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Parkinson’s: 7 strategies used to deal with walking difficulties assessed

A Dutch study assesses the efficacy of a variety of compensation strategies that have been developed by people with Parkinson’s to overcome walking difficulties.

Various strategies can help people with Parkinson's who have difficulty walking, but research finds that many people have never heard of or tried these strategies.

The study is published in the online issue of Neurology, the medical journal of the American Academy of Neurology.

How well different compensation strategies worked depended on the context in which they were used, such as indoors versus outdoors, under time pressure or not, the study also found.

"We know people with Parkinson's often spontaneously invent creative 'detours' to overcome their walking difficulties, to remain mobile and independent," said study author Dr Anouk Tosserams, of the Radboud University Medical Centre in Nijmegen, the Netherlands.

"For example, people walk to the rhythm of a metronome, by mimicking the gait of another person, or by counting in their head. We found they are rarely educated about all the different compensation strategies. When they are, people often find strategies that work better for them and their unique circumstances."

For the study, researchers surveyed 4,324 people with Parkinson's and disabling gait impairments. These include problems like imbalance, shuffling, falling, staggering and freezing. Of the participants, 35% found that their walking difficulties affected their ability to perform their usual daily activities and 52% had one or more falls in the past year.

The survey explained the seven main categories of compensation strategies. They are: internal cueing, like walking to a count in your head; external cueing, like walking in rhythm to a metronome; changing the balance requirement, like making wider turns; altering mental state, which includes relaxation techniques; action observation and motor imagery, which includes watching another person walk; adapting a new walking pattern, like jumping or walking backwards; and other forms of using the legs, like bicycling and crawling. Each category was explained and participants were asked if they were aware of it, if they'd ever used it, and if so, how it worked for them in a variety of contexts.

Researchers found that people with Parkinson's commonly use walking compensation strategies, but are not aware of all seven strategies. For example, 17% of them had never heard of any of these strategies, and 23% had never tried any of them. Only 4% were aware of all seven categories of compensation strategies. The average person knew about three strategies. Other than the use of walking aids and alternatives to walking, the best-known strategy was external cueing, like listening to a metronome, known by 47% of the respondents. That was followed by internal cueing, known by 45%. Action observation and motor imagery was the least known category, known by 14%.

For each strategy, most people who tried it said it had a positive effect. For example, 76% said changing the balance requirement made a positive impact, while 74% said altering their mental state did.

However, researchers also discovered that strategies worked differently according to the context in which the person used it. Internal cueing, for example, seemed highly effective during gait initiation, with a 73% success rate. Only 47% found that tactic useful when trying to stop walking. Similarly, visualising the movements had an 83% success rate when people used it walking outdoors. It only had a 55% success rate when people used it to navigate a narrow space.

"Our findings suggest that a 'one-size-fits-all' approach doesn't work, because different contexts might require different strategies, or because individuals simply respond better to one strategy compared with another," Tosserams said. "We need to go a step further and teach people about all the available compensation strategies, for example through a dedicated online educational platform. This may help each person with Parkinson's find the strategy that works best for them."

A limitation of the study is that people reported their own gait disability, which was not confirmed by an independent neurological examination.

Study details

Perception and Use of Compensation Strategies for Gait Impairment by Persons With Parkinson Disease.

Anouk Tosserams, Lisanne Wit, Ingrid H.W.M. Sturkenboom, Maarten J. Nijkrake, Bastiaan R. Bloem, Jorik Nonnekes

Published in Neurology on 8 September 2021;



Gait impairments are common and disabling in Parkinson’s disease (PD). Applying compensation strategies helps to overcome these gait deficits. Clinical observations suggest that the efficacy of different compensation strategies varies depending on both individual patient characteristics and the context in which the strategies are applied. This has never been investigated systematically, hampering the ability of clinicians to provide a more personalised approach to gait rehabilitation.

We had three aims: (1) to evaluate patients’ awareness and actual use of compensation categories for gait impairments in PD; (2) to investigate the patient-rated efficacy of the various compensation strategies, and whether this efficacy depends on the context in which the strategies are applied; and (3) to explore differences in the efficacy between subgroups based on sex, age, disease duration, freezing status, and ability to perform a dual task.

A survey was conducted among 4,324 adults with PD and self-reported disabling gait impairments.

The main findings are: (1) compensation strategies for gait impairments are commonly used by persons with PD, but their awareness of the full spectrum of available strategies is limited; (2) the patient-rated efficacy of compensation strategies is high, but varies depending on the context in which they are applied; and (3) compensation strategies are useful for all types of PD patients, but the efficacy of the different strategies varies per person.

The choice of compensation strategies for gait impairment in PD should be tailored to the individual patient, as well as to the context in which the strategy needs to be applied.

Classification of Evidence
This data provides Class IV evidence that compensation strategies are an effective treatment for gait impairment in Parkinson's disease patients with gait impairment.


Neurology article – Perception and Use of Compensation Strategies for Gait Impairment by Persons With Parkinson Disease (Open access)


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