Sing for Your Saunter: Using Self-Generated Rhythmic Cues to Enhance Gait in Parkinson's
Phase: PHASE2
Conditions: Parkinson Disease
Sponsor: Washington University School of Medicine

 
 
 
Sing for Your Saunter:  
Using Self-Generated Rhythmic Cues to Enhance Gait in Parkinson's 
 
NCT06115382 
 
November 13, 2023 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 SFYS 1 
I.
SPECIFIC AIMS
The primary objective of this study is to determine how music and singing enhance 
walking ability among people with Parkinson disease (PD). Participants with PD (n = 74) 
will be included in one of two interventions led by a music therapist and a physical 
therapist. The two interventions include 24 one-hour group classes (twice weekly 
excluding holidays) and will focus on standard elements of training in beat perception, 
rhythm production and synchronization of movement to a rhythm. The two interventions 
will be taught nearly identically, with the slight differences on the focus, including the home 
practice. Individuals will focus on either rhythmic movement training using external 
musical cues (Music) or rhythmic movement training using self-generated internal singing 
cues (Singing). As the classes will be taught in waves, participants will not be individually 
randomized but randomized as a group prior to the first date of the class. Pre- and post-
intervention data collection will include assessments of mobility, gait, and inter-tap interval 
variability for tapping. Using tapping as a gait surrogate, participants will also undergo 
task-based fMRI at pre- and post-test time points to understand the neural mechanisms 
underpinning auditory cueing. Twelve weeks after the intervention, participants will 
complete a final questionnaire regarding whether and under what circumstances they 
continue to use cueing in their daily lives. 
During the group classes (n~12), each individual will be pulled aside once per week for a 
ten-minute consultation with the physical therapist. During this individual consultation, the 
participant will practice walking using their personalized cues developed during their 
evaluation. Participants will be provided a recording of their personalized cues on their 
own personal device or a device provided by us and will be asked to practice walking with 
music or mental singing on their own three days a week for a total of 30 minutes per day. 
Specific Aim 1: Compare the effects of training using external musical cues vs. self-
generated singing cues on movement performance among people with PD. 
Specific Aim 2: Compare the effects of training using external musical cues vs. self-
generated singing cues on brain activity among people with PD. 
Specific Aim 3: Compare the acceptability and usability of training using external 
musical cues vs. self-generated singing cues in people with PD. 
II. HYPOTHESIS
Specific Aim 1: Compare the effects of training using external musical cues vs. self-
generated singing cues on movement performance among people with PD. 
Hypothesis 1: Gait speed will improve similarly with both forms of training. 
Temporal variability in gait and finger tapping will improve more with mental singing 
training than with music training. 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 2 
 
Specific Aim 2: Compare the effects of training using external musical cues vs. self-
generated singing cues on brain activity among people with PD. 
Hypothesis 2: Following training, the music group will show increased activation 
in auditory cortex whereas the mental singing group will show increased activation 
of the putamen and cerebellum relative to baseline. Changes in movement timing 
variability will be related to changes in putamen activation. 
Specific Aim 3: Compare the acceptability and usability of training using external 
musical cues vs. self-generated singing cues in people with PD. 
Hypothesis 3: Both music and mental singing training will be acceptable to 
participants; usability will be higher for singing. 
III. BACKGROUND AND SIGNIFICANCE 
Rhythmic movements such as gait are key to everyday function, and people living with 
Parkinson disease (PD) commonly have trouble with their gait which can lead to disability, 
reduced quality of life, and is highly predictive of mortality1. There are currently about 10 
million people living with PD, with approximately 60,000 new diagnoses annually in the 
United States alone. Gait impairment may occur early in the disease process and is 
considered a harbinger of impending disability2. As such, much effort has been devoted 
to developing methods to enhance gait in PD. Gait enhancement via rhythmic sensory 
cues generated externally, for example by music, has been explored extensively (for 
reviews see3,4). Self-generated rhythmic cues, on the other hand, have been neglected 
in research in spite of many reports that patients commonly use them to aid in walking5–
7. Our pilot work suggests use of internal, self-generated rhythmic cues in the form of 
singing - and in particular imagined or mental singing - holds considerable promise for 
gait enhancement in PD.  
 
The studies proposed herein build on our pilot work and are among the first to compare 
training using external musical cues vs. self-generated singing cues. Several studies have 
demonstrated improvements in stride length and gait velocity with training using external 
rhythmic auditory cues (for a comprehensive reviews see3,8). Very few studies have 
examined the effects of external cues on variability and evidence is even scarce regarding 
the effects of training with cues on stride-to-stride variability. However, the literature 
suggests benefits to gait are substantially increased after training with external cues as 
compared to the acute benefits within a single session3. Further evidence suggest cortical 
activation is increased with repeated exposure to rhythmic auditory cues, though this has 
only been shown in older adults during treadmill walking9. However, we lack data on 
training with mental singing and we lack understanding of how cueing training 
interventions work in terms of neural mechanisms. This study will address multiple critical 
gaps in our knowledge. Overall, this work has potential to open up an entirely new 
approach for gait improvement in PD using a fully accessible, adaptable, and low-cost 
approach. 
 
 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 3 
 
The Traditional Approach: External Rhythmic Auditory Cueing to Improve Gait in PD 
For more than forty years, scientists have been exploring the impact of external rhythmic 
cues on movement. Early work described the link between auditory and motor systems, 
implicating these connections in the ability to synchronize movement to sound15. 
Numerous researchers have conducted studies across the decades since, consistently 
showing that rhythmic auditory stimulation can influence gait in people with PD, improving 
gait speed, stride length, and/or cadence6,10–13. Auditory stimulation is generally more 
effective than other types of external cues (e.g., visual, somatosensory)14, which may 
relate to the shorter latency required to react to auditory as compared to visual or 
somatosensory cues, or to the auditory system being ideally suited to detect temporal 
patterns and rhythms7. Furthermore, musical cues are more effective at increasing gait 
speed than isochronous metronome beats, perhaps because of their motivating and 
enjoyable qualities15. Interestingly, recent evidence suggests that a variable external 
rhythmic cue that oscillated based on a model of human gait also provided greater benefit 
than an isochronous external cue16. Self-generated rhythmic cues may possess similar 
biological variability that may be particularly conducive to improving walking. Despite the 
improvements in gait that often occur with external rhythmic auditory cueing, there are 
several noteworthy limitations to its use. One limitation is that not all individuals benefit 
from external rhythmic cues, and it is not yet clear what factors account for ability to 
respond17. Another notable downside is the effects of external cues on walking typically 
persist only briefly once the cues are removed18,19. This necessitates the constant 
presence of an external device to provide stimulation, which could be burdensome and 
reduce accessibility in everyday settings. In addition, as evidenced in our pilot data, 
external cues may not increase temporal stability whereas internally self-generated 
singing does. In this study, we propose a novel approach using self-generated rhythmic 
cues, which are readily accessible at any time and are hypothesized to provide greater 
benefit as compared to external cues. 
 
