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Short walking distances compromise the stride length in Parkinson's disease patients
Parkinsonism and Related Disorders xxx (2015) 1e2
Contents lists available at ScienceDirect
Parkinsonism and Related Disorders journal homepage: www.elsevier.com/locate/parkreldis
Letter to the Editor
Short walking distances compromise the stride length in Parkinson's disease patients
Keywords: Parkinson's disease Motor control Basal ganglia Gait disorders
Disorders of gait are common in Parkinson's disease (PD) [1], and gait performance represents one of the major determinants for independence and quality of life for these patients [2]. PD gait is characterized by a particular difficulty with the internal regulation of stride length [3], even though cadence control (steps per minute) is intact and is easily modulated under a variety of conditions [4]. During a clinical evaluation, it is relatively easy to measure the stride length by asking the patient to walk along a 10 m walkway [5]. The majority of investigations using this distance have reported a significant reduction in stride length in PD patients in comparison with healthy subjects [2e4]. However, it remains inconclusive whether this deficit in stride length in PD patients is affected by the distance which is used to evaluate the gait. Therefore, it is relevant to determine whether a short walking distance is enough to evaluate gait impairments in PD patients. In order to answer this question, sixteen patients with PD (details in Table 1) and sixteen age- and sex-matched healthy controls participated in this study. All subjects gave their informed consent after being informed of the possible risks of the study. The experimental procedures conformed with the Declaration of Helsinki and were approved by the local ethics committee (Universidade de A ~ a). All the subjects were asked to walk at their most comfortCorun able speed along a short corridor (10 m length, in an indoor hall of 12 m length 5 m wide 3 m high) and a long corridor (40 m length in an indoor track facility of 50 m length 10 m wide 4 m high), in two counterbalanced sessions. Speed, stride length and stride cadence were recorded in both sessions, for the central 5 m of the 10 and 40 m corridor walks, using sensitive switches placed in the subject's shoe and synchronized with photocells (BTS SMART Analyzer system). ANOVA of repeated measures was conducted with Group (PD and Control) and distant (Short and Long) as main factors. Post-hoc analysis was conducted using a Bonferroni adjustment. The results showed a significant slower speed for PD patients compared with controls in both the Short and Long distance (F ¼ 6.15, p ¼ 0.018), although both groups increased their speed in the Long compared to the Short distance (F ¼ 86.95, p < 0.001). Similar results were found for the stride
cadence (F ¼ 5.703, p ¼ 0.023 and F ¼ 58.60, p < 0.001 for distance and group factors, respectively). However, the ANOVA showed a significant Group*distance interaction for the stride length (F ¼ 7.732, p ¼ 0.009). For the short distance walk, the stride length was smaller in PD patients compared with control subjects (p ¼ 0.04), but this difference disappears for the long distance walk. Although, all the subjects increases significantly their stride length during the long distance walk in comparison with the short walk, the increase in PD patients (9.75%) was significantly larger (t ¼ 2.87, p < 0.01) than in control subjects (5.97%). The current study shows, for first time, that deficits in the stride length in PD patients are clearly manifested when gait is evaluated using a short walking distance but not when the walking distance is longer. When PD patients walked along the long corridor they were able to reach a similar stride length to that of the control subjects walking at the same speed along the short walkway, suggesting that PD patients were able to normalize their stride length according to their speed. Thus, it is possible that a short distance does not allow the patients to achieve a stable walking speed, and emphasizes the acceleration phase. This is supported by our finding showing higher stride cadence variability during the short compared with the long distance walk across all subjects, that likely results from the progressive shorter duration taken between consecutive steps during the acceleration phase. It is known that PD subjects can vary the stride length voluntarily, by attention control mechanisms, according to the environment in which they walk, as do normal subjects [3]. In the current study this issue is unlikely
Table 1 Demographic data and kinematic results.
