Sir William Richard Gowers Parkinson Disease sketch 1886

Parkinsonian gait (or festinating gait, from

Latin Latin (, or , ) is a classical language belonging to the Italic branch of the Indo-European languages. Latin was originally a dialect spoken in the lower Tiber area (then known as Latium) around present-day Rome, but through the power of the ...

''festinare'' o hurry is the type of gait exhibited by patients with

Parkinson's disease Parkinson's disease (PD), or simply Parkinson's, is a long-term degenerative disorder of the central nervous system that mainly affects the motor system. The symptoms usually emerge slowly, and as the disease worsens, non-motor symptoms becom ...

(PD). It is often described by people with Parkinson's as feeling like being stuck in place, when initiating a step or turning, and can increase the risk of falling. This

disorder Disorder may refer to randomness, non-order, or no intelligible pattern. Disorder may also refer to: Healthcare * Disorder (medicine), a functional abnormality or disturbance * Mental disorder or psychological disorder, a psychological pattern ...

is caused by a

deficiency A deficiency is generally a lack of something. It may also refer to: *A deficient number, in mathematics, a number ''n'' for which ''σ''(''n'') < 2''n'' * dopamine in the

basal ganglia The basal ganglia (BG), or basal nuclei, are a group of subcortical nuclei, of varied origin, in the brains of vertebrates. In humans, and some primates, there are some differences, mainly in the division of the globus pallidus into an exter ...

circuit leading to

motor An engine or motor is a machine designed to convert one or more forms of energy into mechanical energy. Available energy sources include potential energy (e.g. energy of the Earth's gravitational field as exploited in hydroelectric power g ...

deficits. Gait is one of the most affected motor characteristics of this disorder although symptoms of Parkinson's disease are varied. Parkinsonian gait is characterized by small shuffling steps and a general slowness of movement (

hypokinesia Hypokinesia is one of the classifications of movement disorders, and refers to decreased bodily movement. Hypokinesia is characterized by a partial or complete loss of muscle movement due to a disruption in the basal ganglia. Hypokinesia is a sym ...

), or even the total loss of movement (

akinesia Hypokinesia is one of the classifications of movement disorders, and refers to decreased bodily movement. Hypokinesia is characterized by a partial or complete loss of muscle movement due to a disruption in the basal ganglia. Hypokinesia is a sym ...

) in the extreme cases. Patients with PD demonstrate reduced

stride Stride or STRIDE may refer to: Computing * STRIDE (security), spoofing, tampering, repudiation, information disclosure, denial of service, elevation of privilege * Stride (software), a successor to the cloud-based HipChat, a corporate cloud-based ...

length, walking speed during free ambulation and

cadence In Western musical theory, a cadence (Latin ''cadentia'', "a falling") is the end of a phrase in which the melody or harmony creates a sense of full or partial resolution, especially in music of the 16th century onwards.Don Michael Randel (199 ...

rate, while double support duration is increased. The patient has difficulty starting, but also has difficulty stopping after starting. This is due to muscle hypertonicity.

Abnormal gait characteristics

Paralysis agitans-Male Parkinson's victim-1892

Patients with Parkinson's disease exhibit gait characteristics that are markedly different from normal gait. While the list of abnormal gait characteristics given below is the most discussed, it is certainly not exhaustive.

Heel to toe characteristics

Whereas in normal gait, the heel strikes the ground before the

toe Toes are the digits (fingers) of the foot of a tetrapod. Animal species such as cats that walk on their toes are described as being ''digitigrade''. Humans, and other animals that walk on the soles of their feet, are described as being ''plan ...

s (also called heel-to-toe walking), in Parkinsonian gait, motion is characterised by flat foot strike (where the entire foot is placed on the ground at the same time) or less often and in the more advanced stages of the disease by toe-to-heel walking (where the toes touch the ground before the heel). In addition, PD patients have reduced foot lifting during the swing phase of gait, which produces smaller clearance between the toes and the ground. Patients with Parkinson's disease have reduced impact at heel strike and this mechanism has been found to be related to the disease severity with impact decreasing as the disease progresses. Also, Parkinson patients show a trend towards higher relative loads in the

forefoot The forefoot is the anterior aspect of the foot, composed of the five metatarsal bones, the fourteen phalanges and associated soft tissue structures. It is a common site of pathology in podiatry, and is the anatomic region involved in such condi ...

regions combined with a load shift towards medial foot areas. This load shift is believed to help in compensating for postural

imbalance A balance disorder is a disturbance that causes an individual to feel unsteady, for example when standing or walking. It may be accompanied by feelings of giddiness, or wooziness, or having a sensation of movement, spinning, or floating. Balance ...