A Novel Approach: Self-Generated Rhythmic Cueing to Improve Gait in PD 
Given the limitations associated with external rhythmic auditory stimulation noted above, 
it is surprising that studies of self-generated rhythmic cues are lacking. Several pieces of 
evidence suggest self-generated sung cues may be effective for enhancing movement. 
People with PD report using singing as a strategy to aid with initiation and maintenance 
of gait in challenging situations5. In fact, in one of the first reports of training with external 
musical cues, participants reported singing the music in their heads (mental singing) to 
recall the cue and enable them to walk at the desired pace during post-training gait 
evaluation6. Additional support for the use of vocalization to foster movement comes from 
work showing that self-speech enhances upper extremity movements in people with PD, 
resulting in faster and smoother reaching movements on trials where movement was 
accompanied by speech as compared to trials without speech20. However, speech 
performance may degrade over the course of PD, while ability to sing remains relatively 
preserved. Individuals with PD who exhibit dysprosody of speech show no decrements in 
singing prosody21. When singing, ability to maintain tempo, interval size, and interval 
variability is maintained in people with PD despite the fact during speech these abilities 
are impaired. This suggests singing could be used to facilitate linguistic prosody. In 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 4 
 
practice, singing is increasingly used as a therapeutic technique for vocal rehabilitation in 
PD. While the impact of singing on motor function is largely unknown, we hypothesize 
that singing may have benefits that go well beyond vocalization and extend to gait. 
However, in some situations it may not be desirable or appropriate to sing aloud, 
necessitating use of mental singing as an alternative method of self-cueing. A small pilot 
study of eight people with PD who were taught to imagine singing while walking suggests 
that mental singing may enhance gait velocity and turning performance22. (It is worth 
noting this study had several limitations including small sample size, use of subjective 
rating of videos to determine changes in performance, and lack of comparison to other 
cued conditions.) Recent work also shows improvements in gait post-stroke with mental 
singing23. And, our own work suggests mental singing is as effective, if not more effective, 
than singing aloud for improving gait in PD24,25 (see preliminary data section for more 
details). Therefore, the work proposed herein will compare mental singing (rather than 
singing aloud) to external musical cues through a randomized intervention. Our exciting 
preliminary result leaves us eager to explore this topic further to understand the 
differences between responses to external vs. self-generated rhythmic cues as well as 
the brain mechanisms that underlie these responses and the potential to enhance 
response to cues through personalization and training. 
 
Understanding Mechanisms of Cueing Responses 
In spite of decades of research on the effects of cues on movement, little is known about 
the mechanisms that underlie motor synchronization. Production of successful and stable 
locomotor patterns relies on precise timing mechanisms. As faulty internal timing likely 
contributes to gait difficulties in PD, people with PD represent a unique population in which 
to study the mechanisms that enable matching footfalls to cues. External rhythmic 
auditory cues provide a source of regular input that may facilitate movement timing 
through auditory-motor coupling. Movement is synchronized to the beat of the external 
rhythm via entrainment, as the beat creates a template for anticipation of the timing of 
future events7. Multiple pieces of evidence support the influence of the auditory system 
on the motor system. First, connections between the auditory and motor systems are 
present in a wide range of animals from fish to humans. For example, auditory system 
projections can modify spinal motor neuron excitability via reticulospinal pathways26. 
Brain areas involved in rhythm processing overlap substantially with those involved in 
motor control (e.g., premotor and supplementary motor cortices, cerebellum, basal 
ganglia)27–29. Evidence shows that coupling between auditory and premotor cortices is 
enhanced during rhythm processing30,31. The cerebellum may also play a role in 
monitoring ongoing rhythmic movements and adjusting to changing tempos32,33. The 
putamen, in particular, is implicated in rhythmic event sequencing and beat 
perception11,31. In individuals with PD, activity in the putamen, cerebral cortex, and 
corticostriatal pathways is reduced during uncued movements. However, during 
externally cued movements, activity is more similar to that of control participants34. Thus, 
external rhythmic cues are thought to facilitate sensorimotor network activity and may 
also involve executive/attentional control as evidenced by increased prefrontal cortex 
activity when walking with external cues9. Current theories suppose that external cues 
allow bypassing of the impaired basal ganglia to supplementary motor area (SMA) loop 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 5 
 
via activation of cerebello-thalamo-cortical pathways. We hypothesize that external 
musical cues will primarily drive the cerebello-thalamo-cortical pathways whereas mental 
singing, which could be considered a type of internal cue, will drive basal ganglia activity 
and act through the cortico-striato-thalamic pathway (Figure 1). 
 
 
 
Singing is a complex, multimodal task that requires integration across multiple brain 
areas. Neuroimaging studies have begun to elucidate the patterns of brain activation that 
occur during singing and speech. Singing is distinguished by activation of Perisylvian 
regions of the right hemisphere that are not active during speech35. This activation is 
thought to account for the relative preservation of singing vs. speech in some neurological 
conditions including stuttering and aphasia following left hemisphere stroke. This 
distinction between neural control of singing as compared to speech may also contribute 
to the preservation of singing prosody in people with PD who demonstrate speech 
dysprosody21.  
 
Singing also results in activation of several areas within the frontal, parietal, and temporal 
cortices along with subcortical and brainstem structures including pre-SMA, SMA, 
dorsolateral prefrontal cortex, primary somatosensory and auditory cortices, basal 
ganglia, and cerebellum35. Evidence from imaging literature suggests that mental singing 
activates brain areas similar to those activated during singing aloud36. Furthermore, 
processing and producing rhythms activates areas involved in motor control including 
bilateral SMA, inferior frontal gyri, inferior parietal lobules, and cerebellum37. 
 
