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

 

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

Emily Hayworth, SPT

(Project Partner: Stephanie Casnave, SPT)


 

Background

I have had a passion for working with individuals with neurological conditions since I was first exposed to the patient population as a physical therapy technician prior to beginning my Doctorate in Physical Therapy. This is often combined with my strong interest in research which was generated through opportunities to be a part of clinical trials during my undergraduate career. As a result, I am passionate about incorporating clinically relevant evidence-based practice into my care. As a Neuro STEP UP Scholar, I have been lucky enough to gain additional training and experience with neurodegenerative diseases including amyotrophic lateral sclerosis, multiple sclerosis, and Parkinson’s Disease. My clinical education was tailored to these patient populations and the majority of my caseload as a student clinician has been treating individuals with Parkinson’s Disease. Working on a capstone project that combined both of those components was a perfect fit.

My partner and Neuro STEP UP co-scholar, Stephanie Casnave, and I were both very intrigued when we saw the potential project Dr. Mike Lewek had proposed. The project highlighted our interest in neurodegenerative diseases and provided an opportunity to learn more about the joint kinetics underlying the impairments we often treated in the clinic. I knew the ability to work on a research project from the ground up, collaborate with a research team, analyze data, undergo the process of writing a manuscript, and complete a poster presentation at the UNC Human Movement Science Research Symposium would help me develop into a more well-rounded clinician.

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, an increased risk for falls, and a need for assistance with functional tasks.2More 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 a manuscript of a research study to be submitted for peer review
  • Create an academic research posture to be presented at a research conference

Products

  • Critically Appraised Topic (CAT)
    • I reviewed a limited amount of the evidence surrounding resistive gait training and rhythmic auditory stimulation (metronome) for increased step length in individuals with Parkinson’s Disease. This gave me a baseline idea of current literature relating to our research question and enhanced my understanding of gait kinematics in preparation for creating the manuscript.
  • Abstract
    • We worked together to create an abstract in order to succinctly summarize and present our project. This was submitted to the Human Movement Science Conference at UNC and accepted for a poster presentation.
  • Manuscript
    • Last semester (Fall 2021), my partner and I completed a research project under the supervision of Dr. Mike Lewek, PT, PhD, and two PhD candidates, Chelsea J. (CJ) Parker, DPT, PT, and David Rowland, DPT, PT. After its completion, we analyzed the data with the intent of producing a manuscript. 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 a 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 a physical therapist, 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 about the presentation.

Evaluation

  • Evaluation of the project has occurred in several different forms throughout the development of each stage. The initial component was working with CJ, David, and Dr. Lewek to structure the study. After the study was completed, we met weekly with Dr. Lewek to discuss progress on and refine the abstract, manuscript, and poster as they were being created. We also received feedback from our committee on the manuscript and implemented their edits and suggestions in the final product.
  • Additionally, we created a google survey form that was utilized in the at the Human Movement Science Research Symposium by attendees to evaluate the effectiveness of our poster presentation.

Self Assessment/Reflection

  • Ultimately for this project, it was very important for me to gain a deeper understanding of the research process to better evaluate how to utilize evidence in my future practice. Additionally, I wanted to have an in-depth grasp on the biomechanical changes that occur in individuals with PD. I exceeded my expectations in this regard while reviewing current evidence for my CAT, participating in data collections, data analysis, and discussing the results of the study with our advisor.
  • The most challenging components of this project were the timeline, learning curve for the technology involved, and depth of understanding required to produce a manuscript. My partner and I were able to stay on track and utilize the help of our committee and advisor in order to manage all of the moving parts. Additionally, in the second half of the project, we met weekly in order to discuss the progress and address any questions that arose. Stephanie and I were able to work together as a team, effectively share the workload and support each other.
  • Overall, I am incredibly proud of the project my partner and I were able to produce. I believe the insights generated from the study provide a basis for future research that can hopefully produce targeted physical therapy interventions for patients with PD. Additionally, I think the project can be utilized as a resource for understanding baseline changes in gait kinematics with PD for future students and Neuro STEP UP scholars. I am excited about the potential for the future as we continue to work towards submitting the manuscript for publication.

Acknowledgments 

  • Stephanie Casnave, SPT, thank you for being a true partner throughout this project (and the last two years as Neuro STEP UP co-scholars). You genuinely have a superpower for organization and balancing work/life and I appreciate you sharing that with me. I have no doubt you will be a great physical therapist, and I’m excited to see you develop further in your career.
  • Michael Lewek, PT, PhD, thank you so much for lending us your expertise for this project. Your guidance, advice, and assistance are the only way we were able to get to this point. I have learned so much through just our discussions, and appreciate your support in every facet of our development as physical therapists. I’ll miss our weekly meeting with Stephanie every Tuesday, but I’m sure we will be coordinating more in the future!
  • Chelsea J. (CJ) Parker, PT, DPT, and David Rowland, PT, DPT, I have never seen two people who are as busy and work as hard as you two. Yet, you always immediately came to our aid when we need it. Thank you so much for your unwavering support in recruiting patients, dealing with technology (mostly troubleshooting), and just being there as an overall support system. The rehabilitation field is lucky to have you both, and so were we throughout this project.
  • Nina Browner, MD thank you for all your help with recruiting patients and taking time out of your busy schedule to help gather data and complete outcome measures. Your support and input were essential to the development and successful completion of this project.
  • Corinne Murray, PT, DPT, thank you for agreeing to support us as a committee member on this project. Your clinical experience treating individuals with neurodegenerative diseases was invaluable to me as a clinical instructor (CI), and it’s invaluable for feedback on this project and manuscript.
  • Jessica Cassidy, PT, DPT, PhD and Audrey Czejkowski, PT, DPT, NCS, MSCS, thank you both for your support and mentorship as we have been part of the Neuro STEP UP program. I have grown so much as a clinician and person through the experiences and learning opportunities you have helped to facilitate. I am looking forward to continuing with the program post-graduation and helping to give back to future scholars.

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