of the mechanism of this pathophysiology can improve the treatment process effectively.
2.5.1. Pathophysiology mechanism of action
Freezing of Gait (FOG) in Parkinson’s disease (PD) is an intricate multifaceted motor symptom in which patients describe sudden and transient episodes in which their feet seem to become stuck firmly to the ground. The cause of FOG is associated with the abnormality of neural networks in regions of the basal ganglia which are involved in coordinating movements. Particularly, the reduced transmission for the dopaminergic neurotransmitter in substantia nigra of basal ganglia results in the reduced signal between the basal ganglia and motor cortex for prompt and smooth movement. The process of application of visual cueing depends on the usage of external visual signals, which are able to indirectly operate the motor circuits. The concept of visual cueing lies in the use of external focus of attention when a patient is provided with an external target focus (e.g. lines on the floor). It gives the patients a new focus and helps them to re-activate the motor system that is still intact. This process can enable a person to initiate the movement, finally helping to reduce or completely do away with the FOG episodes. The theories supporting the idea of using visual cues have shifted since the earlier developments of understanding of PD and motor control.
2.5.2. Theories for pathophysiological development
The early theories that were developed in the 1990s for motor planning were developed for visual cues. It was very effective to improve the mechanisms and improve the condition of PD patients. Initial research indicated that monitoring played just an important compensatory role and offered hope to patients by demonstrating that visual directions offered an alternate route for motor planning. For instance, patients could re-adjust their gate in response to optical signals. This theory was born from the evidence that patients can overcome FOG by stepping over visual targets which include floor stripes or laser lines and not by using the apparently damaged motor circuits. The investigation developed to identify the role of Central Pattern Generator (CPGs) in managing gait. CPGs are neural networks developing rhythmic motor patterns like walking and they can do so without the input from sensory organs. The pattern generator theory has the hypothesis that these cues may help activate or stabilize these CPGs, especially with the FOG situation, where the regular rhythmic output is interfered. Support for this theory came from studies that compared the effects of dynamic visual stimuli, for example moving lines at slowing FOG. Other theoretical underpinnings are focused on neuroplasticity and cognitive control into which visual cueing intervention has been incorporated.
Neuroplasticity all relates to how the brain of a person is capable of reorganizing itself and creating new neural connections. The studies conducted showed that constant exposure to the signs could improve the brain’s plasticity, which would help to strengthen the neural connections needed for walking. Moreover, according to cognitive control theories, the visual cues recruit higher-level cognitive functions so that the patients are able to consciously control the unwarranted automatic motor manifestations of PD. This may explain why visual cueing is that effective in patients with even progressed forms of PD through this cognitive involvement. Hence, visual cues act as a potent response strategy for FOG and are a colorful supply of help, which may also help alter various active pathways over time. Future research would further make modifications to these theories and come up with better improved intervention programs that will help increase mobility among patients with PD.
Figure 5: Pathophysiological development for Parkinson's disease
2.6. Conclusion
From the studies conducted on the use of visual cueing for the Freezing of Gait (FOG) that affects people with Parkinson’s disease (PD).There are however some limitations and weaknesses in the current literature that have been noted. As in any paper, there are also some limitations that should be discussed. This study has the following advantages. The first one would be pertaining to the failure of the visual cueing interventions on the different reactions it elicited from the patients. Most of the assessments show that there is a considerable change in the FOG symptoms, while others are moderate or even insignificant. This variation may be due to the type of visual cueing that is applied, or the patient’s characteristics and characteristic of their FOG. First, most studies lack large samples and short follow-up periods, thus, it remains rather doubtful whether these defined visual cueing interventions indeed are transportable and efficient in the long run. This type of research is essential because it provides an attempt to fill these shortcomings through systematically searching for and reviewing the literature on visual cueing for systematic evaluation of its effectiveness. Along with the data received in several studies, this research will offer more light to the circumstances that promote and hinder the process of using visual cues for the further studies. This study will be helpful in augmenting the existing knowledge in development of potent visual cueing and it would contribute in enhancing it so that it becomes feasible for various needs of the patients with PD.
