Determinants of Cueing Responsiveness in Parkinson's Disease: Insights from the UNITE-PD Study

Cueing strategies are widely used to improve gait in Parkinson's disease (PD), but interindividual variability in cueing responsiveness remains poorly understood.

The objective of the study was to identify determinants of internal and external cueing efficacy in persons with PD.

We performed a multicenter cohort study within the UNITE-PD consortium, including 277 persons with PD and self-reported gait impairment. Participants underwent motor, cognitive, and affective status assessments, followed by gait evaluations during uncued walking, external cueing (metronome), and internal cueing (silent counting). The dependent variable was cueing efficacy, expressed as change in stride time variability relative to uncued gait. Univariable and multivariable regression analyses, bootstrap resampling, and principal axis factoring were performed separately for internal and external cueing.

Cueing efficacy for both external and internal cueing was greater in persons with higher uncued stride time variability. Bootstrap analyses showed inconsistent selection of individual clinical tests. Factor analysis identified motor and cognitive constructs associated with cueing efficacy for both cueing types, with affective status additionally contributing to internal cueing responsiveness. A significant three-way interaction between stride time variability, motor performance, and cognitive performance was found for internal cueing responsiveness.

Cueing efficacy in PD is governed by uncued gait impairment at baseline and the interplay of motor, cognitive, and affective capacities, rather than by isolated clinical measures. These findings support the concept that cueing responsiveness depends on the availability and recruitment of strategy-specific (sub-)cerebral resources across motor, cognitive, and affective domains, where preserved capacity in one domain seems to offset limitations in another. © 2026 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.