Gait and trunk kinematics during prolonged turning in Parkinson's disease with freezing of gait

https://doi.org/10.1016/j.parkreldis.2019.04.011Get rights and content

Highlights

  • Prolonged turning reveals impaired gait and trunk kinematics in Parkinson's disease with freezing of gait.

  • Individuals with freezing of gait have an impaired ability to adjust cadence.

  • Those with freezing of gait also have reduced variability of stride length, gait speed, and frontal trunk motion.

  • These gait and trunk deficits are able to differentiate between these two parkinsonian groups.

Abstract

Introduction

Although turning during walking is known to trigger freezing of gait (FOG) in Parkinson's disease (PD), little is known about kinematic strategies used by individuals with PD and FOG while performing prolonged turning.

Objective

Our aim was to compare gait and trunk kinematics during straight walking and continuous turning over 20-min in PD with and without FOG.

Methods

18 individuals with idiopathic PD (n = 9 with FOG, n = 9 without FOG), performed two 20-min walking tasks: straight ahead, and turning, in a laboratory setting in their OFF medication state. Accelerometer-based spatial and temporal gait parameters and trunk kinematics (range of motion, peak velocity, variability of range of motion and peak velocity) were analyzed.

Results

During turning, PD with FOG reduced cadence more compared to PD without FOG (P < 0.045), despite similar decline in stride velocity (28–32%) and stride length (24–27%). Participants with FOG had decreased variability of gait speed (P < 0.011), stride length (P < 0.035), frontal trunk range of motion (P < 0.040) and peak trunk velocity (P < 0.017) compared to PD without FOG during turning, whereas there was no difference between groups during straight walking. Gait speed variability and cadence between these two tasks differentiated the PD groups (sensitivity 89% and specificity 78%).

Conclusions

We demonstrate that PD with FOG decreased cadence and reduced variability of walking speed, stride length, and lateral flexion of the trunk compared to PD without FOG during prolonged turning. These real-life gait markers are observable during lab-based gait that is similar to daily-life.

Introduction

Freezing of gait (FOG) occurs in a subset of people with Parkinson's disease (PD) and is characterized by a transient inability to produce effective steps and is significantly related to falls [1,2]. One important trigger of FOG is walking while turning, which makes up more than 50% of our daily steps [3]. This could be in part due to the complex control required for the asymmetric nature of turning, where spatially and temporally asymmetric stepping is required for each leg to travel a different distance but maintain the same step time. Turning while walking naturally induces instability to the body as it requires center of mass to momentarily be shifted outside the lateral boundaries of the base of support [4]. These aspects of irregular gait are thought to pose a greater challenge in individuals with FOG, who have impaired executive functions and require increased voluntary control for tasks that are typically automatic such as gait [5,6]. Thus, understanding changes to the gait pattern under these challenging and cognitively demanding conditions could provide insight to the pathophysiology underlying freezing as well as identify alternate markers of gait impairment in PD with FOG.

Spatial and temporal turning performance deficits in individuals with FOG exist for single walking turns as slight as 30° and are characterized by reduced step length, increased cadence [7], and impaired inter-limb coordination [8]. These impairments are thought to contribute to an increased head-pelvis coupling and reduced trunk range of motion in PD with FOG where turns are performed “en bloc” [9,10]. While these studies have all employed single walking turn paradigms, few studies have examined performance over several consecutive turns which more realistically resembles real-life situations [11]. It has also been proposed that assessing gait over multiple turns is more sensitive for the detection of mobility impairments compared to single turns [12,13]. However, it has not yet been determined how the spatial and temporal gait and trunk kinematics may be impaired during repeated walking turns as compared to steady-state walking.

The aim of this paper was therefore to compare the gait pattern and trunk kinematics during prolonged straight walking and turning in PD with and without FOG. We hypothesized that a lab-based turning paradigm that is more similar to gait in daily-life would provide more information about real-life gait markers for PD with FOG compared to the existing literature mostly assessing trunk and gait kinematics during non-ecological paradigms consisting of just one turn.

Section snippets

Subjects

Eighteen individuals with a clinical diagnosis of idiopathic PD according to the UK Brain Bank criteria, Hoehn and Yahr stage 2 or 3, and the ability to walk for 20 min without assistance were recruited from the Quebec Parkinson Network in Montreal, Canada to participate in this cross-sectional study. Nine participants with a score ≥1 on Part I of the New Freezing of Gait Questionnaire (NFOGQ) [14] were classified as experiencing FOG (FOG+) and nine participants with a score <1 were classified

Freezing during straight walking and turning

Eight of nine of the participants in the FOG + group presented at least one freezing event during the turning task, whereas only two experienced a freezing event during the straight walking task. The mean ± SD number of freezing episodes during the 20-min steering task was 11 ± 16 and the percentage of time spent freezing during the turning task ranged from 0 to 2.6% of the total trial. No subjects in the FOG-group exhibited freezing during either task.

Differences in gait pattern between turning and straight walking

For both PD groups, gait speed during

Discussion

This study was the first to explore changes to gait and trunk control during prolonged straight walking and turning in individuals with PD with and without FOG. We observed that PD with FOG have reduced cadence during prolonged turning compared to PD without FOG, despite a similar reduction in speed across groups. We also found that PD with FOG had decreased variability of gait speed and lateral flexion of the trunk during turning. Our results support the assertion that FOG is related to an

Acknowledgements

This work was supported by Parkinson Canada. Funding support to DC was also received by the Swedish Brain Foundation and Swedish Society for Medical Research. We would like to thank McGill Athletics for testing space and Joelle Amir for assistance conducting these experiments.

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