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Ed by 10 cm [13, 25, 26] or while they stood with their feet together

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Ed by 10 cm [13, 25, 26] or while they stood with their feet together or in a semi-tandem stance with their eyes open and closed [33]. Given the available evidence, it seems that the best recommendation for clinicians seeking to assess standing balance using wearable sensors would be to calculate RMS accelerations or jerk scores from trunk accelerations collected while patients stand with their eyes open and their heels 10 cm apart. However, a degree of caution may be required when considering this recommendation, as three of the four studies that reported differences in standing balance for people with PD appear to have used the same patient cohort, due to the reported demographics being the same for each study [13, 25, 26]. As such, it is possible that the overall interpretation of the existing literature in this area may be biased and the transferability of the findings may be more limited than they appear. In addition to the nine studies that used wearable sensors to assess standing balance, the remaining 65 used these devices to assess walking stability. These studies reported numerous outcome measures derived from the acceleration signals, but the Harmonic Ratio (HR) was the most commonly-reported measure and was calculated for the head [30] and lumbosacral region [14, 17, 19, 20, 30, 31, 35, 39]. The HR seems to be a sensitive and versatile measure of walking stability, as the reviewed literature reports differences between people with PD and controls [14, 19, 20, 30], PD freezers and non-freezers [35], PD fallers and non-fallers [30, 31], PD patients with different dominant symptoms [17] and different RG1662 clinical trials methods of cueing for people with PD [39]. Stride timing FT011 site variability was the second most common outcomePLOS ONE | DOI:10.1371/journal.pone.0123705 April 20,17 /Wearable Sensors for Assessing Balance and Gait in Parkinson’s Diseasemeasure for the studies that assessed walking stability, but careful review of the included studies suggested that it may not be a dependable measure for discriminating between different populations. Of the seven studies that reported this outcome, three described differences in stride timing variability between PD fallers and non-fallers [30], PD patients and controls [22, 30] or carriers and non-carriers of the LRRK2 gene mutation [36]. In contrast, four studies reported no differences between PD patients and controls [19, 28, 29] or patients with different sub-types of PD [17]. A common characteristic of those studies reporting differences for the HR and stride timing variability was that they each assessed walking stability during straight line walking. As such, it is recommended that clinicians who wish to assess walking stability using wearable sensors calculate the HR from trunk accelerations collected while patients walk in a straight line at a self-selected speed. While there is some evidence to support the use of stride timing variability to assess walking stability, it would only be recommended as a secondary measure due to the inconsistencies evident within the current literature. While it was not the primary focus of this review to evaluate the effects of anti-parkinsonian medications, such as levodopa, on measures of standing balance and walking stability, it is an important factor that warrants consideration. It is widely recognised that levodopa improves symptoms of PD (based on the UPDRS) [17, 32], spatiotemporal gait characteristics (e.g. stride length) [52, 53] and performance on clinic.Ed by 10 cm [13, 25, 26] or while they stood with their feet together or in a semi-tandem stance with their eyes open and closed [33]. Given the available evidence, it seems that the best recommendation for clinicians seeking to assess standing balance using wearable sensors would be to calculate RMS accelerations or jerk scores from trunk accelerations collected while patients stand with their eyes open and their heels 10 cm apart. However, a degree of caution may be required when considering this recommendation, as three of the four studies that reported differences in standing balance for people with PD appear to have used the same patient cohort, due to the reported demographics being the same for each study [13, 25, 26]. As such, it is possible that the overall interpretation of the existing literature in this area may be biased and the transferability of the findings may be more limited than they appear. In addition to the nine studies that used wearable sensors to assess standing balance, the remaining 65 used these devices to assess walking stability. These studies reported numerous outcome measures derived from the acceleration signals, but the Harmonic Ratio (HR) was the most commonly-reported measure and was calculated for the head [30] and lumbosacral region [14, 17, 19, 20, 30, 31, 35, 39]. The HR seems to be a sensitive and versatile measure of walking stability, as the reviewed literature reports differences between people with PD and controls [14, 19, 20, 30], PD freezers and non-freezers [35], PD fallers and non-fallers [30, 31], PD patients with different dominant symptoms [17] and different methods of cueing for people with PD [39]. Stride timing variability was the second most common outcomePLOS ONE | DOI:10.1371/journal.pone.0123705 April 20,17 /Wearable Sensors for Assessing Balance and Gait in Parkinson’s Diseasemeasure for the studies that assessed walking stability, but careful review of the included studies suggested that it may not be a dependable measure for discriminating between different populations. Of the seven studies that reported this outcome, three described differences in stride timing variability between PD fallers and non-fallers [30], PD patients and controls [22, 30] or carriers and non-carriers of the LRRK2 gene mutation [36]. In contrast, four studies reported no differences between PD patients and controls [19, 28, 29] or patients with different sub-types of PD [17]. A common characteristic of those studies reporting differences for the HR and stride timing variability was that they each assessed walking stability during straight line walking. As such, it is recommended that clinicians who wish to assess walking stability using wearable sensors calculate the HR from trunk accelerations collected while patients walk in a straight line at a self-selected speed. While there is some evidence to support the use of stride timing variability to assess walking stability, it would only be recommended as a secondary measure due to the inconsistencies evident within the current literature. While it was not the primary focus of this review to evaluate the effects of anti-parkinsonian medications, such as levodopa, on measures of standing balance and walking stability, it is an important factor that warrants consideration. It is widely recognised that levodopa improves symptoms of PD (based on the UPDRS) [17, 32], spatiotemporal gait characteristics (e.g. stride length) [52, 53] and performance on clinic.

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