Expert Briefing: Steady Steps - Improving Gait and Balance in Parkinson's Disease

Dr. James Beck 00:00:00
Hi everyone, welcome to the Parkinson's Foundation's Expert Briefings. I'm Dr. James Beck, Chief Scientific Officer of the Parkinson's Foundation, and it's a pleasure to have you with us today. Today is our fifth of six briefings for 2025. In today's briefing, we will gain a deeper understanding of common gait and balance challenges people with Parkinson's may experience. We'll also explore the common factors that often contribute to these difficulties in Parkinson's disease. But before we get started, we'd like to do as we always do and get a sense of who's joining us today. We should launch a poll in just a minute, and if you're on Facebook Live, you can respond using the comment section. Please tell us, are you a person with Parkinson's? Are you a nurse, nurse practitioner, physician, clinician, a friend, family member or partner of someone with Parkinson's disease? Let us know your connection. Respond to that poll, and we'll see what we get in just a few minutes.

As I expect, we have a lot of people who live with Parkinson's disease joining us today and their loved ones. Today is a really interesting topic, talking about gait and balance, which is one of those ones that is so difficult to deal with, but I'm sure Dr. Afshari, our speaker today, will be able to really provide some insights on that. Okay, so what do we have for results so far?

Drum roll, please.

Yeah, of course. People with Parkinson's and their loved ones. This is really great to hear. This is going to be a great talk for you guys today, so hopefully we'll be able to really get a lot out of it as part of the process. Before we get going, I just want to tell you a little bit about the Parkinson's Foundation and introduce you to it. For those of you who may not know, we're a nonprofit organization dedicated to improving the lives of those living with Parkinson's by enhancing care and advancing research. Our efforts are deeply rooted in collaboration with the Parkinson's community, ensuring that everything we do aligns with your needs and your priorities.

Today's program is an excellent example of how we're working with you to meet those goals.

As part of that, I'd like to talk a little bit about our investment in breakthroughs. The Foundation has invested over $449 million in research and care to improve diagnosis, treatment and scientific breakthroughs. One of our key initiatives is PD GENEration. Through this study, we offer free genetic testing and counseling to those who live with Parkinson's disease. By participating, you can learn not only about your genetic connection to Parkinson's disease, but you can contribute to research that drives new treatments and hopefully a cure one day. We encourage you to share this opportunity with your community. If you've already participated in PD GENEration, let others know. Together, we can really make a difference.

For your convenience, I just want to give you a friendly reminder that we're going to be recording today's Expert Briefing. The recording will be available online shortly after our presentation ends. There's no need to check back regularly to see if it's posted. We'll be emailing a link to all those registered with the recording and other resources related to today's topics, again, for everybody who's registered.

Next, let's move to our main event, our Expert Briefing. It's my pleasure today to introduce Dr. Mitra Afshari. Dr. Afshari is an assistant professor of neurology and rehabilitation at the University of Illinois Chicago and director of the Neurointerventional Program for Movement Disorders there. She's a leading expert in using technology to enhance patient-centered care for people with Parkinson's disease. Her current research focuses on developing telemedicine-based fall prevention programs, work that has earned her a prestigious Parkinson Study Group Research Award. She also co-chairs the International Parkinson and Movement Disorder Society's Telemedicine Study Group and serves as an associate editor for the Movement Disorder Society podcast. That's a mouthful. Dr. Afshari, thank you very much for sharing your time and expertise with us today.

Dr. Mitra Afshari 00:03:50
Thank you so much. Just trying to start my video.

Okay, my video might be...

Crista Ellis 00:04:00
I'm going to send you a prompt, doctor. Sorry. Click yes to start your video. Let's see if that works. Got it. Hey, hey.

Dr. Mitra Afshari 00:04:10
Thank you so much for that kind introduction, Dr. Beck. It's such a pleasure to be here. This is really an honor and actually a dream of mine, to be a part of this series and to be providing a lecture on one of my favorite subjects, which is gait and balance in Parkinson's disease. I'm going to go ahead and share my screen.

Are you able to see the screen well, Crista?

Crista Ellis 00:04:37
Yes, it's looking great. Thank you.

