{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T06:14:16Z","timestamp":1778652856811,"version":"3.51.4"},"reference-count":35,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T00:00:00Z","timestamp":1778630400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Aging Neurosci."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Freezing of gait (FOG) is a disabling gait disturbance in Parkinson\u2019s disease (PD) that responds poorly to pharmacological treatment. External cueing has been proposed as a non-pharmacological strategy to improve gait and mobility; however, the effectiveness of repeated external cueing training on FOG-related outcomes remains uncertain, particularly across different cueing modalities.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs), with a specific focus on repeated external cueing interventions (\u22652 weeks). PubMed, Web of Science, Embase, the Cochrane Library, CNKI, Wanfang, and VIP databases were searched from inception to November 10, 2025. RCTs evaluating external cueing interventions in individuals with PD were included. Primary outcomes were FOG severity assessed by the Freezing of Gait Questionnaire (FOGQ) or New FOGQ (NFOGQ). Secondary outcomes included Timed Up and Go (TUG), MDS\u2013UPDRS part III, and Berg Balance Scale (BBS). Risk of bias was assessed using ROB 2.0, and evidence certainty using GRADE.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Nine RCTs involving patients with PD were included. Pooled analysis showed no statistically significant reduction in FOG severity following external cueing interventions compared with control conditions (SMD = \u22120.30, 95% CI: \u22120.68 to 0.09), with substantial heterogeneity. In contrast, external cueing significantly improved functional mobility as measured by the TUG test (SMD = \u22120.65, 95% CI: \u22121.15 to \u22120.15), although heterogeneity remained high. No consistent benefits were observed for overall motor symptoms or balance outcomes. Exploratory analysis incorporating short-term follow-up data suggested a modest improvement in FOG severity; however, these findings should be interpreted with caution due to persistent heterogeneity. The certainty of evidence for all outcomes was rated as low according to the GRADE framework. The observed heterogeneity was likely attributable to variations in intervention protocols, cueing modalities, and outcome assessment methods.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>External cueing interventions may improve functional mobility in individuals with PD, particularly for tasks involving gait initiation and turning. However, current evidence does not support consistent benefits for FOG severity, overall motor symptoms, or balance. Given the low certainty of evidence, further high-quality, multicenter RCTs with standardized outcome measures and longer follow-up are needed to clarify the clinical role of cueing-based interventions in FOG. These findings highlight important limitations in the current evidence base and provide directions for future research.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Systematic review registration<\/jats:title>\n                    <jats:p>\n                      <jats:ext-link>https:\/\/www.crd.york.ac.uk\/PROSPERO\/view\/CRD420261280910<\/jats:ext-link>\n                      , identifier CRD420261280910.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fnagi.2026.1808824","type":"journal-article","created":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T05:52:52Z","timestamp":1778651572000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Efficacy of repeated external cueing training on freezing of gait and gait performance in Parkinson\u2019s disease: a systematic review and meta-analysis"],"prefix":"10.3389","volume":"18","author":[{"given":"Qingling","family":"Sun","sequence":"first","affiliation":[{"name":"Department of Pharmacy, Beilun People\u2019s Hospital, Ningbo","place":["Zhejiang, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wangfang","family":"Yu","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Beilun People\u2019s Hospital, Ningbo","place":["Zhejiang, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Huafu","family":"Ni","sequence":"additional","affiliation":[{"name":"Department of Neurology, Beilun People\u2019s Hospital, Ningbo","place":["Zhejiang, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2026,5,13]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"e9675","DOI":"10.1371\/journal.pone.0009675","article-title":"Effect of rhythmic auditory stimulation on gait in Parkinsonian patients with and without freezing of gait.","volume":"5","author":"Arias","year":"2010","journal-title":"PLoS One"},{"key":"B2","doi-asserted-by":"publisher","first-page":"2284","DOI":"10.1016\/S0140-6736(21)00218-X","article-title":"Parkinson\u2019s disease.","volume":"397","author":"Bloem","year":"2021","journal-title":"Lancet"},{"key":"B3","doi-asserted-by":"publisher","first-page":"240","DOI":"10.3163\/1536-5050.104.3.014","article-title":"De-duplication of database search results for systematic reviews in EndNote.","volume":"104","author":"Bramer","year":"2016","journal-title":"J. Med. Libr. Assoc."