The ability to walk in the community is arguably one important factor that enables people to participate in activities of daily living, including social and leisure activities. The community environment may impose a variety of complex demands including challenging terrain, crowded spaces or unfamiliar places. These environmental challenges may expose an individual to different physical and cognitive demands. When such demands exceed an individual’s walking confidence or capacity, they may restrict their community ambulation. Parkinson’s disease (PD) is a neurodegenerative disease accompanied by progressive walking and balance difficulty, cognitive impairment and sometimes mood disturbance. These motor and non-motor symptoms may make people with PD particularly vulnerable to experiencing difficulty walking in the community. The primary aim of this thesis was to advance understanding of the factors that impact on community ambulation in people with PD using mixed qualitative and quantitative methods.
Falls are associated with reduced walking confidence and are therefore one factor that may contribute to reduced community ambulation. Study one examined the proportion of falls that occurred in the community and the circumstances of the falls in order to identify contributing factors. People with idiopathic PD (n = 196) prospectively reported the occurrence and circumstances of falls they experienced over a 14-month period. Community-based falls accounted for 17% of reported falls, were experienced by over half of the fallers. Of the falls that occurred in the community, most occurred when walking, and falls were frequently associated with environmental factors such as challenging terrain and attention demands.
The aim of study two was to identify barriers and facilitators to community ambulation perceived by people living with PD. People with PD (n = 18) and their partners (n = 22) were invited to participate in focus groups where their experiences walking in the community were discussed. The results revealed that barriers to community walking were primarily environmental (e.g. complex terrain and attentional demands). In addition, some people with PD use strategies and facilitators including support from others and use of equipment to overcome these barriers, allowing them continue to walk in the community without difficulty.
Study three aimed to extend these findings and explore the differences between people with PD who reported having modified their community walking and those who reported difficulty or no modification. Forty-four percent of 258 survey respondents reported that they had modified how or when they walked in the community. People who had modified their community ambulation did not differ in age, disease duration or the number of falls reported in the 6 months previous from those who had not modified their walking. Compared to the unmodified community walkers the modified community walkers reported greater difficulty with all environmental challenges than the unmodified group and had greater use facilitators such as forward planning, support from others and wearing specific footwear.
Study four evaluated the accuracy and reliability of an activity monitor (ActivPALTM) and a pedometer to measure walking in complex conditions. The ActivPALTM accurately and reliably measured the time and number of steps taken to walk over short and long durations with different environmental challenges (ICC>0.630). In study five the ActivPALTM was used to measure the amount of community walking performed over 3 days in people with PD (n = 49). It was used to compare the amount of community walking between those who had modified, not modified and had difficulty walking in the community. Demographic factors, walking confidence and performance, cognitive, attention and executive functions were assessed. There was no difference across the three groups for the amount of community walking. The modified community walkers only differed from the unmodified community walkers in reduced endurance and decreased walking confidence. Walking capacity, walking confidence and executive function were moderately associated with community walking. Regression analysis showed that these factors only explain a small proportion (22%) of variance in community walking.
Environmental factors such as complex terrain and attentional demands were found to contribute to both falls in the community, and difficulty walking in the community. Further research is needed to explore whether people with PD can be trained to safely negotiate such challenges, or whether people should plan to avoid these environmental barriers. Individual and disease-related factors including walking capacity, walking performance, executive function, fatigue and anxiety also contribute to greater difficulty with community ambulation. Walking capacity, walking performance and executive function were found to explain a modest proportion of variance in actual community walking, however may contribute more to change in community walking over time. Some people with PD report that they are able to modify how or when they walk in the community in order to continue without difficulty. Future research is needed to explore whether modification may serve as an early warning sign for impending disability, and whether the onset of disability can be slowed.