. The intra-individual variability in foot strike pattern is found to be surprisingly lower in PD patients compared with normal people.

Vertical ground reaction force

In normal gait, the vertical

ground reaction force In physics, and in particular in biomechanics, the ground reaction force (GRF) is the force exerted by the ground on a body in contact with it. For example, a person standing motionless on the ground exerts a contact force on it (equal to the perso ...

(GRF) plot has two peaks – one when the foot strikes the ground and the second peak is caused by push-off force from the ground. The shape of the vertical GRF signal is abnormal in PD. In the earlier stages of the disease, reduced forces (or peak heights) are found for heel contact and the push-off phase resembling that of elderly subjects. In the more advanced stages of the disorder where gait is characterized by small shuffling steps, PD patients show only one narrow peak in the vertical GRF signal.

Falls and freezing of gait

Falls and freezing of gait are two episodic phenomena that are common in Parkinsonian gait. Falls and freezing of gait in PD are generally thought to be closely intertwined for several reasons, most importantly: both symptoms are common in the advanced stages of the disease and are less common in the earlier stages, with freezing of gait leading to falls in many instances. Both symptoms often respond poorly and sometimes

paradoxical A paradox is a logically self-contradictory statement or a statement that runs contrary to one's expectation. It is a statement that, despite apparently valid reasoning from true premises, leads to a seemingly self-contradictory or a logically u ...

ly to treatment with dopaminergic medication, perhaps pointing to a common underlying pathophysiology. ''Freezing of Gait'': Freezing of Gait (FOG) is typically a transient episode – lasting less than a minute, in which gait is halted and the patient complains that his/her feet are glued to the ground. When the patient overcomes the block, walking can be performed relatively smoothly. The pathophysiology of the phenomenon is poorly understood but likely extends across a disseminated functional-anatomic network. Sadly, current treatments for FOG offer only limited benefits but a range of novel approaches are being actively explored, and thought is being given to how future research strategies are best coordinated. The most common form of FOG is 'start hesitation' (which happens when the patient wants to start walking) followed in frequency by 'turning hesitation' FOG can also be experienced in narrow or tight quarters such as a doorway, whilst adjusting one's steps when reaching a destination, and in stressful situations such as when the telephone or the doorbell rings or when the elevator door opens. As the disease progresses, FOG can appear spontaneously even in an open runway space. It is proven that psychological interventions can help reduce negative effect of psychosocial factors, like anxiety or depression, that can worsen freezing of gait or tremor in Parkinson's patients. Based on that, every patient could benefit from psychological intervention, not only to reduce anxiety, depression, pain, and insomnia, but also to reduce effect of psychosocial factors in worsening of motor symptoms. ''Falls'': Falls, like FOG are rare in the earlier stages of the disorder and becomes more frequent as the disease progresses. Falls result mainly due to sudden changes in posture, in particular turning movements of the trunk, or attempts to perform more than one activity simultaneously with walking or balancing. Falls are also common during transfers, such as rising from a chair or bed. PD patients fall mostly forward (45% of all falls) and about 20% fall laterally.

Postural sway

Postural instability in upright stance is common in end-stage PD and compromises the ability to maintain balance during everyday tasks such as

walking Walking (also known as ambulation) is one of the main gaits of terrestrial locomotion among legged animals. Walking is typically slower than running and other gaits. Walking is defined by an ' inverted pendulum' gait in which the body vaults ...

, turning and

standing Standing, also referred to as orthostasis, is a position in which the body is held in an ''erect'' ("orthostatic") position and supported only by the feet. Although seemingly static, the body rocks slightly back and forth from the ankle in the s ...

up from

sitting Sitting is a List of human positions, basic action and resting position in which the body weight is supported primarily by the bony ischial tuberosities with the buttocks in contact with the ground or a horizontal surface such as a chair seat, in ...

