Neurol Sci (2012) 33:13371343
DOI 10.1007/s10072-012-1202-y
ORIGINAL ARTICLE
Effect of Global Postural Rehabilitation program
on spatiotemporal gait parameters of parkinsonian
patients: a three-dimensional motion analysis study
Carmine Vitale Valeria Agosti Dario Avella Gabriella Santangelo
Marianna Amboni Rosaria Rucco Paolo Barone Francesco Corato
Giuseppe Sorrentino
Received: 2 September 2012 / Accepted: 17 September 2012 / Published online: 12 October 2012
Springer-Verlag Italia 2012
Abstract The aim of the present study was to evaluate
the effects of a Global Postural Rehabilitation (GPR) pro-
gram on motor symptoms and gait parameters of patients
with Parkinsons disease (PD) by means of three-dimen-
sional motion analysis study. Ten subjects with clinical
diagnosis of PD were enrolled (study group). Age-, sex-
and disease duration-matched PD patients were recruited as
a control group (no treatment). Three-dimensional motion
analysis was conducted by means of a stereophotogram-
metric system. After basal evaluation, the study group
underwent a specific rehabilitation program consisting of
individual 40 min GPR daily sessions, 3 days a week for 4
consecutive weeks. Neurological status and spatiotemporal
C. Vitale and V. Agosti contributed equally to this paper.
C. Vitale
V. Agosti
D. Avella
M. Amboni
R. Rucco

G. Sorrentino (&)
Facolta di Scienze Motorie, Universita degli Studi di Napoli
Parthenope, Naples, Italy
e-mail: giuseppe.sorrentino@uniparthenope.it
C. Vitale
V. Agosti
D. Avella
G. Santangelo

M. Amboni
R. Rucco
P. Barone
F. Corato
G. Sorrentino
Istituto Diagnosi e Cura Hermitage Capodimonte,
Naples, Italy
G. Santangelo
Dipartimento di Psicologia, Seconda Universita degli Studi di
Napoli, Caserta, Italy
R. Rucco
F. Corato
Facolta di Ingegneria, Seconda Universita degli Studi di Napoli,
Caserta, Italy
P. Barone
Centro per le Malattie Neurodegenerative (CEMAND),
Universita degli Studi di Salerno, Salerno, Italy
gait parameters of the two groups were evaluated at study
entry (t0), at 4 weeks (t1, end of rehabilitation protocol) and
at 8 and 12 weeks (t2 and t3, follow-up evaluation). At
baseline evaluation, the two groups did not differ in clinical
features and gait parameters. At the end of rehabilitation
protocol (t1) and at follow-up evaluation (t2 and t3), a
significant improvement in temporal gait parameters and
UPDRS scores was observed in all treated patients as
compared to baseline and controls. Our preliminary find-
ings showed that significant improvements in mobility and
gait parameters of PD patients can be obtained through
GPR treatment, with a parallel improvement in clinical
status. Quantitative analysis of gait pattern can be consid-
ered a useful tool to assess the efficacy of rehabilitation
interventions in patients affected by PD.
Keywords Parkinsons disease
Three-dimensional
motion analysis
Global postural rehabilitation

Stretching exercises
Introduction
Motor impairment is one of the greatest causes of disability
in Parkinsons disease (PD). Severity of motor symptoms is
related to disease progression, neurochemical alterations
and pharmacological treatment [1]. Symptoms such as
bradykinesia, rigidity, resting tremor and postural changes
impact motor abilities of patients who are unable to gen-
erate an adequate amplitude of movement [2]. Axial
impairment and gait disturbances (increased cadence and
double stance time, decreased step length, walking speed
and arm swing) also contribute to decreased quality of life
in PD patients and are associated with increased risk of
falls [35].
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Pharmacological approach is the first-line treatment in
ameliorating the cardinal symptoms of PD, but rarely
achieves complete control. Therefore, a multidisciplinary
strategy for the therapeutic management of patients with
PD, including non-pharmacological interventions, seems
advisable. Several studies investigating the impact of
physical activity on the management of motor impairment
in PD showed its beneficial effects and this was particularly
true of early intervention [613]. Moreover, physical
rehabilitation is known to attenuate the diseases functional
disability and contributes to improve the patients quality
of life [14, 15].
Physical activity programs for PD patients include
intensive sports training, treadmill training with body
weight support, resistance training and aerobic exercises
[615].
