Skip to content

Parkinsonian gait, and how Gondola can help

Gait disturbances in Parkinson’s disease and parkinsonism, also called parkinsonian gait, worsen the risk of falling and directly impact life quality. Parkinsonian gait is a complex combination of multiple factors. At Gondola Medical Technologies, our objective is to help patients improve their walking and balance abilities and enhance their quality of life. However, to tackle this disorder efficiently, it is essential to understand the different aspects of the parkinsonian’s gait and how Gondola AMPS therapy can provide an efficient solution.

Parkinsonian Gait

Current Parkinson’s disease symptoms are resting tremor, rigidity, bradykinesia (slowed movement), hypokinesia (reduced quality of motion), and loss of postural reflexes. These symptoms affect gait characteristics leading to the “Parkinsonian gait.” The Parkinsonian gait englobes different gait abnormalities from continuous gait disturbance to episodic gait impairments (freezing of gait and festination). The continuous changes refer to alterations in the walking pattern that persist and are apparent all the time. The episodic gait disturbances occur occasionally and intermittently, surfacing in a random, inexplicable manner. Both gait disturbances contribute to and exacerbate the risk of falls and reduced daily-life quality.

Continuous gait disturbance

Continuous gait disturbance is the most straightforward aspect to study in parkinsonian gait since it is continuously observable. It has mainly been studied using visual observation, clinical assessments, and quantitative gait analysis. Based on the literature, gait disturbances are summarized as decreased gait speed, reduced steps length and range of motion, increased variability, longer double limb support (time with both feet on the floor), absence of arm swing, and impaired postural control. These changes in the gait pattern evolve at the different stages of the disease and can be used as a biological marker of the disease progression.

 

Early-stage
In the early stages of Parkinson’s disease, patients’ gait slows, and step length shortens, compared with age-matched healthy adults. These changes are not specific to the disease and can be associated with other disorders or aging. The arm swing and smoothness of locomotion are also altered due to bradykinesia and hypokinesia. The steps are asymmetrical since the pathology does not evolve symmetrically in the basal ganglia. Gait is less automatic, the variability is increased, and dual-task while walking (e.g., talking and walking simultaneously) is more complicated. Research is currently investigating the measurement of gait asymmetry and variability as predictors of PD and step velocity and step length as markers of disease progression.

 

Mild-to-moderate stage
In the mild-to-moderate stage, the gait characteristics altered in the early stage of the disease continue to evolve bilaterally. Thus, the asymmetry might decrease, and the bradykinesia (slowed movement) progressed with the disease. At this stage, it is possible to observe shuffling gait defined as dragging feet during the walk, short step length, increase stance duration, and double support with reduced arm movement and axial rotation.

 

Advanced stage
The changes in gait characteristics worsen. Balance and postural functions are reduced, and the severe risk of falling is high. Motor fluctuations and dyskinesias are present in most patients and negatively impact gait. Endurance, muscle strength, and motor capacity further decline participation to a reduced quality of life.
Gondola AMPS therapy has been shown to improve continuous gait disturbance efficiently and can be used for all the disease’s different stages. In this case, our objective is to maintain a physiological gait or reduce the decline of gait parameters. Gondola AMPS therapy is a strategy to promote a more automatic gait and avoid parkinsonian gait strategies.

Episodic gait impairments

The episodic gait disturbances are more difficult to study since by definition; they are not always present. The episodic gait disturbances include festination, freezing of gait, initiation disorders, and en bloc turning. These disturbances can appear during the mild-moderate stage, but they are further worsening in the advanced stage. When it occurs, these episodes drastically increased the risk of falling. Moreover, the gait automaticity (which is a marker of a healthy gait pattern) is further impaired, resulting in problems in initiating gait and fragmented motor control. The ability to turn is impaired. PD patients’ necks and trunks remain rigid, requiring multiple small steps to accomplish a turn which is called turn en bloc. In the advanced stages, motor function freezing of gait and festination become frequent, accompanied by reduced balance and postural control and severe risk of falling.

 

Freezing of gait (FOG)
FOG is defined as an episodic inability to generate effective steps: absence or marked reduction of the feet’ forwarding progression despite the intention to walk. It is most commonly experienced during step initiation, turning and facing obstacles, doorways, stress, and distraction. These short-lasting suspensions of locomotion are most frequent in the later stages of PD (70 %) and occur earlier in the disease. FOG is an incapacitating motor symptom, as it significantly affects patients’ quality of life and levels of activity.
Patients using Gondola AMPS therapy reported reduced frequency in FOG episodes. We are currently running a clinical trial with the collaboration of Dr. Barbes, a neurologist at UKK Hospital Cologne, to understand the possible use of Gondola AMPS for patients suffering from severe FOG episodes.

 

Festinating gait (FSG)
FSG is described as rapid, small steps done to keep the center of gravity in between the feet while the trunk leans forward involuntarily and shifts the COG forward. It can be viewed as an involuntary attempt to correct balance. This strategy is ineffective and inefficient in correcting gait patterns. Instead of making larger steps to restore balance, the patient performs short and quick steps.

