Evaluation of Compensation Strategies for Gait Impairment in Patients With Parkinson Disease

Abstract

Background and objectives: Compensation strategies are essential in Parkinson disease (PD) gait rehabilitation. However, besides external cueing, these strategies have rarely been investigated systematically. We aimed to perform the following: (1) establish the patients' perspective on the efficacy and usability of 5 different compensation strategies; (2) quantify the efficacy of these strategies on spatiotemporal gait parameters; and (3) explore associations between the effects of specific strategies and patient characteristics.

Methods: We recruited persons with PD and self-reported disabling gait impairments for this laboratory-based, within-subject study. Clinimetrics included the following: questionnaires (New Freezing of Gait Questionnaire, Vividness of Movement Imagery Questionnaire, Goldsmiths Musical Sophistication Index), cognitive assessments (Attentional Network Test and Montreal Cognitive Assessment [MoCA], Brixton), and physical examinations (Movement Disorders Society Unified Parkinson's Disease Rating Scale [MDS-UPDRS III], Mini-Balance Evaluation Systems Test, tandem gait, and rapid turns test). Gait assessment consisted of six 3-minute trials of continuous walking around a 6-m walkway. Trials comprised the following: (1) baseline gait; (2) external cueing; (3) internal cueing; (4) action observation; (5) motor imagery; and (6) adopting a new walking pattern. Spatiotemporal gait parameters were acquired using 3-dimensional motion capture analysis. Strategy efficacy was determined by the change in gait variability compared with baseline gait. Associated patient characteristics were explored using regression analyses.

Results: A total of 101 participants (50 men; median [range] age: 66 [47-91] years) were included. The effects of the different strategies varied greatly among participants. While participants with higher baseline variability showed larger improvements using compensation strategies, participants without freezing of gait, with lower MDS-UPDRS III scores, higher balance capacity, and better performance in orienting attention also showed greater improvements in gait variability. Higher MoCA scores were associated with greater efficacy of external cueing.

Discussion: Our findings support the use of compensation strategies in gait rehabilitation for PD but highlight the importance of a personalized approach. Even patients with high gait variability are able to improve through the application of compensation strategies, but certain levels of cognitive and functional reserve seem necessary to optimally benefit from them.

Figure 1. Association of Baseline Gait Variability and Improvement in Gait Variability With (A) External Cueing; (B) Internal Cueing; (C) Action Observation; (D) Motor Imagery; and (E) Adopting a New Walking Pattern

The efficacy of the strategy is presented as the improvement in gait variability compared with baseline gait. Gait variability is defined as stride time variability, expressed by the coefficient of variation. Negative values correspond to an increase in variability compared with baseline, equaling a negative effect of the strategy.

Figure 2. Participants (n) Who Were “Very Likely” to Continue Using a Number of the 5 Investigated Compensation Strategies in Daily Life

Colors represent the strategies persons intended to continue using in daily life (e.g., in the group of participants who were “very likely” to continue using 1 strategy, this most often comprised external cueing or adopting a new walking pattern).