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Gait Re-education in Parkinson's

Original Editor - Purnima Shrivastava Irene Leahy

Top Contributors - Purnima Shrivastava, Laura Ritchie, Kim Jackson, Tolulope Adeniji, Vidya Acharya, Wendy Walker, Irene Leahy, WikiSysop, Alexandra Stead, 127.0.0.1, Mariam Hashem, Claire Knott and Lauren Lopez  

Introduction

Parkinson's disease is a progressive neurodegenerative condition associated with reduced dopamine production in the substantia nigra. Motor features commonly include bradykinesia, rigidity, tremor, postural instability and gait disturbance.[1]

Gait disturbance in Parkinson’s disease may include reduced step length, reduced gait speed, reduced foot clearance, reduced arm swing, festination, freezing of gait, impaired turning and difficulty walking while completing a second task.[2] These impairments can contribute to falls risk, reduced confidence, reduced community mobility and reduced participation.[3]

Gait re-education aims to improve safe, efficient and meaningful walking through person-centred assessment, task-specific gait practice, cueing strategies, balance training, strength and aerobic exercise, dual-task training and education. Physiotherapy management should be individualised according to the person’s disease stage, medication response, falls history, freezing of gait, cognition, fatigue, environment and functional goals.[4][5]

Typical Gait Pattern in Parkinson's

[6]

People with Parkinson’s disease may develop gait changes as the condition progresses.[7] Common gait impairments include:[2][8][9]

  • Reduced step length and gait speed
  • Reduced foot clearance
  • Reduced arm swing
  • Festination, where steps become progressively shorter and quicker
  • Freezing of gait, where there is a brief, episodic inability to initiate or continue stepping
  • Difficulty turning
  • Reduced ability to adapt gait to environmental demands
  • Difficulty walking while completing a second motor or cognitive task

These gait changes can increase falls risk and may reduce confidence, participation and community mobility. Fear of falling may also contribute to activity restriction and social isolation.[3]

Gait Kinematics

Gait kinematics in Parkinson’s disease commonly include reduced stride length, reduced walking velocity and reduced lower limb joint excursion.[10] Three-dimensional gait analysis has shown reduced ankle range of movement during push-off, reduced plantarflexion at toe-off and reduced ankle power generation during pre-swing in people with Parkinson’s disease.[10]

Some people with Parkinson’s disease may demonstrate reduced heel strike, reduced push-off, shorter steps and a flatter foot contact pattern. These changes may affect obstacle negotiation, walking on uneven surfaces, turning and safe mobility in more complex environments.[10] Gait kinematics should therefore be interpreted alongside clinical observation, functional mobility assessment, medication status, falls history and the person’s usual walking environment.[5]

Pathophysiology

Gait disturbance in Parkinson’s disease is multifactorial. Bradykinesia may contribute to reduced movement amplitude, shorter step length and reduced gait speed, while rigidity, impaired postural responses and reduced automaticity may contribute to festination, freezing of gait and falls risk.[2][3]

Festination may occur when step length progressively reduces and cadence increases as the person attempts to maintain forward progression. Freezing of gait is commonly described as a brief, episodic inability to initiate or continue stepping, despite the intention to walk.[2][3]

Postural instability in Parkinson’s disease may also be influenced by impaired postural response organisation and reduced ability to adapt postural strategies to changing task and environmental demands. Horak et al. reported abnormal postural response patterns in people with parkinsonism, including excessive antagonist activity and difficulty adapting to changing support conditions.[11]

These mechanisms help explain why gait re-education often uses external cueing, attentional strategies, task-specific practice, balance training and environmental adaptation to support safer and more effective walking.[5]

Clinical Assessment

Gait re-education should be guided by a person-centred assessment that considers the person’s goals, clinical presentation, functional priorities and walking context.[4][5] Assessment should consider disease stage, medication timing, cognition, falls history, freezing episodes, fear of falling, home environment, activity goals, comorbidities, fatigue and the person’s usual walking environments.[4][5] Where symptoms fluctuate, gait should be considered in relation to “on” and “off” medication periods, particularly when freezing of gait, motor fluctuations or variable mobility are reported.[12]

