Gait disturbances in Parkinson's disease and parkinsonism, also called parkinsonian gait, worsen the risk of falls and directly affect quality of life. Parkinsonian gait is a complex combination of multiple factors. At Gondola Medical Technologies, our goal is to help patients improve their walking and balance skills and their quality of life. However, to address this disorder effectively, it is essential to understand the different aspects of parkinsonian gait and how Gondola AMPS therapy can provide an efficient solution.
Parkinsonian gait
The symptoms of Parkinson's disease are tremor at rest, rigidity, bradykinesia (slowing of movement), hypokinesia (reduced ability to move) and loss of postural reflexes. These symptoms affect walking in precisely those aspects that lead to “parkinsonian gait.” Parkinsonian gait includes various gait disturbances from continuous to episodic (Freezing of walking and festination). Continuous disturbances are those alterations that persist and are always evident in the patient consistently. Episodic disturbances occur occasionally and intermittently, surfacing randomly and unexplained. Both gait disorders contribute to and exacerbate the risk of falls and reduced quality of life.
Continuous walking disorders
Continuous gait disturbance is the easiest to study in parkinsonian gait because it is consistently observable. It has been mainly studied through visual observation, clinical assessments and quantitative gait analysis. Based on the literature, gait disturbances are described as decreased speed, reduced step length and range of motion, more variable stride length (e.g., a patient may take one long step, then consecutively two short steps and one normal step), increased double support time (time with both feet on the floor), absence of arm swing, and impaired postural control. These changes in gait evolve at different stages of the disease and can be used as a biological marker of disease progression.
Initial stage
In the early stages of Parkinson's disease, patients' gait slows and stride length shortens, compared with healthy adults of the same age. These changes are not specific to the disease and may be associated with other disorders or aging. Arm sway and fluidity of movement are also altered due to bradykinesia and hypokinesia. Steps are asymmetrical because the pathology does not evolve symmetrically in the basal ganglia. Gait is less automatic, stride length is more variable, and doing two things simultaneously while walking (e.g., talking and walking simultaneously) is more complicated. Research is currently investigating how to measure gait asymmetry and variability as predictors of Parkinson's disease and gait speed and stride length as indicators of disease progression.
Mid-advanced stage
In the middle to advanced stage, the gait characteristics already altered in the early stage of the disease continue to evolve bilaterally. Therefore, asymmetry may decrease and bradykinesia (slowed movement) progress with the disease. At this stage, a shuffling gait consisting of foot dragging during walking, short stride length, longer duration of stance and double support phase with reduced arm movement and torso rotation can be observed.
Advanced stage
Changes in gait characteristics worsen further. Balance and postural functions are reduced, and the risk of severe falls is high. Motor fluctuations and dyskinesias are present in most patients and have a negative impact on walking. Endurance, muscle strength and motor capacity are reduced further worsening the quality of life.
Gondola AMPS therapy has been shown to effectively improve continuous gait disturbances and can be used in all different stages of the disease. In this case, our goal is to maintain a physiological gait or reduce the decline in gait parameters. Gondola AMPS therapy is a treatment to promote a more automatic gait and avoid parkinsonian gait compensations.
Episodic walking disorders
Episodic gait disorders are more difficult to study because, by definition, they are not always present. Episodic gait disturbances include festination, Freezing of gait, disturbances of initiation (of walking) and blockage in turning in place. These disorders may appear as early as during the mild-to-moderate phase, but they worsen more in the advanced phase. When they occur, these episodes dramatically increase the risk of falling. In addition, gait automatism (which is an indicator of healthy walking) is further impaired, resulting in problems in gait initiation and motor control. The ability to rotate is impaired. The neck and trunk of patients with Parkinson's disease remain rigid, requiring smaller steps to make a turn, which is called “en bloc” rotation. In advanced stages, freezing of walking and gait become frequent, accompanied by decreased balance and postural control and a severe risk of falling.
Freezing of the march
Freezing is defined as an episode in which the patient is unable to continue walking: absence or marked reduction in forward progression of the feet despite the intention to walk. It happens more when trying to start walking, during turning, and when encountering obstacles, doors, stressful situations, and distractions. These short-lived motor blocks are most common in the advanced stages of Parkinson's disease (70%) but can also occur earlier in the disease. Freezing of walking is a disabling motor symptom as it significantly affects patients' quality of life and activity levels.
Patients using Gondola AMPS therapy reported a lower frequency of Freezing episodes. We are currently conducting a clinical trial with the collaboration of Dr. Barbes, a neurologist at UKK Hospital in Cologne, to understand the possible use of Gondola AMPS for patients suffering from severe Freezing episodes.
Festive gait
Festination is defined as a gait with small, quick steps taken to keep the center of gravity between the feet while the trunk involuntarily bends forward shifting the center of gravity forward. It can be regarded as an involuntary attempt to correct balance. This strategy is ineffective and inefficient in correcting walking. Instead of taking wider steps to regain balance, the patient takes short, rapid steps.
AMPS Gondola Therapy
“Automated Mechanical Peripheral Stimulation” (AMPS) therapy is a new noninvasive therapy based on mechanical pressure pulses. AMPS consists of pressures applied to two specific areas of both feet, the head of the big toe and the first metatarsal joint, to increase gait automatism and improve gait function. The effectiveness of AMPS treatment on Parkinsonian gait has been documented in 11 controlled clinical research studies on more than 230 patients with Parkinson's disease.
These studies have shown that AMPS:
- Improves gait, giving increased gait speed, increased stride length and stride cycle, decreased stride length variation, decreased double support time, decreased gait asymmetry.
- Improved reversal during walking (rotation) and TUG (Timed Up and Go) tests resulting in reduced risk of falling.
- Less variation in stride length during walking for patients with Walk Freezing.
- Improved dual-task skills during walking.
AMPS therapy is an exciting and promising opportunity to integrate pharmaceutical treatments and physical rehabilitation to improve walking quality and reduce the risk of falls.
Conclusion
Parkinsonian gait is a complex combination of multiple factors that result in continuous gait disturbances, characterized by slowed and reduced movement, and episodic disturbances, which worsen the risk of falls. Parkinsonian gait evolves at different stages of the disease, and Gondola AMPS improves gait quality by reducing the risk of falls at all stages of the disease.
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