External sensory cueing on gait in Parkinson's disease: a systematic review and network meta-analysis.
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OBJECTIVE: This systematic review and network meta-analysis compares the individual and synergistic efficacy of external sensory cueing modalities to establish a treatment hierarchy for optimizing spatiotemporal gait parameters in individuals with Parkinson's disease (PD). METHODS: A systematic literature search was conducted across Scopus, PubMed, Cochrane CENTRAL, and ClinicalTrials.gov. Randomized controlled trials (RCTs) evaluating visual, auditory, somatosensory, or combined cueing modalities in individuals with PD were eligible. Trials were required to compare at least two active cueing modalities or an active modality against a control condition and report gait velocity and/or stride length. RESULTS: Thirty-three RCTs (n = 1118 participants) were included. For gait velocity, somatosensory (MD = 0.12 m/s; 95% CI 0.04-0.19) and visual cues (MD = 0.11 m/s; 95% CI 0.02-0.20) demonstrated significant improvements over control. For stride length, visual (MD = 11.46 cm; 95% CI 6.40-16.51), somatosensory (MD = 10.74 cm; 95% CI 7.04-14.44), and auditory cues (MD = 5.25 cm; 95% CI 0.43-10.06) all yielded statistically significant benefits. P-score rankings identified somatosensory cues as the top-ranked modality for gait velocity (P-score = 0.71) and visual cues for stride length (P-score = 0.83). Global heterogeneity was substantial (I2 = 64-90%), and no significant publication bias was detected. CONCLUSIONS: External sensory cueing improves spatiotemporal gait parameters in PD, with somatosensory and visual cues emerging as the most effective modalities for enhancing gait velocity and stride length. Both modalities outperformed standalone auditory stimulation, providing a data-driven hierarchy to guide evidence-based cueing selection in clinical practice.