Gait Analysis

Clinical gait analysis should include observation of step length, gait speed, cadence, foot clearance, heel strike, push-off, arm swing, trunk posture, turning, freezing episodes, dual-task walking and the person’s ability to adapt gait to environmental demands.[5][10] The physiotherapist should also observe gait initiation, stopping, turning, doorway negotiation, obstacle negotiation, walking in narrow spaces and walking while carrying out a cognitive or motor task, as these activities may provoke freezing or reveal reduced gait adaptability.[3][2]

Assessment should include safety considerations such as falls history, use of walking aids, footwear, orthostatic symptoms, fatigue, environmental hazards and the level of supervision required during walking practice.[4][5] The person’s goals and usual walking contexts should guide the choice of intervention, for example indoor mobility, outdoor walking, community participation, confidence with turning, or walking while completing everyday tasks.[5]

Outcome Measures

Useful outcome measures may include gait speed, the Timed Up and Go, 10 Metre Walk Test, 6 Minute Walk Test, Mini-BESTest, Berg Balance Scale, Functional Gait Assessment, Freezing of Gait Questionnaire, falls history and self-reported balance confidence or participation measures.[13]

The Functional Gait Assessment and BESTest have demonstrated reliability and validity for assessing balance and falls risk in people with Parkinson’s disease.[14] The Mini-BESTest has also been reported as a clinically useful balance measure in Parkinson’s disease, including for identifying falls risk.[15] The Freezing of Gait Questionnaire is a validated tool for assessing freezing of gait in people with Parkinson’s disease.[16][17]

The choice of outcome measure should reflect the person’s goals, safety, clinical setting, disease stage and the specific gait or balance impairment being assessed.[13][5]

Physiotherapy Management

Physiotherapy management should be individualised, goal-directed and based on the person’s clinical presentation, medication response, safety needs and functional priorities.[4][5] Current clinical practice guidance supports Parkinson’s-specific physiotherapy, including gait training, external cueing, balance training, resistance training, aerobic exercise, task-specific practice and strategies that support long-term physical activity.[5] Treatment should be progressed according to the person’s response to exercise, falls risk, fatigue, cognition, confidence and functional goals.[5]

Flexibility Exercises

Flexibility exercises may be useful where rigidity, reduced range of movement, pain or postural change affects gait and functional mobility. They are best used as part of a broader programme that also includes task-specific gait practice, balance training, strengthening, aerobic exercise and physical activity support.[5]

Reuter et al. reported improvements in 12 m and 24 m Webster Walking Tests following flexibility exercises and relaxation training delivered three times per week for six months.[18] However, greater improvements were reported in the walking and Nordic walking groups, supporting the importance of task-specific walking-based interventions when the primary goal is gait improvement.[18]

Strength Training

[19]

Progressive resistance training can improve strength and physical performance in people with mild-to-moderate Parkinson’s disease, although carryover to all functional performance measures may vary.[20] Resistance training should be considered as part of a broader rehabilitation programme, particularly where weakness, reduced power, reduced walking capacity or reduced balance confidence affects mobility.[5]

Tambosco et al. assessed the efficacy and limitations of aerobic and strength training in physical rehabilitation programmes for Parkinson’s disease.[21] More recent evidence also supports aerobic and resistance training for improving motor function, gait velocity, balance-related outcomes and functional mobility in older adults with Parkinson’s disease.[22]

Balance Training

[23]

Balance training should be considered where postural instability, reduced balance confidence, impaired turning, freezing of gait or falls risk are present.[5] Training may include static and dynamic balance tasks, anticipatory and reactive postural control, stepping strategies, turning practice, obstacle negotiation, dual-task activities and functional balance tasks relevant to the person’s goals.[5]

