Gait freezing in Parkinsons

disease and the stride

length sequence effect
interaction
Group 6

Introduction
Freezing of gait (FOG) paroxysmal
phenomenon commonly in advanced Parkinsons
disease (temporary phenomenon where the feet
failed to progress), the cause is poorly
understood
Freezing episodes are transient, only for a few
seconds
Tend to increase in frequency as the disease
progresses

 FOG during walking was possibly due to

the presence of the sequence effect
(gradual step to step reduction) in
combination with an overall reduced step
length which, if small enough, would
eventually lead to freezing.

The Aim
to test the hypothesis that FOG, during walking,
results
when
the
sequence
effect
is
superimposed on a reduced step length
The progressive reduction in step to step
amplitude (sequence effect), measured by a
linear regression slope, was compared between
Parkinsons
disease
participants
who
experienced freezing (PD + FOG), those who did
not experience freezing (PD - FOG), as well as a
group of elderly control participants (control)

Participants
26 participants with PD (with or without FOG)
PD + FOG (n = 16, males = 14, females = 2)
PD FOG (n = 10, males = 9, female = 1)
PD + FOG matched for aged with PD FOG
They were off medication
Control group (participants with no family
history of PD): n = 10, males = 9, female = 1

Participants Criteria
Able to walk total of 250 m unaided
No history of other neurological conditions,
ortophaedics

surgery,

or

any

musculoskeletal disorders that could affect

gait
MMSE

(Mini

Mental

State

Examination)

score > 24/30

GDS (Geriatric Depression Scale) < 20

 Clinical measures: the motor section (III) of

the Unified Parkinson Disease Rating Scale
(UPDRS), disease duration, Hoehn and
Yahr staging, dan the FOG questionnaire

GAITRite
Electronic walkway to measure the spatial

and temporal gait parameters

collects data through pressure sensors

embedded into the carpet, measuring 8.3m

long and 0.89m wide
Walking speed, cadence, and step length

(intra-class correlations between 0.82 and

0.92 and coefficients of variation between
1.4% and 3.5%)

Additional Materials
Videotape recorder to facilitate
observational analysis to score the
incidence of freezing episodes and allowed
repeat viewing, therefore increasing the
accuracy of reporting

Procedure
Informed concent, mental status, height and
weight measurements
Leg length (to calculate normalized step length
[normalized step length = 0.8 x leg length])
this calculated value of step length (100%),
further reductions of 75%, 50% and 25% of
normalized step length (in centimetre) were
calculated for each individual and marked out
on the floor.

 Participants were instructed to walk at a

self selected pace using the prescribed
step length to the line marked 2m beyond
the end of the mat to minimize the risk of
slowing down
Video recording was viewed independently
by two assessors to count the number of
FOG episodes

Data Analysis
ANOVA (One-way analysis of variace) to
compare group descriptive data and gait
characteristics for the three groups
Coefficient of variability calculated for all
groups and all conditions to determine step
length variability
PD + FOG number of freezing epsiodes for
each condition totalled together to determine
possible associations between step length and
the number of freezing episodes

 The regression slope (), representing the

decrease or increase in step length for each
individual walk, were averaged to formulate
group mean average slopes, which were
compiled for each condition (preferred,
SL100, SL75, SL50 and SL25)
Compared between groups using a one-way
ANOVA and Tukey honestly significant
difference (HSD) post hoc test

 FOG episodes and -values and also freezing

episodes and clinical measures (UPDRS, H&Y,
MMSE, GDS, and FOG-Q) conducted by
Perasons correlation coefficient (r)
-values and clinical measures for the PD +
FOG and PD FOG also correlated using
Perasons r
r = 0.10 to 0.29: small, r = 0.30 to 0.49:
medium, r = 0.50 to 1.0 large. P-values < 0.05
indicated a significant difference (Cohen, 1988)

RESULTS

Table 1 Means and standard deviations of screening measures

and characteristics for PD + FOG, PD FOG and control groups

PD + FOG

PD - FOG

UPDRS

16 - 36
(m = 23.25; SD =
5.42)

9 - 21
(m = 15; SD = 3.67)

Duration

3 - 23 years
(m = 12.44; SD =
5.00)

1 - 8 years
(m = 2.30; SD =
2.45)

MMSE : no significant differences between all

groups
GDS : PD+FOG is higher than PD-FOG &
control group
H&Y : PD+FOG is higher than PD-FOG,
associated with
the significant
differences in duration of disease