Dr. Mitra Afshari 00:04:39
Beautiful.

Today, our lecture is entitled Steady Steps: Improving Gait and Balance in Parkinson's Disease. These are my disclosures. As Dr. Beck mentioned, my research niche is actually in fall prevention in Parkinson's disease. These are some of the generous groups that I've received funding from for my own personal research.

Today, my objectives are: I hope that I can make this very understandable for the audience and very practical as it applies to you or your loved ones. Because this is an Expert Briefing, I want to cover some of the latest research and evidence that's out there so you can really feel like you've left this talk having heard something new. I hope you'll understand by the end of the lecture the primary factors affecting gait and balance in Parkinson’s Disease. We'll also examine how gait and balance issues increase fall risk and affect mobility and independence. As I mentioned, I'll be going through some of the evidence-based approaches to improve gait and balance, such as rehabilitation, exercise and the use of assistive devices. Finally, I really hope based on everything that I present today, you'll be able to see the role of personalized medicine. Like so many things in Parkinson's disease care, personalized, individualized care plans are very important to fall prevention.

It's only been a few months, actually, that a large epidemiologic study revealed that Parkinson's has surpassed Alzheimer's disease as the fastest-growing neurological disease. This is based on projections from a well-known study called the Global Burden of Disease study. Some people are even calling this the pandemic of Parkinson's disease. The projection is that the global number of Parkinson's disease patients will increase by 112% from 2021 to 2050, which actually equates to 25.2 million Parkinson's disease patients worldwide by the year 2050.

When you look at the primary factors that are driving this growth, the data continues to show that aging is the main driver across all countries. The countries with the highest prevalence rates actually continue to be the wealthier countries where life expectancy is the greatest, and that includes the United States. But the greatest growth that is predicted is in the middle-income countries. So why is this forecast important? Why am I starting with this?

I think it's important because it's always critical to keep these numbers in mind as we look at issues in Parkinson's that are most critical, that have the most critical need for our attention and issues that ultimately have the most impact for our patients and for our healthcare system. One of those issues is gait and balance, and ultimately falls. When I was putting together this presentation, I thought it might be helpful to use an analogy for gait and balance because sometimes it's hard to decipher what's what. So you can think of gait and balance kind of like a running car.

Gait, or what we call locomotion, is kind of the forward motion of the car, which requires the wheels to work in a rhythm and in tandem to provide that forward propulsion. Balance is essentially the stability of the car that allows the car to stay on track and to correct for external or outside perturbations that seem to throw it off course. So when either of these two become compromised, ultimately what this means is that you can either sustain a crash of the car, which is essentially a fall, or there's also another issue that can arise where you can have something almost like an ignition failure. The car stalls. These are what we call motor blocks in Parkinson's disease, the most common of these being what's called freezing of gait. I want to bring your attention here to the fact that, again, falls are a huge public health concern at this point in Parkinson's disease.

Dr. Mitra Afshari 00:09:11
It is the leading cause of morbidity, as well as hospitalization, in Parkinson's disease.

What can affect these two elements in Parkinson's disease? What affects gait and balance in Parkinson's disease and ultimately leads to the car either stalling or crashing? These issues can be put into two categories. This is kind of how we approach it from a provider perspective. There can be issues that are continuous in the person with Parkinson's disease, which means that they occur essentially at all times, like while the car is driving. Then there can be issues that are a bit more enigmatic and episodic. These can happen kind of suddenly, out of nowhere, potentially when the car is starting, turning or stopping. These are things like the ignition failure that I was alluding to.

As part of the continuous issues that affect gait and balance, I've listed some of the most common ones. First and foremost, there's slowness in movement. There's slowness in the pace of stepping that affects gait in Parkinson's disease. The steps tend to be shorter, and by shorter, we mean in length, width and height. We often call that shuffling.

There's also variability and asymmetry in stepping. As many of you may know, Parkinson's tends to start out asymmetrically. It starts out on one side of the body, and it actually tends to stay that way throughout a person's course. One side always seems to be a little bit worse, so one foot can catch or is often lagging behind.