A 2023 systematic review and network meta-analysis reported that exergaming, dance, rhythmic auditory exercise and balance training can improve postural balance outcomes in people with Parkinson’s disease.[24] These findings support the use of varied, task-specific and engaging balance interventions, selected according to the person’s presentation, goals, safety and access to resources.[24][5]

Earlier studies have explored specific balance interventions, including Wii Fit balance board training and Parkinson's-weight bearing exercise for better balance training.[25][26] These studies may be useful as examples, but they should be interpreted alongside more recent systematic review and guideline evidence.[24][5]

Cueing Strategies

[27]

External cues may be auditory, visual, verbal, tactile or attentional. Cueing strategies aim to provide an external stimulus or conscious attentional focus to support gait initiation, step length, rhythm, turning and freezing of gait management.[5]

Examples include floor markers, stepping targets, rhythmic auditory stimulation, metronome beats, counting, verbal prompts and attentional strategies such as consciously focusing on step length or foot clearance. Cueing should be individualised because the most effective cueing modality may differ between people and may also vary according to medication state, environment, cognition and the specific gait problem being addressed.[28]

A systematic review evaluating physical therapy for freezing of gait and gait impairments reported that visual cueing, auditory cueing and treadmill training may be effective interventions for freezing of gait and gait impairments in people with Parkinson’s disease.[29] Earlier evidence also reported stronger support for auditory cueing to increase gait speed, although evidence for visual and somatosensory cueing was more limited at that time.[30]

Aquatic Therapy

Aquatic therapy may be considered as an adjunct to land-based rehabilitation where it is safe, accessible and aligned with the person’s goals. It may support confidence, mobility practice, balance, range of movement and general physical activity.[31]

Rodriguez et al. investigated the effects of an aquatic-based physical exercise programme on gait parameters in nine people with idiopathic Parkinson’s disease.[32] Improvements were reported in walking speed, stride length and the relationship between single and double support time, although the small sample size means that findings should be interpreted cautiously.[32]

Treadmill Training

[33]

Treadmill training may improve gait speed, stride length, walking distance and functional mobility in selected people with mild-to-moderate Parkinson’s disease.[34] A more recent systematic review and meta-analysis also suggests that treadmill training can improve motor symptoms and functional mobility in people with Parkinson’s disease, although protocols should consider disease stage, clinical characteristics, exercise tolerance and safety.[35]

Treadmill training may be combined with visual, auditory or attentional cueing, and may be progressed by adjusting speed, duration, incline, body-weight support or task complexity.[5][35] Suitability should be assessed carefully, particularly where there is freezing of gait, falls risk, cognitive impairment, cardiovascular comorbidity, orthostatic symptoms or difficulty using treadmill safety features.[5] Appropriate supervision and safety procedures are required.[5]

Although treadmill training can improve some gait parameters, it may not fully address reduced arm swing if the person relies heavily on handrails. Generalisability to overground walking should therefore be supported by task-specific overground practice, turning practice and environmental adaptation where appropriate.[34][5]

Dual-Task Gait Training

Dual-task difficulty is common in Parkinson’s disease. Walking performance may deteriorate when a person is required to complete a cognitive or motor task at the same time as walking, such as counting, talking, carrying an object or navigating a busy environment.[36]

Dual-task gait training may be useful where walking deteriorates during everyday cognitive or motor dual-task activities. A 2024 systematic review and meta-analysis found that dual-task training may improve dual-task gait parameters, dual-task cost and quality of life when compared with single-task gait training, although certainty of evidence varied across outcomes.[36]

Dual-task training should be introduced gradually and only when safety is maintained. The physiotherapist should monitor gait speed, step length, freezing episodes, balance, fatigue and falls risk during progression.[5]

