Aging Clinical and Experimental Research

, Volume 27, Issue 4, pp 457–463 | Cite as

Concurrent arm swing-stepping (CASS) can reveal gait start hesitation in Parkinson’s patients with low self-efficacy and fear of falling

  • Taylor Chomiak
  • Fernando V. Pereira
  • Terry W. Clark
  • Alexandra Cihal
  • Bin Hu
Original Article



Movement incoordination, freezing of gait, fear of falling, low self-efficacy, and multi-tasking can all contribute to falls in Parkinson’s disease. How these multi-factorial risks interact in individual patients remain poorly understood.


Concurrent arm swing-stepping is a simple motor test in which subjects are first asked to swing their arms before being instructed to initiate the secondary task of leg stepping-in-place. We postulated that in patients with multiple fall risks, sensorimotor impairments in upper- and lower-limb movement control can render concurrent arm swing-stepping a demanding dual task, thereby triggering gait hesitation. A total of 31 subjects with Parkinson’s disease were enrolled in the study.


It was found that concurrent arm swing-stepping induced hesitation primarily in Parkinson’s disease patients with low fall-related self-efficacy and a fear of falling. By contrast, concurrent arm swing-stepping led to limb incoordination in both patients and in healthy elderly controls. The calculated specificity and sensitivity of the concurrent arm swing-stepping test was 100 and 42 % for hesitation and 12 and 77 % for incoordination.


These results suggest that the concurrent arm swing-stepping test can be used in conjunction with conventional psychometric assessments to facilitate multi-factorial assessment of potential fall risk.


Parkinson’s disease Hesitation Freezing Gait Fear Falling 



Thanks to the Canadian Institutes of Health Research, Alberta Innovates-Health Solutions, MITACs, Parkinson Alberta Society, Drs Ranjit Ranawaya and Sarah Furtado and the Movement Disorders Clinic-Alberta Health Services, and to the following Brazilian agencies: National Council for Scientific and Technological Development (CNPq) and Coordination for the Improvement of Higher Education Personnel (CAPES). We would also like to thank Natalie de Bruin and Dr. Lesley Brown for help with control data.

Conflict of interest

On behalf of all the authors, the corresponding authors state that there are no conflicts of interest.


