The Effect of Rhythmic

Auditory Stimulation on

Gait Outcomes in Adults

with Non-Progressive

CNS Diagnoses: A

Systematic Review

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Authors:

Jordan Cominsky SPT

Coleen Joyce SPT

Madeline Raab SPT

Suzanne Leschen SPT

Jennifer Schwartz PT, DPT, NCS

Renee Hakim PT, PhD, NCS

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Overview1,2

Rhythmic auditory stimulation (RAS) is a

novel and inexpensive tool that

involves the use of rhythmic sensory

cueing to influence movement

RAS affects the sense of rhythm through

sound auditory stimuli and activates

various areas of the brain by

synchronizing the motor and sensory

areas

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Overview2

Rhythm serves as an anticipatory and continuous time

reference on which movements are mapped

The relationship between the auditory rhythm and motor

response serves to stabilize and regulate gait patterns

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Gait rhythmicity

Gait velocity

Cadence

Stride length

Tremor reduction

Freezing

Rigidity reduction

Balance

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Overview1,3

RAS has been frequently studied as an intervention for patients with

Parkinson’s disease and has been effective in improving:

Recent data suggests that rehabilitation processes involving movements

which are highly repetitive and rhythmically patterned are particularly

effective in gait training for patients with stroke

Purpose

The purpose of this systematic review was to

determine the effects of rhythmic auditory stimulation

(RAS) on gait outcomes in adults with non-progressive

CNS diagnoses.

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Methods

A literature search (2006-2016) was conducted using:

Cochrane Library

CINAHL

ScienceDirect

MEDLINE/PubMed

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Search Terms

(Rhythmic auditory stimulation OR auditory rhythm OR externally

controlled stimulation OR mechanically controlled cueing OR music

therapy)

AND (gait training OR gait OR walking OR ambulation OR treadmill

training)

AND (non-progressive neurological diagnoses OR stroke OR

cerebrovascular accident OR Traumatic brain injury)

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Methods

Search limits:

English, human subjects, and peer-reviewed RCTs

Selection criteria:

Adults 18 years and older with non-progressive CNS diagnoses

Intervention including RAS training and a measure of gait outcomes

Two reviewers independently assessed each article for methodological

quality and came to a consensus using PEDro guidelines

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PEDro Scores

Study Eligibility

Criteria Random

Allocation Concealed

Allocation Baseline

Comparison Blinded

Subjects Blinded

Therapists Blinded

Assessors Adequate

Follow-Up

Intention-

to-Treat

Analysis

Between

Groups

Comparison

Point

Estimate

and

Variability

PEDro

Score

Cha et al.

(2014) Y Y Y Y N N N Y Y Y Y 7/10

Thaut et al.

(2007) N Y Y Y N N Y N Y Y Y 7/10

Johannsen

et al.

(2010) Y Y Y N N N Y Y Y Y Y 7/10

Suh et al.

(2014) Y Y Y Y N N N Y Y Y Y 7/10

Kim et al.

(2011) Y Y N Y N N N N Y Y Y 5/10

Chouhan

et al.

(2012) Y Y Y Y N N N Y N Y Y 6/10

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11 Records identified through

database searching

(n=27)

Records after duplicates removed

(n=17)

Records excluded after

screening by title and

abstract (n=6)

Full-text articles assessed for eligibility

(n=11)

Full-text articles excluded (n=5) 1. Are the subjects older than

18? (n=1) 2. Is the diagnosis non-

progressive (n=0) 3. Is the study an RCT? (n=3)

4. Does the study test gait? (n=0) 5. Does the study assess RAS as in

intervention? (n=1) Studies included

(n=6)

Ide

ntific

atio

n

Sc

ree

nin

g

Elig

ibili

ty

Inc

lud

ed

1. Language not English

(n=1)

2. Unrelated Title (n=4)

3. Revised Edition (n=1)

PRISMA

Results1-6

A total of 27 articles were screened for eligibility

Following detailed appraisals, 6 RCTs met the criteria

PEDro scores ranged from 5 to 7/10 (avg=6.5)