Demographic data N Age (years) Weight (kg) Height (m) BMI (kg m2) Hoehn & Yard Disease duration (years) UPDRSIII MMSE Kinematic results Speed (ms1) Stride Length (m) Stride Cadence (Hz) CV stride cadence (%)
Parkinson disease
Healthy subjects
16 57.0 ± 11.66 80.72 ± 15.07 1.66 ± 0.06 29.27 ± 5.19 2.07 ± 0.59 4.89 ± 3.91 18.26 ± 9.87 29.56 ± 0.82
20 59.35 ± 11.80 72.24 ± 9.27 1.64 ± 0.08 26.70 ± 2.59
Hall 1.13 1.23 0.92 2.54
± ± ± ±
0.16 0.16 0.05 0.69
Track 1.32 ± 1.35 ± 0.97 ± 1.59 ±
0.22 0.16 0.08 0.63
Hall 1.32 1.34 0.97 1.94
± ± ± ±
0.21 0.17 0.72 0.65
Track 1.44 ± 1.42 ± 1.02 ± 1.26 ±
0.17 0.14 0.06 0.28
Group means ± SD. BMI: body mass index; UPDRSIII: unified Parkinson's disease rating scale (subscale III); MMSE: minimental state examination.
http://dx.doi.org/10.1016/j.parkreldis.2015.03.026 1353-8020/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Fernandez-del-Olmo M, Sanchez JAShort walking distances compromise the stride length in Parkinson's disease patients, Parkinsonism and Related Disorders (2015), http://dx.doi.org/10.1016/j.parkreldis.2015.03.026
2
Letter to the Editor / Parkinsonism and Related Disorders xxx (2015) 1e2
to play a role, since gait improvements were observed in a large facility, and PD patients are more prone to control gait in visually restricted environments as compared to open spaces. Difficulties in gait initiation and balance disturbances, characteristic of PD patients [6], could explain the lower stride length observed only during the short walk in the patients compared with control subjects. In summary, our results suggest that gait acceleration rather than gait at a steady speed compromises the stride length in PD patients. These findings support the 10 m-walk test used by clinicians to evaluate gait deficits in patients with PD.
[3] Morris ME, Iansek R, Matyas TA, Summers JJ. Ability to modulate walking cadence remains intact in Parkinson's disease. J Neurol Neurosurg Psychiatr 1994;57:1532e4. [4] Morris ME, Iansek R, Matyas TA, Summers JJ. The pathogenesis of gait hypokinesia in Parkinson's disease. Brain 1994;117:1169e81. [5] Morris M, Bilney B, Dodd K, Denisenko S, Baker R, Dobson F, et al. Clinical gait analysis in neurology. In: Hausdorff JM, Alexander NB, editors. Gait disorders. Florida: Taylor & Francis Group; 2005. p. 247e73. [6] Marsden CD. Parkinson's disease. J Neurol Neurosurg Psychiatr 1994;57: 672e81.
M. Fernandez-del-Olmo*, J.A. Sanchez Faculty of Sciences of Sport and Physical Education, Department of ~ a, A Corun ~ a, Spain Physical Education, University of A Corun
Acknowledgments n This work was supported by Ministerio de Ciencia e Innovacio (DEP2011-22466), Spain. References [1] Hoehn MM, Yahr MD. Parkinsonism: onset, progression, and mortality. Neurology 1967;17:427e42. [2] Schenkman M. Physical therapy intervention for the ambulatory patient. In: Turnbull GI, editor. Physical therapy management of Parkinson's disease. New York: Churchill Livingstone; 1992. p. 137e92.
