Gait Re-education in Parkinson's Disease
- 1 Introduction
- 2 Typical gait pattern in Parkinson's Disease (PD)
- 3 Pathophysiology
- 4 Physiotherapy Management
- 5 Recent Related Research (from Pubmed)
- 6 References
Parkinson's Disease (PD) is a progressive neurodegenerative movement disorder caused by a lack of dopamine production in the substantia nigra. The cardinal features of this disorder include bradykinesia, gait disturbance, rigidity and tremor.  Impairments of balance and postural stability likely contribute to the increased risk of falls and fractures found in this patient population . In response to perturbations of balance with backward waist pull, individuals with PD demonstrate differences in weight shift, use a modified ankle joint motion before lift-off and land with weight shifted posteriorly compared with healthy age-matched controls  .
Typical gait pattern in Parkinson's Disease (PD)
- hypokinesia (decreased step length with decreased speed)
- decreased coordination
- festination (decreased step length with increased cadence)
- freezing of gait (the inability to produce effective steps at the initiation of gait or the complete cessation of stepping during gait)
- difficulty with dual tasking during gait
Coupled with these gait impairments are an increased risk and rate of falling. Increased probability of falls not only increases the risk of injury such as hip fracture but also affects an individual's independence and ability to interact within the community. Additionally, fear of falling has psychological consequences and can lead to self-isolation and depression.
The changes in gait kinematics include changes in excursion of the hip and ankle joint. Instead of a heel-toe progression, the patient may have a flat-footed or, with disease progression, a toe-heel sequence. The patient with PD appears to have lost the adult gait pattern and is using a more primitive pattern. The flat-footed gait decreases the ability to step over obstacles or walk on carpeted surfaces. The use of three-dimensional gait analysis has shown a decrease in plantar flexion at terminal stance. Changes are also seen in hip flexion, which may alter ankle excursion. However, qualitative aspects of the timing of joint excursion appear intact.
One hypothesis is that festinating gait is caused by the decreased equilibrium responses. If walking is a series of controlled falls and if normal responses to falling are delayed or not strong enough, then the individual will either completely fall or continue to take short, running-like steps. The abnormal motor unit firing seen with bradykinesia may also be the cause of ever-shortening steps. If the motor unit cannot build up a high enough frequency or if it pauses in the middle of the movement, the full range of the movement would decrease. In walking this would lead to shorter steps. Festination may also be the result of other changes in the kinematics of gait. Horak et al (1992) demonstrated coactivation (activation of muscles on both sides of the body) resulting in stiffening of the body and is a very insufficient strategy for the recovery of balance.
A study by Reuter et al (2011)  demonstrated improvement in 12 m and 24 m Webster Walking tests following flexibility exercises and relaxation training. The training focused on stretching, improving balance and range of movements, thrice a week for six months. However, there was more significant improvement in the walking group (warming up, technique training, endurance training and cooling down) and even more significant improvement in nordic walking group. This indicates task specific approach for better results.
The systematic review by Lima et al (2013)  suggested that progressive resistance exercise can be effective and worthwhile in people with mild to moderate PD but carryover of benefit does not occur for all measures of physical performance. The current evidence suggests that progressive resistance training should be implemented in PD rehabilitation, particularly when the aim is to improve walking capacity.
Another review by Tambosco et al (2014)  access the efficacy and the limits of aerobic training and strength training included in physical rehabilitation programs and to define practical modalities in the field of PD management. In this review, five literature reviews and 31 randomised trials were selected. The authors concluded that there is evidence that aerobic and strength training improve physical abilities of patients suffering from PD. It is emphasized that exercise training improves aerobic capacities, muscle strength, walking, posture and balance parameters. Rehabilitation programs should begin as soon as possible, last several weeks and be repeated. They should include aerobic training on bicycle or treadmill and a muscle strengthening program.
A prospective interventional cohort study by Mhatre et al (2013)  assessed the effect of exercise training by using the Nintendo Wii Fit video game and balance board system on balance and gait in adults with PD. The authors conclude that an 8-week exercise training class by using the Wii Fit balance board improved selective measures of balance and gait in adults with PD. However, no significant changes were seen in mood or confidence regarding balance.
A single-blind, randomized controlled clinical trial  was conducted in china in 2013 by Gu et al to determine the effect of PD-weight bearing exercise for better balance (PD-WEBB) exercise on balance impairment and falls in people.
The authors conclude that PD-WEBB training can significantly improve the balance impairment and quality of life to prevent falls. PD-WEBB training is suitable for PD patients in China and is a reasonable, effective and sustainable training of family and community assessment model.
External cues can be auditory or visual.
Attentional strategies are consciously concentrating on a specific aspect of gait.
By using cueing and attentional strategies the defective basal ganglia are bypassed. They no longer automatically have to control the movement as it has now become a cognitive task.
A systematic review of 24 studies showed that there is strong evidence that auditory cueing increased speed but there was insufficient evidence for visual and somatosensory cueing .
A pilot study by Rodriguez et al (2013)  determine the effects of an aquatic-based physical exercise program on gait parameters of patients with PD. A total of nine patients diagnosed with idiopathic PD (stages IIII according to the Hoehn and Yahr scale) carried out an aquatic physical exercise program which lasted for five months with one session per week. At the end of the program, significant improvement in walking speed, stride length and on the relationship between single and double support time (p < 0,05). Although improvements in all tested ranges of motion were obtained, these did not reach statistical significance.