Freezing of Gait (FOG) is a relatively recent term describing a serious complication in Parkinson’s disease (PD), this is an involuntary and transient inability to commence or to continue an action, leading to an elevated risk of falling. Visual cueing has been identified as one of the potential interventions for reducing FOG since they support stimuli that help in movement. The current manuscript is set to compare the evidence on different visual cueing techniques on the effects of FOG on patients with PD. The review analyses the data extraction procedure of the studies properly. Based on the findings of related research, this review aims at presenting the systematic evaluation of the effect of visual information on gait outcomes. This also allows information regarding whether they can be a form of therapeutic intervention to enhance mobility and quality of life in PD patients with FOG. Therefore, this review critically analyses the previously conducted researches that can provide crucial information of this study. Even though some limitation can be observed in the previous researches which are critically analysed for better understanding. Opinions and suggestions of previous researchers can help in this manuscript development.
Freezing of Gait (FOG) in Parkinson’s disease (PD) is a big problem affecting mobility and overall quality of life of the patients. Despite the numerous treatment approaches, the condition persists to be hard to manage, that is why it’s known as FOG. External cues which consist of visual prompts that are used to regulate movement have been found helpful in preventing episodes of FOG. Nevertheless, the efficiency of these interventions is not constant in various investigations. Therefore, a systematic assessment is required (Almathami, 2021). Thus, this systematic review’s objectives are to summarize the existing literature on the effect of visual cueing on FOG in patients with PD. Thus offering a better understanding of its therapeutic application. The issues in visual cues can also be observed from this study effectively, which is important for research development. Hence, by comparing different types of visual cueing approaches, this review can enhance existing for practical application and the future direction of studies for the management of FOG in PD. Apart from that, this provides ideas about the methods and ways how previous researchers has developed studies on FOG.
3.3.1. Aim
The primary aim of this review is to know the impact of freezing cues on PD and how this can affect gait. Various information of the previous researches are provided to conduct effective systematic review.
3.3.2. Objectives
3.5.1. Study Design
The systematic review that concerns the effectiveness of visual cueing for FOG in Parkinson’s patients is going to be according to PRISMA. The first step of literature search has been conducted in databases such as PubMed, Scopus and Cochrane library using keywords and limited to RCTs and quasi-experimental studies. The inclusion and exclusion criteria can also help a lot in research development. Sample criteria can narrow down to include only those Parkinson’s patients who experience FOG, more so, focusing on qualitative studies involving visual cueing based interventions (Bardakan et al. 2022). With data extraction, pertaining characteristics of the study, interventions, outcomes, and bias can be collected. When the data obtained is homogeneous, a manuscript can be completed, otherwise, an effective synthesis can be given. For the quality assessment, Cochrane Risk of Bias Tool can be used. The PRISMA model has also been followed properly.
3.5.2. Study characteristics
The systematic review is planned to investigate the efficiency of physiotherapy interventions for the management of FOG in Parkinson’s disease. Possesses a narrow scope that only deal with randomized controlled trials (RCTs) in order to have high level of evidence. Included are research that compares different types of physiotherapy techniques as well as research that compares physiotherapy with other control interventions. Besides, it follows systematic review ‘s methodology for analyzing neuroimaging data about the neural substrates of FOG in PD. In doing so, the present approach emphasises not only treatment effectiveness but also neural correlates of FOG.
Types of studies included in the current review are basically RCTs, quasi-experimental designs, and cohort studies, ranging from 2012 to 2021 (Janssen et al. 2020). These studies include the use of resting state functional MRI (fMRI), task based MRI, and functional Near-Infrared Spectroscopy (fNIRS) to investigate the structural relationship, connectivity shift and activation link with FOG in PD. In the review, Randomized Controlled Trials (RCTs) and quasi-experimental studies estimating the impact of visual cueing on freezing of gait (FOG) of Parkinson’s disease (PD) patients can be included.
