Elsevier

Gait & Posture

Volume 52, February 2017, Pages 87-94
Gait & Posture

SIAMOC Best Paper Award for 2015
Underwater gait analysis in Parkinson’s disease

https://doi.org/10.1016/j.gaitpost.2016.11.019Get rights and content

Abstract

Although hydrotherapy is one of the physical therapies adopted to optimize gait rehabilitation in people with Parkinson disease, the quantitative measurement of gait-related outcomes has not been provided yet. This work aims to document the gait improvements in a group of parkinsonians after a hydrotherapy program through 2D and 3D underwater and on land gait analysis. Thirty-four parkinsonians and twenty-two controls were enrolled, divided into two different cohorts. In the first one, 2 groups of patients underwent underwater or land based walking training; controls underwent underwater walking training. Hence pre-treatment 2D underwater and on land gait analysis were performed, together with post-treatment on land gait analysis. Considering that current literature documented a reduced movement amplitude in parkinsonians across all lower limb joints in all movement planes, 3D underwater and on land gait analysis were performed on a second cohort of subjects (10 parkinsonians and 10 controls) who underwent underwater gait training. Baseline land 2D and 3D gait analysis in parkinsonians showed shorter stride length and slower speed than controls, in agreement with previous findings. Comparison between underwater and on land gait analysis showed reduction in stride length, cadence and speed on both parkinsonians and controls. Although patients who underwent underwater treatment exhibited significant changes on spatiotemporal parameters and sagittal plane lower limb kinematics, 3D gait analysis documented a significant (p < 0.05) improvement in all movement planes. These data deserve attention for research directions promoting the optimal recovery and maintenance of walking ability.

Introduction

Gait disturbances are a common feature in Parkinson’s disease (PD) [1], with a significant impact on quality of life in the advanced stage of the disease [2]. Gait in PD subjects (PDS) has been thoroughly studied with 3D gait analysis (3DGA) systems in last years documenting a typical hypokinetic gait [3]. The typical kinematics alterations are a reduction of the stride-length with asymmetry between the strides, an increment of the cadence, the stance and double support phases, which compensates for the reduced stride length [4]; a reduction of both the upper arms’ swing and the lower limb joints range of motion (ROM), has also been documented. In PDS the foot tends to drag on the floor, more horizontal than usual due to the important reduction of the angle width between the heel and the sole with freinage and beginning of shuffling [3].

Hydrotherapy is an evidence-based intervention used in treating motor impairments due to orthopaedic [5] and neurological diseases [6]. Aquatic exercises have been used especially when exercise under normal conditions of gravity is difficult and painful. Water buoyancy abolishes gravity thus allowing the body to float, reducing the weight that joints, bones, and muscles have to bear. Consequently, an underwater (UW) environment allows early active mobilization and dynamic strengthening [7].

Recently hydrotherapy has been proposed as an innovative rehabilitative strategy for motor symptoms’ treatments and quality of life in PD [8], in particular for balance dysfunctions documenting significant improvements [9]. Currently no published studies investigated the effects of hydrotherapy on UW gait kinematics in PD. This is mainly due to difficulties in UW video recordings analysis linked to the small target size, the low image quality and the presence of background clutters.

The aim of this pilot-study is to document the modification of gait’s parameters UW through UW GA (UWGA) in a group of PDS and controls (CS). For this purpose a first cohort of subjects was enrolled and evaluated through 2D UWGA (2DUWGA) and on land GA (2DOLGA) before and after a hydrotherapy program. Within this cohort a group of PDS underwent a land based walking (LBW) program for comparison. By considering that in people with PD it has been documented a reduced movement amplitude across all lower limb joints, in all movement planes [3], 3D UWGA (3DUWGA) and OLGA (3DOLGA) were performed on a second cohort of subjects before and after UW gait treatment. Comparisons between the two approaches were made in term of key kinematics variables in order to evaluate if hydrotherapy produces any gait-related outcomes on all movement planes in parkinsonians. Results will allow speculating on the added value of a 3DGA in assessing hydrotherapy derived gait improvements on PDS.

Section snippets

Subjects

Fifty-six subjects were enrolled in the study, divided in two different subjects cohorts (Fig. 1): Protocol 1 and Protocol 2.

The trial was approved by the Ethic Committee. Written informed consent was obtained from the participants or from their spouses if they scored less than 25/30 on the Mini Mental State Examination (MMSE) [10].

Inclusion criteria: participants were eligible for inclusion if they consented to participation, had PD diagnosed according to the current criteria [11], Hoehn and

Results

Table 1 reports the clinical and demographic characteristics of the studied subjects. No significant differences existed between CS1 and CS2, PDS1 UW and PDS1 LBW, PDS2 and CS2 (apart for gender) in relation to the various clinical and demographic parameters (Table 1). Significant differences were observed between PDS1 UW or PDS1 LBW and CS1, PDS1 and PDS2, in terms of age and BMI, but not in term of clinical scales between PDS1 and PDS2. For the clinical outcome measures, a significant (p < 

Discussion

The rehabilitative program was delivered successfully with high adherence in both cohorts and underwater training significantly improved the key clinical variables after hydrotherapy.

The present pilot study has shown that enhancing gait training in a rehabilitation setting as a swimming pool leads to a clinically meaningful effect in PDS with gait impairment. Specifically, we found an overall better clinical outcome in PDS with significant improvement at the end of studied period as compared

Acknowledgements

The authors acknowledge the contribution of Giuseppe Caraccio in providing the facility for underwater and on land measurements as well as treatments, Riccardo Spezzamonte, Fulvia Fichera and Veronica Scalchi for their help in the initial stage of the project.

References (28)

  • N. Giladi

    Gait disturbances in advanced stages of Parkinson’s disease

    Adv. Neurol.

    (2001)
  • M. Morris et al.

    Three-dimensional gait biomechanics in Parkinson’s disease: evidence for a centrally mediated amplitude regulation disorder

    Mov. Disord.

    (2005)
  • A. Nieuwboer et al.

    Abnormalities of the spatiotemporal characteristics of gait at the onset of freezing in Parkinson’s disease

    Mov. Disord.

    (2001)
  • A.R. Marinho-Buzelli et al.

    The effects of aquatic therapy on mobility of individuals with neurological diseases: a systematic review

    Clin. Rehabil.

    (2014)
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