Robotics

Robotic rehabilitation can also be used as part of gait re-education in patients with Parkinson's. A pilot study by Lo et al. examined the potential effect of continuous physical cueing using robot-assisted sensorimotor gait training on reducing freezing of gait episodes and improving gait.[37] Four people with Parkinson’s disease and freezing of gait symptoms received ten 30-minute sessions of robot-assisted gait training to facilitate repetitive, rhythmic and alternating bilateral lower limb movements. All participants showed a reduction in freezing by self-report and clinician-rated scoring following training. Improvements were also observed in gait velocity, stride length, rhythmicity and coordination.[37]

More recent systematic review evidence suggests that robot-assisted gait training may improve some motor and gait outcomes in people with Parkinson’s disease, including balance, walking speed, stride length and walking distance.[38] However, robot-assisted gait training should be considered in the context of access to equipment, clinical expertise, disease stage, safety and the person’s goals.[38]

Current evidence should be interpreted cautiously because intervention protocols, comparison groups and participant characteristics vary across studies. Robot-assisted gait training may be most appropriate in specialist rehabilitation settings where suitable equipment, supervision and safety procedures are available.[38]

Summary

Gait re-education in Parkinson’s disease should be based on person-centred clinical assessment, including gait analysis, falls history, freezing of gait, medication response, cognition, fatigue, confidence and the person’s usual walking environments. Common gait impairments include reduced step length, reduced gait speed, reduced foot clearance, impaired turning, festination, freezing of gait and difficulty walking while completing a second task.

Current evidence supports an individualised rehabilitation approach that may include task-specific gait training, external cueing, balance training, resistance training, aerobic exercise, treadmill training, dual-task gait training and education. The choice of intervention should be guided by the person’s goals, safety, disease stage, response to exercise and access to appropriate resources. Older or small studies on the page should be interpreted alongside newer clinical practice guidelines and systematic review evidence.