The method called Global Postural Rehabilitation (GPR)
[16] is based on the recognition of two muscle chains,
divided into posterior and anterior chains, and proposes
global stretching of antigravity muscles which can be
shortened due to constitutional, behavioral and pathologi-
cal factors. Although the GPR method is often clinically
practiced and some pilot studies were carried out in
patients suffering from muscle and/or skeletal diseases
[1720], no studies were conducted in PD patients.
The aim of the present preliminary study was to evaluate
the efficacy of a GPR program on PD motor symptoms and
to analyze quantitatively the effects of GPR on spatio-
temporal gait parameters of PD patients by means of three-
dimensional motion analysis (MA) assessment.
Patients and methods
Subjects
Ten subjects were enrolled from consecutive PD outpa-
tients admitted to the Movement Disorders Unit of the
University of Naples Federico II (Italy) over the period
from January to May 2011. Age-, sex- and disease
duration-matched PD patients were enrolled as control
group.
Inclusion criteria were: (1) clinical diagnosis of PD
according to the UK Parkinsons Disease Society Brain
Bank [21]; (2) Mini Mental State Examination (MMSE)
score C24; (3) stable dosage of dopaminergic drugs in the
last 2 months prior to enrollment and during the study.
Exclusion criteria were: (1) a history of past or present
muscle and/or skeletal diseases; (2) presence of dyskinesia,
dystonia, or additional neurological impairments; (3)
presence of cardiac or systemic diseases that might impact
gait; (4) required assistive devices to walk/inability to walk
for at least 15 m without the use of walking aids.
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Neurol Sci (2012) 33:13371343
Written informed consent was obtained from all sub-
jects. The study protocol and informed consent document
were approved by the local ethics committee.
Study design
All the patients underwent neurological and MA assess-
ments on entry to the study (t0), at 4 weeks (t1, end of
rehabilitation protocol) and at 8 and 12 weeks after base-
line evaluation (t2 and t3, follow-up evaluation), respec-
tively. After basal evaluation, ten PD patients underwent a
specific GPR program (study group), whereas no treatment
was administrated to the control group participants. Neu-
rological and MA assessments were performed in the
morning, in a single session that lasted approximately 1 h
and, when PD patients were in ON phase, usually about 1 h
after taking their daily antiparkinsonian medication. Par-
ticipants were instructed not to change their habitual motor
routines over the course of the study.
Neurological and demographic assessment
All the patients underwent a neurological examination
consisting of the motor section of the Unified Parkinsons
Disease Rating Scale (UPDRS-section III) to measure the
severity of motor symptoms. Staging was assessed by the
Hoehn and Yahr (HY) scale. The L-Dopa equivalent daily
dose (LEDD) was calculated for dopamine agonists ?
L-dopa (total LEDD) as reported elsewhere [22]. Changes
in daily drug intake were monitored to exclude any varia-
tions of patients therapeutic regimen (i.e., introduction of
L-dopa, switch to another L-dopa formulation, introduction
or substitution of dopamine agonists).
Rehabilitation protocol
Ten PD patients (study group) underwent 3-weekly GPR
sessions during a 4-week period. At each 40 min individual
session (20 min for posture), the patient received the
instruction to extend gradually the legs and/or the arms
every 5 min while maintaining two cardinal posture.
The lying posture with extension of the legs (Fig. 1a)
was aimed to release the diaphragm muscle and to stretch
the anterior muscle chain (diaphragm, pectoralis minor,
scalene, sternocleidomastoid, intercostalis, iliopsoas, arm,
forearm and hand flexors). The progression of the posture
was in the direction of extension of the lower limbs and
adduction of the upper limbs.
The lying posture with flexion of the legs (Fig. 1b) was
aimed to stretch the posterior chain (upper trapezius,
levator scapulae, suboccipital, erector spinae, gluteus
maximus, ischio-tibial, triceps surae and foot intrinsic
muscles). The initial position was lying with the hip flexed
Neurol Sci (2012) 33:13371343
Fig. 1 a Anterior muscle chain stretching, lying posture with leg extension progression. b Posterior muscle chain stretching, lying posture with
hip joint flexion progression
and progression consisted of increasing hip flexion, knee
extension and dorsal flexion of the ankle.
Motion analysis assessment
Motion data were collected using a six-camera stereopho-
togrammetric system (Qualisys Inc., Gothenburg, Sweden)
at 240 Hz. According to the modified Davies protocol [23],
42 sphere-shaped reflective markers, 15 mm in diameter,
were positioned to patients bone landmarks to track body
movements. After standing calibration and adequate prac-
tice, the patients walked through the measurement space
(10 m) at his/her self-selected comfortable speed. A cus-
tom-developed MATLAB (MathWorks Inc., Natick, MA,
USA) program was used for the four gait events detection
between two sequential heel strikes (left/right heel strikes)
and toe off (left/right toe off). A specific software system
(Visual 3D, C-Motion Inc., Germantown, MD, USA) was
used to define the skeletal body segments and for the gait
clinical report. At least three good trials were recorded for
each subject.