3.5.3. Types of participants
The study mainly has certain specific criteria for selecting the participant group, which brings a better balance to 5-7 studies, mainly by defining the participant group. All participants must be adults with Parkinson’s disease (PD) and it especially with Freezing of Gait (FOG). Only research in which FOG is described to be present according to objective criteria such as the UPDRS or specific FOG questionnaires will be used. They should have intentness cueing therapy that has in one way or the other to reduce FOG symptoms. Patients who have other comorbidity, other neurodegenerative diseases or who have severe dementia will be excluded to keep the group’s homogeneity. Furthermore, works describing initial PD without FOG or deep brain stimulation has been reviewed excluding, as it is assumed that these studies will interfere with the assessment of the efficacy of visual cueing. This targeted participant sampling helps in ensuring that only the right and scientifically valid studies are included in the systematic review thus minimizing on the heterogeneity that comes with having too many studies and maximizing on the validity of the results.
Inclusion and exclusion criteria
| Inclusion criteria | Exclusion criteria |
| Studies that provide effective information of FOG and PD are only accepted. | Studies that are unable to provide proper information on PD or FOG have not been accepted. |
| Studies that are available with full text information | Studies that are not accessible |
| Studies before 2020 have not been taken for this review. | Studies that were published after 2020 have been taken only. |
| Studies available in the English language are only considered. | Studies that are not available in the English language have not been taken for the review. |
Table 1: Data extraction
3.5.4. Types of interventions
The systematic review aims to describe the efficacy of Visual Cueing Interventions in the treatment of Freezing of Gait (FOG) in Parkinson’s Disease (PD) patients. The types of the visual cueing interventions that include interventions using different types of the modalities are the following: VFO – visible floor instruction, floor visual cues (laser lights or steps markers), positive visual feedback, pads with integrated visual cues, and wearable devices visual cues. The purpose of these interventions is to offer various external cues that assist patients when it comes to the difficulties related to gait and to minimize the number of FOG episodes. Intervention studies that involve other forms of cueing, for example, auditory cueing, or pharmacological treatments are considered only if the primary treatment is visual cueing (Tinuan et al. 2024). The current review limits its analysis to studies that involved using visual cueing while excluding the ones that incorporated other therapies including pharmacological treatments or deep brain stimulation so as not to mix the effects of visual cueing with other treatments. The focus will be only on those studies that directly compare the effects of the visual cueing for FOG or only use visual cueing in a limited way together with other interventions.
3.5.5. Types of outcomes
The systematic review uses different outcome measures with an aim of providing a comprehensive view in relation to the efficacy of visual cueing interventions for FOG in patients with PD. This gives information regarding how visual cues affect the occurrence of FOG, which stands as a key issue in addressing gait disturbances in PD.
Frequency of FOG Episodes: This metric measures the duration of every FOG episode. In this way, the time analysis helps to identify the required time intervals during FOG decrease, and therefore can be helpful to measure the applicability of the intervention in terms of its symptomatic relief.
Duration of FOG Episodes: This measure examines the proportion that is strolled in FOG out of the total walking time (Geerse et al. 2022). Assessing the presence of visual cues, it provides information in which FOG affects gait features.
Proportion of FOG Duration in Total Gait Cycles: These parameters are step length, gait speed, and cadence such that the impact of visual cueing on gait beside FOG episodes is well grasped.
Gait Parameters: Some instruments like New Freezing of Gait Questionnaire (NFOGQ) quantifies how FOG affected an individual’s daily life and their quality of life, this point of view is very subjective yet very important to evaluate the effectiveness of the treatment.
Quality of Life Assessments: Research using fMRI and other imaging modalities measures alterations in activity and network of FOG and visual cueing to gain an understanding of the brain changes produced by the intervention.