References

  1. ↑ Bennett DA, Beckett LA, Murray AM, et al. Prevalence of parkinsonian signs and associated mortality in a community population of older people. N Engl J Med. 1996;334:71–76.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Morris M, Iansek R, Galna B. Gait festination and freezing in Parkinson's: pathogenesis and rehabilitation. Mov Disord. 2008;23 Suppl 2:S451–S460.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Bloem BR, Hausdorff JM, Visser JE, Giladi N. Falls and freezing of gait in Parkinson's: a review of two interconnected, episodic phenomena. Mov Disord. 2004;19(8):871–884.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 National Institute for Health and Care Excellence. Parkinson’s disease in adults: diagnosis and management. NICE guideline NG71. London: NICE; 2017.
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 5.20 5.21 5.22 5.23 Osborne JA, Botkin R, Colon-Semenza C, et al. Physical therapist management of Parkinson disease: a clinical practice guideline from the American Physical Therapy Association. Phys Ther. 2022;102(4):pzab302. doi:10.1093/ptj/pzab302.
  6. ↑ Belal Alsabek. Parkinsonian Gait Demonstration. Available from: http://www.youtube.com/watch?v=j86omOwx0Hk [last accessed 09/09/16].
  7. ↑ Gray P, Hildebrand K. Fall risk factors in Parkinson's. J Neurosci Nurs. 2000;32:222–228.
  8. ↑ Plotnik M, Giladi N, Hausdorff JM. Bilateral coordination of gait and Parkinson's: the effects of dual tasking. J Neurol Neurosurg Psychiatry. 2009;80:347–350.
  9. ↑ Yogev G, Plotnik M, Peretz C, et al. Gait asymmetry in patients with Parkinson's and elderly fallers: when does the bilateral coordination of gait require attention? Exp Brain Res. 2007;177:336–346.
  10. ↑ 10.0 10.1 10.2 10.3 Sofuwa O, Nieuwboer A, Desloovere K, Willems AM, Chavret F, Jonkers I. Quantitative gait analysis in Parkinson's disease: comparison with a healthy control group. Arch Phys Med Rehabil. 2005;86(5):1007–1013. doi:10.1016/j.apmr.2004.08.012.
  11. ↑ Horak FB, Nutt JG, Nashner LM. Postural inflexibility in parkinsonian subjects. J Neurol Sci. 1992;111(1):46–58. doi:10.1016/0022-510X(92)90111-W.
  12. ↑ Keus SHJ, Munneke M, Graziano M, et al. European Physiotherapy Guideline for Parkinson’s Disease. Nijmegen: ParkinsonNet; 2014.
  13. ↑ 13.0 13.1 Academy of Neurologic Physical Therapy. Parkinson Disease EDGE Task Force: Outcome Measures Recommendations. American Physical Therapy Association; 2013.
  14. ↑ Leddy AL, Crowner BE, Earhart GM. Functional Gait Assessment and Balance Evaluation Systems Test: reliability, validity, sensitivity, and specificity for identifying individuals with Parkinson disease who fall. Phys Ther. 2011;91(1):102–113. doi:10.2522/ptj.20100113.
  15. ↑ Leddy AL, Crowner BE, Earhart GM. Utility of the Mini-BESTest, BESTest, and BESTest sections for balance assessments in individuals with Parkinson disease. J Neurol Phys Ther. 2011;35(2):90–97. doi:10.1097/NPT.0b013e31821a620c.
  16. ↑ Giladi N, Shabtai H, Simon ES, Biran S, Tal J, Korczyn AD. Construction of freezing of gait questionnaire for patients with Parkinsonism. Parkinsonism Relat Disord. 2000;6(3):165–170. doi:10.1016/S1353-8020(99)00062-0.
  17. ↑ Giladi N, Tal J, Azulay T, et al. Validation of the Freezing of Gait Questionnaire in patients with Parkinson’s disease. Mov Disord. 2009;24(5):655–661. doi:10.1002/mds.21745.
  18. ↑ 18.0 18.1 Reuter I, Mehnert S, Leone P, Kaps M, Oechsner M, Engelhardt M. Effects of a flexibility and relaxation programme, walking, and Nordic walking on Parkinson’s disease. J Aging Res. 2011;2011:232473. doi:10.4061/2011/232473.
  19. ↑ Physical Therapist Assistant. Parkinson's Gait Training. Available from: http://www.youtube.com/watch?v=v008VgRgJt8 [last accessed 09/09/16].
  20. ↑ Lima LO, Scianni A, Rodrigues-de-Paula F. Progressive resistance exercise improves strength and physical performance in people with mild to moderate Parkinson's disease: a systematic review. J Physiother. 2013;59(1):7–13. doi:10.1016/S1836-9553(13)70141-3.