Temporal gait parameters including gait speed, cycle
time, stance time, swing and step time and step and stride
cadence were recorded. The following spatial gait param-
eters were also calculated: step length, stride length and
stride width.
MA assessment was performed at Neuromechanic
Laboratory of University Parthenope of Naples (Italy).
Statistical analysis
Statistical analysis was carried out using the SPSS for
Windows statistical package, version 16.0. For all analyses,
a type I error of 0.05 was taken to indicate statistical sig-
nificance. Chi-square, t test, and MannWhitney U test
analyses were performed to evaluate differences in the
distribution of demographic and clinical variables between
the study and control groups. A multivariate analysis
1339
(MANOVA) for repeated measures was performed to
evaluate changes in the clinical and spatiotemporal gait
parameters occurring within the study and control groups
over the time course of the study. Post hoc analyses were
carried out by means of Fishers least significant difference
(LSD) test.
Results
Clinical and demographic assessment
At baseline evaluation, the two groups did not differ on
clinical and demographic aspects. The mean age of the
whole PD sample was 63 4.4 years (range 5670 years);
disease duration was 6.2 2.5 years (range 416 years).
Total LEDD ranged from 300 to 800 mg (mean SD
647.5 140.9 mg). The overall mean UPDRS-III scores
were 20.1 2.7 (range 1624). The H & Y scores ranged
from stage I to stage III (mean SD 1.7 0.6). Onset of
motor symptoms was asymmetric in all the patients; a left-
dominant side was evident in all but two patients (clinical
and demographic features of patients are detailed in
Table 1).
Neurological and motion analysis assessment
The multivariate analysis on the UPDRS-III scores and gait
parameters measured at baseline and at follow-up assess-
ments (t1, t2, t3) revealed a significant overall time effect
(F = 3.128, p \ 0.001). In detail, time factor significantly
affected the following variables: UPDRS-III scores
(F = 104.516, p \ 0.001), gait speed (F = 3.933, p =
0.013), cycle time (F = 4.342, p = 0.008), cycle time left
(L) and right (R) (F = 4.154, p = 0.010; F = 5.181,
p = 0.003, respectively), swing time L (F = 3.800,
p = 0.015), step time L (F = 4.043, p = 0.012), step
cadence L (F = 4.674, p = 0.006) and stride cadence L
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Table 1 Demographic and clinical features of PD patients
Study group
Age (years) 62.9 4.7
Sex (M/F) 9/1
Disease duration (years) 6.5 3.5
UPDRS-III-t 19.9 2.9
Total LEDD (mg) 640 164.6
MAS (L/R) 9/1
H & Y-t 1.7 0.6
PD Parkinsons disease, UPDRS-III-t unified Parkinsons disease rating scale-III at baseline evaluation, H & Y Hohen & Yahr, Total LEDD total
L-dopa equivalent daily dose, MAS most affected side, SD standard deviation, R right, L left
and R (F = 3.245, p = 0.029; F = 4.327, p = 0.008,
respectively).
Within the study group, post hoc comparisons among
baseline evaluation (t0), the end of rehabilitation protocol
(t1) and follow-up evaluations (t2 and t3) showed a signif-
icant increase for gait speed, step cadence L and stride
cadence L and R. These changes were also maintained at t2
and t3. A significant decrease was recorded for cycle time,
cycle time L and R, and for both step and swing time L,
also maintained at t2 and t3. With regard to clinical out-
comes, at the end of the treatment period (t1) and at follow-
up evaluation (t2 and t3), a significant improvement in
UPDRS-III scores was observed in all treated patients as
compared to baseline evaluation. In particular, at t1 we
observed a significant decrease in UPDRS motor scores
which persisted at both t2 and t3 (clinical and spatiotem-
poral gait parameters of the study group are detailed in
Table 2). Within the control group, no significant differ-
ences were found among baseline, t1 and follow-up
assessments (t2, t3) in all examined parameters (data not
shown).