. An inability to adequately balance the body's center of mass over the base of support combined with inflexibility in body movements (due to increased rigidity) causes patients with advanced PD to fall. Whereas postural sway in normal stance usually increases in patients with balance disorders arising from stroke, head injury and cerebellar

ataxia Ataxia is a neurological sign consisting of lack of voluntary coordination of muscle movements that can include gait abnormality, speech changes, and abnormalities in eye movements. Ataxia is a clinical manifestation indicating dysfunction of ...

it is often reduced in patients with PD. The reason for this because in PD the problem appears to be a lack of flexibility in shifting postural responses. This inflexibility increases the tendency to fall in these patients.

Electromyographic studies

Electromyographic Electromyography (EMG) is a technique for evaluating and recording the electrical activity produced by skeletal muscles. EMG is performed using an instrument called an electromyograph to produce a record called an electromyogram. An electromyo ...

(EMG) studies of the leg muscles in PD patients have shown an extreme reduction in the activation of the

tibialis anterior muscle The tibialis anterior muscle is a muscle in humans that originates along the upper two-thirds of the lateral (outside) surface of the tibia and inserts into the medial cuneiform and first metatarsal bones of the foot. It acts to dorsiflex and inve ...

in the early stance and in the early and late swing phases, and a reduction in

triceps surae muscle The triceps surae consists of two muscles located at the calf – the two-headed gastrocnemius and the soleus. These muscles both insert into the calcaneus, the bone of the heel of the human foot, and form the major part of the muscle of the ...

bursting at push-off. The

quadriceps The quadriceps femoris muscle (, also called the quadriceps extensor, quadriceps or quads) is a large muscle group that includes the four prevailing muscles on the front of the thigh. It is the sole extensor muscle of the knee, forming a large ...

and

hamstring In human anatomy, a hamstring () is any one of the three posterior thigh muscles in between the hip and the knee (from medial to lateral: semimembranosus, semitendinosus and biceps femoris). The hamstrings are susceptible to injury. In quadrupe ...

muscles on the other hand, show prolonged activation in the stance phase of gait. This implies that PD patients have higher passive stiffness of ankle joints, show larger background EMG activity and more co-contraction of leg muscles in stance. Stiffer joints lead to abnormal postural sway in the PD patients.

Gait improvement strategies

Drugs

The most widely used form of treatment is

L-dopa -DOPA, also known as levodopa and -3,4-dihydroxyphenylalanine, is an amino acid that is made and used as part of the normal biology of some plants and animals, including humans. Humans, as well as a portion of the other animals that utilize -DOPA ...

in various forms. L-dopa is able to pass the blood–brain barrier as a prodrug and is decarboxylated in the brain to the neurotransmitter dopamine by the enzyme aromatic-L-amino-acid decarboxylase. In this way, L-DOPA can replace some of the deficit in dopamine seen in Parkinsonism. Due to feedback inhibition, L-dopa results in a reduction in the endogenous formation of L-dopa, and so eventually becomes counterproductive. ''Effect on gait parameters'': The stride length and the

kinematic Kinematics is a subfield of physics, developed in classical mechanics, that describes the motion of points, bodies (objects), and systems of bodies (groups of objects) without considering the forces that cause them to move. Kinematics, as a fiel ...

parameters (swing velocity, peak velocity) related to the energy are Dopa-sensitive. Temporal parameters (stride and swing duration, stride duration variability), related to rhythm, are Dopa-resistant. ''Effect on falls and freezing of gait'': Levodopa treatment decreases the frequency and the akinetic type of FOG, with a tendency for shorter FOG episodes. Results indicate that this is primarily because L-dopa increases the threshold for FOG to occur but the fundamental pathophysiology for FOG did not change. It has also been shown that other dopamine agonists like

ropinirole Ropinirole, sold under the brand name Requip among others, is a medication used to treat Parkinson's disease (PD) and restless legs syndrome (RLS). In PD the dose needs to be adjusted to the effect and treatment should not be suddenly stopped. ...

pramipexole Pramipexole, sold under the brand Mirapex among others, is medication used to treat Parkinson's disease (PD) and restless legs syndrome (RLS). In Parkinson's disease it may be used alone or together with levodopa. It is taken by mouth. Pramipex ...

and

pergolide Pergolide, sold under the brand name Permax and Prascend (veterinary) among others, is an ergoline-based dopamine receptor agonist used in some countries for the treatment of Parkinson's disease. Parkinson's disease is associated with reduced do ...