 
IV. METHODS 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 6 
 
PARTICIPANTS RECRUITMENT 
Recruitment of participants with PD will be through: 
• Movement Disorders Clinic in the Department of Neurology at Washington 
University School of Medicine  
• Flyers and newsletter blurb via the American Parkinson Disease Association St. 
Louis Chapter.   
• Advertisements through Meta (Facebook and Instagram) that will target older 
adults and people with Parkinson disease. The ads will contain a link to a 
RedCap survey where individuals can provide their contact information to the 
study team.  
• We will also use ads managed by the study team and the Director of Marketing 
for the Program in Physical Therapy or Volunteers for Health. The ads will be 
provided on Facebook, Instagram, Google, or Twitter. The ad will have a "learn 
more" link that directs potential participants to a recruitment survey. The content 
of the ads will be drawn from the attached ad titles and descriptions (Social 
Media Ads) and the attached recruitment images (Photos-Ads). An ad will be a 
combination of one title, one description, and one image. The ad will have a 
"learn more" link that directs potential participants to the recruitment survey 
referenced in 1.8.  To maintain privacy, all ads will  have the comments disabled 
if possible. (If it is not possible to disable the comments the Director of Marketing 
for the Program of Physical Therapy will continually monitor comments and hide 
them in a timely manner; no member of the research team or marketing 
department will respond to any comments on social media ads).  In addition, to 
maintain privacy all ads will not include PHI and have any list of followers of the 
social media page hidden. Access to social media accounts also will be limited 
to the research team, the Director of Marketing for the Program in Physical 
Therapy, and Volunteers for Health. A disclaimer will be added to 
advertisements that cannot have comments disabled asking viewers to refrain 
from disclosing any sensitive personal information in comments. 
We will also post advertisements on the Program in Physical Therapy social media 
homepages (twitter, facebook, and Instagram) and post flyers around Washington 
University campuses. 
PARTICIPANT INCLUSION AND EXCLUSION CRITERIA 
For inclusion in the study, participants with PD must be:  
• at least 30 years of age; 
• diagnosis of idiopathic, typical Parkinson disease according to the UK Brain Bank 
Criteria; 
• Hoehn & Yahr stages 2-3 (mild to moderate disease severity); 
• stable on all PD medications for at least one month prior to study entry; 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 7 
 
• willing and able to provide informed consent; 
• right-handed or ambidextrous; 
• score of ≥ 1 on the MDS-UPDRS-III Item #10 indicating observable gait 
impairment; 
• able to walk for 10 continuous minutes with or without an ambulatory device;  
• a score of 1 or less on item # 7 on the New Freezing of Gait Questionnaire;  
• weigh less than 250 pounds; 
• no contraindications for magnetic resonance imaging (e.g., metallic implants); 
and 
• MMSE score of >=24 to indicate no significant cognitive impairment. 
 
 
Exclusion criteria:  
• diagnosis of any other neurological condition; 
• unstable medical or concomitant illnesses or psychiatric conditions which, in the 
opinion of the investigators, would preclude successful participation; 
• cardiac problems that interfere with ability to safely participate (i.e., uncontrolled 
congestive heart failure, myocardial infarction in past 6 months, complex cardiac 
arrhythmias, significant left ventricular dysfunction, dyspnea on exertion, chest 
pain or pressure, resting tachycardia (>100 beats/min);  
• orthopedic problems in the lower extremities or spine that may limit walking (i.e., 
severe neuropathy, spinal stenosis); or 
• uncontrolled tremor or dyskinesia while on PD medications 
• Inability to pass a hearing screen without hearing aids 
• Using specific strategies to assist in your walking, such as rhythmic cueing or use 
of music to specifically regulate your walking pattern, meaning walking to the 
beat of a song regularly (e.g., once a day) 
• Currently participating in LSVT or planning to start LSVT 
 
Participants with PD will remain on their normal anti-PD medications throughout the study.  
Evaluations will be conducted in the ON medication state because this represents 
everyday life. All visits at pre- and post- testing will be scheduled at the same time of day 
as noted by that person as their optimal ON period when their medications work best.   
 
MATERIALS 
 
Pre-assessment materials via phone 
 
• Phone screen to inform the participant about the study and ask questions to 
determine eligibility.  
• MRI Screening Questionnaire will be administered to people with PD who are 
eligible to participate to ensure they can safely participate in the fMRI portion of 
the study. 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 8 
 
Pre-assessment materials during pre-intervention assessment, Visit one 
• Participants will complete the Mini-Mental State Exam (MMSE)38 as a measure of 
cognitive performance. In order to qualify for the study people with PD must 
score ≥24 on the MMSE, indicating no significant cognitive impairment. In earlier 
phases of this project we determined that the potential risks for those with 
possible cognitive impairment did not outweigh the potential benefits. Therefore, 
were are using the MMSE to screen for low cognitive performance and will 
exclude these individuals. 
• Participants will complete a demographic form that includes questions about 
mobility and fall history.  
• Participants will complete the New Freezing of Gait Questionnaire to identify 
individuals with severe freezing.  
• Pure-tone hearing test to ensure hearing abilities are proficient for the testing. 
• MDS-UPDRS-III Motor Assessment (for people with PD) – to ensure participants 
have a Hoehn and Yahr score of 2-3 and observable gait disturbance per scoring 
of the gait item on this test.  
 
Evaluation materials during pre-intervention assessment, visit one 
• Six Opal inertial sensors (APDM, Inc) will be worn to provide an assessment of 
gait parameters. APDM sensors are worn on both feet, both wrists, chest, and 
posterior trunk at the level of L5 with elastic Velcro bands as the subjects perform 
their tasks (uncued, listening to music, and mentally singing). This will allow quick 
assessment of stride length during the different tempos. 
• A catalog of songs that are commonly known (e.g., Row Row Row your boat), 
cross-cultural, age-appropriate, and have characteristics appropriate for gait 
training (e.g., salient beat, 4/4 timing, activating) will be available.   
• Keyboard for finger tapping and finger tapping data collection sheet 
• Balance test: Mini-BEST test 
• Beat Alignment Test 
• Additional questionnaires to take home and return at visit two: MDS-UPDRS-I, 
MDS-UPDRS-II, PDQ-39, Beat Alignment Test Questionnaire 
Evaluation materials during pre-intervention imaging assessment, visit two 
• MRI data will be collected on a new, state-of-the-art 3T Prisma scanner system, 
using multiband factor 4, which capitalizes on simultaneous multi-slice acquisition 
to improve spatial resolution without increased scan time. The scanner is located 
in the Neuroimaging Laboratory 
 
Evaluation materials during intervention 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 9 
 
• Participants will complete a weekly 10MWT with the physical therapist. Time to 
completion using a stopwatch and number of steps will aid in accounting for 
progression of pace during the 24 class intervention. General notes from the 
therapist on the weekly check-in can be added to this collection sheet as well.  
 
