Biomechanical outcomes of the pendulum test characterize individual differences in activated versus resting leg rigidity in people with Parkinson’s disease

Abstract

Leg rigidity is associated with frequent falls in people with Parkinson's disease (PD), suggesting a potential role in functional balance and gait impairments. Changes in neural state due to secondary tasks, e.g. activation maneuvers, can exacerbate (or 'activate') rigidity, possibly increasing the risk of falls. However, the subjective interpretation and coarse classification of the standard clinical rigidity scale has prohibited the systematic, objective assessment of resting and activated leg rigidity. The pendulum test is an objective diagnostic method that we hypothesized would be sensitive enough to characterize resting and activated leg rigidity. We recorded kinematic data during the pendulum test in 15 individuals with PD, spanning a range of leg rigidity severity (slight to severe). From the recorded data of leg swing kinematics we measured biomechanical outcomes including first swing excursion, first extension peak, number and duration of the oscillations, resting angle, relaxation index, maximum and minimum angular velocity. We examined associations between biomechanical outcomes and clinical leg rigidity score. We evaluated the effect of increasing rigidity through activation maneuvers on biomechanical outcomes. Finally, we assessed whether either biomechanical outcomes or changes in outcomes with activation were associated with fall history. Our results suggest that the biomechanical assessment of the pendulum test can objectively quantify leg rigidity among people with PD. We found that the presence of marked rigidity during clinical exam significantly impacted biomechanical outcomes, i.e. first extension peak, number of oscillations, relaxation index and maximum angular velocity. No differences in the effect of activation maneuvers between groups with clinically assessed moderate and marked rigidity were observed, suggesting that activated rigidity may be independent of resting rigidity and should be scored as independent variables. Moreover, we found that fall history was more common among people whose rigidity was increased with a secondary task, as measured by biomechanical outcomes. We conclude that different mechanisms contributing to resting and activated rigidity may play an important yet unexplored functional role in balance impairments. The pendulum test may contribute to a better understanding of fundamental mechanisms underlying motor symptoms in PD, evaluating the efficacy of treatments, and predicting the risk of falls.