A significant group effect was observed for gait speed
(F = 4.486, p = 0.048), cycle time L (F = 9.564,
p = 0.006), stance time R (F = 5,611, p = 0.029), step
cadence L (F = 4.486, p = 0.048) and UPDRS motor
scores score (F = 1254.222, p \ 0.001). In detail, at
baseline evaluation, the two groups did not differ in gait
parameters, whereas at t1, the study group performed sig-
nificantly better in gait speed, cycle time L, stance time R,
step cadence L and UPDRS-III scores, as compared to
controls. These changes were also significant at t2 and t3.
Finally, a significant interaction between time and group
was observed for gait speed (F = 3.933, p = 0.013), cycle
time (F = 4.342, p = 0.008), cycle time L and R
(F = 4.154, p = 0.010 and F = 5.181, p = 0.003), swing
time L (F = 3.800, p = 0.015), step time L (F = 4.043,
p = 0.012), step cadence L (F = 4.674, p = 0.006), stride
cadence L and R (F = 3.245, p = 0.029 and F = 4.327,
p = 0.008) and UPDRS motor scores (F = 131.581,
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Neurol Sci (2012) 33:13371343
Controls t test/U test P
63.1 4.2 0.099 0.922
9/1
6 0.81 -0.439 0.666
20.3 2.5 0.320 0.753
655 121.2 0.232 0.819
9/1
1.8 0.6 45.5 0.739
p \ 0.001). In detail, within the study group, a 4-week
GPR program led to a significant improvement in both
clinical and gait parameters; these improvements persisted
at both 4 and 8 weeks after completion of the treatment as
compared to controls.
Discussion
To our knowledge, this is the first study that quantita-
tively describes changes in gait parameters recorded after
GPR intervention in patients with PD. Our findings show
that significant improvements in gait parameters can be
obtained through a GPR program, with a parallel
improvement in clinical status. Moreover, three-dimen-
sional MA can be considered a useful tool to measure
changes in patients gait pattern and mobility, following
rehabilitation interventions.
Four-week GPR program improved the overall gait
pattern of PD patients within the study group. At the end of
the treatment period, gait speed, step cadence and stride
cadence increased, while cycle time, step and swing time
L, decreased, suggesting an immediate effect of GPR on
gait pattern. Furthermore, at follow-up evaluation, t2 and t3
measures confirmed that all subjects maintained these
improvements in the 2 months following GPR program as
compared to either baseline or t1 evaluation.
The GPR method combines sequential motor activities.
These motor activities require components of functional
capacity such as strength, flexibility and agility [16, 17].
Higher levels of strength, flexibility and agility can con-
tribute to better performance in both gait and global
mobility. Therefore, the decrease in time required to
perform motor tasks observed in our patients can be a
consequence of improvement in these components. Finally,
the maintenance of patients clinical status during the
follow-up evaluation confirms the benefits of GPR in
attenuating the negative effects of motor disability in PD
patients, thus ameliorating their motor performances.
Neurol Sci (2012) 33:13371343 1341

Table 2 Clinical and spatiotemporal gait parameters of the study group (mean SD)
Gait parameters Pre-test t0 Post-test t1 Post-test t2 Post-test t3 F P

Temporal gait parameters

Gait speed (m/s) 0.950 0.063 1.144 0.061* 1.145 0.061* 1.087 0.050* 3.933 0.013
Cycle time (s) 1.228 0.052 1.106 0.040* 1.091 0.026* 1.125 0.029* 4.342 0.008
Cycle time L (s) 1.246 0.057 1.100 0.063* 1.059 0.026* 1.102 0.030* 4.154 0.010
Cycle time R (s) 1.210 0.051 1.083 0.042* 1.060 0.026* 1.096 0.031* 5.181 0.003
Stance time L (s) 0.705 0.055 0.729 0.054 0.620 0.028 0.634 0.029 2.690 0.055
Stance time R (s) 0.698 0.036 0.625 0.034 0.632 0.030 0.653 0.022 1.278 0.291
Swing time L (s) 0.546 0.045 0.443 0.021* 0.460 0.016* 0.472 0.022* 3.800 0.015
Swing time R (s) 0.470 0.020 0.439 0.018 0.451 0.010 0.461 0.021 1.368 0.262
Step time L (s) 0.655 0.048 0.547 0.017* 0.539 0.015* 0.564 0.019* 4.043 0.012
Step time R (s) 0.542 0.018 0.526 0.026 0.525 0.014 0.536 0.023 0.418 0.741
Step cadence L (s) 101.166 3.347 111.825 3.579* 112.577 2.901* 109.914 2.529* 4.674 0.006
Step cadence R (s) 108.638 7.441 127.985 15.508 115.388 3.066 114.079 5.013 1.127 0.346
Stride cadence L (s) 51.163 1.688 57.547 3.109* 57.053 1.393* 55.442 1.562* 3.245 0.029
Stride cadence R (s) 51.874 1.632 56.300 2.107* 56.989 1.342* 55.668 1.636* 4.327 0.008
Spatial gait parameters
Step length L (m) 0.573 0.025 0.584 0.018 0.608 0.023 0.593 0.020 1.232 0.307