Evaluation materials during post-intervention assessment, visit three 
• Participants will complete the Mini-Mental State Exam (MMSE) as a measure of 
cognitive performance. 
• Participants will complete the New Freezing of Gait Questionnaire to measure 
freezing in participants  
• MDS-UPDRS-III Motor Assessment (for people with PD)  
• Six Opal inertial sensors (APDM, Inc) will be worn to provide an assessment of 
gait parameters. APDM sensors are worn on both feet, both wrists, chest, and 
posterior trunk at the level of L5 with elastic Velcro bands as the subjects perform 
their tasks (uncued, listening to music, and mentally singing). This will allow quick 
assessment of stride length during the different tempos. 
• Keyboard for finger tapping and finger tapping data collection sheet 
• Balance test: Mini-BEST test 
• Beat Alignment Test 
• Additional questionnaires to take home and return at visit four: MDS-UPDRS-I, 
MDS-UPDRS-II, PDQ-39, Beat Alignment Test Questionnaire 
Evaluation materials during post-intervention imaging assessment, visit four 
• Same materials as “pre-intervention imaging assessment”: MRI data will be 
collected on a new, state-of-the-art 3T Prisma scanner system, using multiband 
factor 4, which capitalizes on simultaneous multi-slice acquisition to improve 
spatial resolution without increased scan time. The scanner is located in the 
Neuroimaging Laboratory 
 
Evaluation materials during follow-up time point 
• A survey will be sent to those who participated in the intervention at 12 weeks 
after the completion of the intervention. This survey will be focused on whether 
and under what circumstances they continue to use cueing in their daily lives 
 
PROTOCOL 
 
Consent 
 
Participants will receive and sign the informed consent during the first in-person visit. 
We will ensure the participants have the opportunity to ask the researcher any 
questions they may have regarding the study and procedure.  
 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 10 
 
Participants will need to provide verbal consent on the phone prior to us using their 
email for communications. We will explain to the participant the purpose of contacting 
them by email (i.e., scheduling, visit information, or completing surveys), notify them 
that some emails may contain health information, risks associated with using email 
(could be intercepted), that we will send a test email, remind the participant of their 
responsibilities (protect their username and password to their email account, log out, 
and if they share computer or cell phone with family member and want privacy then 
need to provide an email that only they can access), and let them know they can tell us 
if they want us to stop using their email as a method of communication. 
Pre-intervention assessment 
 
Pre-intervention assessment, Visit one 
After the consent form is signed, a trained researcher will administer the MMSE, 
demographics form, hearing test, and MDS-UPDRS-III. We will also collect medical 
history and medications, fill out the MRI Screening Form a second time, and administer 
the New Freezing of Gait- Questionnaire (NFOG-Q). After this in-person screening, we 
will determine if the participant meets inclusion criteria.  
If the participant passes the in-person screening, sensors will be put on the participant to 
record data during the gait assessments. All participants will be fitted with a safety belt 
and research team members will be close by to prevent falls during the visit.   
A balance test will be conducted first. The Mini-Best is a clinically relevant balance test 
that is valid and reliable for individuals with PD. The test includes sections to test 
anticipatory balance, reactive postural control, sensory orientation, and dynamic gait. 
Next, participants will complete the uncued walking and tapping assessments. Then be 
asked to choose from the song catalog the song that is most familiar to them.   
Participants will then complete the walking and tapping assessments during the mental 
singing, singing out loud, and music conditions.   
Six Minute Walk: This condition will be used to measure walking endurance. Participants 
are asked to cover as much ground as possible over the course of six minutes. This will 
occur with no cueing. 
Baseline Uncued: This condition will be used to represent normal baseline walking and 
will provide a point of comparison for the other conditions. It will include three, 30-second 
trials. Participants will be asked to walk at their preferred walking speed. This will occur 
in silence, as no cueing will be provided. 
The following music and mental singing conditions will be conducted at four tempos (90%, 
100%, 110%, and 120%) to identify the optimal tempo to use for the finger tapping 
assessments. 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 11 
 
Music: Our music condition represents traditional cueing techniques in which music will 
play and participants will be asked to walk to the beat. Once the song is turned on for 
each trial, participants will be told to take as long as needed to listen to the song, pick out 
the beat, and begin walking. 
Sing: Participants will be asked to sing the song out loud while walking without music 
playing. Participants will first hear the music played and once the song is over they will 
be instructed to sing the song out loud at the same pace as the music they just heard 
while walking. 
Mental Singing: Participants will be asked to mentally sing while walking without music 
playing. Participants will first hear the music played and once the song is over they will 
be instructed to mentally sing at the same pace as the music they just heard while walking.  
Using output from the APDM Sensors, the tempo that elicited the longest stride length, 
determined by average stride lengths across the music and mental singing trials within 
each tempo, will be used for the finger tapping tasks. This tempo will also be used as the 
starting tempo for the music-walking programs.  
Finger tapping tasks will next be assessed. Using the tempo selected from the walking 
assessments, participants will complete three, 30 second trials during both listening to 
music, singing out loud, and mentally singing conditions.  
Pre-intervention assessment, Visit two 
 
During this visit, participants will have 2 structural scans: a T1-weighted (T1W) sagittal, 
magnetization prepared rapid acquisition with gradient echo (MP-RAGE, TR=2400 ms, 
TI=1000 ms, TE=3.16 ms, FA=15°,1.0 mm3 voxels, 8:09 min) and a T2-weighted fast 
spin echo (TR=3200 ms, TE=455 ms, 1.0 mm3 voxels, 4:43 min). A midsagittal scout 
T1W spin-echo pulse sequence will be used for positioning. A brief fieldmap scan (54 
seconds) will be used to correct for spatial distortion caused by spatial inhomogeneties 
inside the scanner. 
 
Task-based fMRI will consist of two T2* echo-planar BOLD scans (EPI; MB = 4; 
TR=1200ms, TE=26.6ms, 3.0 mm3 voxels, FoV = 213mm, 48 slices) with whole-brain 
coverage including the cerebellum. During the fMRI scans, participants will view the 
instructions on a mirror mounted to the head coil and receive auditory input through 
headphones delivered via a custom made ePrime program.  
 
Five functional scans, using the design shown in Figure 2, will consist of eight task blocks 
(36 sec per block) interleaved with 12 second rest blocks throughout the period of one 
scan, lasting approximately 6.5 minutes per fMRI scan for each of the five different 
conditions (uncued tapping, music with tapping, mental singing with tapping, music only, 
and mental singing only)  
 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 12 
 
The order of task/rest block pairs will be randomized across scans and participants to 
avoid order and practice effects. Tapping responses and start/stop times of music 
listening and mental singing will be recorded using an MR-compatible response pad (Mag 
Design and Engineering, Redwood City, CA). Note that mental singing removes the 
potential motion confound induced by the act of singing aloud, to be confirmed with out-
of-scanner pilot testing to assess for large differences in movement or breathing patterns 
between mental singing and listening to music while finger tapping. Participants will be 
observed throughout the scan session; scans with observable, sustained body motion 
(e.g, tremor, dystonia) will be excluded. 
 
 
Figure 2. Boxcar design that will be used for FMRI scans. 
 
