609
Journal of Parkinson’s Disease 3 (2013) 609–619 DOI 10.3233/JPD-130217 IOS Press
Research Report
Walking Economy During Cued versus Non-Cued Treadmill Walking in Persons with Parkinson’s Disease Paul M. Galloa , Tara L. McIsaaca,b and Carol Ewing Garbera,∗ a Teacher’s b Arizona
College, Columbia University, New York, NY, USA School of Health, Science, A.T. Still University, Mesa, AZ, USA
Abstract. Background: Gait impairment is common in Parkinson’s disease (PD) and may result in greater energy expenditure, poorer walking economy, and fatigue during activities of daily living. Auditory cueing is an effective technique to improve gait; but the effects on energy expenditure are unknown. Objective: To determine whether energy expenditure differs in individuals with PD compared with healthy controls and if auditory cueing improves walking economy in PD. Methods: Twenty participants (10 PD and 10 controls) came to the laboratory for three sessions. Participants performed two, 6minute bouts of treadmill walking at two speeds (1.12 m·sec−1 and 0.67 m·sec−1 ). One session used cueing and the other without cueing. A metabolic cart measured energy expenditure and walking economy was calculated (energy expenditure/power). Results: PD had worse walking economy and higher energy expenditure than control participants during cued and non-cued walking at the 0.67 m·sec−1 speed and during non-cued walking at the 1.12 m·sec−1 . With auditory cueing, energy expenditure and walking economy worsened in both participant groups. Conclusions: People with PD use more energy and have worse walking economy than adults without PD. Walking economy declines further with auditory cuing in persons with PD. Keywords: Gait, rehabilitation, walking, Parkinson disease, physical fitness and exercise
INTRODUCTION Gait impairment is common in Parkinson’s disease (PD), and is characterized by a shortened step length and decreased walking velocity [1–3]. PD-related gait impairments are associated with decreased functional mobility and increased risk of falling, which negatively impact activities of daily living and quality of life [4, 5]. Persons with mild to moderate PD may compensate for gait impairments by increasing step frequency or ∗ Correspondence to: Carol Ewing Garber, Teacher’s College, Columbia University, 525 West 120th Street, Box 93, New York, NY 10027, USA. Tel.: +1 212 678 3891; Fax: +1 212 678 3322; E-mail: [email protected].
cadence. This inefficient gait pattern may result in an increase in energy expenditure during walking [6, 7], and, in turn, result in increased fatigue and impaired ability to engage in activities of daily living. Fatigue in people with PD has been linked to physical inactivity [8, 9], axial, postural and gait impairments [10], freezing [11], increased task difficulty [12], and fear of falling [13]. In older and younger adults, fatiguing exercise has been associated with changes in spatiotemporal factors affecting gait [14], and impaired balance [15, 16], both of which may contribute to falling [17]. There is limited research investigating the impact of gait impairment on walking economy in mild to
ISSN 1877-7171/13/$27.50 © 2013 – IOS Press and the authors. All rights reserved
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P.M. Gallo et al. / Walking Economy in PD
moderate PD [6, 18]. Persons with PD seem to expend more energy during ambulation and may have poorer walking economy when compared to healthy adults [6, 18]. However, no studies have measured walking economy [6, 18], which is a standardized index of the energy expenditure for each unit of work or power during a set volume of physical activity that allows comparison of energy expenditure under varying exercise conditions [19]. Rhythmic auditory cueing is a technique commonly used in gait rehabilitation that is typically administered by having an individual coordinate their steps to a selected metronome cadence [20–22]. Research on the effectiveness of auditory cueing has centered predominantly on biomechanical aspects of walking [20, 22, 23]. Reported improvements in gait with the use of auditory cueing have been achieved through increasing step length and walking velocity [2, 23]. To our knowledge, there are no studies evaluating the effects of auditory cueing on walking economy or energy expenditure and, in particular, whether or not the improvements in gait resulting from auditory cueing are accompanied by improvements in walking economy in persons with PD. This could have important clinical implications for the benefits of gait training. Therefore, the primary aims of this study were to determine 1) if persons with PD have poorer walking economy and higher energy expenditure during treadmill walking compared with age- and gender-matched control participants; and 2) whether auditory cueing improves walking economy during treadmill walking in persons with PD. An exploratory aim of this study is to determine whether persons with PD will have lower perception of effort during cued versus non-cued walking. MATERIALS AND METHODS
balanced in the second and third sessions. Participants were scheduled to report to the laboratory at the same time of day for each visit, when they felt “most on” and had minimal motor symptoms. The time since the last dose of medication was recorded and consistent across laboratory visits. Due to the wide variability in the absorption of medications [24] we believe this approach was more effective in identifying peak effect. The treadmill was calibrated per the manufacturer’s recommendations. The study was conducted in accordance with the policies and procedures of the Teacher’s College, Columbia University Institutional Review Board. Participant recruitment Men and women ages 55–80 years of age were recruited from a laboratory database of participants recruited from local neurologists for previous studies conducted in our laboratories, respondents to flyers posted on the Teacher’s College, Columbia University (New York, NY) campus and by word of mouth. Inclusion criteria for persons with PD were: stable idiopathic PD diagnosed by a neurologist, Hoehn and Yahr (H&Y) stage of 2.0–3.0, on a stable medication regimen without adjustment for the previous 3 months, and no physician-documented or self-reported history of autonomic dysfunction. Control participants were required to have no history of PD and not be medicated with or exposed to dopamine agonist drugs. Any volunteer was excluded if they had a history of dementia or cognitive impairment, a Mini-Mental State Examination (MMSE) score