},{"key":"B4","doi-asserted-by":"publisher","first-page":"117086","DOI":"10.1016\/j.jns.2020.117086","article-title":"Effects of multimodal balance training supported by rhythmical auditory stimuli in people with advanced stages of Parkinson\u2019s disease: A pilot randomized clinical trial.","volume":"418","author":"Capato","year":"","journal-title":"J. Neurol. Sci."},{"key":"B5","doi-asserted-by":"publisher","first-page":"2023","DOI":"10.1093\/ptj\/pzaa146","article-title":"Multimodal balance training supported by rhythmic auditory stimuli in Parkinson disease: Effects in freezers and nonfreezers.","volume":"100","author":"Capato","year":"","journal-title":"Phys. Therapy"},{"key":"B6","doi-asserted-by":"publisher","first-page":"849","DOI":"10.1136\/jnnp-2014-308786","article-title":"Parkinson\u2019s disease beyond 20 years.","volume":"86","author":"Cilia","year":"2015","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"B7","doi-asserted-by":"publisher","first-page":"105189","DOI":"10.1016\/j.neubiorev.2023.105189","article-title":"One cue does not fit all: A systematic review with meta-analysis of the effectiveness of cueing on freezing of gait in Parkinson\u2019s disease.","volume":"150","author":"Cosentino","year":"2023","journal-title":"Neurosci. Biobehav. Rev."},{"key":"B8","doi-asserted-by":"publisher","first-page":"902","DOI":"10.1177\/0269215514527299","article-title":"Randomized cross-over trial to investigate the efficacy of a two-week physiotherapy programme with repetitive exercises of cueing to reduce the severity of freezing of gait in patients with Parkinson\u2019s disease.","volume":"28","author":"Fietzek","year":"2014","journal-title":"Clin. Rehab."},{"key":"B9","doi-asserted-by":"publisher","first-page":"407","DOI":"10.1016\/j.rehab.2017.08.002","article-title":"Cueing for people with Parkinson\u2019s disease with freezing of gait: A narrative review of the state-of-the-art and novel perspectives.","volume":"61","author":"Ginis","year":"2018","journal-title":"Ann. Phys. Rehabil. Med."},{"key":"B10","doi-asserted-by":"publisher","first-page":"924","DOI":"10.1136\/bmj.39489.470347.AD","article-title":"GRADE: An emerging consensus on rating quality of evidence and strength of recommendations.","volume":"336","author":"Guyatt","year":"2008","journal-title":"BMJ"},{"key":"B11","doi-asserted-by":"publisher","first-page":"1539","DOI":"10.1002\/sim.1186","article-title":"Quantifying heterogeneity in a meta-analysis.","volume":"21","author":"Higgins","year":"2002","journal-title":"Stat. Med."},{"key":"B12","doi-asserted-by":"publisher","first-page":"557","DOI":"10.1136\/bmj.327.7414.557","article-title":"Measuring inconsistency in meta-analyses.","volume":"327","author":"Higgins","year":"2003","journal-title":"BMJ"},{"key":"B13","doi-asserted-by":"publisher","first-page":"181","DOI":"10.1136\/jnnp.55.3.181","article-title":"Accuracy of clinical diagnosis of idiopathic Parkinson\u2019s disease: A clinico-pathological study of 100 cases.","volume":"55","author":"Hughes","year":"1992","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"B14","doi-asserted-by":"publisher","first-page":"199","DOI":"10.1002\/mdc3.12893","article-title":"The new freezing of gait questionnaire: Unsuitable as an outcome in clinical trials?","volume":"7","author":"Hulzinga","year":"2020","journal-title":"Mov. Disord. Clin. Pract."},{"key":"B15","doi-asserted-by":"publisher","first-page":"101620","DOI":"10.1016\/j.rehab.2021.101620","article-title":"Robot-assisted gait training with auditory and visual cues in Parkinson\u2019s disease: A randomized controlled trial.","volume":"65","author":"Kim","year":"2022","journal-title":"Ann Phys Rehabil Med."},{"key":"B16","doi-asserted-by":"publisher","first-page":"3310","DOI":"10.1007\/s00415-022-11031-z","article-title":"Managing freezing of gait in Parkinson\u2019s disease: A systematic review and network meta-analysis.","volume":"269","author":"Kwok","year":"2022","journal-title":"J. Neurol."},{"key":"B17","doi-asserted-by":"publisher","first-page":"46","DOI":"10.1186\/1471-2377-8-46","article-title":"A randomised controlled trial evaluating the effect of an individual auditory cueing device on freezing and gait speed in people with Parkinson\u2019s disease.","volume":"8","author":"Ledger","year":"2008","journal-title":"BMC Neurol."},{"key":"B18","doi-asserted-by":"publisher","first-page":"264","DOI":"10.1002\/mds.28837","article-title":"Addressing the challenges of clinical research for freezing of gait in Parkinson\u2019s disease.","volume":"37","author":"Lewis","year":"2022","journal-title":"Mov. Disord."},{"key":"B19","first-page":"822","article-title":"Effects of combined strength training and rhythmic auditory attentional stimulation in older patients with Parkinson\u2019s disease.","volume":"30","author":"Liu","year":"2021","journal-title":"Chinese J. Convalescent Med."