Intervention 
Participants will be assigned to either the music-based or mental singing-based 
intervention. Randomization will done by group so that once the first set of ~12 people 
are enrolled, a random number generator will select if all 12 individuals will participate in 
the music-based focus class or the mental singing-based focus class (Figure 3). The 
next class will be the opposite matching class. Class randomization will occur before the 
beginning of every set of classes, with a set of classes consisting of one mental singing-
based class and one music-based class. 
Figure 3. Randomization by class set. *indicates when randomization occurs 
All participants will receive 24 classes of the intervention (Figure 4). The interventions 
will be delivered jointly by a music therapist and a physical therapist. Interventions will 
consist of twice weekly (excluding holidays), 1-hour group classes that will focus on 
learning how to identify a beat in music, how to make a steady rhythm, and how to 
match your movement to a musical rhythm. Both music-based and singing-based 
classes will be taught in a similar way with focus on identical elements. The key 
difference will be on the home practice of either musical or sung depending upon the 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 13 
 
group. During the group work, each individual will be pulled aside once per week for a 
10-minute consultation with the physical therapist. During this individual consultation, 
the participant will practice walking to music or walking while mentally singing using 
their personalized cues (developed in the pre-intervention assessment session, see 
following section). Participants will be provided with a recording of their personalized 
cue on their own personal device or a device provided by us and will be asked to 
practice walking with music or mental singing on their own three days a week for a total 
of 30 minutes per day, to be done on the days when they do not attend the group class. 
Participants will keep a weekly log to document their participation in the home program. 
Gait performance of each participant in the uncued condition will be assessed every 
week and their cues adjusted as necessary to match their current performance. 
Participants will complete a weekly 10MWT with the physical therapist. This test 
includes walking a distance of 10 meters at their preferred comfortable pace. Time to 
completion and number of steps will aid in accounting for progression of pace during the 
24 class intervention. General notes from the therapist on the weekly check-in can be 
added to this collection sheet as well. If cadence increases by more than five steps per 
minute for 2 consecutive weeks, the physical therapist may choose to increase the 
tempo of their personalized cue to account for increases in velocity/cadence over the 
course of training. Ultimately any changes will be at the discretion of the therapist to 
encourage safe walking. 
 
Figure 4. Consort diagram showing flow of participants through the clinical trial. 
 
Post-intervention and Follow-up assessments 
Post-intervention assessment, Visit one 
All tests and procedures will be repeated after the music-based walking program as 
mentioned in “Pre-intervention assessment, Visit one.” This includes the MMSE, MDS-

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 14 
 
UPDRS, medications, the New Freezing of Gait- Questionnaire (NFOG-Q), PDQ-39, beat 
alignment test, Mini-Best, and tapping assessments and the six-minute walk test. 
After the six-minute walk test, a shortened version of the walking tests will be completed 
(see example diagram below; Figure 5). First, individuals will walk at their preferred, 
self-selected pace while no cue or instruction is provided. Participants will then complete 
a block of music trials and block of singing trials at the pre-evaluation or post-evaluation 
tempo, randomized, and with the order of music and singing blocks randomized.  In 
total, 4 conditions will be completed: Pre-evaluation tempo Mental Singing, Pre-
evaluation tempo Music, Post-evaluation tempo mental singing, and Post-evaluation 
tempo Music.  
• Pre-evaluation tempo: At the pre-evaluation, a research team member identified 
the participant’s “optimal percentage” (either 90%, 100%, 110%, or 120% of 
uncued cadence) that elicited longest stride length. This was then converted to 
the optimal pre-evaluation tempo, i.e. how many beats per minute rounded to the 
nearest 5-beat increment.   
 
For example, using the data from the pre-evaluation, if an individual walked 
uncued at 100 steps per min and the “optimal percentage” selected was 120%, 
than the “optimal pre-evaluation tempo” would be 120 bpm (100 steps per min x 
1.20 = 120).  
 
• Post-evaluation tempo:  At post-evaluation, if the same individual noted above 
now walked uncued at 110 steps per min, the optimal post-evaluation tempo 
would be 132 beats per min (110 steps per min x 1.2 = 132). Rounding to the 
nearest 5, the post-evaluation optimal post-evaluation tempo is 130 bpm. Both 
conditions of music and mental singing will be completed while the selected song 
plays at 120bpm and, in two separate trials, at 130bpm. 
No other tempos will be tested, and singing out loud will also not be tested. 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 15 
 
 
Figure 5. Example Post-test walking 
 
Additional questionnaires will include participant experiences with the training program, 
continued use of the program, soliciting opinions about acceptability, usability and 
satisfaction (including specific questions to address use of a single song vs. a suite of 
songs to inform future studies). 
Post-intervention assessment, Visit two 
All tests and procedures will be repeated after the music-based walking program as 
mentioned in “Pre-intervention assessment, Visit two.” The tapping rhythm will be 
identical to the “optimal tapping” identified in the Pre-intervention assessment. 
Follow-up time point 
A series of questionnaires will be mailed and/or sent via email to participants after 12 
weeks have passed after the conclusion of the intervention. These questionnaires will 
by focused on whether and under what circumstances they continue to use cueing in 
their daily lives. 
 
OUTCOME MEASURES 
• Gait Speed – A measure of how quickly someone walks; this measure is a 
product of stride length and cadence. 
• Stride Time Variability – an assessment of temporal stability of gait that indicates 
how consistent the duration of each stride is throughout a period of walking. 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 16 
 
• Inter-tap interval variability – a measure of temporal stability of tapping of the 
finger  
• MRI BOLD Beta Weights – measure of blood oxygen levels which is indicative of 
level of activity within different brain regions 
• Beat Alignment Test – measure of ability to perceive rhythmic beats and 
synchronize movement to these beats 
• Cueing Activity Log - Measure of frequency and duration that participants engage 
in for their at-home practice of either music or mental singing 
• Post-intervention survey - Report of participant experiences with the training 
program, soliciting opinions about acceptability, usability and satisfaction 
(including specific questions to address use of a single song vs. a suite of songs 
to inform future studies) 
• Six Minute Walk distance - Measure of walking endurance that tracks distance a 
person can cover in six minutes 
• Parkinson Disease Questionnaire (PDQ-39) – Self-report measure of quality of 
life specific to Parkinson disease  
• New Freezing of Gait Questionnaire – Self-report questionnaire that assesses 
frequency, duration, and circumstance of freezing of gait episodes 
MDS-UPDRS – Gold standard measure of global disease severity in PD, including 
measures of motor signs, non-motor symptoms, and activities of daily living 
V. RISKS AND BENEFITS 
 
There are several risks associated with this protocol. In addition to the ones listed 
below, there may be other unknown risks, or risks that we did not anticipate, associated 
with being in this study. 
 
