Most evenings, Mark Mason can be seen out walking under a lush canopy of live oaks in his Gainesville, FL, neighborhood, using poles that allow him to stay upright and move smoothly and with confidence. Poles are often used by hikers and speed walkers to navigate hilly or rocky terrain, but for Mason, a 72-year-old retired NASA computer scientist with Parkinson's disease, they serve a different purpose: They enable him to walk two to three miles most days of the week—something he couldn't do otherwise. “They help me increase my stride and walk more upright,” he says. “Without them, I'd curl inward and shuffle.”
And walking outside is more enjoyable than getting on a treadmill in a gym, Mason says. “It gets me out in nature, which is uplifting and beautiful and soul-cleansing.”
Anna Grill, who was diagnosed with Parkinson's disease 14 years ago, uses a different tactic to get going. She experiences freezing, a sensation that makes her feel as if her feet are stuck to the floor. “It usually happens when I'm forced to stop short, say, in a crowded mall,” says the 52-year-old resident of Vienna, VA. “I have to pause, and I can't resume. I just can't move my legs.”
Through trial and error, Grill and her care team figured out a solution. “I get myself in a runner's stance, like I'm standing at a starting line, with one foot in front of the other,” she says. “Then I do a ‘ready, set, go’ in my head, and launch myself forward.”
Problems with walking and balance are common in people with Parkinson's disease, often because of bradykinesia (slowness of movement), tremor, or rigidity, says Fay Horak, PhD, PT, professor of neurology at Oregon Health & Science University in Portland. Another part of disease progression, she says, is a decline in proprioception—the body's ability to sense position, movement, and location—which can complicate walking.
Normally, Dr. Horak explains, the legs, head, eyes, and torso work in a coordinated fashion in ambulation. In people with Parkinson's disease, movement slows down and is less stable. People also make smaller rotations of the head, trunk, and pelvis. “This makes it especially difficult to turn safely,” Dr. Horak says. “We've done studies showing that people turn, on average, about a thousand times a day.” Falling when trying to turn is more likely to result in a hip fracture than falling while walking, she says.
The experiences of Mason and Grill illustrate that different situations call for different corrective methods. “Trying to improve stride length and posture during daily walks outside requires a different approach from trying to get yourself going after a freeze,” says Anouk Tosserams, MD, professor of medicine at Radboud University Medical Center in the Netherlands.
For a paper published in the September 2021 issue of Neurology, Dr. Tosserams and her co-investigator Jorik Nonnekes, MD, PhD, surveyed 4,324 adults with Parkinson's disease who reported disabling gait impairments to find out how much they knew about and used various compensation strategies. The researchers grouped the strategies into seven categories: internal cues (such as walking to an imagined beat), external cues (walking to the beat of a metronome or using a laser pointer to create a target on the ground), making wider turns, incorporating relaxation techniques to reduce stress, watching other people walk and mimicking their movements, adopting new walking patterns (such as raising the knees high or walking backward), and using the legs in other ways (such as riding a bicycle). Mason's walking poles are an external cue, while Grill's reciting of “ready, set, go” would be an internal cue.
Dr. Tosserams and Dr. Nonnekes found that most strategies generally work well for most patients, but they need to experiment to find the best ones for their circumstances, says Dr. Tosserams, who believes that being aware of different strategies helps. “If you're having trouble with one, you can try one of the others,” she says.
“A lot of these ideas are great and creative,” says Michael S. Okun, MD, FAAN, endowed professor of neurology at the University of Florida in Gainesville and a medical adviser for the Parkinson's Foundation. His own research shows that syncing your rhythm to music is an effective way to improve stride and increase arm swing. And the type of music matters. For example, Dr. Okun found that using an up-tempo, beat-propelled song like the Bee Gees' 1977 disco hit “Staying Alive” was highly effective in improving walking performance. “The Bee Gees were better than a metronome,” he says. “But what works for one patient might not work for others,” he adds.
Dr. Horak agrees. “Because some of these cues work for a while and then stop, you should have more than one handy,” she says. “Let's say you've been walking using your laser pointer and you freeze. You might want to turn on the metronome feature on your phone.”
Patients also should involve their care teams. “If you're having problems with walking or balance or freezing, it's important to discuss internal cueing and assistive devices with your neurologist and physical therapist,” says Dr. Okun. “Different folks will respond to different cues, and those cues can change because Parkinson's is a progressive disease. So don't get discouraged.”
For now, Grill is sticking with her “ready, set, go” approach, and with an exercise regimen that includes boxing classes and indoor rock climbing. “If it isn't broken, don't fix it,” she says. “I'm going to keep doing it and be grateful that I can.”
The ongoing search for strategies may be its own benefit: It may help reduce apathy. “Apathy is a loss of motivation, independent of depression, that can occur in people with Parkinson's disease,” says Jori Fleisher, MD, MSCE, FAAN, associate professor of neurologic sciences at Rush University Medical Center in Chicago. “It can be a barrier to starting and maintaining exercise programs and can create tension between patients and their care partners and family members,” she says. “Sharing activities can help overcome this.” That has worked for Mark Mason and his wife, Kathleen, who often joins him on his early-evening walks. “Finding things that work can be motivating,” Kathleen says, “and even fun.”
