Sing for Your Saunter: Using Self-generated Rhythmic Cues to Enhance Gait in Parkinson's
Phase: NA
Conditions: Parkinson Disease
Sponsor: Washington University School of Medicine

  
  
  
  
Sing for Your Saunter  
NIH R61AT010753  
NCT04246476  
August 1, 2023  
  
  

  
Participants:  
People with Parkinson disease (PD) will be recruited through the Movement Disorders Clinic at  
Washington University in St. Louis School of Medicine and through flyers via the American  
Parkinson Disease Association. Age- and gender-matched controls will be recruited through the  
Washington University Older Adults Participant Pool and the Research Participant Registry.  
Additional recruitment occurred through advertisements, flyers, and social media.   
Inclusion Criteria: 1) at least 30 years of age, 2) right-handed (criterion for MRI), 3) normal to 
corrected hearing, 4) able to walk for 10 continuous minutes independently, and 5) willing and 
able to provide informed consent. Additional inclusion criteria for people with PD included: 1) 
diagnosis of idiopathic, typical Parkinson disease according to the UK Brain Bank Criteria, 2)  
Hoehn & Yahr stages 2-3 (mild to moderate disease severity), 3) score of ≥ 1 on the Movement  
Disorders Society Unified Parkinson Disease Rating Scale – Part III – Motor Aspects 
(MDSUPDRS-III)31 item #10 indicating observable gait impairment; 4) a score of 1 or less on 
item # 7 on the New Freezing of Gait Questionnaire (nFOG-Q), indicating that the freezing 
episodes are not moderately or significantly disturbing to daily walking, 5) stable on all PD 
medications for at least 2 months prior to study entry.   
Exclusion Criteria: 1) diagnosis of any other neurological condition; 2) significant cognitive 
impairment (i.e., Mini-Mental Status Examination (MMSE) score of <24); 3) other medical 
conditions that might interfere with ability to safely participate.   
This study will be approved by the Institutional Review Board (IRB) of Washington University 
in  

St. Louis School of Medicine.  
  
Study design:  
  
All participants will come to the lab for a single session lasting 2-3 hours. The session involves 
behavioral assessments and motor assessments. People with PD will be tested while on their 
normal anti-PD medications to represent everyday conditions. Evaluations will be scheduled at 
the time of day identified by each individual as their optimal ON period when their medications 
worked best.   
  
Motor Assessments:  
  
Motor assessments will consist of several walking trials under varied conditions. Gait data will 
be recorded using the Mobility Lab System gait and posture analysis system (APDM, Inc., 
Portland, OR). This system is designed to quantify human movement and is equipped with six 
wearable Opal sensors placed on the wrists, feet, sternum, and lumbar spine. It is lightweight 
and wireless, allowing full freedom of movement and continuous monitoring of ambulation over 
long distances.   
  
All walking trials will be performed in a 30m hallway in which participants walked continuously 
in an ellipse. A tone produced by the APDM software will indicate the start and end of each 
trial. In each condition, participants will perform three 30-second trials. All participants will be 

followed by a trained physical therapist during walking trials to reduce fall risk during the 
intervention.  
  
Uncued walking: Baseline walking trials will be done in silence and used to represent ‘normal’ 
baseline walking and to provide a point of comparison for the other conditions. Participants will 
be asked to walk at their preferred walking speed.   
  
These trials will be averaged to determine baseline walking cadence and then used to calculate 
four individualized cue rates: 90%, 100%, 110%, and 120% of uncued cadence. Cues will be 
prerecorded on a piano keyboard and were rounded to the nearest five beats per minute 
increment.  
  
During calculation of cue rates, participants will select a cue song from a curated catalogue of 10 
songs compiled by a music therapist. These commonly known songs will be selected for having 
characteristics appropriate for gait training such as 4/4 timing, beat salience, familiarity, and 
simple lyrics. Participants will be asked to select the song most familiar to them.  
  
The songs available will be as follows: “I’ve Been Working on the Railroad”, “You Are My  
Sunshine”, “This Land is Your Land”, “Skip to My Lou”, “She’ll Be Coming Around the  
Mountain”, “Don’t Sit Under the Apple Tree”, “When the Saints Go Marching In”, “You Can’t  
Hurry Love”, “When Johnny Comes Marching Home Again”, and “Seventy-Six Trombones.” 
All cued musical stimuli will be recorded on a keyboard using single notes. Only the chorus will 
be played to keep cues simple and repetitive to facilitate motor synchronization.  

  
Once participants select a song, they will be given the song lyrics to review. To ensure each 
participant knows the lyrics, participants will then be asked to sing the song aloud without 
reading the lyrics. Participants will then practice singing the lyrics aloud while walking to 
familiarize them with performing the two tasks simultaneously.   
  
Cued walking: Cues will be delivered from a laptop with external speakers. Tempos will be 
presented in randomized blocks and two cue types (Music and Mental) were randomized within 
each tempo.   
   
• 
Music: This condition represents traditional cueing techniques in which music played 
and participants were asked to walk to the beat. Each song will be played once through 
before the starting tone sounded and participants began walking to the music. 
Participants will be monitored to ensure that they are not singing during this condition 
and that they walk on the underlying beat rather than the melody.   
  
• 
Mental: This condition represents our experimental cueing paradigm in which 
participants were asked to mentally sing while walking without music playing. Each 
song will be played once through, then turned off before the starting tone sounds and 
participants begin walking and mentally singing. To ensure that participants are correctly 
doing the task, participants will be asked to confirm that they were mentally singing in 
their heads after each trial. Participants will be instructed not to move their mouths 
during the task and this will be carefully monitored.   

  
Each participant will complete a total of 27 walking trials of 30 seconds each. Upon completion 
of all walking trials, each participant’s optimal tempo (i.e., the tempo with the longest stride 
length) will be determined by averaging stride length across the music and mental trials within 
each tempo.   
  
Analysis:   
T-tests will be used to compare baseline characteristics between groups. Repeated measures 
(RM) ANOVAs will be used to compare gait characteristics (velocity, stride length variability) 
across conditions (uncued, music, mental) and between groups (PD, control). For cued 
conditions, the optimal tempo (those at the tempo that elicited the longest strides for each 
participant) for each individual will be used for analysis. For significant main effects of 
condition, adjusted pairwise comparisons will be used to indicate differences between 
conditions.