Improving Gait Performance in Parkinson's Disease

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Please cite this article in press as: Mathieson I, et al., Improving gait performance in Parkinson’s disease: a case report suggesting a role

for footwear modifications, Physiotherapy (2007), doi:10.1016/j.physio.2007.04.009

ARTICLE IN PRESSPHYST-303; No.of Pages 4

Physiotherapy xxx (2007) xxx–xxx

Improving gait performance in Parkinson’s disease: a casereport suggesting a role for footwear modifications

Ian Mathieson a,∗, Sarah Curran a, Sue Hallam b, Judi Corne b

a Wales Centre for Podiatric Studies, University of Wales Institute, Cardiff, Western Avenue, Cardiff CF5 2YB, UK b Springfield Physiotherapy Department, Springfield Day Unit, St. Woolos Hospital, Stow Hill, Newport NP20 4SZ, UK

Abstract

This case report describes a patient with Parkinson’s disease who, frustrated by increasing falls, modified his footwear by applying an

external forefoot sagittal plane wedge to elevate his toes off the ground. The patient claimed improved gait performance, and the authorssought to investigate the basis for these claims using tests of functional gait performance. Insight into the mechanism of action was also

sought using PEDAR© (Novel Gmbh, Munich, Germany) in-shoe pressure analysis and Quintic© (Quintic Consultancy, Coventry, UK) gait

analysis system. Performance against all functional tests suggested small improvements. For example, the ‘Timed up and go test’ changed

from 15 seconds with nine steps without the modified footwear to 10 seconds with five steps with the modified footwear. PEDAR analysis

suggests that this may originate from improved control of the centre of pressure, which is consistent with improvements suggested by Quintic.

These include a longer period of ground contact. Further research is warranted to investigate the role of this intervention in the management

of gait dysfunction in Parkinson’s disease.

© 2007 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Keywords: Parkinson’s disease; Gait; Footwear

Introduction

Parkinson’s disease is a common, progressive, neurode-

generative disorder [1,2] that is associated with a range of

disablingfeatures includingimmobility, loss of independence

in the activities of daily living and postural instability [2].

Falls are common, as illustrated by a year-long prospective

study which recorded a total of 585 fall events (median 3,

range 1–60) in a group of 109 Parkinson’s patients [3]. The

association of falls with femoral fractures, increased depen-

dency and risk of nursing home admission, reduced quality

of life and social isolation because of fear of falling [3,4]

illustrates their relevance.

Whilst pharmacological intervention is the mainstay of

Parkinson’s treatment [5,6], there is little evidence to suggest

that drug therapy consistently improves balance to reduce

falls [1,2]. Gait training has emerged as a potentially useful

alternative, with reports suggesting that intensive training in

∗ Corresponding author. Tel.: +44 29 2041 6864; fax: +44 29 2041 7191.

E-mail address: [email protected] (I. Mathieson).

the use of compensatory steps to cope with externally applied

perturbations [4], and treadmill-based gait and stability train-

ing [7] may improve stability and reduce fall frequency.

Despite such studies, Grimbergen et al. [8] recently asserted

that there have been no dramatic breakthroughs in the man-

agement of falls in Parkinson’s disease.

This case report illustrates a novel, non-pharmacological

intervention associated with improved gait performance in a

74-year-old male with idiopathic Parkinson’s disease.

Participant characteristics

The patient was diagnosedwithidiopathicParkinson’s dis-

ease in August 1994. The disease followed a characteristic

course with gradually worsening symptoms. Over the first 6

years of the disease, the symptoms included visual hallucina-

tions, freezing, stooped posture, bradykinesia and problems

with forward falls, which were first noted in July 1999. Dur-

ing three courses of physiotherapy between 2002 and 2004,

the ‘Timed-up-and-go test’ (TUG) was recorded consistently.

