The relation between Parkinson’s disease and ageing Comparison of the gait patterns of young Parkinson’s disease subjects with healthy elderly subjects
IN C ER O V P A Y R M IG E H DI T C ® A
P. SALE 1*, M. F. DE PANDIS 2*, S. L. VIMERCATI 4, I. SOVA 1, C. FOTI 3, N. TENORE 1 M. FINI 1, F. STOCCHI 1, G. ALBERTINI 1, M. FRANCESCHINI 1*, M. GALLI 4*
Background. The gait of healthy elderly and of subjects with Parkinson’s disease (PD) displays some common features, suggesting that PD may be a model of ageing. Aim. The aim of the study was to quantify highlight the differences and similarities between the gait patterns of young PD and healthy elderly, to uncover if PD could be assumed as a model of ageing. Design. An optoelectronic system was used for 3D gait analysis evaluation. Population and methods. We compared the gait parameters of 15 young PD (YPD) with the gait of 32 healthy elderly subjects (ES) and 21 healthy subjects age-matched with the PD subjects. Results. Common features between YPD and ES were majorly found in the parameters that reflect the presence of an unstable, uncertain gait, and of corrective strategies employed to reduce instability. On the other side, typical features were present in the gait patterns of PD subjects. Conclusion. Our study helped identifying some typical characteristics of the onset disease, and to unravel the symptoms of ageing from those of PD by comparing young PD subjects to elderly healthy subjects. Clinical rehabilitation impact. This allows a deeper understanding of the mechanisms underlying the gait in ageing and PD. Key words: Parkinson disease - Aging - Parkinsonian disorders - Gait disorders, neurologic.
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EUR J PHYS REHABIL MED 2012;48
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oth ageing and disease cause changes to the nervous, muscular, skeletal systems, and every other system in the body. These changes affect the Corresponding author: P. Sale, IRCCS San Raffaele Roma, via della Pisana, 00163 Rome, Italy. E-mail:
[email protected]
Vol. 48 - 2012
1IRCCS San Raffaele, Rome, Italy Raffaele Cassino, Cassino, Frosinone, Italy 3Physical and Rehabilitation Medicine Chair, Tor Vergata University, Rome, Italy 4Bioeng Department, Politecnico di Milano, Milan, Italy 2San
balance and gait control as well as other functions.1 Balance impairment may prejudice most of patients’ daily activities such as standing and walking and often lead to falls and dramatic injuries.2 With normal aging, changes in the central as well as peripheral nervous system occur: neuronal loss is common and, in addition, the density and number of nerve fibres in peripheral nerves decrease, and skeletal muscle looses fibers.3 It is thus not surprising that there are multiple types of “senile gaits”, and characteristics of normal aged gaits and dysfunctional gaits often overlap. Normal gaits, in fact, vary widely in elderly patients, from a relatively brisk, springing gait to a shuffling gait resembling that seen in Parkinson’s Disease.3 In a study regarding the comparison between elderly PD and elderly age-matched healthy subjects, Plotnik et al.4 found in fact great variability in the spatiotemporal parameters of these two groups of subjects, and stated that the aging brain has a limited capacity to accurately and consistently time the gait cycle of one leg with respect to the other, and this phenomenon was even more evident in elderly PD. As a consequence of these findings, a few authors have formulated the hypothesis that age-associated changes represent, in part, a tendency towards parkinsonism.3, 5
EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE
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The relation between Parkinson’s disease and ageing
erly PD subjects, the effect of the disease is strongly interweaved with the effect of ageing, and it is not possible to distinguish one from the other. Moreover, it is not possible to understand if, as a few authors suggest,3-5 PD gait could be assumed as a model of an “acceleration” process of normal aging. In order to test this hypothesis it could be therefore helpful to study the gait of young PD subjects versus elderly healthy subjects, in order to separate the effects of aging from the effects of the disease. The aim of our study was, therefore, to identify, quantify and compare, by means of 3D Gait Analysis, the spatiotemporal and kinematic parameters of the gait of a group of young PD subjects (YPD), healthy elderly subjects (ES) and young (PD agematched) healthy subjects (HS), in order to highlight the differences and similarities between the gait patterns of these three groups.
IN C ER O V P A Y R M IG E H DI T C ® A
In literature some studies have evaluated and compared quantitatively the gait of healthy elderly versus healthy younger subjects using 3D gait analysis (GA). It was found that healthy elderly people walk slowly and that this speed reduction is due to a reduction in step length rather than cadence.6-9 The double support phase increased, while push off ability decreased and there was a more flat-footed landing. All of these differences indicate adaptation by the elderly toward a safer, more stable gait pattern.8 Also, decreases in the range of motion of the lower limbs with age have been reported, primarily in the flex-extension of the hip, knee and ankle joints.9, 10 In another study regarding the control of upright stance in young, elderly and persons with Parkinson’s disease, Termoz et al. suggest that PD subjects modified a stiffening strategy to control their balance in postural tasks.12 We have previously discussed how gait changes with aging can be attributed to age-associated decline in musculoskeletal function as well as changes in the central nervous system.4 Similar changes occur in the development of Parkinson’s disease (PD), which is one of the most frequent cause of motor dysfunction in aging. It results from a progressive loss of dopaminergic and other subcortical neurons, which leads to a dysfunctional motor control of skilled voluntary movements. In literature the characteristics of PD gait are widely described by the cited authors and by many others, but the articles refer to the gait of elderly PD subjects, compared to an age-matched control group. Some of the cardinal features of the PD locomotors dysfunction are akinesia, bradykinesia, rigidity, postural instability and tremor, which result in typical gait patterns characterized by shortened stride length, increased variability of stride, reduced walking speed and a festinating gait.12-16 An excessive flexion at the hips and knees throughout the gait cycle is present, with reduced total excursion of movement for the lower limb joints. The kinematic movement profiles are therefore shifted upwards towards flexion.12 In order to better clarify the features of the walking patterns in typical elderly PD, in Figure 1A it is possible to observe the walking patterns of the lower limb joints in the sagittal plane for a typical PD subject. Note the shifted-towards flexion profiles and the decreased ROMs at the lower limbs joints, particularly at the knee. Since the subjects considered in literature are eld-
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This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
SALE
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Materials and methods
The young parkinsonian group (YPD) was composed of 15 subjects with idiopathic PD (11 women and 4 men), with an onset of clinical disease under 50 years (mean age: 50.80±4.96 years) and with a 4.8±1.47 years of disease. Patients with PD were diagnosed according to the UK brain bank criteria. Clinical testing was conducted using the Unified Parkinson’s Disease Rating Scale (UPDRS) and H&Y scale.16, 17 The severity of extrapyramidal symptoms was rated using the motor section of UPDRS (UPDRS III).16 All Patients with Mini-mental state examination (MMSE)