Neuroimaging Data: These outcome measures are chosen based on the approach that is best suited to assess both the objective as well as subjective aspects of FOG and the management of fogg by the use of visual cueing interventions (Kim et al. 2022). Such measures are included in this review, which represents an approach to measuring the efficacy and its underlying mechanism of VC for enhancing gait and QOL of PD patients.
3.6.1. Search strategy
While selecting the articles for this systematic review, the keywords and a proper Boolean operator will be applied based on the inclusion and exclusion criteria. The research questions and objectives will help to formulate keywords to be used in the research. The search strategy will revolve around the different findings of any study that would deal with the use of visual cue for FOG in Parkinson’s disease patients. Search terms like, Parkinsonian disease, Freezing, Gait, visual cueing will be used with Boolean operators like Boolean AND, Boolean OR and NOT in order to refine the search. For instance, including Parkinson’s disease AND Freezing of Gait AND visual cueing allows only the studies that focus on these terms, and NOT deep brain stimulation which is irrelevant. The sources will be restricted to Peer reviewed RCTs and quasi-experimental study conducted after the year 2020. It is planned to use such databases as PubMed, Scopus, and Cochrane in the search for materials with further refinement by adding full-text and materials published in English. Using this method, the review to be systematic will therefore focus on a form of literature that is relevant and of quality, speaking to the physiotherapy interventions for FOG in PD patients and leave out those that are irrelevant and those that could not be accessed.
Key words and Boolean operators
| Key words | Boolean operators |
| Parkinsonian disease, Freezing, Gait, visual cueing | AND, OR, NOT |
Used key phrases for searching method:
3.6.2. Risk of biasness
The evidence on physiotherapy for freezing of gait (FOG) in Parkinson’s disease has involved the credibility of the research. Firstly, the selection bias could be observed since most of the studies had excluded patients with cognitive impairment, such findings may not be generalizable to the larger PD patients’ population. This can be observed in the first two journals of the review. However, it appears that physiotherapy interventions are shown more effective than they really are in the journals. The differences in the duration of intervention adherence rates among the studies bring performance bias which may change the outcomes (Baugher et al. 2023). Finally, the validity of the report measures such as the Freezing of Gait Questionnaire (FOG-Q) is questionable since response tendency may lead to response bias resulting from expectation or social desirability. These biases thus demand for better studies and samples with an aim of increasing the sample and population base. Therefore, for all of the studies some of the biasness can be observed.
3.6.3. Data extraction & management
The data extraction format which is designed as a protocol aims at providing a step by step plan in order to ensure that the data is collected, sorted and handled effectively in contributing to the content of the manuscript. Use of PRISMA model can help a lot in the development of the data extraction. This involves defining pre-specified predictor variables and the associated outcomes of interest, these can include aspects such as the design of the study, the number of patients, the age, gender, the type of the intervention trial duration and FOG, being the primary outcomes for the freezing of Gait in Parkinson’s disease (Karpodini et al. 2022). This protocol helps to make data collection and management to be coherent, confidential and replicable as this forms the substantial part of the offered manuscript. The CASP checklist has been followed for this review. By this critical appraisal of the 5 journals have been conducted. Only 5 journals have been considered that are able to provide effective information for research.
Figure 6: Data extraction importance
3.6.4. Assessment of methodological quality
There are multiple areas that should be addressed in a systematic review, one of them being the valuation of the methodological quality of the works under analysis. This process helps in achieving quality evidence based findings and minimises on biasness. Specific checklists, for example, the Cochrane Risk of Bias Tool for randomised controlled trials and the Newcastle-Ottawa Scale for observational studies, are applied for evaluating different factors randomisation, blinding, sample size, and reporting, for instance (Wadhera, 2021). Methodological quality was kept high by including only studies with well-defined inclusion and exclusion criteria, inclusion of patients with relatively similar conditions, and including only high-quality studies such as randomised controlled trials in patients with Freezing of Gait (FOG). All the included studies were assessed for quality, any study with methodological issues was ruled out. Effective reliability was maintained through the adherence of strategies in coordinating the extraction and analysis of data so that the information drawn is accurate and of good quality.