  21. ↑ Tambosco L, Percebois-Macadré L, Rapin A, Nicomette-Bardel J, Boyer FC. Effort training in Parkinson's disease: a systematic review. Ann Phys Rehabil Med. 2014;57(2):79–104. doi:10.1016/j.rehab.2014.01.003.
  22. ↑ Song H, Ge S, Li J, Jiao C, Ran L. Effects of aerobic and resistance training on walking and balance abilities in older adults with Parkinson’s disease: a systematic review and meta-analysis. PLoS One. 2025;20(1):e0314539. doi:10.1371/journal.pone.0314539.
  23. ↑ Clare's Fitness Pages. Parkinson's Exercises Balance. Available from: http://www.youtube.com/watch?v=Zdmuaexs9kY [last accessed 09/09/16].
  24. ↑ 24.0 24.1 24.2 Wang D, Li Y, Xu Y, et al. Effectiveness of different exercises in improving postural balance among Parkinson's disease patients: a systematic review and network meta-analysis. Front Aging Neurosci. 2023;15:1215495. doi:10.3389/fnagi.2023.1215495.
  25. ↑ Mhatre PV, Vilares I, Stibb SM, Albert MV, Pickering L, Marciniak CM, Kording K, Toledo S. Wii Fit balance board playing improves balance and gait in Parkinson disease. PM R. 2013;5(9):769–777. doi:10.1016/j.pmrj.2013.05.019.
  26. ↑ Gu S, Song Z, Fan X, Chen R, Zheng W, Yan W. Effect of PD-WEBB training on balance impairment and falls in people with Parkinson's. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2013;38(11):1172–1176. doi:10.3969/j.issn.1672-7347.2013.11.015.
  27. ↑ The Lancet TV. Freezing of gait. Available from: http://www.youtube.com/watch?v=3-wrNhyVTNE [last accessed 09/09/16].
  28. ↑ Cosentino C, Putzolu M, Mezzarobba S, Cecchella M, Innocenti T, Bonassi G, Botta A, Lagravinese G, Avanzino L, Pelosin E. One cue does not fit all: a systematic review with meta-analysis of the effectiveness of cueing on freezing of gait in Parkinson’s disease. Neurosci Biobehav Rev. 2023;150:105189. doi:10.1016/j.neubiorev.2023.105189.
  29. ↑ Rutz DG, Benninger DH. Physical therapy for freezing of gait and gait impairments in Parkinson’s disease: a systematic review. PM R. 2020;12(11):1140–1156. doi:10.1002/pmrj.12337.
  30. ↑ Lim I, van Wegen E, de Goede C, Deutekom M, Nieuwboer A, Willems A, Jones D, Rochester L, Kwakkel G. Effects of external rhythmical cueing on gait in patients with Parkinson's disease: a systematic review. Clin Rehabil. 2005;19(7):695–713.
  31. ↑ Gomes Neto M, Pontes SS, Almeida LdO, da Silva CMC, da Conceicao Sena C. Effects of water-based exercise on functioning and quality of life in people with Parkinson's disease: a systematic review and meta-analysis. Clin Rehabil. 2020;34(11):1425–1435. doi:10.1177/0269215520943660.
  32. ↑ 32.0 32.1 Rodriguez P, Cancela JM, Ayan C, do Nascimento C, Seijo-Martínez M. Effects of aquatic physical exercise on the kinematic gait pattern in patients with Parkinson's disease: a pilot study. Rev Neurol. 2013;56(6):315–320.
  33. ↑ physicaltherapyvideo. How to Help Parkinson's Freezing Episodes: 3 Great Tips. Available from: http://www.youtube.com/watch?v=VwUoAMAis1g [last accessed 09/09/16].
  34. ↑ 34.0 34.1 Earhart GM, Williams AJ. Treadmill training for individuals with Parkinson disease. Phys Ther. 2012;92(7):893–897. doi:10.2522/ptj.20110471.
  35. ↑ 35.0 35.1 Boccali E, Simonelli C, Nardone A, et al. Treadmill training in patients with Parkinson’s disease: a systematic review and meta-analysis on rehabilitation outcomes. Brain Sci. 2025;15(8):788. doi:10.3390/brainsci15080788.
  36. ↑ 36.0 36.1 Sarasso E, Parente E, Agosta F, et al. Dual-task vs. single-task gait training to improve spatiotemporal gait parameters in people with Parkinson’s disease: a systematic review and meta-analysis. Brain Sci. 2024;14(5):517. doi:10.3390/brainsci14050517.
  37. ↑ 37.0 37.1 Lo AC, Chang VC, Gianfrancesco MA, Friedman JH, Patterson TS, Benedicto DF. Reduction of freezing of gait in Parkinson’s disease by repetitive robot-assisted treadmill training: a pilot study. J Neuroeng Rehabil. 2010;7:51.
  38. ↑ 38.0 38.1 38.2 Jiang X, Zhou J, Chen Q, Xu Q, Wang S, Yuan L, Zhang D, Bi H, Li H. Effect of robot-assisted gait training on motor dysfunction in Parkinson’s patients: a systematic review and meta-analysis. J Back Musculoskelet Rehabil. 2024;37(1):253–268. doi:10.3233/BMR-220395.
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