Staying UpRight in Parkinson's disease: a novel postural intervention

Abstract

Background
Postural changes are common in Parkinson’s disease (PD), from the classic flexed posture to Pisa syndrome (lateral lean). Poor posture in PD has a negative effect on pain, balance, and mobility, with links to increased falls risk. Currently few interventions for postural misalignment exist. Recently, cueing, in the form of tactile stimulation, has shown promise in improving postural alignment in PD. Therefore, this study aimed to determine the feasibility and efficacy of an off-the-shelf tactile feedback wearable device (UpRight) for improving postural alignment in PD.
Methods
Postural angles were measured for two minutes in sitting, standing and during walking in 11 people with PD (Disease duration; 11.4±6.6years, UPDRS-III; 41.9±11.5, On meds, n=6 Pisa syndrome) using inertial measurement units (Moveo, Opals, APDM) under single and dual-task (forward digit span) conditions. Standardized clinical tests (distance of tragus, occipital, C7 to wall while standing) also measured posture. Testing was conducted without and with an UpRight device on the upper back, which was paired to a smartphone application. The device was calibrated after participants were positioned in an upright posture by a clinician; it then vibrated when posture became flexed (~5°). Primary outcomes included maximal neck and low back flexion angles.
Results
Results showed that postural alignment improved with the UpRight device in PD. A significant improvement in neck posture was found in all clinical measures (Tragus; p=.012, Occiput; p=.008, and C7; p=.008). There was also reduction in maximal neck flexion angles during sitting (Average; 8.8° to 5.4°), standing (7.3° to 6.4°) and walking (4.6° to 3.7°) under single-task, particularly for those with Pisa syndrome. However, maximal low back flexion angles did not change, and flexed posture worsened with feedback while using the UpRight under dual-task.
Conclusions
Our preliminary findings suggest that an off-the-shelf, novel, wearable tactile feedback system can improve postural alignment in PD, particularly neck flexion. However, this kind of tactile feedback may distract attention and is possibly not effective for low back postural issues. In addition, long-term effects and ability of the patient to use the application need to be further investigated on a larger cohort.

Full text

70
80
90
Sit Stand Sit Stand
Single task Dual task
METHODS
Staying UpRight in Parkinson’s disease: a novel postural intervention
Samuel Stuart¹, Alan Godfrey², Lynn Rochester³, Fay Horak¹and Martina Mancini¹
¹Department of Neurology, Oregon Health and Science University, Portland, OR, USA
²Computer and Information Sciences, Northumbria University, Newcastle-upon-Tyne, UK
³Institute of Neuroscience, Newcastle University, Newcastle-upon-Tyne, UK
@samstuart87 stuarts@ohsu.edu
@martima80 mancinim@ohsu.edu
OBJECTIVE
To determine the feasibility and efficacy of an off-the-shelf tactile feedback
wearable device (UpRight Technologies Inc.) for improving postural alignment in
PD.
BACKGROUND
•Postural changes are common in Parkinson’s disease (PD), from typical flexed
posture to Camptocormia (forward lean) or Pisa syndrome (lateral lean) [1]
•Poor posture in PD has a negative effect on pain, balance, and mobility, with
links to increased falls risk [2]
•Currently few interventions to improve postural alignment exist. Recently,
cueing, in the form of tactile stimulation, has shown promise in improving
postural alignment in PD [3]
RESULTS
CONCLUSIONS AND FUTURE WORK
•Preliminary findings suggest that UpRight can improve postural alignment in PD,
particularly neck flexion
•However, UpRight may distract attention (worse under dual-task) and is possibly
not effective for low back postural issues
•Long-term effects of frequent use and ability of people with PD to use the
application in daily life need to be further investigated on a larger cohort, as well
as the effect on mobility and falls
ACKNOWLEDGEMENTS
We thank our participants for generously donating their time to participate. Grants: Medical
Research Foundation of Oregon (PI: Stuart). SS is supported in part by a postdoctoral fellowship from
the Parkinson’s Foundation (Grant No.PF-FBS-1898)
UpRight
REFERENCES
[1] Doherty et al. (2011). The Lancet Neurology, 10(6), pp. 538-549.
[2] Horak (2006). Age and Ageing, 35(2), pp. ii7-ii11.
[3] van Wegen et al. (2018). Parkinsonism & Related Disorders, 46(1), pp. S57-S61.
Clinical measures of postural alignment improved
(reduced flexion) with UpRight
Gait characteristics worsened with UpRight, but postural
alignment was maintained
Usual
•25 people with PD, ON medication
•Age 69.7±6.3 years
•Disease duration 11.1±6.8 years
•UPDRS-III 38.5±10.8
Postural conditions;
•n=8 with Pisa syndrome
•n=1 Camptocormia
•n=1 Neck drop
•Sat, stood and walked for two minutes
•Single and dual-task (forward digit span)
•With and without UpRight
•Standard clinical postural tests; distance of
tragus to wall, C7 to wall, occiput to wall
•Inertial sensors (Moveo, APDM) and video
analysis (Kineova) for postural angles, gait
and balance
•Angular displacement: movement from 3
second baseline (“zeroed”) position with or
without UpRight
Postural alignment improved during two minute tasks
with UpRight, but dual-tasking may impact response
Outcomes
Intervention
0
10
20
30
Tragus to wall C7 to wall Occiput to wall
Usual UpRight
Distance from wall (cm)
All p<0.001*
•Set to allow ~5º of flexion (Range of motion level 1)
•Strong and long vibration prompt beyond ~5º
UpRight wearable postural
intervention (synched to a
smartphone application)
Absolute Angle (º)
Neck Flexion (video)
-0.4
-0.2
0
0.2
0.4
Gait Speed ST
Stride Length ST
Double Support
Time ST
Stride Time SD ST
Gait Speed DT
Stride Length DT
Double Support
Time DT
Stride Time SD DT
Series1
Series2
UpRight
Usual
*
*
*
Parkinson's (n=15)
-1.6
-0.8
0.0
Postural Condition (n=10)
Neck Flexion (head sensor)
Absolute Angle from Vertical (º)
Sit Stand Sit Stand
Single task Dual task
Low Back Flexion (lumbar sensor)
-0.2
0.0
0.2
Sit Stand Sit Stand
Single task Dual task
0.0 = vertical
Extension
Flexion
Flexion
Extension
Feedback
•ACCEPTABLE = 76%
•PRACTICAL = 84%
•EASY TO USE = 93%
•ACCEPTABLE = 82%
•PRACTICAL = 82%
•EASY TO USE = 82%
Laboratory
7 Days at Home
0
15
30
Neck Low
Back
Neck Low
Back
Single task Dual task
Max flexion during walking
Angular
Displacement (º)
Flexion
Flexion
Those with postural conditions had poorer posture but
still benefitted from UpRight (reduced neck flexion)
p=0.026*
Group Effect: F=7.3 p=.033*
UpRight Effect: F=4.5 p=.047*
Group Effect: F=0.84 p=.568
UpRight Effect: F=1.5 p=.235
Upright x DT Effect: F=10.1 p=.004*
Sub-group n=12