Of the Likely / Common risks, the majority are considered Mild and are related to the 
walking tasks during the evaluations and during the classes themselves. These include: 
• Fatigue: Participants may feel tired or weak during the walking tasks or while 
performing the tapping tasks during the imaging session. Research staff will ask 
several times if a break should be taken, and participants will be encouraged to 
inform a member of the research team if they need a break. The research team 
will help participants take a break from the study or discontinue the study if 
necessary. 
• Physical discomfort: Participants may experience physical discomfort such as 
muscle soreness while engaging in the walking exercises. Participants will be 
encouraged to not move in ways that cause discomfort. 
• Discomfort during group learning experiences: Participants may experience 
discomfort during group learning experiences. In any group setting participants 
may feel uncomfortable or embarrassed while participating with others. 
• Discomfort answering questions: Participants may experience some discomfort 
when completing some of the surveys during the pre-evaluation testing and post-

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 17 
 
evaluation testing as they ask about their daily lives including emotion states. 
Participants may skip any questions they like. 
• Technological burden: Participants will be asked to use a personal audio player 
which they may consider burdensome. The research team will provide multiple 
options and train individuals on how to best use the devices.  
 
Of the Less Likely / Less Common risks, there is a chance that participants may 
stumble during walking tasks in the testing sessions or in the classes themselves. The 
research team will fit individuals with gait belts to assist if needed. We consider this a 
mild risk. 
 
There is a rare risk of falling that would be considered a moderate risk. It is unlikely that 
individuals will fall during the walking testing or during class but, as mentioned, the 
research team is nearby to assist as needed.  
 
There are multiple risks related to the MRI / imaging portion of the evaluations.  
Common risks include: 
• Discomfort inside MRI scanner, particularly if participant has claustrophobia 
• Muscle stiffness from lying still 
• Muscle cramping that may be caused nerve stimulation that can occur during 
MRI scans 
• Tissue heating causing the participant to be warm 
Rare risks include: 
• Hearing loss due to loud noise of MRI scanner 
• Sensation of flashing lights while in the scanner 
• Burns, including serious burns 
If participants have devices including pacemaker, bone hardware, stents or other 
devices, there may be additional risks. While the research team is fully trained in 
accordance with the facility regulations, these risks include heating or movement of 
device, device malfunction, and damage of tissue surrounding the device.  
 
There may or may not be specific benefit to participants. Generally, the research team 
hope that individuals may benefit by improving their walking ability and performance, but 
this is not known at this point. Other people (in the future) may benefit from this study as 
it will provide information on the benefits of music-based walking therapy for improving 
walking among people with Parkinson disease. 
 
Participants will be paid, via check, for their participation. Participants can receive up to 
$400 for completing the entire study which will be pro-rated if they do not complete all 
study visits. The pro-rated payment schedule includes $50 for the first pre-testing visit 
and $125 for the second pre-testing visit (the first MRI). There is an additional $50 for 
the first, post-testing visit and $125 for the second post-testing visit (the second MRI). 
The participants will receive $50 for finishing the follow-up surveys. If they do not 
complete all the study visits they will be paid for those they do complete. Completing the 
first MRI visit is required prior to starting the music-based walking program. 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 18 
 
 
VI. STATISICAL ANALYSES 
Aim 1: Compare the effects of training using external musical cues vs. self-generated 
singing cues on movement performance in people with PD. 
 
Gait speed will improve (i.e., increase) similarly with both forms of training. 
• Repeated measures analysis (RM ANOVA, alpha = .05) to compare average gait 
speed across time (pre- vs post-) between both training groups (mental singing 
vs music training).  
Temporal stability in gait, measured with stride time variability, will improve more 
(i.e., decrease) with mental singing training than with music training. 
• Repeated measures analysis (RM ANOVA, alpha = .05) to compare stride time 
variability across time (pre- vs post-) between both training groups (mental 
singing vs music training). 
Temporal stability in tapping, measured with inter-tap interval variability, will 
improve more (i.e., decrease) with mental singing training than with music 
training.  
• Repeated measures analysis (RM ANOVA, alpha = .05) to compare inter-tap 
interval variability across time (pre- vs post-) between both training groups 
(mental singing vs music training). 
 
Aim 2: Compare the effects of training using external musical cues vs. self-generated 
singing cues on movement performance in people with PD. 
 
Following training, the music group will show increased activation in auditory 
cortex whereas the mental singing group will show increased activation of the 
putamen and cerebellum relative to baseline.  
• Repeated measures analysis (RM ANOVA, alpha = .05) to compare activation in 
the auditory cortex across time (pre- vs post-) between both training groups 
(mental singing vs music training). 
• Repeated measures analysis (RM ANOVA, alpha = .05) to compare activation in 
the putamen across time (pre- vs post-) between both training groups (mental 
singing vs music training). 
• Repeated measures analysis (RM ANOVA, alpha = .05) to compare activation in 
the cerebellum across time (pre- vs post-) between both training groups (mental 
singing vs music training). 
 
Changes in inter-tap interval variability will be related to changes in putamen 
activation. 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 19 
 
• We will determine correlations between changes of inter-tap interval variability 
and changes in putamen activation in both groups (alpha = .05). 
 
Aim 3: Compare the acceptability and usability of training using external musical cues 
vs. self-generated singing cues in people with PD. 
 
Both music and mental singing training will be acceptable to participants; 
usability will be higher for singing. 
• Program satisfaction as a minimum average rating of >1.5 on the Client 
Satisfaction Questionnaire (CSQ) questions 1-6. 
• Program Acceptability as a minimum average rating of >1.5 on the Client 
Acceptability Questionnaire (SAQ) question 1 & 2 
• Program Usability as a minimum average rating of >1.5 on the Client Usability 
Questionnaire (SUQ) questions 1-3 
 
Feasibility Objectives 
• Demonstrate that cueing with music and with mental singing can be delivered 
consistently in a group setting as defined by 75% of participants attending at 
least 75% of training sessions 
• Demonstrate acceptable adherence to the intervention as defined by 75% of 
participants completing at least two out of three weekly home training 
assignments 
• Demonstrate the safety and tolerability of music and mental singing to facilitate 
movement in the study, as defined by less than 20% of participants experiencing 
an adverse event related to the intervention 
• Demonstrate the ability to recruit and retain subjects in the clinical study by being 
within 25% of our target accrual rate and having 70% of participants who initiate 
the study complete the full training protocol. 
POWER  
Aim 1: Gait velocity is our primary variable. Data from our pilot data show that cues 
increase gait speed significantly with an effect size of .80 for music and .72 for mental 
singing. Our secondary variable of stride time variability had an effect size of .78 for music 
and .83 for mental singing. Our secondary variable of inter-tap interval variability had an 
effect size of .79 for music and .96 for mental singing. Given these effect sizes, we 
powered Aim 1 to detect an effect size of .7 (Cohen’s d) in a RM ANOVA with 2 groups 
(music vs. mental) and three outcomes (gait velocity, stride time variability and inter-tap 
interval variability). At total sample size of 37 would be needed to detect an effect size of 
.7 for the within factor main effect, at 80% power, correlation among repeated measures 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 20 
 
of .30, and alpha = .017 (to account for three outcomes). To account for 20% attrition a 
total sample size of 41 is needed for Aim 1. 
Aim 2: We powered this neuroimaging aim to detect a moderate effect size (Cohen’s d = 
.5) in a RM ANOVA with 2 groups (music vs mental) and three outcomes (changes in 
auditory, putamen, cerebellum). A total sample size of 62 would be needed to detect a 
moderate effect size for the within factor main effect, at 80% power, correlation among 
repeated measures of .30, and alpha = .017 (to account for the three outcomes). To 
account for 20% attrition, we will recruit an additional 12 participants for a total sample 
size of 74 needed for Aim 2. 
 
