Walking with Parkinson

Walking difficulties in Parkinson's disease

Walking difficulties are among the most bothersome symptoms of Parkinson's disease and atypical parkinsonism. Due to walking difficulties, people with Parkinson's become less mobile, less active, and prone to falling, resulting in injuries.

• Types of walking difficulties

  In people with Parkinson's disease, gait changes are usually continuous. This can be subtle, such as a decreased arm swing, or more pronounced, such as a shuffling gait with short strides.

  There may also be walking difficulties that are not continuous, but occur from time to time: also known as episodic gait problems. Freezing of gait is the most important episodic gait problem in people with Parkinson's. During freezing of gait, people feel as if their feet are suddenly stuck to the ground. Freezing of gait often occurs when starting to walk, when walking through a doorway and when turning. Anxiety or wanting to do two things at the same time can also be important triggers for freezing of gait. An example of freezing of gait is shown in the video below.

  A second form of episodic gait problems is festination. People with festination walk faster and faster with increasingly smaller steps. The strides can become so small that festination eventually turns into freezing of gait. Often the upper body leans too much forward. You can see an example of festination in the video below.

• Cause of walking problems

  Gait control is complex and not regulated by just one part of the brain. To be able to walk properly, different parts of the brain, brainstem and spinal cord are involved; these parts together form a circuit that is responsible for controlling gait.

  Walking difficulties in people with Parkinson's arise because this walking circuit does not work as well. The circuit works less efficiently due to a shortage of the neurotransmitter dopamine in the brain. A deficiency of other neurotransmitters (such as acetylcholine) probably also plays a role. To make things a little more complex, it seems that walking can be controlled in different ways. For example, a different circuit is involved when we walk without consciously thinking about it (using our 'autopilot') than when we walk very purposefully (completely focused on walking). In people with Parkinson's disease, automatic walking in particular works less well, and walking improves when someone walks very consciously. In everyday life at home, the focus is often on the purpose or process of the task at hand, such as taking clothes out of the wardrobe, cooking, or having a conversation, rather than on consciously walking.

• Treatment of walking difficulties

  The treatment of both continuous and episodic gait problems consists of drugs that compensate for the deficiency of dopamine (dopaminergic drugs, such as levodopa). Unfortunately, the walking problems do not disappear completely with medication, or medication cannot be dosed high enough because of bothersome side effects. Therefore, additional rehabilitation treatment is needed. An important part of rehabilitation is learning to apply compensation strategies, also known as 'tricks'. The idea behind these strategies is that it makes walking more goal-directed or purposeful, thereby bypassing the affected circuitries in the brain that are responsible for walking on ‘autopilot’. Learn more about these tricks: compensation strategies.

Compensation strategies

Unfortunately, the walking problems in Parkinson's do not completely disappear with the use of medication. It is also possible that the medicines cause bothersome side effects. Therefore, additional rehabilitation treatment is needed. An important part of this is learning to apply compensation strategies. These are ‘tricks’ that people with Parkinson's disease can use to improve walking. Examples include: walking to the beat of a metronome, bouncing a ball while walking, walking sideways, or imitating the movements of someone else.

Categories of compensation strategies

Generally, the available compensation strategies can be classified into seven main categories:

1. Using external stimuli (external cues);

2. Using self-generated stimuli (internal cues);

3. Changing the balance requirements;

4. Altering the mental state;

5. Observing or visualizing walking (action observation and motor imagery);

6. Adopting a new walking pattern;

7. Alternatives to walking by using the legs.

Numerous strategies are available within each category. A more detailed explanation of exactly what these seven categories entail, along with practical examples of strategies, can be found on the overview page of Walking with Parkinson.

Finding the best strategy for you

Strikingly, individual compensatory strategies do not all have the same effect on every person with Parkinson's disease. What works for one person may have no, or even a negative effect on walking for another. In addition, the effect of a strategy can also depend on the situation in which the strategy is needed. It is likely that starting walking will require a different strategy than making a turn or traversing a narrow space. It is therefore important to try out several different compensation strategies, in order to determine which strategies work best for each person and situation. More information about this can be found in our step-by-step on finding the best strategy.

Hopefully the overview on this website will provide you with inspiration, and will help you discover useful ways to improve walking!