0031-9406/$ – see front matter © 2007 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.physio.2007.04.009

http://dx.doi.org/10.1016/j.physio.2007.04.009

mailto:[email protected]



mailto:[email protected]







2 I. Mathieson et al. / Physiotherapy xxx (2007) xxx–xxx

Results of 17 seconds with 28 steps in 2002 worsened, and

by 2004, a walking stick and supervision were required to

achieve a result of 38 seconds with 39 steps. An entry from

the medical notes in August 2003 stated that ‘. . .this patient

is getting very difficult to treat’.

In the summer of 2004, the patient became increasingly

frustrated by his gait dysfunction, where his toes felt stuck to the ground: ‘. . .as if by magnets. . .’. He attached wooden

wedges to the soles of his shoes in an effort to physically

lift his forefoot off the ground. Whilst the hardness of the

wood caused some minor discomfort, the patient claimed

a clear improvement in postural stability, gait and fall fre-

quency. A cobbler, who was simply told that the forefoot

should be higher than the rearfoot, made permanent mod-

ifications and the wedge was tapered down to merge with

the sole at the level of the metatarsal heads. The patient

claims that the initial improvement has been sustained. An

entry in his medical notes from August 2005 stated that the

patient ‘. . .looked extremely well. . .is obviously coping bet-

ter with his Parkinson’s symptoms. . .’. Attribution of theseimprovements to the modifications was suggested in Novem-

ber 2005 when the Parkinson’s nurse wrote in the notes that

‘. . .mobility is good and has certainly improved with his

newlyfittedshoes. This hascertainly reduced hisfrequency of

falls.’

Method of investigation

A battery of tests was performed to investigate the effect

and mechanism of action of the modification objectively.

The Hoehn and Yahr rating system was used to documentthe extent of disease on the day of testing. Performance

against various established measures of functional perfor-

mance (TUG [9], 10-metre walk and 6-minute walk tests

[10,11], and the Problem-oriented Assessment of Mobility

[12]) was conducted in ‘normal’ and then ‘modified’ shoe

states. Measurements were recorded three times and aver-

aged, although the 6-minute walk was considered too tiring

to repeat. The PEDAR© (Novel Gmbh, Munich, Germany)

in-shoe pressure measurement system, sampling at a fre-

quency of 50 Hz with a threshold of 3 N/cm2

, was usedto obtain information on the maximum and average veloc-

ity (metres/second), and distance travelled by the centre of

pressure. Quintic© (Quintic Consultancy, Coventry, UK) was

used to provide insight into gross gait changes, and involved

visual assessment of two midgait steps recorded during the

10-metre walk test. The nature of the tests was explained

and informed consent was obtained. Medication was taken at

1.45 pm, with data collection taking place between 2.45 and

4 pm.

Results

The Hoehn and Yahr rating on the day of the test was Stage

3. Results of the tests of functional performance, walking

capacity and PEDAR analysis are provided in Table 1.

PEDAR images (Fig. 1) illustrate the influence of the

modification on the pathway of the centre of pressure. The

distance travelled and velocity changes detailed in Table 1

are consistent with the changes displayed.

Quintic analysis comprised visual assessment of stance

kinematics. Images were captured at footstrike, midstance

and contralateral footstrike. These images (Fig. 2) suggest

several effects associated with the footwear modification:

• increased step length;

• improved footstrike position with the ankle closer to a

neutral to slightly dorsiflexed position; and

Table 1

Results of tests of functional performance, the Problem-oriented Assessment of Mobility (POAM) and PEDAR analyses

Test Normal footwear Modified footwear

Timed-up-and-go 15 seconds 10 seconds

9 steps to turn 180◦ 5 steps to turn 180◦

10-metre walk 10 seconds 10 seconds

22 steps 18 steps

6-minute walk 329 metres 339 metres

25 ‘touches’ No ‘touches’3 ‘averted falls’ No ‘averted falls’