that have a strong affinity to D2 receptors (as opposed to L-dopa which has a strong D1 receptor affinity) increase the frequency of FOGs. ''Effects on postural sway'': Parkinson's disease have abnormal postural sway in stance and treatment with levodopa increases postural sway abnormalities. During movement, it has been shown that early autonomic postural disturbances are only partially corrected while the later occurring postural corrections are not affected by dopamine. These results indicate that non-dopaminergic

lesion A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals. Types There is no designated classif ...

s play a role in postural imbalance in PD patients. Digital metronome 2

Auditory and visual cues

Basal ganglia The basal ganglia (BG), or basal nuclei, are a group of subcortical nuclei, of varied origin, in the brains of vertebrates. In humans, and some primates, there are some differences, mainly in the division of the globus pallidus into an exter ...

dysfunction in PD causes it to stop acting as an internal cue for gait in Parkinson's patients. Hence various external sensory cues like auditory and visual cues have been developed to bypass the basal ganglia's cueing functions. ''Visual cues'': The

visual The visual system comprises the sensory organ (the eye) and parts of the central nervous system (the retina containing photoreceptor cells, the optic nerve, the optic tract and the visual cortex) which gives organisms the sense of sight (th ...

cues are commonly transverse lines or rods on the floor (floor markers). Such cues have been shown to improve stride length and velocity in Parkinsonian gait by substituting kinaesthetic feedback with visual feedback for regulating movement amplitude. In addition gait initiation has been shown to be significantly improved in PD patients compared with auditory cues. Virtual reality glasses have also been developed recently to aid walking in PD patients. ''Auditory cues'': The auditory cues are commonly

rhythm Rhythm (from Greek , ''rhythmos'', "any regular recurring motion, symmetry") generally means a " movement marked by the regulated succession of strong and weak elements, or of opposite or different conditions". This general meaning of regular re ...

ic cues generated by a

metronome A metronome, from ancient Greek μέτρον (''métron'', "measure") and νομός (nomós, "custom", "melody") is a device that produces an audible click or other sound at a regular interval that can be set by the user, typically in beats pe ...

or equivalent, sometimes embedded in music, set at or slightly above the subject's usual cadence. Rhythmic auditory cues have been associated with increases in velocity and cadence and sometimes stride after gait has been initiated. Auditory cues have been shown to have little or no effect in gait initiation. Moreover, there are prediction algorithms to support auditory cueing more efficient. These algorithms predict freezing episodes so that a cueing can be initiated.

Deep brain stimulation

Deep brain stimulation Deep brain stimulation (DBS) is a neurosurgical procedure involving the placement of a medical device called a neurostimulator, which sends electrical impulses, through implanted electrodes, to specific targets in the brain (the brain nucleus ...

(DBS) in the pedunculopontine nucleus, a part of the brainstem involved in motor planning, has been shown to improve gait function in patients with Parkinson's disease. DBS in the subthalamic nucleus (STN) and the globus pallidus have also been shown to have positive effects on gait abnormalities presented by Parkinson's Disease patients. DBS in the STN has been reported to reduce freezing of gait significantly at 1 and 2 year follow up. Contradictory results have been reported on the effects on DBS on postural stability The results seem to be highly location specific. The studies which do report positive effects suggest that the effectiveness of DBS in improving postural stability is due to its ability to affect non-dopaminergic pathways (in addition to dopaminergic pathways) which are believed to cause postural sway in PD patients. Several studies suggest that STN stimulation with low frequencies (60–80 Hz) better alleviates gait deficits than with the commonly used high frequencies (>130 Hz).

Other treatments strategies

''Attention strategies'': By consciously paying more attention to walking and rehearsing each step before actually making it, PD patients have shown to improve their gait. Sometimes, a companion walking alongside reminds the patient to concentrate on gait or they create a visual cue to step over by putting a foot in front of the person with PD over which the person must step. This causes the patient to focus their attention on the stepping action, thus making this a voluntary action and hence bypassing the faulty basal ganglia pathway (which is responsible for involuntary actions like walking). Avoidance of dual tasks that require motor attention or cognitive attention has also been shown to normalize gait in the PD patients. ''Exercise'': Physical therapy and exercise have been shown to have positive effects on gait parameters in PD patients. Physiotherapists may help improve gait by creating training programs to lengthen a patient's stride length, broaden the base of support, improve the heel-toe gait pattern, straighten out a patient's posture, and increase arm swing patterns. Research has shown gait training combining an overhead harness with walking on a treadmill has shown to improve both walking speed and stride length. The harness assists the patient in maintaining an upright posture by eliminating the need to use a

mobility aid A mobility aid is a device designed to assist walking or otherwise improve the mobility of people with a mobility impairment. There are various walking aids which can help people with impaired ability to walk, and wheelchairs or mobility scoot ...