Gondola AMPS therapy

“Automated Mechanical Peripheral Stimulation” (AMPS) therapy is a novel, non-invasive therapy based on mechanical pressure pulses. AMPS are pressures applied in two specific areas of both feet, the head of the big toe and the first metatarsal joint, to enhance the gait automaticity and improve gait function. The efficacy of the AMPS treatment on Parkinsonian gait has been documented in 11 controlled clinical research studies of over 230 Parkinson’s disease patients.

 

These studies showed that AMPS:
• Improved gait characteristics, including increased gait velocity, increased step, stride length, decreased walking variability, decreased double support, decreased walking asymmetry.
• Improved U-turn and Timed Up and Go assessments associated with a reduced risk of falling.
• Reduced gait variability for patients with freezing episodes.
• Enhanced dual-task abilities while walking.

 

AMPS therapy is an exciting and promising opportunity to complement standard pharmaceutical treatments and physical therapy to improve gait quality and reduce the risk of falling.

Summary

Parkinsonian’s gait is a complex combination of multiple factors resulting in continuous gait disturbance characterized by slowed and reduced motion and episodic gait impairment that worsens the risk of falls. The parkinsonian’s gait evolves at the different stages of the disease, and Gondola AMPS improves the quality of gait and reduces the risk of falls along all stages.

References:

Barbic, F. (2014). Effects of mechanical stimulation of the feet on gait and cardiovascular autonomic control in Parkinson’s disease. Journal of Applied Physiology116(5), 495‑503. https://doi.org/10.1152/japplphysiol.01160.2013

Chaudhuri KR. (2016) Unmet needs in Parkinson’s disease: New horizons in a changing landscape. Parkinsonism & Related Disorders. 2016;33:S2-S8. doi:10.1016/j.parkreldis.2016.11.018

Chen P.H. (2013). Gait Disorders in Parkinson’s Disease Assessment and Management. International Journal of Gerontology, 7(4), 189-193. https://doi.org/10.1016/j.ijge.2013.03.00

Del Din, S. (2019). Gait analysis with wearables predicts conversion to parkinson disease. Annals of neurology86(3), 357–367. https://doi.org/10.1002/ana.25548

Galli M. (2015) Timed Up and Go test and wearable inertial sensor: a new combining tool to assess change in subject with Parkinson’s disease after automated mechanical peripheral stimulation treatment. Int J Eng Innov Technol., 4(11):155-163. ISSN: 2277-3754

Galli. (2018). Peripheral neurostimulation breaks the shuffling steps patterns in Parkinsonian gait: A double blind randomized longitudinal study with automated mechanical peripheral stimulation. Eur J Phys Rehabil Med. 54(6):860-865. doi: 10.23736/S1973-9087.18.05037-2

Giladi N, (2001). Gait festination in Parkinson’s disease. Parkinsonism Relat Disord. 7(2):135-138. doi: 10.1016/s1353-8020(00)00030-4. PMID: 11248595.

Giladi N. (2008). Understanding and treating freezing of gait in parkinsonism, proposed working definition, and setting the stage. Mov Disord, 23(2), S423-S425 doi: 10.1002/mds.21927.

Hausdorff J. M. (2009). Gait dynamics in Parkinson’s disease: common and distinct behavior among stride length, gait variability, and fractal-like scaling. Chaos (Woodbury, N.Y.)19(2), 026113. https://doi.org/10.1063/1.3147408

 

Heremans E. (2013). Freezing of gait in Parkinson’s disease: where are we now? Curr Neurol Neurosci Rep., 13(6):350. doi: 10.1007/s11910-013-0350-7. PMID: 23625316.

Kleiner A. (2015). The Parkinsonian Gait Spatiotemporal Parameters Quantified by a Single Inertial Sensor before and after Automated Mechanical Peripheral Stimulation Treatment. Parkinsons Dis. 2015:390512. doi: 10.1155/2015/390512

Kleiner A. (2018). Automated Mechanical Peripheral Stimulation Effects on Gait Variability in Individuals With Parkinson Disease and Freezing of Gait: A Double-Blind, Randomized Controlled Trial. Arch Phys Med Rehabil. 99(12):2420-2429. doi: 10.1016/j.apmr.2018.05.009

Mirelman, A. (2019). Gait impairment in Parkinson’s disease. The Lancet neurology 18(7), p.697-708 doi: 10.1016/S1474-4422(19)30044-4

Pagnussat A.S. (2018). Plantar stimulation in parkinsonians: From biomarkers to mobility – Randomized-controlled trial. Restor Neurol Neurosci. 36(2):195-205. doi: 10.3233/RNN-170744

Pinto C. (2018). Automated Mechanical Peripheral Stimulation Improves Gait Parameters in Subjects with Parkinson Disease and Freezing of Gait: A Randomized Clinical Trial. Am J Phys Med Rehabil. 97(6):383-389. doi: 10.1097/PHM.0000000000000890.

Quattrocchi C. (2015). Acute modulation of brain connectivity in Parkinson disease after automatic mechanical peripheral stimulation: A pilot study. PLoS One. 10(10):1-19. doi: 10.1371/journal.pone.0137977

Stocchi F. (2015) Long-term effects of automated mechanical peripheral stimulation on gait patterns of patients with Parkinson’s disease. Int J Rehabil Res. 38(3):238-245. doi: 10.1097/MRR.0000000000000120.