Dystonia and dyskinesia can come into play both early and later in the disease, when a patient is on and off levodopa. Another continuous issue that can affect gait and balance is posture. Patients with Parkinson's tend to have a stooped posture, so their center of gravity tends to be more forward.

Also, one of the most early signs of Parkinson's is a reduced arm swing, and it tends to be asymmetric, again, on the worse side and the first side that the Parkinson's disease started on. Finally, one issue that I think is often overlooked, but I would classify it as a continuous issue and that is critically important, is fear of falling. This can be really debilitating for a lot of Parkinson's patients. I do feel that Parkinson's patients have a tendency toward fear of falling because they do tend to be more anxious in general.

This fear of falling, even if everything in the car is working well, if a patient has sustained a fall in the past, a huge fear can build up, and that can actually lead to abnormal gait patterns where the patient is essentially protecting themselves. It can cause a secondary immobility, even though everything in the car might still be working.

In terms of episodic issues, these would be the motor blocks that I was alluding to earlier, where the car would be stalling or there would be issues turning or stopping. The most common of these is the well-known phenomenon known as freezing of gait, and this tends to happen during initiation of gait, during turning, thresholds or stopping. We'll talk about this more later in the lecture. There's another type of freezing. It's actually a sister to freezing called festination. Then also, another episodic issue that is very common in Parkinson's disease patients is the transient loss of postural stability.

Dr. Mitra Afshari 00:13:09
Parkinson's patients have a tendency to have what's called retropulsion, or a tendency to fall backwards specifically. For instance, a simple example of this is when they open the fridge door, they might lose their balance and tend to fall backwards if their lower extremities are not keeping up with their upper body.

I'm sorry.

Why do these issues occur in Parkinson's? Remember, Parkinson's is a movement disorder. The main issue is one of movement. We see these issues in Parkinson's because of the low dopamine state, which causes these five things.

First off, Parkinson's and the low dopamine state causes bradykinesia. This is progressively smaller movements, and this is what ultimately results in kind of that shuffling gait pattern.

Second, Parkinson's disease causes rigidity, or stiffness, not just stiffness in the extremities, but also stiffness in the spine and the trunk. That stiffness also manifests as that asymmetric arm swing, potentially, and all of these things change the fluidity of walking.

Third, Parkinson's disease causes that postural instability I was just talking about, which is that propensity to fall backwards. I want to highlight that these first three items, bradykinesia, rigidity and postural instability, are the cardinal motor features of Parkinson's disease. So you can see why, inherently, Parkinson's disease puts you at risk for gait and balance issues.

Over time, as Parkinson's disease progresses and there's less and less dopamine available to these deep brain structures that we call the basal ganglia, which essentially automate our gait and our locomotion, that automation is lost. As Parkinson's disease progresses even further and the disease expands beyond those deep brain structures and goes to the cortex, we kind of start to lose the reserve that we have in the rest of the brain, in the cerebral cortex, that is essentially lending a helping hand to the deep brain for us to overcome those gait challenges.

Ultimately, all of these issues lead to falls. Prospective studies have revealed that 60% of persons with Parkinson's, that's PWPs, fall once within a year, and 39% fall recurrently within a year. The consequences of falls are actually quite grave. Falls lead to injury and fractures, with literature showing that the most common fracture is indeed a hip fracture. If someone sustains a hip fracture, that definitely can lead to secondary immobility.

Falls have been associated with reduced quality of life, of course, and independence. Unfortunately, falls in Parkinson's disease patients are the leading cause of institutionalization. That's nursing home placement.

Falls are also very costly for our healthcare system. In the United States, a single hospitalization due to a fall-related injury is essentially equivalent to the total annual expenditure for a single Parkinson's disease patient. Prevention is really key.

Dr. Mitra Afshari 00:16:58
This is a common figure that we use in the research community to show the disease course of Parkinson's disease and all of the issues that commonly arise over the various stages of Parkinson's. As you can see here, falls are noted in the late stage, but I would argue that fall prevention should really start upon diagnosis of Parkinson's disease.

As I mentioned, these factors, bradykinesia and rigidity, definitely contribute to abnormalities in gait and balance. We really should be instituting fall prevention strategies upon diagnosis. Just remember that these strategies may change over time. I think we've probably heard this ad nauseam, but Parkinson's disease is a moving target. So just as Parkinson's disease changes over time, your specific therapeutic needs will also change over time.