},{"key":"B20","doi-asserted-by":"publisher","first-page":"25","DOI":"10.1038\/s41531-019-0099-z","article-title":"Freezing of Gait can persist after an acute levodopa challenge in Parkinson\u2019s disease.","volume":"5","author":"Lucas McKay","year":"2019","journal-title":"NPJ Parkinsons Dis."},{"key":"B21","doi-asserted-by":"publisher","first-page":"783","DOI":"10.1002\/mds.27709","article-title":"Clinical and methodological challenges for assessing freezing of gait: Future perspectives.","volume":"34","author":"Mancini","year":"2019","journal-title":"Mov. Disord."},{"key":"B22","doi-asserted-by":"publisher","first-page":"179","DOI":"10.1097\/NPT.0000000000000093","article-title":"A randomized controlled feasibility trial of a specific cueing program for falls management in persons with Parkinson disease and freezing of gait.","volume":"39","author":"Martin","year":"2015","journal-title":"J. Neurol. Phys. Ther."},{"key":"B23","doi-asserted-by":"publisher","first-page":"134","DOI":"10.1136\/jnnp.200X.097923","article-title":"Cueing training in the home improves gait-related mobility in Parkinson\u2019s disease: The RESCUE trial.","volume":"78","author":"Nieuwboer","year":"2007","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"B24","doi-asserted-by":"publisher","first-page":"S53","DOI":"10.1016\/S1353-8020(09)70781-3","article-title":"Motor learning in Parkinson\u2019s disease: Limitations and potential for rehabilitation.","volume":"15","author":"Nieuwboer","year":"2009","journal-title":"Parkinsonism Relat. Disord."},{"key":"B25","doi-asserted-by":"publisher","first-page":"768","DOI":"10.1016\/S1474-4422(15)00041-1","article-title":"Freezing of gait: A practical approach to management.","volume":"14","author":"Nonnekes","year":"2015","journal-title":"Lancet Neurol."},{"key":"B26","doi-asserted-by":"publisher","first-page":"255","DOI":"10.3233\/JPD-130282","article-title":"Freezing of gait and falls in Parkinson\u2019s disease.","volume":"4","author":"Okuma","year":"2014","journal-title":"J. Parkinsons Dis."},{"key":"B27","doi-asserted-by":"publisher","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews.","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"B28","doi-asserted-by":"publisher","first-page":"760","DOI":"10.1038\/nrn2915","article-title":"Goal-directed and habitual control in the basal ganglia: Implications for Parkinson\u2019s disease.","volume":"11","author":"Redgrave","year":"2010","journal-title":"Nat. Rev. Neurosci."},{"key":"B29","doi-asserted-by":"publisher","first-page":"391","DOI":"10.1046\/j.1468-1331.2003.00611.x","article-title":"Characterization of freezing of gait subtypes and the response of each to levodopa in Parkinson\u2019s disease.","volume":"10","author":"Schaafsma","year":"2003","journal-title":"Eur. J. Neurol."},{"key":"B30","doi-asserted-by":"publisher","first-page":"463","DOI":"10.1177\/0269215515588836","article-title":"Visual cues combined with treadmill training to improve gait performance in Parkinson\u2019s disease: A pilot randomized controlled trial.","volume":"30","author":"Schlick","year":"2016","journal-title":"Clin. Rehabil."},{"key":"B31","doi-asserted-by":"publisher","first-page":"562","DOI":"10.1016\/j.apmr.2012.10.026","article-title":"Cueing and gait improvement among people with Parkinson\u2019s disease: A meta-analysis.","volume":"94","author":"Spaulding","year":"2013","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"B32","doi-asserted-by":"publisher","first-page":"2563","DOI":"10.1002\/mds.23327","article-title":"Freezing of gait in Parkinson\u2019s disease: The impact of dual-tasking and turning.","volume":"25","author":"Spildooren","year":"2010","journal-title":"Mov. Disord."},{"key":"B33","doi-asserted-by":"publisher","first-page":"l4898","DOI":"10.1136\/bmj.l4898","article-title":"RoB 2: A revised tool for assessing risk of bias in randomised trials.","volume":"366","author":"Sterne","year":"2019","journal-title":"BMJ"},{"key":"B34","doi-asserted-by":"publisher","first-page":"1277","DOI":"10.3390\/s19061277","article-title":"Technological review of wearable cueing devices addressing freezing of gait in Parkinson\u2019s disease.","volume":"19","author":"Sweeney","year":"2019","journal-title":"Sensors"},{"key":"B35","doi-asserted-by":"publisher","first-page":"876","DOI":"10.1002\/mds.29762","article-title":"On-demand cueing for freezing of gait in Parkinson\u2019s disease: A randomized controlled trial.","volume":"39","author":"Zoetewei","year":"2024","journal-title":"Mov. Disord."}],"container-title":["Frontiers in Aging Neuroscience"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fnagi.2026.1808824\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T05:52:55Z","timestamp":1778651575000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fnagi.2026.1808824\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,13]]},"references-count":35,"alternative-id":["10.3389\/fnagi.2026.1808824"],"URL":"https:\/\/doi.org\/10.3389\/fnagi.2026.1808824","relation":{},"ISSN":["1663-4365"],"issn-type":[{"value":"1663-4365","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,13]]},"article-number":"1808824"}}