Table of Contents
1. How Parkinson’s Progresses
2. Parkinson’s Progression Scale
3. Conventional Treatment
4. Potential Treatment Options
5. Gait Disturbance
6. Characteristics of Abnormal Gait
7. Walking Aids
8. Useful Tips for Walking Canes
10. Expert Contribution
Parkinson’s disease (PD) affects nearly one million people in the US. It is a progressive and chronic progressive movement disorder, meaning the symptoms will continue and worsen over time. The cause of PD is largely unknown, but researchers have found evidence that a toxin produced in the brain, DOPAL, is responsible for a series of cellular events that are the precursors to Parkinson’s disease. DOPAL plays a key role in destroying dopamine neurons that trigger the disorder.(1) Though there is presently no cure for PD, there are treatment options available. Surgery and medication can help to alleviate the symptoms.
As more nerve cells die, the amount of dopamine supplied to the brain is decreased. This, in turn, sends chemical messages to the part of the brain that controls coordination and movement. As Parkinson’s progresses, the quantities of dopamine produced inside a person’s brain is decreased which subsequently prevents the patient from being able to control normal movement.
The progressive symptoms of Parkinson’s Disease include:
• rigidity of the muscles
• slowness of movement
• postural instability
These symptoms may be mild, in the early stages of the disease, but will steadily become more debilitating and intense. Rates of progression in patients vary, and the progression of the symptoms of the disease may take 20 years or longer to fully manifest.
Many doctors use a tool named the Hoehn and Yahr Scale to allow patients to assess their disease progression. The progression of PD is delineated based on the following stages:
• Stage 1: Parkinson's symptoms only affect one side of the patient’s body.
• Stage 2: Symptoms start to affect both sides of the body, but balance remains intact.
• Stage 3: Symptoms of PD in the patient are mild to moderate. Balance is impaired, but the patient can function independently.
• Stage 4: Patients at this stage suffer from severe disability, yet continue to stand or walk without assistance.
• Stage 5: The patient becomes bedridden or wheelchair-bound.
A doctor will be able to tell a Parkinson’s patient how far along they are on the Hoehn and Yahr Scale; however, there is no accurate way to tell when they will progress to the next stage. Patients who experience worsening symptoms can expect that their physical functioning will decline, as well.
Parkinson’s disease has no cure, but there are treatments that can ease the symptoms. When the symptoms begin affecting a person’s functioning, the medications Parcopa or Sinemet will usually be able to effectively and significantly reduce symptoms for about one to five years — even longer in about 25 % of patients.
Many PD patients, on medication for their symptoms, experience dyskinesia, involuntary movements that happen when the medication dose has reached peak performance. Patients need to have their medication adjusted when this occurs. Often a change of medication is also required. Symmetrel is an example of an additional medication that may be added to the regime. Surgery may also help at this stage of the disorder.
When patients begin experiencing the most advanced stages of PD, they will experience severe flare-ups of dyskinesia and alternating with severe symptoms, even with adjustment to medications. The best treatment when this occurs is often surgery. Deep brain stimulation, as the surgery is called, involves the implantation of electrodes in the brain. The electrodes are connected to an external device that is similar to a heart pacemaker that helps control the electrical impulses, thus influencing flexibility and movement.
Potential Treatment Options
There are promising new treatment options available for the treatment of Parkinson’s, according to researchers at Harvard-affiliated McLean Hospital. Their study found that when fetal dopamine cells were transplanted into the brains of patients with PD, they were able to remain functional and healthy for up to 14 years.
The findings could lead to new treatments and better therapies for patients. They could also reduce the reliance on dopamine replacement drugs.
Patients suffering from the progression of PD have difficulty with walking. Their gait is often characterized by a typical slowness of movement (hypokinesia), small shuffling steps, and even total loss of movement (akinesia) in extreme cases. Patients with this disorder have reduced stride length and walking speed when walking from one place to another and when cadence rate and double support duration is increased.
The patient will experience difficulty initiating walking, but will also have difficulty stopping once they have started. This is caused by muscle hypertonicity.
Patients that have Parkinson’s disease walk with markedly different gait characteristics than a person who is disease-free. The list below discusses abnormal gait attributes commonly found in Parkinson’s patients:
• Heel to Toe Strike
• Vertical Ground Reaction Force
• Freezing and Falls of Gait
• Postural Sway
Heel to Toe Stike
In cases of normal gait individuals, the heel will strike the ground before their toes do. For patients that have PD, the entire foot is placed on the floor at the same time. In advanced stages of the disorder, the patient’s toes will touch the floor before the heel does. Additionally, patients show a marked reduction during foot lifting, the swing phase of their gait, which results in a smaller clearance between the ground and the toes.