I made this figure not to throw more jargon at you, but I hope that I can highlight that when we talk about gait in Parkinson's disease, there are elements to gait beyond just speed that require attention. These are the different kind of gears of the car that contribute to gait: pace, which is speed; truncal stability; asymmetry; rhythm; variability; and turning ability.

This is why there are so many different exercise programs out there and why a knowledgeable physical therapist can be helpful, to make sure that the program that you're choosing or the exercises that they're prescribing are targeting your specific issues. For each patient, each of these gears may have different proportions. One patient might have issues more with their pace. Another patient may have more issues with their turning ability, so the therapies and the exercises need to be targeted for those individual difficulties.

When it comes to balance, it's not just about steering the car. Balance also includes domains of dynamic stability that relate to gait, postural stability that relate to standing, anticipatory postural adjustments that relate to transitions like going from sitting to standing, and automatic postural adjustments, which have to do with external perturbations while you're walking or standing.

There are so many different gears that kind of work together, again, to make sure that your gait and balance are in check. As I've mentioned, it really should start at diagnosis. Physical training is medicine, and it's like medicine. It needs to be titrated to the individual, both the mechanism that you're focusing on in the patient, but also the dose and the frequency. It should, like I said, start at diagnosis, be ongoing, and that prescription may change over time.

One of the keys, and this is something that a lot of researchers in the United States are working on in order to provide new models of care so that you may gain access to specialized physical therapists, is to find a physical therapist who has experience with Parkinson's disease so that you can provide targeted therapy and provide the right prescription also for long-term exercise. I have pictured here one of my wonderful colleagues from Northwestern University. Her name is Miriam Rafferty.

Dr. Mitra Afshari 00:20:59
We also work on some research projects together, but one of her goals in her research is to create a new model of care where she can provide consultative physical therapy services, potentially over telemedicine, for Parkinson's disease patients upon diagnosis and throughout their diagnosis, so that she and her colleagues can keep up with that moving target.

Let's look at the body of literature that there has been with respect to all of the rehabilitative and exercise modalities that have proven to be beneficial. It's hard to summarize all of this work in this short lecture, but let's take a stab at it. Many of the literature sources that I'm showing are part of large meta-analyses. These are research investigations aimed at summarizing large amounts of data from multiple studies in a systematic way so that we can present trends.

The following modalities have shown good evidence that, at least in the short term, they can reduce the severity of those cardinal motor symptoms that might be contributing to gait and balance disturbances in Parkinson's disease. Those include conventional physical therapy, aerobic exercise, dance, Nordic walking and various martial arts. As part of dance, that would include tango, ballroom dance and waltz. As part of martial arts, that would include tai chi and karate.

If we summarize the data with respect to programs that aim to impact balance, and where we have seen benefit with respect to balance outcomes in Parkinson's disease, these are the modalities that have shown the most benefit. These include combined gait and balance training; strategy training, which involves essentially teaching patients complex movement strategies, as well as cueing strategies, which come into play with freezing of gait; resistance training; dance; martial arts; Nordic walking; aerobic exercise; exergaming, which is essentially exercise combined with gaming or reward; and then also hydrotherapy or aquatherapy.

Finally, if we look at the data with respect to outcomes related to gait specifically, these are the modalities that have proven to be most beneficial: conventional PT, combined gait and balance training, treadmill training, exergaming, dance and martial arts. I'd like to talk a little bit more about treadmill training. The reason why is that this is something that could be very readily available to you or your loved one.

Logically, treadmill training makes sense because ultimately it provides task-based training for gait, and it allows you to essentially practice and strengthen your walking and your balance. First off, time and time again, there have been multiple studies that have shown that treadmill training, even in a person who is at high risk for falls, is well tolerated. That means there have been very low dropout rates in these studies and there have been very low adverse events, meaning patients have not sustained high fall rates while participating in these studies and while being on the treadmill.