3.6.5. Data synthesis and analysis
The methods of synthesizing and analysing data for this systematic review that focuses on Freezing of Gait (FOG) visual cueing in Parkinson patients can entail a description synthesis. First, the studies can be grouped according to the type of visual cueing intervention evidenced, participants’ characteristics as well as outcomes assayed. Extracted data from the studies can be presented in table form, using features such as study type, sample size, intervention description and outcomes. The description synthesis can specially regard the comparison of the overall efficacy of different forms of visual cueing strategies across the studies included.
3.7.1. PRISMA flowchart
Figure 9: PRISMA flowchart
The above PRISMA diagram shows the selection of journals that has helped to conduct the systematic review. After following all the inclusion and exclusion criteria only 5 journals have been considered for this review to conduct the manuscript. In the beginning 310 from database search and 10 additional journals found. After that, the CASP checklist has also been followed properly for the effective development of this review. Identification, screening has been done properly so that the journals that provide the effective outcomes can be observed. Therefore, it can be said that the PRISMA diagram is very effective in this review as it helps in journal selection and research development a lot. The outcomes, methods and results of these journals are discussed in this review effectively for better understanding.
3.7.2. Data extraction protocol
| Author | Year | Participants | Power calculation | Sample size | Compliance reported | Intervention groups | Methods |
| Bardakan, Zapparoli, Fink, Paulesu, Bottini, and Weiss. | 2022 | Information from different studies and WM tract has been gathered. | WM connectivity has been conducted in patients. | Not clearly mentioned | Hemispheric lateralization has been observed which has caused abnormalities in the researches. | This study had no special interventional groups because this study was a meta-analysis of previously published neuroimaging articles on freezing of gait (FOG) in Parkinson’s disease patients. This group analyses has been done effectively. | The review compared various neuroimaging methods which focused on resting-state fMRI as well as task-based MRI with virtual reality and motor imagery, and fNIRS to investigate structural and functional change associated with FOG. |
| An, Sim, Kim and Kim | 2023 | The sample comprised 10 patients with IPD and with FOG in this characteristic, in whom the study was conducted. Section four highlighted one of the participants excluded because of the low K-MMSE score leaving ten participants for the analysis. All the participants were male =9) and their disease duration ranged from 1. 5 to 10 years and age ranging 69-88. | The power analysis for future studies showed that the total sample size needed would be 10 to obtain 95% power for anterior putamen effect size and 20 for the same for posterior putamen. | 10 | There were no participant attrition or noncompliance with the study measurements and all participant completed the study. However, the study acknowledged a possibility of selection bias since all patients recruited in the study showed FOG in all the stages, hinting at possible sampling of patients with severe symptoms. | The participants were divided into two groups based on their response to visual cueing: Improve the response group = 5, poor response group= 5. Quantitative outcome measures, namely, FOG episodes, gait parameters and dopamine transporter availability (DAT) in the anterior and posterior putamen, were used to compare groups. | Following visual cueing, participants’ FOG was rated for its frequency, duration and the proportion of cycles affected. The DAT levels were assessed with the help of the FP-CIT PET scans. The comparisons were made both within and between the groups making use of the non-parametric tests. |
| Janssen, Salim, de Ruyter van Steveninck, Bloem, Heida, Cockx, and Van Wezel | 2020 | 16 | No effective calculation was observed. | 12 | Some of the participants were unable to complete the process in the provided time. Compliance from there raised. | The study incorporated 16 patients diagnosed with PD-FOG. Participants performed 180° turns under three conditions: The three experimental groups include: (1) HoloLens providing AR visual cues, (2) Auditory cues and (3) No cues (control). | Navigational motion data was obtained from 17 inertial measurement units. FOG episodes were defined by observers from video recordings where two raters were used in this process. The analysis of FOG parameters and kinematics was done between conditions. |
| Geerse, van Hilten, Coolen, and Roerdink | 2022 | 24 PD patients | No effective power calculation was observed. | 24 | The entire research protocol was followed properly. Therefore, no compliance raised. | The study involved two groups: A study wanted to compare the efficacy of: (1) a group that used the Holocue wearable holographic cueing application, and (2) a group that received standard care but no access to Holocue. | To tackle this, the intervention group employed the Holocau device during walking activities in order to avail visual cues intended at mitigating freezing of gait. The sample’s gait performance was evaluated based on parameters, such as the number of episodes of freezing, the gait velocity, and the gait length. |
