BJMB
Brazilian Journal of Motor Behavior
Special issue:
“Control of Gait and Posture: a tribute to Professor Lilian T. B.
Gobbi”
!
Sirico et al.
2023
VOL.17
N.4
118 of 125
The effects of social isolation on gait parameters of older people with Parkinson’s
disease
THIAGO M. SIRICO
1
| DIEGO ORCIOLI-SILVA
1
| VINICIUS C. ZAMPIER
1
| GABRIEL A. G. MORACA
1
| EMERSON F.
O. SANTOS
1
| VICTOR S. BERETTA
1,2
| LILIAN T. B. GOBBI
1
(in memoriam)
1
São Paulo State University (Unesp), Institute of Biosciences, Posture and Gait Studies Laboratory (LEPLO), Rio Claro, Brazil.
2
São Paulo State University (Unesp), School of Technology and Sciences, Physical Education Department, Presidente Prudente, Brazil.
Correspondence to:!Thiago Martins Sirico. São Paulo State University. Av. 24A, 1515, Bela Vista, Rio Claro, SP – Brazil; Phone: +55 19 3526-4365.
email: thsirico@gmail.com
https://doi.org/10.20338/bjmb.v17i4.367
HIGHLIGHTS
• The SI period negatively affected the mobility of people
with PD.
• Stride length and velocity are the main parameters
reduced after SI period.
• People with PD decrease their functionality after a
period of SI.
ABBREVIATIONS
CNS Central nervous system
COVID-19 Coronavirus disease
H&Y Hoehn & Yahr scale
MDS – UPDRS III Movement Disorder Society -
Unified Parkinson’s Disease Rating
Scale
MMSE Mini-Mental State Examination
PD Parkinson’s disease
pwPD People with Parkinson’s disease
SI Social isolation
WHO World Health Organization
PUBLICATION DATA
Received 26 05 2023
Accepted 19 06 2024
Published 20 06 2023
BACKGROUND: The COVID-19 disease acquired pandemic proportions in 2020. To deal
with the scenario, social isolation (SI) was adopted, which configures a lack of contact with
people and places. The impediments of this measure, however, can bring risks to older people
with Parkinson's disease (PD), such as impairments in gait parameters.
AIM: To verify the effects of SI on gait parameters in people with Parkinson's disease.
METHOD: Thirty-three people with PD were recruited. Gait assessment was conducted in two
periods: February 2020 and March 2022 (before and after the SI, respectively). For that,
participants were invited to walk on a 5.74m mat with pressure sensors under two conditions:
preferred walking speed and fast walking speed. Three trials were performed for each
condition. The gait parameters analyzed were Stride Length, Stride Time, Double Support
Time, Stride Velocity, Stride Width, and Cadence. Statistical Analysis was performed by
paired t-tests for the comparison of gait parameters between moments (pre and post-SI).
RESULTS: In the preferred walking speed condition, the participants reduced their Stride
Length (t
15
= 3.88, p = 0.001) and Stride Velocity (t
15
= 3.63, p = 0.002) in the post-SI period.
In the fast-walking speed condition, the participants also reduced their Stride Length (t
15
=
3.73, p = 0.002) and Stride Velocity (t
15
= 2.86, p = 0.012) in the post-SI period.
INTERPRETATION: The SI period reduced the stride length and velocity of people with PD. A
possible explanation is the lack of physical activity resulting from this public safety measure.
KEYWORDS: Walking | COVID-19 | Neurodegenerative disease
INTRODUCTION
Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus that took pandemic proportions in
2020. COVID-19 led to more than 761 million cases of infection, which resulted in ~6.8 million deaths worldwide until March 2023
1
.
COVID-19 primarily affects the respiratory system, causing symptoms such as breathing difficulties, headaches, dry cough, and fever
2
.
At the moment, several vaccines have been approved by the World Health Organization (WHO) and regulatory agencies; moreover, the
vaccination process is ongoing in several countries, thus, helping to prevent more infections as well as the aggravation
3
of symptoms.
