Balance Impairment and Falls in Parkinson’s Disease
One of the most challenging symptoms of Parkinson’s disease (PD) that fundamentally affects quality of life is balance impairment that can lead to falls.
Falls are one of the major causes of emergency room visits and hospitalizations for people with PD, so finding ways to prevent as many falls as possible is a high priority for people with PD. Thankfully there are things you can do to improve your stability and decrease the likelihood of falling, and we’ll share some helpful tips and advice below.
Causes of falls in people with Parkinson’s
The most important first step to prevent falls is to identify the cause or causes of the falls. It may seem that everyone with PD falls for the same reason, but in fact, there are multiple factors that need to be assessed.
- Postural instability – this is often referred to as one of the four cardinal features of PD (along with rest tremor, bradykinesia or slowness of movements, and rigidity or stiffness). Postural instability refers to the inability to right oneself after being thrown off balance. It is typically tested in the doctor’s office when the neurologist tugs backward on your shoulders to see if you are able to prevent yourself from falling. A person with PD with postural instability may fall if they are jostled. This symptom is not typically present early in the disease and tends to develop as the disease progresses.
- Freezing of gait – This is an abnormal gait pattern that can accompany PD (as well as other parkinsonian disorders) in which you experience sudden, short, and temporary episodes during which you cannot move your feet forward despite the intention to walk. In a sense, you’re stuck. This results in the characteristic appearance of the feet making quick-stepping movements in place. However, while the feet remain in place, the torso still has forward momentum which makes falls common in the context of freezing of gait.
- Festinating gait – this is another abnormal pattern of walking that can occur in some people with PD. In this gait, the person takes short steps which get smaller and faster, until it looks like they are almost running. The person may not be able to stop this pattern of walking and may end up hitting up against barriers in order to stop. Festination can lead to falls.
- Dyskinesias – These are extra, involuntary movements that occur in some people as a side effect of Levodopa ingestion. When severe, dyskinesias can throw a person off-balance and cause falls.
- Visuospatial dysfunction – One of the typical cognitive challenges that can affect people with PD is deficits in visuospatial thinking. Deficits in this cognitive area lead to an inability to navigate oneself in three dimensions. A person may have difficulty maneuvering around obstacles in a room or backing up to sit down in a chair. This difficulty can also lead to falls.
- Orthostatic hypotension – A common non-motor feature of PD is drops in blood pressure upon changing head position. This can lead to dizziness and even passing out, which can be interpreted by the bystander as a fall.
- Posture problems – PD can be associated with stooped or tilted posture which can contribute to imbalance.
Understanding which factors are contributing to falls is important since each is treated in a different way.
- The postural instability of Parkinson’s may be responsive to increases in PD medications.
- Sometimes episodes of freezing of gait and gait festination can be reduced with increases in medication as well.
- Bothersome dyskinesias can be treated by adjusting PD medications or initiating amantadine or amantadine ER.
- A number of strategies can be used to manage orthostatic hypotension including increased fluids and dietary salt as well as compression stockings. If necessary, medications to increase blood pressure can also be considered.
Another important step in falls prevention – which is necessary to consider whatever the cause of falls – is modification of the home environment, such as:
- Remove rugs and potential obstacles.
- Install grab bars in key areas in which falls are more likely, such as the bathroom.
- Choose the right shoes for you: some like rubber soles and some do better with leather soles; check that shoes are not loose-fitting and provide support. Wear shoes with a slight heel to reduce falling in the backward direction, but no high heels.
- Wear a medical alert bracelet or pendant in case a fall does occur.
A very important part of managing someone who tends to fall, which is often overlooked, is assessing bone density. If thinning of the bones or osteoporosis is detected, medications can be prescribed to improve this, which can prevent a fracture should a fall occur. Your primary care physician can arrange for bone density testing, which is done via a quick and painless x-ray scan.
Why is fall prevention so important?