Literature review by Earhart and Williams (2012)  focused on the research question 'Can treadmill training improve the gait of individuals with Parkinson disease?'. The authors reviewed 8 randomised control trials and randomised contolled crossover trials. Based on the results of this systematic review, they concluded that treadmill training is safe and appropriate for some individuals with mild to moderate PD. These individuals must have the cognitive and physical ability to utilize the treadmill, must understand and use the necessary safety precautions, and have adequate supervision as needed. Treadmill training can be expected to result in improvements in gait speed, stride length and walking distance. Treadmill training does not appear to influence cadence but this finding should not be viewed negatively. The maintenance of cadence following treadmill training, in conjunction with increased stride length, results in faster gait speed which is a positive outcome. The review does not include information to support or refute the effects of treadmill training on other aspects ofgait, such as dual task walking and decreased coordination. In addition, treadmill training may not address reduced arm swing, which is commonly seen in people with PD, as arm swing is limited during treadmill training through use of handrails. Furthermore, generalizability of treadmill training may be limited, as the studies that were reviewed excluded individuals with a history of cognitive, depressive, cardiovascular or orthopedic conditions.
Dual Task gait training
Difficulty performing more than one task at a time (dual tasking) is a common and disabling problem experienced by people with PD. If asked to perform another task when walking, people with PD often take shorter steps or walk more slowly. A study by D'souza et al (2014)  investigated whether treadmill training can improve the performance of gait on dual tasking in people with PD. Three individuals were evaluated in the on-phase of the antiparkinsonian medication regarding the kinematics (Qualisys Motion Capture System) while in gait, simultaneously performing cognitive activities. Subsequently, the subjects performed a 20-minute workout on the treadmill and were reassessed during gait in cognitive activities. There were increases in the length of the cycle (p=0.01), the length of the step (p=0.01) and in total swing time (p=0.03), and a decrease in the total length of support (p=0.03). These results indicate that treadmill training can promote improvement in the performance of dual tasking on gait in individuals with PD.
A pilot study by Lo et al (2010)  examined the potential effect of continuous physical cueing using robot-assisted sensorimotor gait training on reducing freezing of gait episodes and improving gait. Four individuals with PD and FOG symptoms received ten 30-minute sessions of robot-assisted gait training (Lokomat) to facilitate repetitive, rhythmic and alternating bilateral lower extremity movements. All participants showed a reduction in freezing both by self-report and clinician-rated scoring upon completion of training. Improvements were also observed in gait velocity, stride length, rhythmicity and coordination.
Recent Related Research (from Pubmed)
- Bennett DA, Beckett LA, Murray AM, et al. Prevalence of parkinsonian signs and associated mortality in a community population of older people. N Engl J Med. 1996;334:71–76
- Johnell O, Melton LJ, III, Atkinson EJ, O’Fallon WM, Kurland LT. Fracture risk in patients with parkinsonism: A population-based study in Olmsted County, Minnesota. Age Ageing. 1992;21:32–38.
- McVey MA, Stylianou AP, Luchies CW, et al. Early biomechanical markers of postural instability in Parkinson’s disease. Gait Posture. 2009;30:538–542
- Belal Alsabek. Parkinsonian Gait Demonstration. Available from: http://www.youtube.com/watch?v=j86omOwx0Hk [last accessed 09/09/16]
- Gray P, Hildebrand K. Fall risk factors in Parkinson's disease. J Neurosci Nurs. 2000;32:222–228
- Morris M, Iansek R, Galna B. Gait festination and freezing in Parkinson's disease: pathogenesis and rehabilitation. Mov Disord. 2008;23:S451–S460
- Plotnik M, Giladi N, Hausdorff JM. Bilateral coordination of gait and Parkinson's disease: the effects of dual tasking. J Neurol Neurosurg Psychiatry. 2009;80:347–350
- Yogev G, Plotnik M, Peretz C, et al. Gait asymmetry in patients with Parkinson's disease and elderly fallers: when does the bilateral coordination of gait require attention? Exp Brain Res. 2007;177:336–346
- Bloem BR, Hausdorff JM, Visser JE, Giladi N. Falls and freezing of gait in Parkinson's disease: a review of two interconnected, episodic phenomena. Mov Disord. 2004;19:871–884
- Reuter, I., Mehnert, S., Leone, P., Kaps, M., Oechsner, M and Engelhardt, M. (2011). Effects of a Flexibility and Relaxation Programme, Walking, and Nordic Walking on Parkinson’s Disease. Journal of Aging Research, 2011, 232473. doi:10.4061/2011/232473
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- Tambosco L,Percebois-Macadré L,Rapin A, Nicomette-Bardel J, Boyer FC ;Effort training in Parkinson's disease: a systematic review.Ann Phys Rehabil Med. 2014 Mar;57(2):79-104. fckLRdoi: 10.1016/j.rehab.2014.01.003.
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- Mhatre PV, Vilares I, Stibb SM, Albert MV, Pickering L, Marciniak CM, Kording K, Toledo S.fckLRWii Fit balance board playing improves balance and gait in Parkinson disease.PM R. 2013 Sep;5(9):769-77. fckLRdoi: 10.1016/j.pmrj.2013.05.019.
- Gu S,Song Z,Fan X,Chen R,Zheng W,Yan W ;Effect of PD-WEBB training on balance impairment and falls in people with Parkinson's disease;Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2013 Nov;38(11):1172-6. doi: 10.3969/j.issn.1672-7347.2013.11.015.
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- Lim, I., Van Wegen, E., de Goede, C., Deutekom, M., Nieuwboer,A., Willems, A., Jones, D., Rochester, L and Kwakkel.G. (2005) 'Effects of external rhythmical cueing on gait in patients with Parkinson's Disease: a systematic review', Clinical Rehabilitation, 19(7), 695-713
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