However, at the beginning of the pandemic, when vaccines were not available and COVID-19 spread rapidly in many countries, public
health measures, such as social isolation (SI), had to be adopted in 2020.
The SI is an imposing measure generally implemented to stop certain threats to the population, such as the virus responsible
for COVID-19
4
. This type of isolation is defined as a state in which an individual refrains from being in any social group and certain
places, regarding proximity or physical contact. Therefore, SI leads to difficulties in maintaining several activities as well as quality
relationships
5
. Despite being an effective measure against the SARS-CoV-2 virus spread, the SI presents some risks, especially in older
populations
5,6
, such as the decline in motor function
7
and an increase of mortality
6
, dementia
8
, gait impairments
9
, and in the number of
falls
10
. Although several studies have verified the effects of SI on physical health components of older people
11
, studies that focus on the
effects of SI on gait parameters, especially in populations such as older people who have mobility impairments (e.g., people with
Parkinson's disease - PD), are still necessary.
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Brazilian(Journal(of(Motor(Behavior(
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Sirico et al.
2023
VOL.17
N.4
119 of 125
Special issue:
“Control of Gait and Posture: a tribute to Professor Lilian T. B. Gobbi”
PD is the second most common neurodegenerative disease in the world
12
, ranging from 57 (0.057%) to 230 (0.23%) cases for
each group of 100,000 people
13
, mainly affecting the population over 50 years of age
14
. PD is a pathology that affects the central
nervous system (CNS), caused by progressive and asymmetrical degeneration of dopaminergic neurons in the substantia nigra pars
compacta
15
. These neurons are responsible for the production of dopamine – a neurotransmitter that regulates cortex activity
16
. Such
degeneration causes abnormalities in the neurotransmission from the basal ganglia to the different cortical and subcortical areas, such as
the motor cortex
17
. As a result, people with Parkinson’s Disease (PwPD) present motor symptoms, which include tremor, rigidity,
bradykinesia, hypometria, and postural instability
18
. In addition, previous studies have reported gait impairments in PwPD – for example,
a decrease in step length and gait speed, and a longer double support time
19-22
.
Due to the progressive nature of the disease, it is expected that walking impairments in PwPD become worse over time.
Although SI was necessary as a public health measure, this may reduce the physical activity level in PwPD, which may contribute to the
disease progression and lead to negative motor behavior outcomes, including in the gait parameters. In fact, previous studies have
revealed that physical inactivity/sedentary behavior are associated with slower gait speed
23,24
. In addition, the analysis of walking under
different conditions has shown promising results. For example, an analysis of preferred walking speed may estimate physical function,
risk for adverse events (e.g., hospitalization, falls, fractures, or death), and chronic diseases
25-27
, while an analysis of fast walking speed
may estimate the individual’s overall health, skeletal muscle mass quantity, and risk of falls
25
. Thus, studies that verify the effects of SI on
the gait parameters, especially under different conditions, are necessary to deepen the knowledge of this type of situation (lockdown) and
to prevent the worsening of some motor deficits. In this context, the present study aimed at analyzing the effect of SI on the gait
parameters during preferred and fast waking speed in PwPD. Furthermore, in order to identify the factors such as clinical/cognitive
characteristics and physical activity levels that may influence the decline in gait parameters, we also investigated the association between
the change in gait parameters and clinical, cognitive, and physical activity levels characteristics of PwPD. We expected that PwPD with
worse clinical and cognitive characteristics as well as a lower level of physical activity would present a higher decline in gait parameters.