Samples ranged from 16 to 155 subjects (total=272) with acute (200)

and chronic stroke (72)

Treatment parameters varied widely with durations ranging from 4 days

to 6 weeks in clinical settings

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Results1-6

Primary outcome measures

included:

Gait parameters

Dynamic Gait Index (DGI)

Timed Up and Go (TUG)

10 Meter Walk Test

Secondary outcomes measures

included:

Berg Balance Scale (BBS)

Standing balance (Biosway)

Fugl-Meyer lower extremity

scale

Stroke Specific Quality of Life

(SS-QOL) Scale

EMG recordings

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Results

5 of 6 studies were clinically and statistically significant in gait outcomes using RAS1-5

4 of 6 studies found significant improvements in:1,2,4,6

Velocity

Stride length

Cadence

Swing symmetry

Double support

Step length

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Results

2 studies found significant improvements in DGI and TUG

scores3,5

2 studies found significant gains in BBS scores and standing

balance1,4

Additional benefits of utilizing RAS included increased EMG

activity of the lower extremity, peak-to-peak joint angular

displacement, and quality of life5

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Conclusion

There is moderate to strong evidence supporting the

use of RAS in gait training for patients with non-

progressive CNS disorders, in particular patients with

acute and chronic stroke.

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Limitations

Sample size

Lack of long-term follow-up

Short study durations

Databases

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Clinical Relevance

Clinicians should consider the use of RAS gait training in

patients with non-progressive CNS disorders to improve gait

outcomes

RAS is feasible and easily implemented in the clinic in order to

improve gait outcomes and recovery in functional ability

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Recommendations

Improvements can be seen in as few as 4 days, but

the literature most commonly suggested 30

minutes/day, 5x/week, for 3 to 6 weeks duration.

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Future Research

Focus on developing a uniform protocol to be used by clinicians in the rehabilitation of patients post-stroke

Determine if there is a difference in gait outcomes when utilizing RAS via metronome or music

Determine the stage of recovery during which RAS has the greatest effect on gait training

Implement long term follow-up in future research

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Acknowledgements

Jennifer Schwartz PT, DPT, NCS

Renee Hakim PT, PhD, NCS

John Sanko PT, EdD

Tracey Collins PT, PhD, MBA, GCS

Bonnie Oldham MS, MLS, AB

DPT faculty and students

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Thank You!

Any questions?

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References

1. Suh J, Han S, Chong H, et al. Effect of rhythmic auditory stimulation on gait and balance in hemiplegic stroke patients. Neurorehabilitation. January 2014;34(1):193-199 7p. doi: 10.3233/NRE-131008.

2. Thaut M, Leins A, Fetter M, et al. Rhythmic auditory stimulation improves gait more than NDT/Bobath training in near-ambulatory patients early poststroke: a single-blind, randomized trial. Neurorehabil Neural Repair. October 2007;21(5):455-459 5p. doi: 10.1177/1545968307300523

3. Chouhan S, Kumar S. Comparing the effects of rhythmic auditory cueing and visual cueing in acute hemiparetic stroke. Int J of Ther Rehabil. June 2012;19(6):344-351 8p. doi: 10.12968/ijtr.2012.19.6.344

4. Cha Y, Kim Y, Hwang S, Chung Y. Intensive gait training with rhythmic auditory stimulation in individuals with chronic hemiparetic stroke: A pilot randomized controlled study. Neurorehabilitation. November 2014;35(4):681-688 8p. doi: 10.3233/NRE-141182.

5. Kim J, Oh D, Kim S, Choi J. Visual and kinesthetic locomotor imagery training integrated with auditory step rhythm for walking performance of patients with chronic stroke. Clin Rehabil. February 2011;25(2):134-145 12p. doi: 10.1177/0269215510380822

6. Johannsen L, Wing A, McManus R, et al. Seated bilateral leg exercise effects on hemiparetic lower extremity function in chronic stroke. Neurorehabil Neural Repair. March 2010;24(3):243-253 11p. doi: 10.1177/1545968309347679

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