Dr. Mitra Afshari 00:24:39
This is a common factor that has been seen across multiple studies, which I've aimed to summarize in these figures. I'm sorry if the figures are a little bit blurry, but this is again a meta-analysis, which is a summary of the data that has shown that treadmill training, at least in the short term, most certainly improves motor severity, those cardinal motor symptoms of Parkinson's. It can also improve functional mobility, gait speed and stride length.

But unfortunately, treadmill training may not touch on some of the balance issues that can come into play. There have not been significant benefits to cadence and walking distance. This is meant to highlight that one exercise, a single exercise or a single approach, may not be the solution to all of your issues when it comes to gait and balance. Multi-modal training is optimal.

Since treadmill training, as I just mentioned, has been shown to be very successful, what if we took it one step further? As you saw, it seemed like treadmill training helps the mechanics of gait, enhances the forward motion of the car, but perhaps it doesn't touch on the issues with balance. Maybe introducing a new element to treadmill training that challenges balance could be useful. There are several groups out there around the world working on this, and this is called treadmill training with perturbations.

They're using things as simple as what's called a split belt, where the belt of the treadmill is split in half, so one side may be operating at a different speed than the other side in order to challenge one's gait. Or the treadmill is connected to a kind of harness worn around the waist, and this harness essentially introduces pulls that act as perturbations in the gait.

Several smaller studies have demonstrated benefits to gait speed, symmetry, variability and also several additional measures of balance in response to this perturbation training on a treadmill. But we're still early in this process, and longer-duration and dose-finding studies are really needed and ongoing. From my perspective, this is something that could potentially be readily available for a large population, since treadmills are very easily accessible by many patients.

Dr. Mitra Afshari 00:27:42
Let's look at long-term trends in exercise specifically. You've probably heard this many times, but unfortunately, we don't have any medications that slow down the progression of Parkinson's disease. But the one thing that we do know that can slow down the progression is exercise. While this is not necessarily a lecture completely focused on exercise, I do want to highlight long-term exercise.

This meta-analysis specifically highlights high-quality randomized trials of various exercise programs of six to 12 months' duration, and there's very clearly a trend that shows that exercise can have a potential neuroplastic effect or disease-modifying effect in terms of reducing Parkinson's disease severity when they compare patients who are part of the exercise program to PD patients who are not a part of the exercise program, and when they specifically look at Parkinson's disease severity in the off-levodopa state.

I'd like to highlight that this analysis specifically included two of the largest and most well-known exercise studies in the United States and the Netherlands: the first, the American Phase 2 SPARX2 trial of moderate- to high-intensity treadmill-based exercise, and then the Dutch Phase 2 Park-in-Shape stationary cycle-based exercise trial that involved exergaming.

Because those two large studies showed such positive trends, there are now other studies that have moved into Phase 3 in testing these modalities. The SPARX3 study specifically is currently enrolling and ongoing. This is meant to enroll early PD patients and is enrolling at 25 sites around the United States. Most recently, a new cycling study called CYCLE-II out of the Cleveland Clinic, with the PI, the main investigator, being Professor Jay Alberts, has closed, and the results for this are pending and hopefully will be released soon.

I had previously shown you the various gears that contribute to balance. So what are the different programs that could specifically target balance? There are tons of different programs that have been tried out there, and each of these programs tends to strengthen different elements of those various gears that I had presented before. Unfortunately, what we found when we were looking at large meta-analyses of all of these balance programs that have been developed is that there's not one single approach that proves to be superior for all domains of balance.

Some of these programs are individual programs, and some of them are even group-based therapy. One consistent finding has been that the integration of cognitive engagement, like feedback cues or attentional demands like dual-tasking, and the incorporation of things like reward and motivation, kind of like the exergaming we were talking about, does seem to provide added benefit.

Dr. Mitra Afshari 00:31:19
Looking at the data in general with respect to balance programs, again, I think this highlights that balance training should be tailored to the individual difficulties of the patient. So again, I want to bring it back to the key point for today: finding an experienced physical therapist who can really hone in on the right approach for you.

One thing I wanted to highlight on this slide is that there is a new test that has come out in the last decade or so, both in real-world settings and in research settings, that has really been great for Parkinson's disease care. This is the Mini-BESTest, or scale. This scale actually allows providers to objectively measure how patients with Parkinson's disease are doing in all of those several domains of balance that get compromised with the disease.