, a practice which normally promotes a forward flexed posture. It is believed the activation of the

central pattern generator Central pattern generators (CPGs) are self-organizing biological neural circuits that produce rhythmic outputs in the absence of rhythmic input. They are the source of the tightly-coupled patterns of neural activity that drive rhythmic and stereo ...

leads to the improvement in gait pattern. Improving trunk flexibility, along with strengthening of the core muscles and lower extremities has been associated with increased balance and an improvement in gait pattern.

Aerobic exercises Aerobic exercise (also known as endurance activities, cardio or cardio-respiratory exercise) is physical exercise of low to high intensity that depends primarily on the aerobic energy-generating process. "Aerobic" is defined as "relating to, inv ...

such as tandem bicycling and water aerobics are also crucial in improving strength and overall balance. Due to PD's progressive nature it is important to sustain an exercise routine to maintain its benefits. Strategies such as using a vertical walking pole can also help to improve upright postural alignment. The therapist may also use tiles or footprints on the ground to improve foot placement and widen the patient's base of support.

Creative visualization Creative visualization is the cognitive process of purposefully generating visual mental imagery, with eyes open or closed, simulating or recreating visual perception, in order to maintain, inspect, and transform those images, consequently modi ...

of walking with a more normalized gait pattern, and mentally rehearsing the desired movement has also shown to be effective. The patient should also be challenged by walking on a variety of surfaces such as tile, carpet, grass, or foamed surfaces will also benefit the individual's progress towards normalizing their gait pattern.

Comparison with other gait disorders

Subcortical arteriosclerotic encephalopathy (SAE), also called lower-body parkinsonism, and

cerebellar ataxia Cerebellar ataxia is a form of ataxia originating in the cerebellum. Non-progressive congenital ataxia (NPCA) is a classical presentation of cerebral ataxias. Cerebellar ataxia can occur as a result of many diseases and may present with symptom ...

are two other gait disorders whose symptoms seem to closely resemble that of Parkinson's. However, through

regression analysis In statistical modeling, regression analysis is a set of statistical processes for estimating the relationships between a dependent variable (often called the 'outcome' or 'response' variable, or a 'label' in machine learning parlance) and one ...

studies have revealed that in Parkinson's, increasing the

velocity Velocity is the directional speed of an object in motion as an indication of its rate of change in position as observed from a particular frame of reference and as measured by a particular standard of time (e.g. northbound). Velocity i ...

of walking changes the stride length

linear Linearity is the property of a mathematical relationship ('' function'') that can be graphically represented as a straight line. Linearity is closely related to '' proportionality''. Examples in physics include rectilinear motion, the linear ...

ly (which resembles that of controls). However, in SAE and cerebellar ataxia stride length had a disproportionate contribution to increasing velocity, indicating that SAE and cerebellar ataxia have common underlying mechanisms different from those of Parkinson's.

Socio-economic impact

Mobility issues associated with falls and freezing of gait have a devastating impact in the lives of PD patients. Fear of falling in itself can have an incapacitating effect in PD patients and can result in social seclusion leaving patients largely isolated leading to depression. Immobility can also lead to osteoporosis which in-turn facilitates future fracture development. This then becomes a vicious circle with falls leading to immobility and immobility facilitating future falls. Hip fractures from falls are the most common form of fracture among PD patients. Fractures increase treatment costs associated with health care expenditures in PD. Also, when gait is affected it often heralds the onset of

Lewy body dementia Lewy body dementias are two similar and common subtypes of dementia—dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD). Both are characterized by changes in thinking, movement, behavior, and mood. The two conditions have si ...

References

External links

Medfriendly: Festinating gait

GP Notebook

Stage discrimination based on gait
{{Nervous and musculoskeletal system symptoms and signs Parkinson's disease Gait abnormalities