*
ns, Corresponding author. Av. Ernesto Che Guevara 121, Pazos-Lia ~ a, Spain. Tel.: þ34 981167000; fax: þ34 15179 Oleiros, A Corun 981167048. E-mail address: [email protected] (M. Fernandez-del-Olmo). 23 January 2015
Please cite this article in press as: Fernandez-del-Olmo M, Sanchez JAShort walking distances compromise the stride length in Parkinson's disease patients, Parkinsonism and Related Disorders (2015), http://dx.doi.org/10.1016/j.parkreldis.2015.03.026
Contents lists available at ScienceDirect
Parkinsonism and Related Disorders journal homepage: www.elsevier.com/locate/parkreldis
Letter to the Editor
Short walking distances compromise the stride length in Parkinson's disease patients
Keywords: Parkinson's disease Motor control Basal ganglia Gait disorders
Disorders of gait are common in Parkinson's disease (PD) [1], and gait performance represents one of the major determinants for independence and quality of life for these patients [2]. PD gait is characterized by a particular difficulty with the internal regulation of stride length [3], even though cadence control (steps per minute) is intact and is easily modulated under a variety of conditions [4]. During a clinical evaluation, it is relatively easy to measure the stride length by asking the patient to walk along a 10 m walkway [5]. The majority of investigations using this distance have reported a significant reduction in stride length in PD patients in comparison with healthy subjects [2e4]. However, it remains inconclusive whether this deficit in stride length in PD patients is affected by the distance which is used to evaluate the gait. Therefore, it is relevant to determine whether a short walking distance is enough to evaluate gait impairments in PD patients. In order to answer this question, sixteen patients with PD (details in Table 1) and sixteen age- and sex-matched healthy controls participated in this study. All subjects gave their informed consent after being informed of the possible risks of the study. The experimental procedures conformed with the Declaration of Helsinki and were approved by the local ethics committee (Universidade de A ~ a). All the subjects were asked to walk at their most comfortCorun able speed along a short corridor (10 m length, in an indoor hall of 12 m length 5 m wide 3 m high) and a long corridor (40 m length in an indoor track facility of 50 m length 10 m wide 4 m high), in two counterbalanced sessions. Speed, stride length and stride cadence were recorded in both sessions, for the central 5 m of the 10 and 40 m corridor walks, using sensitive switches placed in the subject's shoe and synchronized with photocells (BTS SMART Analyzer system). ANOVA of repeated measures was conducted with Group (PD and Control) and distant (Short and Long) as main factors. Post-hoc analysis was conducted using a Bonferroni adjustment. The results showed a significant slower speed for PD patients compared with controls in both the Short and Long distance (F ¼ 6.15, p ¼ 0.018), although both groups increased their speed in the Long compared to the Short distance (F ¼ 86.95, p < 0.001). Similar results were found for the stride
cadence (F ¼ 5.703, p ¼ 0.023 and F ¼ 58.60, p < 0.001 for distance and group factors, respectively). However, the ANOVA showed a significant Group*distance interaction for the stride length (F ¼ 7.732, p ¼ 0.009). For the short distance walk, the stride length was smaller in PD patients compared with control subjects (p ¼ 0.04), but this difference disappears for the long distance walk. Although, all the subjects increases significantly their stride length during the long distance walk in comparison with the short walk, the increase in PD patients (9.75%) was significantly larger (t ¼ 2.87, p < 0.01) than in control subjects (5.97%). The current study shows, for first time, that deficits in the stride length in PD patients are clearly manifested when gait is evaluated using a short walking distance but not when the walking distance is longer. When PD patients walked along the long corridor they were able to reach a similar stride length to that of the control subjects walking at the same speed along the short walkway, suggesting that PD patients were able to normalize their stride length according to their speed. Thus, it is possible that a short distance does not allow the patients to achieve a stable walking speed, and emphasizes the acceleration phase. This is supported by our finding showing higher stride cadence variability during the short compared with the long distance walk across all subjects, that likely results from the progressive shorter duration taken between consecutive steps during the acceleration phase. It is known that PD subjects can vary the stride length voluntarily, by attention control mechanisms, according to the environment in which they walk, as do normal subjects [3]. In the current study this issue is unlikely
Table 1 Demographic data and kinematic results.