If you feel like you can have a conversation with your therapist about the Mini-BESTest, I would urge you to do so. This can potentially help them hone in on the issues that you're having the most difficulty with.

Finally, I know we're running low on time, but I would really like to talk about freezing of gait. This is a favorite topic of mine, and this is honestly a lecture unto itself, but this is one of the major contributors to gait and balance impairment in Parkinson's disease, especially for those in more advanced stages of disease.

It may even be the most common contributor to gait and balance issues late in PD. Freezing of gait is one of those episodic issues we talked about earlier. The definition is that freezing of gait is a brief, episodic absence or marked reduction of forward progression of the feet despite the intention to walk. This often manifests as start hesitations. Again, the car is stalling, and that can be upon initiating gait and stepping. It can also manifest as arrest during actual gait and locomotion.

Patients can experience stuttering steps and pure motor block. I wanted to show a short, quick video here of what freezing of gait can look like. This is a patient with Parkinson's in the off-medication state, and as you can see here, as he's approaching and as he's on that new surface where the floor essentially looks different, you saw that he had some stuttering steps.

Now as he's trying to turn to go back, he's also experiencing some more of a pure motor block. He's experiencing freezing. Essentially, the feet during freezing are, patients say, a lot of patients say that their feet feel glued to the floor.

One key thing to keep in mind is that freezing is also, by definition, precipitated and relieved by external factors. The beauty of that is that these external factors are often modifiable. Freezing of gait, like I tell all of my patients, tends to be precipitated by circumstances that require small steps and/or circumstances that challenge the gait. When you're turning, you often have to take small steps.

When you're approaching a threshold, you're slowing down in order to make a decision to go right or left, and that is requiring small steps. When you're in tight spaces, when you're maneuvering around obstacles, those often require smaller steps. These are often circumstances that bring out freezing. Then there are other circumstances, like changing floor patterns, like you saw with this patient, or textures of the floor, like a rug.

Also, dual-tasking, which means doing two things at once, like walking and also looking at your phone or talking to someone. These are all things that can bring out freezing of gait, but are also largely modifiable from a behavioral perspective. By definition, freezing is relieved by certain cues that tend to bring the focus back to gait to overcome those challenges. In this next video, what you see is the same freezing patient, still in that off-medication state.

Dr. Mitra Afshari 00:36:24
So in a low-dopamine state, see how nicely he responds and is able to overcome freezing. The first video was when there were visual cues with the tape on the floor, and he was able to use that tape to overcome that ignition failure and lengthen his stride to prevent those small steps and overcome his freezing. The second part of that video showed, you weren't able to hear it, but there was a metronome, and he was able to keep his momentum in taking big steps by using an auditory cue like a metronome.

Freezing of gait affects about 50% of all persons with Parkinson's disease, and it becomes more and more prominent with progressive disease. That means it affects about 80% of advanced Parkinson's disease patients. Prospective studies have shown that 60 to 69% of falls in Parkinson's disease can be attributed to freezing of gait.

We spoke earlier about the continuous versus the episodic issues that affect gait and balance in Parkinson's disease. Freezing of gait falls into that episodic category, which often causes a lot of confusion for patients, unfortunately, because it seems like the difficulty is coming out of nowhere. It's quite possible that patients may not recognize that they're freezing, and we might not be able to catch that they are freezers in the clinic environment because the clinic environment may not be bringing out their freezing and may not have those precipitants that they may be experiencing at home.

I know that we're running low on time, and I'm happy to provide another lecture one day on freezing of gait management strategies, but one important thing I want you to take away from this slide as we go through the next couple slides quickly is that there are different types of freezing of gait. The most common type of freezing of gait, and by far the most common type of freezing of gait, and the freezing of gait that happens earlier in a patient's course, tends to be levodopa responsive.

It tends to occur when patients are either coming down on their levodopa or are in an off-dopamine state. The number one treatment for managing freezing of gait is to ensure that the patient's dopaminergic regimen is optimal and smooth. Oftentimes, if providers are not able to get the appropriate history from a patient, it's very important that our providers bring patients in for what we call on-off examinations. This is something that you can actually encourage your provider to do for you: 'Hey doc, can I come in without my meds, and I'll take my meds, and you can see exactly what's happening to me?' Sometimes that's just the easier way to figure out what's going on.