Step length R (m) 0.569 0.026 0.582 0.020 0.595 0.029 0.592 0.024 0.821 0.488
Stride length (m) 1.143 0.049 1.167 0.035 1.202 0.051 1.185 0.038 1.221 0.311
Stride width (m) 0.121 0.006 0.117 0.008 0.119 0.008 0.125 0.007 0.910 0.442
Clinical parameter
UPDRS-III 20 2.9 12.6 1.8* 11 1.8* 12.1 1.9* 104.516 <0.001
Significant parameters are in boldtype
Pre-test t0 baseline evaluation, Post-test t1 end of treatment at 4 weeks, Post-test t2,3 follow-up evaluation at 8 and 12 weeks, SD standard
deviation, R right, L left, UPDRS Unified Parkinsons Disease Rating Scale
* Statistical significance as compared to baseline evaluation (pre-test)

With regard to step and swing time, a left-sided signif-
icant decrease was observed for both these variables over
the time course of the study. The asymmetric changes
observed in these temporal gait parameters might be due to
the left-dominant extrapyramidal side presented by all but
one patient. As a consequence, by improving such vari-
ables, GPR program ameliorated the global cycle time and
decreased step and swing asymmetry.
The improvement in the temporal gait pattern observed
in our patients occurred without changes in spatial
parameters such as stride and step length. This discrepancy
could be related to the specific rehabilitation intervention
adopted for this study. Two major rehabilitation approa-
ches have been advocated for PD: movement strategy
training and musculoskeletal exercises [24, 25]. Movement
strategy methods are aimed to train PD patients to improve
mobility using cognitive control. These real movements
require the participant to use the feedback/feedforward
mechanisms to carry out functional tasks resulting in
more efficient sensory afferent and efferent information
processing [13]. Several studies have shown that in PD
patients, both spatial and temporal gait parameters improve
when external cues are provided or verbal instructions to
increase step length are given [2632].
In contrast, musculoskeletal exercises, such as GPR, are
aimed to improve strength, joint range of movement, muscle
length, endurance and aerobic capacity [24, 25, 3335].
Stretching rehabilitation programs have been proved to
acutely ameliorate gait speed and stride length in elderly
healthy subjects by reversing age-related hip flexion con-
tracture and reduced peak ankle plantar flexion [3638]. In
PD patients, factors other than hip flexion and ankle plantar
excursions may therefore be responsible for the reduced gait
speed and step length [39]. Hence, changes in gait param-
eters may be determined by complex disease-related factors
including augmented reflex responses and development of
tonic stretch reflex and shortening reaction [39, 40].
Accordingly, we hypothesize that stretching of muscle
chains in PD patients might selectively impact temporal
gait pattern as a consequence of a pure proprioceptive
stimulus relying mainly on viscoelastic property of tissue.
In the absence of other active cues, reinforcing somesthesic
drive to the cortical areas, static muscle elongation does not
promote learning of motor strategies and may at least in

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part counteract the tonic stretch behavior observed in PD
patients, but not in healthy subjects.
Finally, with regard to clinical outcome measures, mul-
tivariate analysis revealed a significant improvement in total
UPDRS-III scores from baseline (t0) to the end of rehabili-
tation program (t1). Moreover, at both 4 and 8 weeks after
completion of the treatment, the mean UPDRS-III scores
were still significantly lower than baseline values, thus
suggesting a long-term efficacy of GPR in ameliorating
motor disability and global clinical status.
In summary, GPR treatment was effective in improving
mobility and temporal gait pattern in patients with PD.
Quantitative analysis of gait pattern can be considered a
useful tool for formulating functional prognosis and mon-
itoring the effects of rehabilitation in PD patients. More-
over, three-dimensional MA allows us to dissect the
specific contribution of spatiotemporal gait parameters and
to select goal-directed rehabilitation interventions to
monitor recovery and counteract motor disability in PD
patients.
This is a preliminary open study with the limitation of
small sample size study population. Further validation
should be investigated in the context of a randomized
controlled trial with a larger population.
Acknowledgments This work was supported by a grant from MIUR
(Firb RBNE08LN4P_006).
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