Assessing Limb Propulsion and Gait Kinetics Using Resistance in Early-Stage Parkinson’s Disease

 

Background

I have always had a strong interest in neuroanatomy and physiology which was one of the main influences in applying for the UNC Neuro STEP UP Program. Following a rotation in outpatient neuro at the UNC Center for Rehabilitation Care, I grew intrigued working with individuals with Parkinson’s Disease (PD) and I wanted to continue improving my knowledge of this population, ultimately choosing to pursue certification in LSVT BIG. In thinking about the framework of LSVT BIG and its push for large amplitude of movements, I was interested in learning more about how this concept would translate to regular gait training activities within individuals with PD and completed my critically acclaimed topic project on this idea. Additionally, as part of the Neuro STEP UP program, my co-scholar, Emily Hayworth and I decided to create a research project and capstone that centered around gait mechanics in PD. Specifically, we were interested in knowing the effects of resisting walking at the hip and ankle in individuals with PD on spatiotemporal and kinematic aspects of gait. We were able to collect, analyze and interpret this data utilizing a motion capture system and created a manuscript and poster presentation which was presented at the UNC Human Movement Science Research Symposium. 

 

Statement of Need

Individuals with PD are commonly faced with motor challenges attributed to the four cardinal signs of rigidity, bradykinesia, tremor and postural instability.¹ Due to the progressive nature of the disease, these symptoms worsen over time leading to impaired locomotion, balance and increased risk for falls and need for assistance with functional tasks.² More specifically, gait impairments associated with PD include decreased cadence and step length leading to the hallmark “shuffling gait” pattern. Additionally, deficits in propulsion and movement amplitude are common in PD, but it is uncertain which components contribute to the breakdown in the locomotive pattern that elicits shuffling gait.³ There are many treatment ideas such as large amplitude movements and external cueing through different methods to stimulate appropriately proportioned, fluid movements that counteract these deficits. Similarly, resisted gait training on a treadmill and rhythmic auditory stimulation (RAS) aim to cue symmetrical and forceful movements required from PD patients to achieve a seemingly normal amplitude.^4,5 Through quantifying the propulsive reserve and movement amplitude in individuals with PD, we are able to extract information on mechanics underlying altered limb propulsion in individuals with PD as well as relationships between level of severity and limb propulsion. Due to the limited research on this particular topic, the purpose of our research is to address how impairments in propulsion or amplitude may contribute to common gait deficits in PD. Additionally, we aim to analyze and compare how varying resistance administered at the hip and ankle with and without RAS while walking on a steady-state treadmill influences gait mechanics to determine the most effective strategy to improve step length and cadence to ultimately improve methods of gait training in individuals with PD. This project will allow me the opportunity to participate in data collection, processing, entry, analysis, manuscript creation, and presentation. This is an important area of study, but also allows me the opportunity to grow as a clinician both through research and understanding the underlying mechanics of future patients with PD.

Bibliography

1.    Sveinbjornsdottir S. The clinical symptoms of Parkinson’s disease. J Neurochem. 2016;139 Suppl 1:318-324. doi:10.1111/jnc.13691
2.    Janssens J, Malfroid K, Nyffeler T, Bohlhalter S, Vanbellingen T. Application of LSVT BIG intervention to address gait, balance, bed mobility, and dexterity in people with Parkinson disease: a case series. Phys Ther. 2014;94(7):1014-1023. doi:10.2522/ptj.20130232
3.    Oh J, Eltoukhy M, Kuenze C, Andersen MS, Signorile JF. Comparison of predicted kinetic variables between Parkinson’s disease patients and healthy age-matched control using a depth sensor-driven full-body musculoskeletal model. Gait Posture. 2020;76:151-156. doi:10.1016/j.gaitpost.2019.11.011
4.    Thaut MH, Abiru M. Rhythmic auditory stimulation in rehabilitation of movement disorders: A review of current research. Music Percept. 2010;27(4):263-269. doi:10.1525/mp.2010.27.4.263
5.    Scandalis TA, Bosak A, Berliner JC, Helman LL, Wells MR. Resistance training and gait function in patients with Parkinson’s disease. Am J Phys Med Rehabil. 2001;80(1):38-43; quiz 44. doi:10.1097/00002060-200101000-00011

 

Purpose Statement: We sought to understand limb and joint kinetics associated with gait in people with PD, and examine whether deficits (and a concurrent reserve) in push-off or leg swing might contribute to the development of shortened step lengths for people with PD. We hypothesized that people with PD will have reduced hip flexor torque (during swing) and reduced ankle plantar flexor torque during push-off compared to unimpaired individuals yet have the capacity or reserve to be able to take longer steps through an increase in both hip flexor and ankle plantar flexor torque.

 

Objectives: 

• Demonstrate the ability to create and include all necessary components of a manuscript that is prepared for publication in a scientific journal.
• Demonstrate knowledge and understanding of gait biomechanics including kinematic and spatiotemporal adaptations to resisted gait training in individuals with PD.
• Demonstrate understanding of standard data analysis procedures to allow for meaningful understanding and discussion of research findings.
• Create manuscript of research study to be submitted for peer review.
• Create academic research posture to be presented at a research conference.