| Tinuan, Chuensiri, Bhidayasiri, and Khongprasert | 2024 | 36 | There an analysis of 80% power and 0.05% significance has been observed. | Divided based on participants. | No compliance was observed. | The study involved two groups like a Step Training group, which can use a multi-visual-cue mat, and a Control group, who cannot use the visual-cue mat and can receive standard care. | Members in the Step Training group performed gait training with a mat that has an intention to give visual guidance in the stepping pattern concerning gait disturbances in Parkinson’s disease. The Control group was just left to their normal treatment of care. This work also evaluated the effects of gait through pre- and post-intervention assessment of the functionality of the participants. |
Table 2: Data extraction
8 Years | MSc
3.8.1. General interpretation of results
Bardakan et al. (2022) examine the neural substrates of FOG in Parkinson’s disease through noninvasive imaging procedures. It becomes evident from this study that FOG is linked with major changes in brain function particularly in the areas of motor and cognitive control. Imaging results demonstrate diffuse connectivity abnormality in basal ganglia, frontal cortex, supplementary motor areas that are required in the regulation of movements as well as gait stability. These results support the notion that FOG is not only a motor disorder, but a cognitive and executive functioning impairment as well. The present neuroimaging findings may explain some of the heterogeneity of FOG in patients with PD and support the need for a multimodal approach toward this disabling symptom.
Figure 7: Pathophysiological model of freezing of gait
The pre-specified aim of this study was to evaluate the consequences of visual prompt on FOG in patients with IPD and identify the efficiency of visual prompt in comparison with DAT availability among patients. The results also showed that a rise in DAT uptake in Putamen anterior and a decrease in NFOGQ led to an enhanced response to VC in the aspects of the FOG frequency, the FOG duration, and the FOG duration percentage of gait cycle. The research also concluded that DAT density was higher with anterior putamen of the better response group than the poorer response group and this has proved that DAT defines the efficiency of visual cueing (An et al. 2023). Based upon these observations therefore, these results suggest that visual cueing is a better cueing strategy in the groups with less FOG and higher DAT level of the cerebro-cortical areas under discussion. Early treatment suggestions are suggested by the current investigation, while the DAT result also implies that the anterior putamen DAT may be the determinant of successful application of the visual cueing in the treatment of FOG.
Janssen et al. (2020) conducted the study to assess the Effects of Augmented Reality Visual Cues for Turning in Place for Patient with Parkinson’s disease and Freezing of Gait. It was also observed from the study that fixing of AR visual cues enhanced the patients’ performance in turning in place as compared to the condition without any visual cues. It was intended to project Visual Markers on the floor through the AR system to assist with the turning process of patients. In conclusion, it is possible to state that the use of AR visual cues may help to improve motor performance of the patients with Parkinson’s disease as the external cues proved to be helpful in promoting smoother and more controlled movements of the patients. These results can be specifically helpful in solving the problem of freezing of gait which is commonly associated with increased risk of falls in patients. However, to implement this method improved technology is necessary.
According to the study done by Geerse et al. (2022) that is focused on using Holocue, a cueing system in the form of a holographic wearable device to help lessen FOG in patients with Parkinson’s disease. Thus, the study proved that Holocue enhanced gait ability, and there was a decrease in the number of FOG events. Holocue overlays had the potential of enhancing the level of mobility among participants observed by increased walking velocity alongside an augmentation in stride length and a reduction in freezing time. Even though for all time this method cannot be effective as this has some side effects. The study also focused on the fact that the users of Holocue app are able to find the holographic cues useful and easy to use throughout their day. Therefore, the findings of the study indicate that Holocue can be helpful, accessible, and useful for managing FOG in Parkinson’s disease. As the patients receive visual prompting from the system, the nature of their walking is more rhythmic and fluid resulting in improved locomotion and self-functioning.