Oftentimes a fall will cause no injury or a mild, easily reversible injury, however, sometimes a fall can cause moderate to significant injury.
In addition to the fall itself potentially causing a fracture or head injury, the fall could possibly result in an ER visit, hospital stay, or surgery, which can sometimes set off a series of events that has the possibility of worsening a person’s PD even more substantially. Hospitalizations can interfere with medication timing, contribute to simultaneous infection, precipitate hallucinations, and increase confusion. Each of these setbacks can spawn additional setbacks which can contribute to the worsening of PD overall. In addition, immobilization after a fracture can interfere with exercise and physical therapy goals. For all of these reasons and more, it is important to do all that you can to reduce the chance of falls.
More Ways to Help Manage Balance for People with PD
Once medications are optimized and the home environment is as safe as possible, the next step in the treatment of falls in Parkinson’s is a comprehensive rehabilitative assessment by a trained physical therapist. A physical therapist will then design a program that can address postural instability, freezing of gait, festination of gait, visuospatial dysfunction, and problems with posture, depending on the active problems that are identified.
Check out our additional resources on balance and falls prevention for even more important information, such as our tips on overcoming a freezing gait. In addition, APDA’s Let’s Keep Moving series shares expert physical therapy advice on a range of topics, including a three-part series dedicated to balance.
Sometimes, the balance is affected to the point that an assistive device for walking becomes necessary.
The use of a cane is often discouraged by physical therapists who are experienced with Parkinson’s. With only one side of the body using the cane, this creates an additional imbalance that is not present when using a walker. In addition, the cane itself can get caught up in furniture or other obstacles and contribute to falls.
Because of these concerns, walkers are often suggested as the assistive device of choice for people with PD. There are many types of walkers that are available for people with walking difficulties. Here is a simple guide:
- Basic walker – this is usually just a metal frame without wheels
- Wheeled walker – a metal frame with wheels. The wheels may be on two or four legs and the wheels may swivel or be fixed
- Rollator – a walker with swivel wheels on all four legs and hand brakes. The brakes typically need to be engaged for the walker to stop. Often the rollator has a seat and a basket for convenience.
- U-step walker – designed specifically with the concerns of people with PD in mind, particularly freezing of gait. The U-step walker has a reverse braking system which means that without engaging anything, the walker is in the braked position and the wheels will not turn. A lever must be gripped or pressed in order for the wheels to turn. Therefore, if freezing of gait occurs, the walker should stay stable. The walker can be ordered with a laser light and/or a sound cueing module which can be used to interrupt a freeze.
Your physical therapist can help you determine the walking aid that is best suited for your specific situation.
Should I be using a walker?
This is a critical question that many people with Parkinson’s grapple with and is best answered for each individual by their neurologist or physical therapist. I often hear the concern from people with PD that if they start to use a walker, they may become “dependent” on it, and they won’t be able to walk without one in the future. If your balance is impaired and falling is a concern for you, talk with your neurologist about the potential steps that could improve your situation and prevent falls (as discussed above). If all adjustments have been made and poor balance is still present, the reality is that it will likely remain that way and will not be worsened or perpetuated unnecessarily by the use of a walker. At that point, a walker becomes essential for you to maintain your independence. Embracing its use is the best way to maximize your quality of life.
Research to prevent falls
APDA is proud to fund research into fall prevention. Dr. Aasef Shaikh, recipient of the prestigious APDA George C. Cotzias Fellowship award for 2018-2021, is working to understand the different components that contribute to balance impairment in PD.
Tips and Takeaways
- There are many potential causes of falls in PD. Assessing why falls occur can inform the strategies used to prevent falls
- Optimizing the home environment with de-cluttering and grab bars is an important part of falls prevention
- Physical therapy is especially essential for those susceptible to falling
- An assistive walking device may be necessary to maximize stability and quality of life
- By supporting our research efforts, you can help fund important work on critical topics like fall prevention