Journal of Parkinson’s Disease 3 (2013) 609–619 DOI 10.3233/JPD-130217 IOS Press
Research Report
Walking Economy During Cued versus Non-Cued Treadmill Walking in Persons with Parkinson’s Disease Paul M. Galloa , Tara L. McIsaaca,b and Carol Ewing Garbera,∗ a Teacher’s b Arizona
College, Columbia University, New York, NY, USA School of Health, Science, A.T. Still University, Mesa, AZ, USA
Abstract. Background: Gait impairment is common in Parkinson’s disease (PD) and may result in greater energy expenditure, poorer walking economy, and fatigue during activities of daily living. Auditory cueing is an effective technique to improve gait; but the effects on energy expenditure are unknown. Objective: To determine whether energy expenditure differs in individuals with PD compared with healthy controls and if auditory cueing improves walking economy in PD. Methods: Twenty participants (10 PD and 10 controls) came to the laboratory for three sessions. Participants performed two, 6minute bouts of treadmill walking at two speeds (1.12 m·sec−1 and 0.67 m·sec−1 ). One session used cueing and the other without cueing. A metabolic cart measured energy expenditure and walking economy was calculated (energy expenditure/power). Results: PD had worse walking economy and higher energy expenditure than control participants during cued and non-cued walking at the 0.67 m·sec−1 speed and during non-cued walking at the 1.12 m·sec−1 . With auditory cueing, energy expenditure and walking economy worsened in both participant groups. Conclusions: People with PD use more energy and have worse walking economy than adults without PD. Walking economy declines further with auditory cuing in persons with PD. Keywords: Gait, rehabilitation, walking, Parkinson disease, physical fitness and exercise
INTRODUCTION Gait impairment is common in Parkinson’s disease (PD), and is characterized by a shortened step length and decreased walking velocity [1–3]. PD-related gait impairments are associated with decreased functional mobility and increased risk of falling, which negatively impact activities of daily living and quality of life [4, 5]. Persons with mild to moderate PD may compensate for gait impairments by increasing step frequency or ∗ Correspondence to: Carol Ewing Garber, Teacher’s College, Columbia University, 525 West 120th Street, Box 93, New York, NY 10027, USA. Tel.: +1 212 678 3891; Fax: +1 212 678 3322; E-mail: [email protected].
cadence. This inefficient gait pattern may result in an increase in energy expenditure during walking [6, 7], and, in turn, result in increased fatigue and impaired ability to engage in activities of daily living. Fatigue in people with PD has been linked to physical inactivity [8, 9], axial, postural and gait impairments [10], freezing [11], increased task difficulty [12], and fear of falling [13]. In older and younger adults, fatiguing exercise has been associated with changes in spatiotemporal factors affecting gait [14], and impaired balance [15, 16], both of which may contribute to falling [17]. There is limited research investigating the impact of gait impairment on walking economy in mild to
ISSN 1877-7171/13/$27.50 © 2013 – IOS Press and the authors. All rights reserved
610
P.M. Gallo et al. / Walking Economy in PD
moderate PD [6, 18]. Persons with PD seem to expend more energy during ambulation and may have poorer walking economy when compared to healthy adults [6, 18]. However, no studies have measured walking economy [6, 18], which is a standardized index of the energy expenditure for each unit of work or power during a set volume of physical activity that allows comparison of energy expenditure under varying exercise conditions [19]. Rhythmic auditory cueing is a technique commonly used in gait rehabilitation that is typically administered by having an individual coordinate their steps to a selected metronome cadence [20–22]. Research on the effectiveness of auditory cueing has centered predominantly on biomechanical aspects of walking [20, 22, 23]. Reported improvements in gait with the use of auditory cueing have been achieved through increasing step length and walking velocity [2, 23]. To our knowledge, there are no studies evaluating the effects of auditory cueing on walking economy or energy expenditure and, in particular, whether or not the improvements in gait resulting from auditory cueing are accompanied by improvements in walking economy in persons with PD. This could have important clinical implications for the benefits of gait training. Therefore, the primary aims of this study were to determine 1) if persons with PD have poorer walking economy and higher energy expenditure during treadmill walking compared with age- and gender-matched control participants; and 2) whether auditory cueing improves walking economy during treadmill walking in persons with PD. An exploratory aim of this study is to determine whether persons with PD will have lower perception of effort during cued versus non-cued walking. MATERIALS AND METHODS
balanced in the second and third sessions. Participants were scheduled to report to the laboratory at the same time of day for each visit, when they felt “most on” and had minimal motor symptoms. The time since the last dose of medication was recorded and consistent across laboratory visits. Due to the wide variability in the absorption of medications [24] we believe this approach was more effective in identifying peak effect. The treadmill was calibrated per the manufacturer’s recommendations. The study was conducted in accordance with the policies and procedures of the Teacher’s College, Columbia University Institutional Review Board. Participant recruitment Men and women ages 55–80 years of age were recruited from a laboratory database of participants recruited from local neurologists for previous studies conducted in our laboratories, respondents to flyers posted on the Teacher’s College, Columbia University (New York, NY) campus and by word of mouth. Inclusion criteria for persons with PD were: stable idiopathic PD diagnosed by a neurologist, Hoehn and Yahr (H&Y) stage of 2.0–3.0, on a stable medication regimen without adjustment for the previous 3 months, and no physician-documented or self-reported history of autonomic dysfunction. Control participants were required to have no history of PD and not be medicated with or exposed to dopamine agonist drugs. Any volunteer was excluded if they had a history of dementia or cognitive impairment, a Mini-Mental State Examination (MMSE) score