From the study done by Tinuan et al. (2024) conducted a study aiming at determining the possibility of making use of a multi-visual-cue mat for step training in patients with Parkinson’s disease. The training in this case was to focus on gait dysfunction which is characteristic of Parkinson’s disease, for example, reduced stride length and slow walking speed. The evaluators also recognized that people who went through the study utilizing the visual-cue mat had achieved particular enhancements of the varying aspects of gait, such as the steps’ length as well as the increased speed compared to the start situation. The multi-visual-cue mat offered dynamic cues whereby, it is expected that motor control and coordination during ambulation was enhanced.
Figure 8: Parkinson's disease Pathophysiology
3.8.2. Limitations of evidences
The literature on intervention targeting FOG in PD has the following limitations of research. Furthermore, Bardakan et al., (2022) emphasised the heterogeneity of FOG which make it challenging to directly interpret neuroimaging assessment and also require particularly individualistic strategies, however, their observational evidence derives through non–invasive imaging approach which could be incongruous with complexities of cognitive and motor enmeshment. Miller et al. (2020) stress the effectiveness of physiotherapy, yet their systematic review demonstrates the heterogeneity of the results for different kinds of interventions which means that although individualized approach can be deemed essential, it does not currently have the same level of standardization. Janssen et al. (2020) and Geerse et al. (2022) show the possibilities of augmented reality and the use of holographic cues but these technologies might not be readily available or easily applicable to patients. Tinuan et al. have increased it with the help of a visual-cue mat. However, the researcher failed to explore dynamic aspects and the sustainable efficiency of the cues. That is why, all these limitations needs to be focused on for further researches.
Figure 9: Augmented reality visual cues
3.8.3. Limitation of this review
First, it is confined only to the recent literature, leaving aside more important early research works. Lack of standardization in study designs and small sample sizes used in the included studies may thus lead to bias and reduction in generalization ability. For instance, the argument of this study to rely on self-reported measures such as the FOG-Q may be biased because of response bias. Also, the review focuses on publications in English only meaning that there can be valuable research undertaken in other languages which can be left without consideration. Last but not least, the variety of implemented visual cues and the ways they are used can cause difficulties in comparison and integration of results.
3.8.4. Implications & future directions
The data suggest that future studies should emphasize more on the creation of guidelines for selecting the most appropriate physiotherapy approach according to the patient’s characteristics and on the selection of the combined programs of applying multiple interventions and therapies. Further research has to be done regarding the application of augmented reality and other wearable technologies. Such findings should evaluate how useful, accessible, and affordable such innovations are in the long run in application throughout many communities. Further and larger-scale research investigations are required for understanding the interaction of both cognitive and the motor domains. The concurrent use of Visual Prompting along with the effect on gains in gait and walking abilities as well as quality of life. From all of the 5 studies that has been used for systematic review, this implication can be very effective.
Figure 10: Visual cues in Perkinsons’ disease
3.9. Conclusion
There are the ways in which the visual cueing interventions decrease the FOG in patients with Parkinson’s disease. Research has it that AR cues as well as devices such as Holocue appear to have potential of enhancing gait movements and minimizing FOG incidents. Task specific and balance training also provide a lot of mileage in physiotherapy intervention even though the effectiveness varies from one type of interventional approach to the other. Thus, the addition of visual cueing into physical therapy could improve mobility and quality of life among Parkinson’s patients. However, more investigations must be done in order to establish an industry level and demonstrate the durability of the effects. Therefore, this review provides essential knowledge on visual cues effects on FOG and Parkinson’s disease.
Reference List
Journals
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