 
 
VII. 
MONITORING & STORAGE OF DATA FOR FUTURE USE 
The data safety and monitoring plan includes recording all reportable events with start 
dates occurring any time after informed consent is obtained until 7 (for non-serious 
adverse events) or 30 days (for serious adverse events) after the last day of study 
participation. Unanticipated problems that are serious adverse events will be reported to 
the IRB, Independent Safety Monitors, and NCCIH within 7 days of the investigator 
being aware of the event. Any other unanticipated problem will be reported to the same 
entities within 14 days of the investigator becoming aware of the problem.  
Study progress and safety will be checked monthly for accuracy, compliance, and 
completeness by the senior scientist and concerns will be discussed with the PI.  
An independent monitoring committee (DSMB) not associated with the research project 
will receive reports semi-annually regarding progress, recruitment, retention/attrition, 
and adverse events. An annual report will also be compiled that will include a list and 
summary of adverse events and this will be sent to the Independent Monitors and 
forwarded to the IRB and NCCIH. 
All data recorded in hard form will be stored in the laboratory in a manner compliant with 
all HIPAA requirements. All paper forms will be labeled with study visit data and study 
participant ID. All records will be kept in a secured laboratory that is locked when 
research team members are not present. Electronic records will be referenced by coded 
numbers in our databases, stored on password-protected computers in a locked office 
and/or on secure networks in full compliance with HIPAA guidelines for security of 
protected health information. Identifiable data will be destroyed when the project is 
closed. 
The data we collect in this study may be made available for studies ongoing or for 
studies in the future. These studies are not limited to the researchers at Washington 
University, but also other research centers and institutions, or potentially private 
companies involved in research. Data may be shared with large data repositories for 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 21 
 
use by others. In accordance with protecting information, all names and other identifying 
information will be removed before sharing. All reasonable precautions will be taken to 
protect participants’ privacy and confidentiality. Necessary approvals will be obtained to 
use the data.  
Participants will be provided with the option to not allow their data to be shared for other 
research studies. Participants who elect to not share their data will still be allowed to 
participant. For those participants electing to allow for future use of their data, they may 
change their mind at any time by contacting the research team.  

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 22 
 
REFERENCES CITED 
1. Studenski S. Gait Speed and Survival in Older Adults. JAMA. 2011;305(1):50. 
doi:10.1001/jama.2010.1923 
2. Shulman LM. Understanding disability in Parkinson’s disease: Understanding 
Disability in PD. Mov Disord. 2010;25(S1):S131-S135. doi:10.1002/mds.22789 
3. Ghai S, Ghai I, Schmitz G, Effenberg AO. Effect of rhythmic auditory cueing on 
parkinsonian gait: A systematic review and meta-analysis. Sci Rep. 2018;8(1):506. 
doi:10.1038/s41598-017-16232-5 
4. Rocha PA, Porfírio GM, Ferraz HB, Trevisani VFM. Effects of external cues on gait 
parameters of Parkinson’s disease patients: A systematic review. Clinical Neurology 
and Neurosurgery. 2014;124:127-134. doi:10.1016/j.clineuro.2014.06.026 
5. Jones D, Rochester L, Birleson A, et al. Everyday walking with Parkinson’s disease: 
Understanding personal challenges and strategies. Disability and Rehabilitation. 
2008;30(16):1213-1221. doi:10.1080/09638280701828955 
6. Thaut MH, McIntosh GC, Rice RR, Miller RA, Rathbun J, Brault JM. Rhythmic 
auditory stimulation in gait training for Parkinson’s disease patients. Movement 
disorders: official journal of the Movement Disorder Society. 1996;11(2):193-200. 
7. Nombela C, Hughes LE, Owen AM, Grahn JA. Into the groove: Can rhythm 
influence Parkinson’s disease? Neuroscience & Biobehavioral Reviews. 
2013;37(10):2564-2570. doi:10.1016/j.neubiorev.2013.08.003 
8. Spaulding SJ, Barber B, Colby M, Cormack B, Mick T, Jenkins ME. Cueing and Gait 
Improvement Among People With Parkinson’s Disease: A Meta-Analysis. Archives 
of Physical Medicine and Rehabilitation. 2013;94(3):562-570. 
doi:10.1016/j.apmr.2012.10.026 
9. Vitorio R, Stuart S, Gobbi LTB, Rochester L, Alcock L, Pantall A. Reduced Gait 
Variability and Enhanced Brain Activity in Older Adults With Auditory Cues: A 
Functional Near-Infrared Spectroscopy Study. Neurorehabil Neural Repair. 
2018;32(11):976-987. doi:10.1177/1545968318805159 
10. Thaut MH, McIntosh KW, McIntosh GC, Hoemberg V. Auditory rhythmicity enhances 
movement and speech motor control in patients with Parkinson’s disease. 
Functional neurology. 2001;16(2):163-172. 
11. McIntosh GC, Brown SH, Rice RR, Thaut MH. Rhythmic auditory-motor facilitation 
of gait patterns in patients with Parkinson’s disease. Journal of Neurology, 
Neurosurgery & Psychiatry. 1997;62(1):22-26. doi:10.1136/jnnp.62.1.22 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 23 
 