Vertical Ground Reaction Force
For a person with a normal gait, the vertical ground reaction force (GRF) plot possesses two peaks – the first peak is when the foot hits the ground, and the second is caused by their push-off force from the floor. For patients with PD, the shape of the vertical GRF signal has abnormal characteristics.
In early stages of the disorder, reduced peak heights (or force) are encountered for contact of the heel contact and push-off phase. For more advanced stages, the gait characteristics are with small, shuffling steps. Patients with PD exhibit only a singular, narrow peak in the vertical GRF signal.
Freezing and Falls of Gait
Freezing and falls of gait are episodic phenomena that are commonly seen in Parkinson’s patients. Both symptoms are often seen in the advanced stages of the disorder but seen less commonly in the earlier stages. Freezing of gait is a temporary episode for PD patients that usually lasts less than a minute and is described by patients as feeling as if their feet are glued to the floor. Importantly, freezing of gait will often lead to falls--mainly due to a sudden change in posture.
In the end stages of PD, a postural instability in the upright stance is commonly seen in patients. This condition limits the ability for the patient to maintain their balance during everyday tasks, such as walking and standing up after sitting. This inability to effectively balance the body's center of mass throughout the base of support combined with the increased rigidity of the patient’s body movements is what causes patients with advanced Parkinson’s to fall.
With the diagnosis of Parkinson’s disease comes the necessity to adjust the activities of daily living to enable management of the physical instability that comes along with the disease. There are many types and brands of walking aids that increase stride, normalize walking, and help with freezing. If balance is particularly off in the morning, before taking your dosage of Parkinson’s medication, it is a good rule of thumb to keep a cane by the bedside to help with walking safely to different rooms in the house.
The use of a walking cane is especially useful in crowded areas, such as a shopping mall or grocery store, and should be encouraged. In addition to helping with balance, the cane is a visual cue to a passerby to maintain safe interpersonal space.
Also, walking sticks can be helpful for trail walkers with PD that have a stooped posture, as they are designed to be taller than the person that uses them. If a person with PD has more frequent episodes of falling, it may become necessary for them to switch over to a walker. Before purchasing any mobility aids, it is recommeneded to consult with a licensed physical therapist to get a proper fit and the training to use them effectively.
• A rubber-tipped, straight cane is recommended.
• The hand grips on the cane should be adjustable and comfortable to provide good support.
• Laser canes work well if the patient is experiencing freezing of gait.
Parkinson’s disease comes with health issues that can often be difficult to manage, but there are medications and treatments that can help minimize symptoms throughout the different stages of the disease. There are many options available to assist a patient with walking--the walking cane being one of the chief options to turn to initially. Although patients that suffer from PD can be fearful of a need to rely on others for important tasks, a walking cane and other mobility aids can broaden their options for independence and bring them peace of mind.
1. Saint Louis University. Natural toxin implicated as triggering Parkinson’s disease http://www.sciencedaily.com/releases/2011/02/110210123026.htm. Accessed June. 4, 2014.
2. Parkinson’s disease Foundation. What is Parkinson’s disease? http://www.pdf.org
3. McCoy, Krisha. Recognizing the Progression of Parkinson’s disease Symptoms. http://www.everydayhealth.com/parkinsons-disease/parkinsons-disease-progression.aspx. Accessed June. 5, 2014.
4. McCoy, Krisha. Recognizing the Progression of Parkinson’s disease Symptoms. http://www.everydayhealth.com/parkinsons-disease/parkinsons-disease-progression.aspx. Accessed June. 5, 2014.
5. McCoy, Krisha. Recognizing the Progression of Parkinson’s disease Symptoms. http://www.everydayhealth.com/parkinsons-disease/parkinsons-disease-progression.aspx. Accessed June. 5, 2014.
6. McLean Hospital. Transplanted fetal stem cells for Parkinson's show promise.
http://www.sciencedaily.com/releases/2014/06/140605141505.htm. Accessed June. 6, 2014.
7. Wikipedia. Parkinsonian gait.
http://en.wikipedia.org/wiki/Parkinsonian_gait. Accessed June. 5, 2014.
8. Wikipedia. Parkinsonian gait.
http://en.wikipedia.org/wiki/Parkinsonian_gait. Accessed June. 5, 2014.
9. National Parkinson’s Foundation. Getting Around: Canes.
http://www.parkinson.org/Parkinson-s-Disease/Living-Well/Activities-of-Daily-Living/Getting-Around--Canes. Accessed June. 6, 2014.
Parkinson's Disease and the Need for a Walking Cane is Written by: Dr. Elizabeth Lewis