POAM Balance = 7 Balance = 9

Gait = 10 Gait = 15

Total = 17 Total = 24

PEDAR analysis

Left foot Right foot Left foot Right foot

Maximum velocity (metres/second) 1.40 ± 0.25 2.35 ± 0.10 0.52 ± 0.11 1.26 ± 0.54

Average velocity (metres/second) 0.35 ± 0.01 0.38 ± 0.02 0.20 ± 0.01 0.24 ± 0.02

Distance (centimetres) 14.11 ± 0.40 15.45 ± 2.50 16.00 ± 0.90 18.10 ± 2.10

‘Touches’ and ‘averted falls’ represent intervention by the accompanying physiotherapist to aid stability or prevent a fall, respectively. The POAM indicates

falls risk, where ≤18 suggests high risk, 19–23 suggests moderate risk and ≥24 suggests low risk.








I. Mathieson et al. / Physiotherapy xxx (2007) xxx–xxx 3

Fig. 1. The pathway of the centre of pressure in the normal (left) and modified (right) states. The pathway of the centre of pressure is represented by the heavy

line within the footprint. On the scale at the bottom of each picture, both the white and black boxes on the left relate to 20 kPa. The white represents zones

where the threshold of 20 kPa has not been achieved, to eliminate ‘noise’, whilst the black box represents zones where a pressure of 20 kPa or more has been

achieved.

Fig. 2. Photoboards providing insight to stance phase function. In both photoboards, a physiotherapist can be seen walking alongside the patient and a walking

stick is being used. The top strip shows the unmodified footwear position and the bottom strip shows the modified footwear position.

• longer midstance phase with a longer heel contact period,

as opposed to the rapidunloading thatcharacterises Parkin-

son’s gait.

Discussion

The seemingly positive response of this patient to this

intervention is intriguing. The tests used are employed rou-

tinely to evaluate gait function [8–12] and areused commonly

within the authors’ department. Measurements indicate a

modest change in scores between states. For example, 10

more steps over 6 minutes and a reduction of four steps dur-

ing the 10-metre walk test are small changes. Five seconds

faster with four fewer steps for the TUG is also a small effect,

especially given recent findings which indicate that the vari-

ability of this test increases with the time taken to perform it,

with a 10-second result varying from 7 to 15 seconds and a

40-second result varying from 26 to 61 seconds [13]. There-

fore, despite appearing positive with improvement in all tests,

the results must be interpreted with caution.

PEDAR and Quintic analysis suggest a plausible mech-

anism of action. A wedge extending from the proximal

metatarsal heads to the tip of the toes results in the produc-

tion of an ankle dorsiflexion moment that is, theoretically,

capable of resisting forward motion. This mechanism of

action is consistent with the improvement in the pathway

of the centre of pressure visible on PEDAR and the enhanced

unloading pattern observed on Quintic. However, this is not

an entirely satisfactory explanation as a forefoot wedge act-ing in stance fails to explain changes in footstrike position.

This patient was enthusiastic about a modification that he

had helped to develop and this may account for his increased

optimism about his Parkinson’s disease. There may be a

placebo/psychological dimension acting, and this potential

source of bias is important. Furthermore, if the mechani-

cal effect described is accurate, there must be a threshold at

which a backward fall becomes a possibility and this requires

investigation.

Further research is required and the authors have started to

plan a systematic investigation. A phase I, proof of concept

trial is being designed in an effort to establish if there is a con-








4 I. Mathieson et al. / Physiotherapy xxx (2007) xxx–xxx

sistent effect across a smallgroup of homogenousParkinson’s

disease patients. This will be conducted in a tightly controlled

environment with safety issues paramount. Several forms of

modification will also be examined to investigate the opti-

mal dimensions. In addition to using various measures of

functional gait performance, kinematic and kinetic data will

be recorded to gain insight into the mechanism of action.Footwear modifications such as these may have some role to

play in the management of gait dysfunction in Parkinson’s

disease.

Ethical approval: None required.

Conflict of interest: None.

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