Demographic data N Age (years) Weight (kg) Height (m) BMI (kg m2) Hoehn & Yard Disease duration (years) UPDRSIII MMSE Kinematic results Speed (ms1) Stride Length (m) Stride Cadence (Hz) CV stride cadence (%)
Parkinson disease
Healthy subjects
16 57.0 ± 11.66 80.72 ± 15.07 1.66 ± 0.06 29.27 ± 5.19 2.07 ± 0.59 4.89 ± 3.91 18.26 ± 9.87 29.56 ± 0.82
20 59.35 ± 11.80 72.24 ± 9.27 1.64 ± 0.08 26.70 ± 2.59
Hall 1.13 1.23 0.92 2.54
± ± ± ±
0.16 0.16 0.05 0.69
Track 1.32 ± 1.35 ± 0.97 ± 1.59 ±
0.22 0.16 0.08 0.63
Hall 1.32 1.34 0.97 1.94
± ± ± ±
0.21 0.17 0.72 0.65
Track 1.44 ± 1.42 ± 1.02 ± 1.26 ±
0.17 0.14 0.06 0.28
Group means ± SD. BMI: body mass index; UPDRSIII: unified Parkinson's disease rating scale (subscale III); MMSE: minimental state examination.
http://dx.doi.org/10.1016/j.parkreldis.2015.03.026 1353-8020/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Fernandez-del-Olmo M, Sanchez JAShort walking distances compromise the stride length in Parkinson's disease patients, Parkinsonism and Related Disorders (2015), http://dx.doi.org/10.1016/j.parkreldis.2015.03.026
2
Letter to the Editor / Parkinsonism and Related Disorders xxx (2015) 1e2
to play a role, since gait improvements were observed in a large facility, and PD patients are more prone to control gait in visually restricted environments as compared to open spaces. Difficulties in gait initiation and balance disturbances, characteristic of PD patients [6], could explain the lower stride length observed only during the short walk in the patients compared with control subjects. In summary, our results suggest that gait acceleration rather than gait at a steady speed compromises the stride length in PD patients. These findings support the 10 m-walk test used by clinicians to evaluate gait deficits in patients with PD.
[3] Morris ME, Iansek R, Matyas TA, Summers JJ. Ability to modulate walking cadence remains intact in Parkinson's disease. J Neurol Neurosurg Psychiatr 1994;57:1532e4. [4] Morris ME, Iansek R, Matyas TA, Summers JJ. The pathogenesis of gait hypokinesia in Parkinson's disease. Brain 1994;117:1169e81. [5] Morris M, Bilney B, Dodd K, Denisenko S, Baker R, Dobson F, et al. Clinical gait analysis in neurology. In: Hausdorff JM, Alexander NB, editors. Gait disorders. Florida: Taylor & Francis Group; 2005. p. 247e73. [6] Marsden CD. Parkinson's disease. J Neurol Neurosurg Psychiatr 1994;57: 672e81.
M. Fernandez-del-Olmo*, J.A. Sanchez Faculty of Sciences of Sport and Physical Education, Department of ~ a, A Corun ~ a, Spain Physical Education, University of A Corun
Acknowledgments n This work was supported by Ministerio de Ciencia e Innovacio (DEP2011-22466), Spain. References [1] Hoehn MM, Yahr MD. Parkinsonism: onset, progression, and mortality. Neurology 1967;17:427e42. [2] Schenkman M. Physical therapy intervention for the ambulatory patient. In: Turnbull GI, editor. Physical therapy management of Parkinson's disease. New York: Churchill Livingstone; 1992. p. 137e92.
*
ns, Corresponding author. Av. Ernesto Che Guevara 121, Pazos-Lia ~ a, Spain. Tel.: þ34 981167000; fax: þ34 15179 Oleiros, A Corun 981167048. E-mail address: [email protected] (M. Fernandez-del-Olmo). 23 January 2015
Please cite this article in press as: Fernandez-del-Olmo M, Sanchez JAShort walking distances compromise the stride length in Parkinson's disease patients, Parkinsonism and Related Disorders (2015), http://dx.doi.org/10.1016/j.parkreldis.2015.03.026