Effect of rhythmic auditory cueing on gait in cerebral palsy: a systematic review and meta-analysis

Abstract

Auditory entrainment can influence gait performance in movement disorders. The entrainment can incite neurophysiological and musculoskeletal changes to enhance motor execution. However, a consensus as to its effects based on gait in people with cerebral palsy is still warranted. A systematic review and meta-analysis were carried out to analyze the effects of rhythmic auditory cueing on spatiotemporal and kinematic parameters of gait in people with cerebral palsy. Systematic identification of published literature was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and American Academy for Cerebral Palsy and Developmental Medicine guidelines, from inception until July 2017, on online databases: Web of Science, PEDro, EBSCO, Medline, Cochrane, Embase and ProQuest. Kinematic and spatiotemporal gait parameters were evaluated in a meta-analysis across studies. Of 547 records, nine studies involving 227 participants (108 children/119 adults) met our inclusion criteria. The qualitative review suggested beneficial effects of rhythmic auditory cueing on gait performance among all included studies. The meta-analysis revealed beneficial effects of rhythmic auditory cueing on gait dynamic index (Hedge’s g=0.9), gait velocity (1.1), cadence (0.3), and stride length (0.5). This review for the first time suggests a converging evidence toward application of rhythmic auditory cueing to enhance gait performance and stability in people with cerebral palsy. This article details underlying neurophysiological mechanisms and use of cueing as an efficient home-based intervention. It bridges gaps in the literature, and suggests translational approaches on how rhythmic auditory cueing can be incorporated in rehabilitation approaches to enhance gait performance in people with cerebral palsy.

Keywords:

• entrainment
• spastic diplegia
• hemiplegia
• ataxia
• rehabilitation
• balance

Supplementary materials

Figure S1 Forest plot illustrating individual studies evaluating the effects of rhythmic auditory cueing on gait velocity in children with cerebral palsy.

Notes: Negative effects indicate reduction in gait velocity, positive effects enhancement in gait velocity. Weighted-effect sizes – Hedge’s g (boxes) and 95% CI (whiskers) – demonstrate repositioning errors for individual studies. The diamond represents pooled effect sizes and 95% CI. Negative mean differences indicate favorable outcomes for control groups, positive mean differences favorable outcomes for experimental groups.

Abbreviation: C, children.

Figure S2 Forest plot illustrating individual studies evaluating the effects of rhythmic auditory cueing on gait velocity in children with cerebral palsy posttraining.

Notes: Negative effects indicate reduction in gait velocity, positive effect sizes enhancement in gait velocity. Weighted-effect sizes – Hedge’s g (boxes) and 95% CI (whiskers) – demonstrate repositioning errors for individual studies. The diamond represents pooled effect sizes and 95% CI. Negative mean differences indicate favorable outcomes for control groups, positive mean differences favorable outcomes for experimental groups.

Abbreviation: C, children.

Figure S3 Forest plot illustrating individual studies evaluating the effects of rhythmic auditory cueing on stride length in children with cerebral palsy.

Notes: Negative effects indicate reduction in stride length, positive effects enhancement in stride length. Weighted-effect sizes – Hedge’s g (boxes) and 95% CI (whiskers) – demonstrate repositioning errors for individual studies. The diamond represents pooled effect sizes and 95% CI. Negative mean difference indicate favorable outcomes for control groups, positive mean difference favorable outcomes for experimental groups.

Abbreviation: C, children.

Figure S4 Forest plot illustrating individual studies evaluating the effects of rhythmic auditory cueing on pelvic kinematics in adults with cerebral palsy.

Notes: Negative effects indicate reduction in pelvic kinematics, positive effects enhancement in pelvic kinematics. Weighted-effect sizes – Hedge’s g (boxes) and 95% CI (whiskers) – demonstrate repositioning errors for individual studies. The diamond represents pooled effect sizes and 95% CI. Negative mean differences indicates favorable outcomes for control groups, positive mean differences favorable outcomes for experimental groups.

Figure S5 Forest plot illustrating individual studies evaluating the effects of rhythmic auditory cueing on hip kinematics in adults with cerebral palsy.

Notes: Negative effects indicate reduction in hip kinematics, positive effects enhancement in hip kinematics. Weighted-effect sizes – Hedge’s g (boxes) and 95% CI (whiskers) – demonstrate repositioning errors for individual studies. The diamond represents pooled effect sizes and 95% CI. Negative mean differences indicate favorable outcomes for control groups, positive mean differences favorable outcomes for experimental groups.

Figure S6 Forest plot illustrating individual studies evaluating the effects of rhythmic auditory cueing on knee kinematics in adults with cerebral palsy.

Notes: Negative effects indicate reduction in knee kinematics, positive effects enhancement in knee kinematics. Weighted-effect sizes – Hedge’s g (boxes) and 95% CI (whiskers) – demonstrate repositioning errors for individual studies. The diamond represents pooled effect sizes and 95% CI. Negative mean differences indicate favorable outcomes for control groups, positive mean differences favorable outcomes for experimental groups.

Figure S7 Forest plot illustrating individual studies evaluating the effects of rhythmic auditory cueing on ankle kinematics in adults with cerebral palsy.

Notes: Negative effect sizes indicate reduction in ankle kinematics, positive effects enhancement in ankle kinematics. Weighted-effect sizes – Hedge’s g (boxes) and 95% CI (whiskers) – demonstrating repositioning errors for individual studies. The diamond represents pooled effect sizes and 95% CI. Negative mean differences indicate favorable outcomes for control groups, positive mean difference favorable outcomes for experimental groups.

Figure S8 Forest plot illustrating individual studies evaluating the effects of rhythmic auditory cueing on foot kinematics in adults with cerebral palsy.

Notes: Negative effects indicated reduction in foot kinematics, positive effects enhancement in foot kinematics. Weighted-effect sizes – Hedge’s g (boxes) and 95% CI (whiskers) – demonstrate repositioning errors for individual studies. The diamond represents pooled effect sizes and 95% CI. Negative mean differences indicate favorable outcomes for control groups, positive mean differences favorable outcomes for experimental groups.

Table S1 Individual PEDro scores

Acknowledgments

Publication of this article was funded by the Open Access Fund of Leibniz Universität, Hannover.

Author contributions

SG conceptualized the study, carried out the systematic review and statistical analysis, and wrote the paper. IG and AOE were involved in the systematic review process and reviewed the final manuscript. All authors contributed toward data analysis, drafting and revising the paper and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.