 

Products: 

• Critically Appraised Topic
• Abstract
  • We worked together to create an abstract in order to succinctly summarize and present our project and manuscript. This was submitted to the Human Movement Science Conference at UNC and accepted for a poster presentation.
• Manuscript
  • At the start of last semester (Fall 2021), Emily and I completed  a research project under the supervision of Dr. Mike Lewek, PT, PhD and two PhD students, Chelsea Parker, DPT, PT and David Rowland, DPT, PT. After its completion we analyzed the data with the intent of producing a manuscript and poster presentation for the research conference. The creation of the manuscript was a multiple month endeavor including weekly meetings with our advisor Dr. Mike Lewek to create, revise, and produce a paper that could be potentially published in the future. 
• Poster Presentation
  • We created this poster as a visual representation of our work to be presented at the UNC Human Movement Science Conference. We participated in the conference day, interacted and answered questions from the attendees about our findings. 

Health Literacy

In our lab group, we discussed appropriate poster presentation considerations at the research conference. At a research conference and for our manuscript, we have the luxury of not having to worry as much about health literacy levels considering most individuals will likely be in the science realm and have some form of college education.  However, because there will be a plethora of disciplines and individuals reviewing the materials and listening to our presentation and not everyone will be physical therapists, we may not have to get too deep into the weeds regarding the specifics of the biomechanics, joint moments, etc. For this reason, it will be important to come up with an “elevator speech” to describe what we did in our project in layman’s terms. We have been working hard on this and are excited for the presentation. 

 

Evaluation

We received feedback via “track changes” on Microsoft Words from our committee members which we implemented into our final draft. Additionally, we created a google survey form with evaluation questions for our poster presentation where guests were able to scan a QR code and fill out this survey.

Overall, it seemed as though our manuscript and poster presentation were received very well. We received a lot of helpful feedback throughout the year from our advisors and committee members and plan to continue to implement changes before submitting for peer review.

 

Reflection

• One of my personal goals included participating in a research elective to gain more knowledge on the process of data collection, analysis and interpretation. We were able to successfully collect data on 9 participants with PD and created a manuscript that we will continue to improve in hopes of achieving publication in a peer review journal in addition to a poster presentation that was presented at the UNC Human Movement Science Research Symposium. Through weekly meetings with our advisor and help from current Human Movement Science PhD students, my co-scholar and I were able to stay on track with our proposed timelines and due dates, ask questions when necessary to improve my understanding, and learn the basic operation of equipment.
• Another goal I had was to gain a better understanding of gait kinematics in individuals with PD. Through completing my Critically Appraised Topic Project in the Evidence Based Practice 2 course and performing a thorough literature review on gait in individuals with PD as well as healthy controls, I was able to gain knowledge in similar and different factors between the two groups and improve my understanding of its impact on rehabilitation and function. 
• The most challenging aspect of the project was staying organized. This project was extremely involved and had a lot of moving parts which made it easy to get behind. However, because I ensured to utilize a planner, had weekly meetings with my co-scholar and advisor, and ensured to complete my tasks within the project in a timely manner, we were able to successfully complete all aspects of the project without any issue. I am proud of Emily and I’s ability to keep each other on track and truly work together as an effective team. 
• Overall, I am extremely proud of our project and the products we produced as it provided an interesting perspective on gait mechanics in PD and will serve as a resource to future students, Neuro STEP UP Scholars and hopefully the rest of the profession if approved for publication.

Acknowledgements

Emily Hayworth, SPT, thank you for keeping me on track and agreeing to meeting hundreds of times over the course of the year. Your work ethic and tenacity are quite admirable and I wish you the very best in your career.

Michael Lewek, PT, PhD , thank you so very much for your guidance and advice over the last year, for academics, career goals and life in general. You were a joy to work with and I am so proud of the project you helped us create. We couldn’t have done this without you!

Chelsea J Parker, PT, DPT and David Rowland, PT, DPT, you two are the real MVPs. I don’t think we would have made it through data collection and analysis without you both and we cannot begin to thank you enough for all of the help and millions of questions you’ve answered. Additionally, thank you both for the feedback you provided on our materials and for agreeing to be on our committee. I am so excited to see where you both end up.

Nina Browner, MD, thank you for providing us assistance in patient recruitment and making sense of our results. You were instrumental in getting our project going, thank you for all that you do.

Corinne Murray, PT, DPT, thank you so much for your advice and input as part of our committee. We greatly appreciate your expertise and knowledge and are thankful for everything you’ve done for us as a CI, committee advisor and VLT leader.

Jessica Cassidy, PT, DPT, PhD and Audrey Czejkowski, PT, DPT, NCS, MSCS, thank you both for being such caring and understanding mentors throughout our time in the Neuro STEP UP program. It was truly an honor to work with and learn from you all and I am so excited to continue to work with you as a VLT leader and mentor to other scholars in the coming years. It is amazing what you all were able to evolve the program into and I am looking forward to the future of UNC Neuro STEP UP.

Aubrey and Andrew Brown, thank you both for your motivation, praises and for keeping me sane throughout this last year, at least most of the time.