  1. 1.
    Grimbergen YA, Munneke M, Bloem BR (2004) Falls in Parkinson’s disease. Curr Opin Neurol 7:405–415CrossRefGoogle Scholar
  2. 2.
    van der Marck MA, Klok MP, Okun MS, Giladi N, Munneke M, Bloem BR (2013) Consensus-based clinical practice recommendations for the examination and management of falls in patients with Parkinson’s disease. Parkinsonism Relat Disord 20:360–369PubMedCrossRefGoogle Scholar
  3. 3.
    Jacobs JV, Horak FB, Tran VK, Nutt JG (2006) Multiple balance tests improve the assessment of postural stability in subjects with Parkinson’s disease. J Neurol Neurosurg Psychiatry 77:322–326PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Bryant MS, Rintala DH, Hou JG, Rivas SP, Fernandez AL, Lai EC, Protas EJ (2012) The relation of falls to fatigue, depression and daytime sleepiness in Parkinson’s disease. Eur Neurol 67:326–330PubMedCrossRefGoogle Scholar
  5. 5.
    Nutt JG, Bloem BR, Giladi N, Hallett M, Horak FB, Nieuwboer A (2011) Freezing of gait: moving forward on a mysterious clinical phenomenon. Lancet Neurol 10:734–744PubMedCrossRefGoogle Scholar
  6. 6.
    Boonstra TA, van der Kooij H, Munneke M, Bloem BR (2008) Gait disorders and balance disturbances in Parkinson’s disease: clinical update and pathophysiology. Curr Opin Neurol 21:461–471PubMedCrossRefGoogle Scholar
  7. 7.
    Bloem BR, Hausdorff JM, Visser JE, Giladi N (2004) Falls and freezing of gait in Parkinson’s disease: a review of two interconnected, episodic phenomena. Mov Disord 19:871–884PubMedCrossRefGoogle Scholar
  8. 8.
    Plotnik M, Giladi N, Hausdorff JM (2008) Bilateral coordination of walking and freezing of gait in Parkinson’s disease. Eur J Neurosci 27:1999–2006PubMedCrossRefGoogle Scholar
  9. 9.
    van Nimwegen M, Speelman AD, Hofman-van Rossum EJ, Overeem S, Deeg DJ, Borm GF, van der Horst MH, Bloem BR, Munneke M (2011) Physical inactivity in Parkinson’s disease. J Neurol 258:2214–2221PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Grimbergen YA, Schrag A, Mazibrada G, Borm GF, Bloem BR (2013) Impact of falls and fear of falling on health-related quality of life in patients with Parkinson’s disease. J Parkinsons Dis 3:409–413PubMedGoogle Scholar
  11. 11.
    Nieuwboer A, Giladi N (2013) Characterizing freezing of gait in Parkinson’s disease: models of an episodic phenomenon. Mov Disord 28:1509–1519PubMedCrossRefGoogle Scholar
  12. 12.
    Heremans E, Nieuwboer A, Vercruysse S (2013) Freezing of gait in Parkinson’s disease: where are we now? Curr Neurol Neurosci Rep 13:350PubMedCrossRefGoogle Scholar
  13. 13.
    Speelman AD, van de Warrenburg BP, van Nimwegen M, Petzinger GM, Munneke M, Bloem BR (2011) How might physical activity benefit patients with Parkinson disease? Nat Rev Neurol 7:528–534PubMedCrossRefGoogle Scholar
  14. 14.
    Chamberlin ME, Fulwider BD, Sanders SL, Medeiros JM (2005) Does fear of falling influence spatial and temporal gait parameters in elderly persons beyond changes associated with normal aging? J Gerontol A Biol Sci Med Sci 60:1163–1167PubMedCrossRefGoogle Scholar
  15. 15.
    Bandura A (1982) Self-efficacy mechanism in human agency. Am Psychol 37:122–147CrossRefGoogle Scholar
  16. 16.
    Nilsson MH, Drake AM, Hagell P (2010) Assessment of fall-related self-efficacy and activity avoidance in people with Parkinson’s disease. BMC Geriatr 10:78PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Brown LA, White P, Doan JB, de Bruin N (2011) Selective attentional processing to fall-relevant stimuli among older adults who fear falling. Exp Aging Res 37:330–345PubMedCrossRefGoogle Scholar
  18. 18.
    Thomas AA, Rogers JM, Amick MM, Friedman JH (2010) Falls and the falls efficacy scale in Parkinson’s disease. J Neurol 257:1124–1128PubMedCrossRefGoogle Scholar
  19. 19.
    Chomiak T, Cihal A, Clark T, Ranawaya R, Hu B (2013) Concurrent arm swing-stepping (cass) test for dual task-related movement incoordination and hesitation in Parkinson’s disease. J Parkinson’s Dis 3(Supp 1:88)Google Scholar
  20. 20.
    Nantel J, de Solages C, Bronte-Stewart H (2011) Repetitive stepping in place identifies and measures freezing episodes in subjects with Parkinson’s disease. Gait Posture 34:329–333PubMedCrossRefGoogle Scholar
  21. 21.
    Greenberg SA (2011) Assessment of fear of falling in older adults: the falls efficacy scale-international (fes-i); best practices in nursing care to older adults. The Hartford Institute for Geriatric Nursing, New York University, College of Nursing, New YorkGoogle Scholar
  22. 22.
    Schaafsma JD, Balash Y, Gurevich T, Bartels AL, Hausdorff JM, Giladi N (2003) Characterization of freezing of gait subtypes and the response of each to levodopa in Parkinson’s disease. Eur J Neurol 10:391–398PubMedCrossRefGoogle Scholar
  23. 23.
    Cakit BD, Saracoglu M, Genc H, Erdem HR, Inan L (2007) The effects of incremental speed-dependent treadmill training on postural instability and fear of falling in Parkinson’s disease. Clin Rehabil 21:698–705PubMedCrossRefGoogle Scholar
  24. 24.
    Adkin AL, Frank JS, Jog MS (2003) Fear of falling and postural control in Parkinson’s disease. Mov Disord 18:496–502PubMedCrossRefGoogle Scholar
  25. 25.
    Delbaere K, Close JC, Mikolaizak AS, Sachdev PS, Brodaty H, Lord SR (2010) The falls efficacy scale international (fes-i). A comprehensive longitudinal validation study. Age Ageing 39:210–216PubMedCrossRefGoogle Scholar
  26. 26.
    Serrien DJ, Swinnen SP, Stelmach GE (2000) Age-related deterioration of coordinated interlimb behavior. J Gerontol B Psychol Sci Soc Sci 55:P295–P303PubMedCrossRefGoogle Scholar
  27. 27.
    Greene LS, Williams HG (1996) Aging and coordination from the dynamic pattern perspective. Adv Psychol 114:89–131CrossRefGoogle Scholar
  28. 28.
    Mak MK, Pang MY (2009) Fear of falling is independently associated with recurrent falls in patients with Parkinson’s disease: a 1-year prospective study. J Neurol 256:1689–1695PubMedCrossRefGoogle Scholar
  29. 29.
    Poewe W, Mahlknecht P (2009) The clinical progression of Parkinson’s disease. Parkinsonism Relat Disord 15(Suppl 4):S28–S32PubMedCrossRefGoogle Scholar
  30. 30.
    Themanson JR, Hillman CH, McAuley E, Buck SM, Doerksen SE, Morris KS, Pontifex MB (2008) Self-efficacy effects on neuroelectric and behavioral indices of action monitoring in older adults. Neurobiol Aging 29:1111–1122PubMedCentralPubMedCrossRefGoogle Scholar
  31. 31.
    Lewis SJ, Barker RA (2009) A pathophysiological model of freezing of gait in Parkinson’s disease. Parkinsonism Relat Disord 15:333–338PubMedCrossRefGoogle Scholar
  32. 32.
    Amboni M, Cozzolino A, Longo K, Picillo M, Barone P (2008) Freezing of gait and executive functions in patients with Parkinson’s disease. Mov Disord 23:395–400PubMedCrossRefGoogle Scholar
  33. 33.
    Hiraoka K, Matsuo Y, Abe K (2005) Soleus h-reflex inhibition during gait initiation in Parkinson’s disease. Mov Disord 20:858–864PubMedCrossRefGoogle Scholar
  34. 34.
    Kawanishi M, Yahagi S, Kasai T (1999) Neural mechanisms of soleus h-reflex depression accompanying voluntary arm movement in standing humans. Brain Res 832:13–22PubMedCrossRefGoogle Scholar
  35. 35.
    Slivko EI, Bogutskaya GA (2008) Modulation of the soleus muscle reflex caused by ballistic voluntary arm movements in humans. Neurophysiology 40:130–136CrossRefGoogle Scholar
  36. 36.
    Aravamuthan BR, Stein JF, Aziz TZ (2008) The anatomy and localization of the pedunculopontine nucleus determined using probabilistic diffusion tractography [corrected]. Br J Neurosurg 22(Suppl 1):S25–S32PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  1. 1.Department of Clinical Neurosciences, Hotchkiss Brain InstituteUniversity of CalgaryCalgaryCanada

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