Dr. Mitra Afshari 00:39:53
There are lots of other medications that can be tried to manage freezing of gait. A lot of these medications are speaking to some of those compensatory mechanisms we talked about that often involve the cerebral cortex that might be lending a helping hand, again, to the deep brain. Finally, rehabilitative strategies, as you saw, by definition, freezing of gait can be overcome with certain strategies. Rehabilitative strategies are super important.

In addition to what you saw on the video, the visual, auditory and even tactile cues, there are other rehabilitative strategies that can be taught, such as weight shifting and a focus just on big steps, that can help you overcome freezing of gait on your own at home. Lastly, the physical environment is very important, and this is a particular interest of mine. We'll talk about that in a second.

This is a table of various cueing strategies that I personally provide all of my patients. I'm sure that this lecture will be provided to you at the end. I'm happy to share it. One of the major cueing strategies that I talk about are visual cues and using the blue painter's tape in areas in your home where you feel like you're having freezing. There are certain assistive devices that can help with visual cues as well, including this U-Step walker, which has a built-in laser. There are also things like laser canes, where you push down on the cane and a laser will appear on the floor.

These are really nice assistive devices that a physical therapist can help train you on in order to overcome your freezing. Beyond just freezing of gait, assistive devices can be very useful for patients, especially when you've gotten to a point in your Parkinson's disease where falling has become a daily occurrence. Ultimately, what we want to do is prevent that fall that will lead to secondary immobility and prevent nursing home placement.

It's not unheard of to be able to rely on assistive devices to prevent falls. The important thing with respect to assistive devices is that you get proper training to use them appropriately and that they are adjusted appropriately to your height. I always tell my patients, if you are going to physical therapy, please take your cane with you. Please take your walker with you so you can make sure you're making the best choices with respect to using those devices.

Dr. Mitra Afshari 00:42:44
I wanted to bring it back to falls. Again, this is something that's not advertised as much, but it should be: 80% of our falls in Parkinson's occur in the home. This is increasingly important in light of the increasing aging population, but also in light of public health crises like the COVID pandemic that occurred, where we were spending more and more time in our home. Because I'm talking about freezing of gait and modifiable fall risk factors, I wanted to focus a little bit on the home as well and talk to you about environmental or extrinsic fall risk factors.

I wanted to show you some videos of a patient of mine who had been involved in research with me, where we are trying to develop a home-based fall prevention program that is enabled by telemedicine, where we gain access to the home via video and they gain access to our expertise via video. This is a lovely patient of mine, and one of her issues was freezing of gait.

She was having a lot of freezing of gait around her kitchen table, which was previously a square kitchen table. We asked her to change her table to a round table so she could navigate the table a little bit better. You saw even in this video she had a little bit of freezing as she was approaching her chair, but this is so much better than when we had first started adjusting her environment, where she was trying to navigate the sharp corners of her square kitchen table.

The other thing that happened with this patient is that she told us it was very important to her to be able to cook meals for her husband. As you saw, her kitchen actually is quite narrow. She lives in an apartment. She was saying that she was having so much freezing in her kitchen. When we asked her, 'When are you having the freezing?' she told us, 'It's because I'm constantly going back and forth from one side of my kitchen to the other side of my kitchen. That's what's happening. That's when I'm freezing, when I'm constantly pivoting back and forth, grabbing something from one drawer, grabbing something from the refrigerator.'

Dr. Mitra Afshari 00:45:08
What we recommended to her was to get this little kitchen cart where she could do all of her food prep, where she could put all of her items for food prep on the cart and just cart it over to the oven where she wanted to cook. This small recommendation made a huge change in her quality of life because she was still able to cook for her husband.

She was always mentioning that she was having lots of freezing when coming out of the kitchen. As you can see there, we asked her to put the blue painter's tape in the threshold coming out of her kitchen, and she was able to use that as a visual cue to step over the tape. I tell patients either step over the tape with a big step or, depending on your distance, you can also step onto the tape and take a big step and try to overcome your freezing. Keep that momentum going to take big steps. She thought that this was so useful that she extended this blue painter's tape to other rooms in her house, which we'll see in a moment.