12. Rochester L, Hetherington V, Jones D, et al. The Effect of External Rhythmic Cues 
(Auditory and Visual) on Walking During a Functional Task in Homes of People With 
Parkinson’s Disease. Archives of Physical Medicine and Rehabilitation. 
2005;86(5):999-1006. doi:10.1016/j.apmr.2004.10.040 
13. Willems AM, Nieuwboer A, Chavret F, et al. The use of rhythmic auditory cues to 
influence gait in patients with Parkinson’s disease, the differential effect for freezers 
and non-freezers, an explorative study. Disability and Rehabilitation. 
2006;28(11):721-728. doi:10.1080/09638280500386569 
14. Lim I, van Wegen E, de Goede C, et al. Effects of external rhythmical cueing on gait 
in patients with Parkinson’s disease: a systematic review. Clinical Rehabilitation. 
2005;19(7):695-713. doi:10.1191/0269215505cr906oa 
15. Styns F, Van Noorden L, Moelants D, Leman M. Walking on music. Human 
Movement Science. 2007;26(5):769-785. doi:10.1016/j.humov.2007.07.007 
16. Dotov DG, Bayard S, Cochen De Cock V, et al. Biologically-variable rhythmic 
auditory cues are superior to isochronous cues in fostering natural gait variability in 
Parkinson’s disease. Gait & Posture. 2017;51:64-69. 
doi:10.1016/j.gaitpost.2016.09.020 
17. Bella SD, Benoit CE, Farrugia N, Schwartze M, Kotz SA. Effects of musically cued 
gait training in Parkinson’s disease: beyond a motor benefit: Auditory cueing in 
Parkinson’s disease. Ann NY Acad Sci. 2015;1337(1):77-85. 
doi:10.1111/nyas.12651 
18. Nieuwboer A, Kwakkel G, Rochester L, et al. Cueing training in the home improves 
gait-related mobility in Parkinson’s disease: the RESCUE trial. Journal of Neurology, 
Neurosurgery & Psychiatry. 2007;78(2):134-140. doi:10.1136/jnnp.200X.097923 
19. Nieuwboer A, Baker K, Willems AM, et al. The Short-Term Effects of Different 
Cueing Modalities on Turn Speed in People with Parkinson’s Disease. Neurorehabil 
Neural Repair. 2009;23(8):831-836. doi:10.1177/1545968309337136 
20. Maitra K. Enhancement of reaching performance via self-speech in people with 
Parkinson’s disease. Clin Rehabil. 2007;21(5):418-424. 
doi:10.1177/0269215507074058 
21. Harris R, Leenders KL, De Jong BM. Speech dysprosody but no music ‘dysprosody’ 
in Parkinson’s disease. Brain and Language. 2016;163:1-9. 
doi:10.1016/j.bandl.2016.08.008 
22. Satoh M, Kuzuhara S. Training in Mental Singing while Walking Improves Gait 
Disturbance in Parkinson’s Disease Patients. Eur Neurol. 2008;60(5):237-243. 
doi:10.1159/000151699 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 24 
 
23. Lee SY, Seok H, Kim SH, Park M, Kim J. Immediate Effects of Mental Singing While 
Walking on Gait Disturbance in Hemiplegic Stroke Patients: A Feasibility Study. Ann 
Rehabil Med. 2018;42(1):1. doi:10.5535/arm.2018.42.1.1 
24. Harrison EC, Horin AP, Earhart GM. Internal cueing improves gait more than 
external cueing in healthy adults and people with Parkinson disease. Sci Rep. 
2018;8(1):15525. doi:10.1038/s41598-018-33942-6 
25. Harrison EC, Horin AP, Earhart GM. Mental Singing Reduces Gait Variability More 
Than Music Listening for Healthy Older Adults and People With Parkinson Disease. 
Journal of Neurologic Physical Therapy. 2019;43(4):204-211. 
doi:10.1097/NPT.0000000000000288 
26. Rossignol S, Jones GM. Audio-spinal influence in man studied by the H-reflex and 
its possible role on rhythmic movements synchronized to sound. 
Electroencephalography and Clinical Neurophysiology. 1976;41(1):83-92. 
doi:10.1016/0013-4694(76)90217-0 
27. Bengtsson SL, Ullén F, Henrik Ehrsson H, et al. Listening to rhythms activates motor 
and premotor cortices. Cortex. 2009;45(1):62-71. doi:10.1016/j.cortex.2008.07.002 
28. Chen JL, Penhune VB, Zatorre RJ. Listening to Musical Rhythms Recruits Motor 
Regions of the Brain. Cerebral Cortex. 2008;18(12):2844-2854. 
doi:10.1093/cercor/bhn042 
29. Grahn JA, Brett M. Rhythm and Beat Perception in Motor Areas of the Brain. Journal 
of Cognitive Neuroscience. 2007;19(5):893-906. doi:10.1162/jocn.2007.19.5.893 
30. Chen JL, Zatorre RJ, Penhune VB. Interactions between auditory and dorsal 
premotor cortex during synchronization to musical rhythms. NeuroImage. 
2006;32(4):1771-1781. doi:10.1016/j.neuroimage.2006.04.207 
31. Grahn JA, Rowe JB. Feeling the Beat: Premotor and Striatal Interactions in 
Musicians and Nonmusicians during Beat Perception. Journal of Neuroscience. 
2009;29(23):7540-7548. doi:10.1523/JNEUROSCI.2018-08.2009 
32. Bijsterbosch JD, Lee KH, Hunter MD, et al. The Role of the Cerebellum in Sub- and 
Supraliminal Error Correction during Sensorimotor Synchronization: Evidence from 
fMRI and TMS. Journal of Cognitive Neuroscience. 2011;23(5):1100-1112. 
doi:10.1162/jocn.2010.21506 
33. Thaut MH, Stephan KM, Wunderlich G, et al. Distinct cortico-cerebellar activations in 
rhythmic auditory motor synchronization. Cortex. 2009;45(1):44-53. 
doi:10.1016/j.cortex.2007.09.009 

Sing for your Saunter R33 Protocol – 11/13/2023 v4 
 
 
 
 SFYS 25 
 
34. Taniwaki T, Yoshiura T, Ogata K, et al. Disrupted connectivity of motor loops in 
Parkinson’s disease during self-initiated but not externally-triggered movements. 
Brain Research. 2013;1512:45-59. doi:10.1016/j.brainres.2013.03.027 
35. Mavridis IN, Pyrgelis ES. Brain Activation During Singing: “Clef de Sol Activation” Is 
the “Concert” of the Human Brain. Medical Problems of Performing Artists. 
2016;31(1):45-50. doi:10.21091/mppa.2016.1008 
36. Kleber B, Birbaumer N, Veit R, Trevorrow T, Lotze M. Overt and imagined singing of 
an Italian aria. NeuroImage. 2007;36(3):889-900. 
doi:10.1016/j.neuroimage.2007.02.053 
37. Konoike N, Kotozaki Y, Miyachi S, et al. Rhythm information represented in the 
fronto-parieto-cerebellar motor system. NeuroImage. 2012;63(1):328-338. 
doi:10.1016/j.neuroimage.2012.07.002 
38. Cockrell JR, Folstein MF. Mini-mental state examination (MMSE). Psychopharmacol 
Bull. 1988;24(4):689-692.