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

 
 
 
Sing For Your Saunter – Dementia Supplement 
NCT04518917 
NIH R61AT010753-02S1 
March 15, 2024 
 
 

Study Design 
This study was a single center, cross-sectional, interventional study.  
Participants 
Participants were recruited through the Movement Disorders Clinic (MDC) at 
Washington University in St. Louis School of Medicine. Inclusion criteria for this study were as 
follows: a diagnosis of idiopathic, typical Parkinson disease according to the UK Brain Bank 
Criteria; Hoehn & Yahr stage 2-3 (mild to moderate disease severity); stable on all PD 
medications for at least two months prior to study entry; normal or corrected to normal hearing; 
score of ≥ 1 on the Movement Disorders Society Unified Parkinson Disease Rating Scale – Part 
III – Motor Aspects (MDS-UPDRS-III) item #10 indicating observable gait impairment; able to 
walk for ten continuous minutes independently; a score of one or less on item #7 on the New 
Freezing of Gait Questionnaire (nFOG-Q), indicating freezing episodes are not moderately or 
significantly disturbing to daily walking; and dementia as defined by a Clinical Dementia Rating 
(CDR) score of 0.5-1.0 (very mild to mild dementia). Seventeen individuals met these inclusion 
criteria and were enrolled in the study.  
As this was a within-group cross-over study, there was no control group and no group 
randomization. This study was approved by the Institutional Review Board (IRB) of Washington 
University in St. Louis School of Medicine.  
Protocol 
This study consisted of one in-person lab visit. All testing was done with participants in 
their on-state for medication. During the lab visit, participants were first assessed using the 
MDS-UPDRS-III and nFOG-Q to confirm eligibility for the study. Participants were also asked if 
they had any previous musical training. After eligibility was confirmed, participants were fitted 
with six APDM Opal sensors worn on the feet, wrists, lumbar spine, and sternum. These 
sensors sample at a frequency of 128 Hz and were used to collect various gait parameters, with 
a focus on velocity, cadence, and stride length. For all gait tasks, participants completed three 

30-second trials of each cueing type and condition in a 100-foot hallway. All participants were 
followed by a trained physical therapist during walking trials to reduce fall risk during the 
intervention. No falls or adverse events occurred during data collection.  
All participants first completed three 30-second uncued walking trials to determine 
baseline gait parameters. The average cadence over these uncued trials was then used to 
calculate four cueing tempos for each participant: 90%, 100%, 110%, and 120% of uncued 
walking cadence. These cues were selected based upon previous work in our group looking at 
internal vs. external cues in people with PD without dementia. Cues were rounded to the 
nearest five beats per minute. While cueing tempos were being calculated, participants were 
presented with a list of songs to choose from for the cued walking tasks. The list included songs 
selected with the help of a music therapist that have a 4/4 beat, salient tempo, and are likely to 
be familiar to many individuals. The songs available were 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.” Participants were provided with the song lyrics prior to starting the cued tasks to 
ensure they knew the words. After reviewing the lyrics, participants were recorded singing the 
song out loud without reading the lyrics from the sheet to ensure they remembered the lyrics 
correctly. Additionally, they practiced walking and singing out loud to ensure they were able to 
perform the two tasks simultaneously.  
After cueing tempos were determined, participants received two different cueing 
methods at each tempo. The two cueing methods were A) Music and B) Mental.  Music served 
as the externally generated cue, while Mental served as the internally generated cue. For all 
cued trials, one chorus of the selected song was played at the correct tempo while the 
participant was standing still as a reminder of the tempo. Cues were delivered via speakers and 
volume was adjusted so participants could hear throughout the entire trial. During the Music 

task, the cue kept playing and participants were instructed to walk to the beat, rather than the 
melody, of the song as they listened. During the Mental task, the cue turned off and participants 
were instructed to walk to the beat of the song while singing in their heads in silence. To ensure 
participants were doing the task, they were asked if they were singing in their heads after each 
trial. Participants were instructed not to move their mouths during the mental singing task, and 
this was monitored by the physical therapist who was walking with the participant for safety. 
Prior to the start of the cued trials, a member of the research team demonstrated walking on the 
beat to ensure all participants received the same instruction. To mitigate order effects, task 
order for each participant was randomized first by tempo, then Music vs Mental condition order 
was randomized within each tempo. This meant that both cueing types at a given tempo 
occurred one after the other, but the order of cue type presented at each tempo was random. In 
total, participants completed 27 walking trials of 30 seconds each.  
Statistical Analysis 
All data were analyzed using R statistical software. Gait parameters including velocity 
and stride length were averaged across the three trials for a given condition (i.e., Mental 110%). 
Mixed-effect models were used to predict velocity and stride length as a function of cue type 
and tempo (as fixed effects) and to account for the within-subject nature of the design (as 
random effects) using the lmer4 package in R. These models tested the main effects of Cue 
Type (Music v. Mental), Tempo (90, 100, 110, and 120%), and their interaction as categorical 
factors. Random effects of participant, the interaction of participant:cue type, and the interaction 
of participant:tempo were included to account for the within-subject nature of the manipulation. 
To determine the statistical significance of these effects, we used F-tests with Satterthwaite’s 
approximation for the degrees of freedom. The Type I error rate for all tests was set at α=.017 to 
account for multiple comparisons.