Festinating gait and it's physiotherapy management

It talks about how festinating gait is seen and it's detailed physiotherapy management to be followed.

1. PARKINSON’S GAIT OR FESTINATING GAIT

2. DEFINITION: Festination is characterized by a flexed posture of the trunk and extremities, a tendency to take small, accelerating steps, and a difficulty in initiating or maintaining a normal walking pace. It is associated with a high risk of falls and can significantly impact patient’s quality of life.

3. TYPES OF FESTINATION There are two basic phenotypes of festination. The first phenotype entails a primary locomotion disturbance. More specifically, this first basic phenotype of festination is due to so-called sequence effect: a progressive shortening of step length , accompanied by a compensatory increase in cadence . This phenotype most commonly starts in the beginning of walking (e.g. during gait initiation, or after turning).

4. The second phenotype is not a primary locomotion disturbance, but represents a secondary phenomenon, resulting from a combined postural deficit (forward leaning of the trunk) and a balance control deficit (inappropriately small balance-correcting steps). In festinating gait, these compensatory balance-correcting steps are often too small, and are therefore insufficient to restore the center of gravity within the base of support. Thus, to prevent falling, patients increase their cadence, and reduce their step length.

5. Figure 2: Two phenotypes of festination

6. ETIOLOGY OF FESTINATING GAIT The etiology of festinating gait or possible pathological pathway is based on the phenotype of the gait. The underlying mechanisms in case of first phenotype of gait is due to progressive shortening of steps and acceleration of step frequency. This is caused due to defective cue production by basal ganglia. The basal ganglia is a key component for automatic motor control and motor plan. Thus, dysfunction of basal ganglia results in defective cue production and haphazard motor events.

7. Alternatively, if cerebellum is affected then there is stimulation of excitation center of cerebellum resulting in increased gait speed and reduced step length. The second phenotype is result of combined forward leaning of the trunk and small balance correcting steps. Forward leaning of the body is also commonly seen in case of festinating gait and the phenomenon is called camptocormia. Camptocormia can be defined as an involuntary flexion of the spine of at least 30 degrees at the lumbar fulcrum or 45 degrees at thoracic fulcrum, which is present during standing or walking and resolves in supine position. Apart from postural disturbances there can also be n igrostrial degeneration which may result in festinating gait.

8. CONDITION ASSOCIATED WITH FESTINATING GAIT Festinating gait is commonly associated with Parkinson’s disease. It is a chronic, progressive neurodegenerative disease characterized by motor and non-motor features. The term parkinsonism is a complex topic which consists of 4 main cardinal features – Resting tremor. Rigidity. Akinesia or freezing of gait. Postural instability. Gait disorders represent one of the most disabling features of Parkinson’s disease. Gait impairment in the form of shuffling, short steps, or freezing of gait often occurs in Parkinson’s disease, generating substantial disability.

9. CHANGES OBSERVED IN PHASES OF GAIT CYCLE. The three- dimensional motion analysis describes abnormalities in cadence, stance duration, swing duration, double support duration, step length, velocity as well as ranges of motion (ROMs) of hip, knee and ankle joints. Reduced stride length; increased step to step variability Reduced speed of walking Cadence (steps per minute) typically intact; may be reduced in case of advanced PD Increased time: double limb support Insufficient hip, knee and ankle flexion: leads to shuffling gait.

10. Reduced Insufficient heel strike with increased fore foot loading trunk rotation: decreased or absent arm swing Freezing of gait (FOG) Difficulty turning: increased steps per turn Difficulty with dual tasking: simultaneous motor and/or cognitive tasks Difficulty with attention demands of complex environments Patients typically demonstrate difficulty in attaining and sustaining walking speed and may have difficulty in foot clearance with shuffling gait patterns seen in case of advanced disease. There is a strong association with duration and severity of PD with increased risk of falls.

11. STANCE PHASE (80-85%) SWING PHASE (15-20%) stride length : reduced Insufficient hip, knee and ankle flexion Insufficient heel strike with increased fore foot loading. Reduced trunk rotation decreased or absent arm swing Double support time: increased Disturbed gait rhythm Cadence : typically intact may e reduced incase of advanced PD Freezing of gait (FOG) Mean stance time increased Difficulty turning : increased steps per turn Step length : reduced Swing length : decreased

12. GOALS OF TREATMENT SHORT TERM GOALS Patient and caregiver knowledge and awareness of the gait pattern, prognosis and it's plan of care. Impact of impairments has to be reduced. Risk of secondary complications LONG TERM GOALS Postural control has to be improved. Gait and locomotion have to be improved. Independence in activities of daily living is increased. Ability to resume self-care and home management is improved. Ability to assume work (job/ school/play), community, and leisure roles is improved.

13.   Insight self- confidence, self-management skills are improved. Health, wellness and fitness are improved. Patient/client satisfaction is enhanced. Prevention of inactivity and management of fear of falls. Management of global motor activities. Reduction of pain. Delaying the onset of physical limitations.

14. PHYSIOTHERAPY MANAGEMENT The management of physiotherapy based is on the phenotype of festination. First phenotype is caused due to defective cue production, it usually benefits from cueing strategies. Spatial(visual) cues usually correct and regulate the scaling and amplitude generation during walking, whereas temporal(auditory) cues facilitate gait timing. Ambulatory cueing devices, such as visual cueing using a laser shoe, or smart glasses that enable visual cueing using augmented reality are now being developed. For the second phenotype, treatment should primarily target the underlying postural control deficits and balance impairment, and not the locomotion disturbance. Postural education and tactile cues using Kinesio tapes are given.  

15. Locomotor training focuses on primary gait impairments. Training programs are designed to lengthen stride, broaden base of support, improve stepping, improve heel-toe gait pattern, increase contralateral trunk movement and arm swing, increase speed and provide a program of regular walking. Locomotor training is an activity-based therapy to help improve and recover walking movement through challenged practice and lower extremity weight bearing. Aquatic therapy to improve the speed of walking, strength of muscles and overall body fitness. Dual task gait training Robotic assisted training.

16. Monitarized treadmill training with an overhead harness to improve gait speed, stride length and walking distance.

17. Rehabilitation program It is comprised of one 60 -min session/day, performed 3 days/week. Participants within the program were encouraged to progress based on pre-defined progression criteria by performing progression exercises including ROM exercises, stretching, and improving balance, standing, sitting, transferring, and walking.  

18. Detailed list of exercises Standing up from and sitting down onto the floor Standing and walking on foam with and without perturbations (pushes and pulls) to the trunk Sitting down onto and rising from a chair while dual tasking Getting into and out of bed

19. Rolling over in bed Walking with large steps and large amplitude arm swings Walking around and over obstacles Walking with sudden stops and changes in direction, including walking backwards Walking and maintaining balance while dual tasking, such as talking, carrying an object, or turning the head left to right to view wall mounted dots or photos and reporting what is seen. Walking and maintaining balance while dual tasking, such as talking, carrying an object, or turning the head left to right to view wall mounted dots or photos and reporting what is seen. Turning around in open, small, and narrow spaces. Climbing steps.