METHODS
Participants
Thirty-three individuals diagnosed with PD who regularly attended the Physical Activity Program for Patients with Parkinson’s
Disease (PROPARKI) prior to the COVID-19 pandemic were selected for this study. For inclusion criteria, the individuals should have a
PD diagnosis based on UK Brain Bank criteria, be of age >50 years, take their PD medication, and have independent locomotion. The
exclusion criteria were: to present musculoskeletal, vestibular, or visual impairments that could affect the performance in the experimental
protocol; to present a score above III in the adapted Hoehn & Yahr scale (H&Y); and cognitive decline indicated by a score <24 in Mini-
Mental State Examination (MMSE)
28
. Seventeen PwPD did not participate in the experimental protocol after the SI. Thus, 16 participants
were analyzed before and after SI (Figure 1). Study approval was obtained from the research ethics committee at São Paulo State
University (n. 3936). All participants gave their signed informed consent before their participation.
Figure 1. Study flowchart.
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Special issue:
“Control of Gait and Posture: a tribute to Professor Lilian T. B. Gobbi”
Experimental procedures
All experimental procedures were performed at the Posture and Gait Studies Laboratory (LEPLO), Sao Paulo State University
(Unesp), Rio Claro. Clinical, cognitive, and gait assessments were performed before (i.e., February 2020) and after SI (i.e., March 2022).
In addition, the physical activity level was measured at the post-SI moment. Participants were tested during the ‘ON’ state of
dopaminergic medication in both periods.
Clinical, cognitive, and physical activity level assessments
Firstly, the participants answered an anamnesis, and anthropometric data was obtained for characterization. An experienced
researcher assessed the motor severity and the stage of PD using the motor section of the Movement Disorder Society Unified
Parkinson’s Disease Rating Scale (MDS-UPDRS III) and the adapted Hoehn and Yahr scale, respectively. The MMSE was used as a
screening tool for cognitive assessment. To evaluate the physical activity levels of the participants during SI, the Modified Baecke
Questionnaire
29
was applied in the post-SI period. This questionnaire considered the habitual physical activity in the last 12 months in
three dimensions: occupational physical activity, physical exercises/sports in leisure, and leisure and commuting activities.
Gait evaluation
Each individual was asked to walk 8m in a straight line in two conditions: (i) preferred and (ii) fast walking speed. Three trials
were performed for each condition. A 5.74m long carpet with pressure sensors (GAITRite
®
, CIR Systems Inc., Sparta, USA), with a
sampling frequency of 200 Hz, was placed in the middle of the straight line to record the gait parameters. All steps recorded by the
system were considered for the calculation of the dependent variables, which included stride length, stride time, double support time,
stride velocity, stride width, and cadence.
Statistical analysis
SPSS 26.0 (SPSS, Inc) was used for statistical analysis. The level of significance was set at p<0.05 for all analyses. The
Shapiro-Wilk and Levene’s tests were applied to verify the normality and homogeneity of the data, respectively. Paired t-tests were used
for the gait parameters comparison between moments (pre vs. post-SI). Cohen’s d statistic provided estimates of the effect sizes for the t-
test (d: 0.2 = small, 0.5 = moderate, 0.8 = large)
30
. Pearson’s correlation coefficient was used between gait parameters (considering the
difference between post- and pre-SI; Δ) and the scores from MDS-UPDRS III, MMSE, and The Modified Baecke Questionnaire to verify if
there were significant relations between gait parameters and clinical, cognitive, and physical activity level data.
RESULTS
The demographics and clinical characteristics of the participants are shown in Table 1.
Table 1. Participants characteristics. The parametric variables are shown as mean and standard deviations, and the non-
parametric variables as medians and 25-75 percentile.
Sample size = 16
Age (years)
69.37±7.79
Weight (kg)
72.46±12.10
Height (cm)
165.02±7.35
MDS-UPDRS III (0-132)
33.5 (26.75-40.25)
H&Y stage (1/1.5/2/2.5/3)
0/0/9/4/3
MMSE (0-30)
28 (25.00-29.00)
Baecke (score)
7.66 (6.41-10.12)
MDS-UPDRS III: Movement Disorder Society Unified Parkinson’s Disease Rating Scale part III; H&Y: Hoehn & Yahr
Scale; MMSE: Mini-Mental State Examination.