Table 2 Spatiotemporal characteristics of gait in preferred

condition for each group

PD + FOG

PD - FOG

Step Length

smaller

bigger

Velocity

smaller

bigger

Cadence

no difference

no difference

PD + FOG walked with significantly smaller step

length and velocity to the PD - FOG

Table 3 Summary of average step length and coefficient of

variability (COV%) values for the three groups across conditions
for each group

 PD + FOG had a greater variability step in

SL, especially in 25% and 50% conditions
PD FOG & control group no difference
in SL variability
PD + FOG greater in SL variability in 75%
compared to control group
In SL 100%, PD+FOG had a greater
variability, but post hoc analysis results no
difference

Analysis for PD+FOG group: number

of freezing episodes
Through FOG-Q PD+FOG reported
freezing episode
Total counted freezing in PD+FOG : 245

Figure 1 (A) Number of freezing of gait episodes in each condition in the PD

+FOG group. (B) Number of FOG episodes in each condition, in the subgroup

Analysis based on average slopes ()

in each condition across all groups
Slopes for PD+FOG greater than PD-FOG &
control group, particularly at reduce SL
No difference in SL 100
value in SL 75, SL 50, SL 25 for PD+FOG
> PD-FOG & control group
Tukeys HSD test had a difference in
located in PD+FOG compared to PD-FOG &
control group

Figure 2 (A) Relationship between step length and step number

for a single PD + FOG participant in the SL25 condition. (B)
Relationship between step length and step number for a single
PD FOG participant in the SL25 condition. (C) Relationship
between step length and step number for a single control
participant in the SL25 condition.

 Fig. 2A PD+FOG participant had a

negative slope within each walking trial,
indicating the presence of the sequence
effect
Fig. 2B&C PD-FOG & control group were
able to maintain a stable step length

Analysis of slopes () in preferred

condition for PD+FOG group and its
relation to FOG episodes

Table 5 Summary of b-values for PD +FOG group and significance in

preferred condition and associated freezing episodes

 There
was
a
significant
negative
relationship between the number of
freezing episodes and the preferred
average slope, indicating the number of
episode increase as the value of the slope
in the preferred walking trials decreased
The freezing in SL 25 correlated strongly
with the duration of disease
The number of freezing episode did not
correlate significantly with H&Y, UPDRS,
FOG-Q, MMSE, and GDS scores

Discussion

 This study examined the hypothesis that

FOG during walking in people with PD, is
dependent upon both presence of the
sequence effect & an adequately reduced
SL to enable the step to step reduction of
the sequence effect lead to a motor block
Motor block occurred only in PD+FOG group
A reduction in SL as a contributing factor to
FOG

 Average slopes were compared across all

groups there was a significant
difference in the SL 75, SL 50, and SL 25
normalize condition post hoc results the
difference only in PD+FOG group
PD+FOG group had greater SL variabilty in
the conditions when freezing episodes
more frequent-preferred, 50% and 25%
conditions

 PD+FOG demonstrated a significantly greater

duration of disease, higher FOG-Q scores,
UPDRS and H&Y scores compared to PD-FOG
The more severe disease, PD+FOG had
significantly shorter SL compared to PD-FOG
& control group
Theres a strong association between FOD
and disease progression. It was observed
that those who classified as severe freezer
were attributed higher H&Y stages

 Difficulty of evaluating FOG although all

participants in PD+FOG group reported
freezing in the FOG-Q, five failed to freeze
during the testing session
Number of freezing episodes
correlate with the scores on FOG-Q

didnt

A small sample size may account for the

non-significant difference in between
groups in preferred condition, despite the
fact that there were prominent visible
differences in slopes

 The slopes are independent of these

variables which supports the hypothesis
that FOG is a result of decreased SL in the
presence of the sequence effect
The number of FOG episodes was greatest
when SL was reduced which suggest the
risk of freezing may increase on turning
PD+FOG walked at a preferred SL very
similar to the 50% reduction of ideal SL, a
value where the motor blocks became
more frequent

 The factors that contributed to a motor

block occurred in PD+FOG were the
sequence effect, the preferred SL of the
individual, the effect of medication on the
background stride length and the capacity
of the individual to focus attention on
walking

Conclusion
Demonstrating that a reduction in step
length is one of the contributing factors to
FOG (support previous research)
Rehabilitative techniques should focus on
assisting Parkinsons disease patients to
concentrate on maintaining step length
during walking episodes to prevent gait
difficulties.

THANK YOU