The reason why I wanted to show you these videos is to kind of bring it back home and make this very practical for you, that you can make these small changes in order to overcome freezing and to really prevent falls in your home. This is the next line of my research, to create this home-based fall prevention program for patients.

I think that this probably ends our presentation. The last thing that I wanted to mention is the Parkinson's Foundation has tons of great resources. This is just one of the resources that summarizes recommendations from experts like myself with respect to exercise. The recommendation is to participate in 150 minutes of moderate- to high-intensity exercise per week to hopefully slow the progression of Parkinson's and to slow the gait and balance disturbances that come with increased severity of disease.

The one thing I want to leave you with is that even though I presented so many different studies, so many different modalities of exercise, it's really important to set realistic expectations of yourself. Really, the best exercise is truly just the exercise that you will actually do. Anything is better than nothing. This is really what I tell my patients, and we try to talk about little steps toward becoming more active, like scheduling coffee dates on Monday, Wednesday and Friday at the local coffee shop and using that as motivation to become more active. We talk about these specific strategies. I wanted to leave you with that. Thank you so much.

Dr. James Beck 00:48:24
Thank you very much, Dr. Afshari. That was a great presentation. Nice background, too.

Dr. Mitra Afshari 00:48:31
Thank you.

Dr. James Beck 00:48:32
As we jump into the questions with you, I just want to remind our viewers that we're still reviewing questions as they come in, so please do that. Facebook Live, you can go in and put them in. We're organizing them by topic. We're going to really address the ones that are specific to what Dr. Afshari was talking about today, but we'll do our best to get to everyone's. There are a lot of people who've joined today, which is fantastic, so we won't get to them all. With that said, let me just jump in with some of these early questions here.

Dr. Afshari, you touched a little bit about medications and regarding freezing of gait. What is the role of medications in helping with overall gait and balance? You mentioned, I think it was five, maybe six things, and three of them were really cardinal features of Parkinson's disease: postural instability, bradykinesia and rigidity. Those seem to be helped by medications, but I've heard sometimes gait and balance can be resistant to regular medication. What is your take on that, and what do you advise your patients?

Dr. Mitra Afshari 00:49:45
Levodopa and other dopaminergic medications are definitely the first step toward gait and balance. As I mentioned, the cardinal features of Parkinson's, bradykinesia, rigidity, postural instability, are all levodopa responsive. That's always the first step, to optimize levodopa regimens and to ensure that you have adequate coverage because often a lot of these issues come up, they become problematic, when you fall off the dopamine, right? When you're entering into the off state. That is the most common scenario.

But unfortunately, what can also happen with progressive disease, and we had mentioned how we have kind of our reptilian, deep brain, right?

Dr. James Beck 00:50:34
This is the basal ganglia, right?

Dr. Mitra Afshari 00:50:35
The basal ganglia. In Parkinson's disease, low-dopamine states essentially affect the basal ganglia at first, and we kind of lose our gait automaticity. But with advanced Parkinson's, what happens is that that pathophysiology, which is ultimately the bad protein building up in the brain, goes beyond the substantia nigra and those deep structures. That bad protein, which accumulates in these things called Lewy bodies, essentially starts spreading to the rest of the brain. That happens with more progressive disease.

When that happens, what happens is we lose the help that we're getting. We lose the compensatory helping hands that we get from the rest of the brain that's helping us overcome those challenges in gait. Over time, like you said, patients' issues with gait become more refractory to dopamine. There's not enough dopamine that can help them. We have to kind of take advantage of other mechanisms, other compensatory approaches that we could optimize. So for instance, cognition.

Dr. Mitra Afshari 00:51:52
Cognition has a lot to do with gait because gait is such a complex thing. Let us optimize the rest of the cortex. Let us optimize the cognitive piece that might be helping out with our gait. That's why we resort to other medications like those cognitive medications, which unfortunately I didn't get a chance to talk about, but donepezil and rivastigmine.

There's actually a newer trial, and the results of that trial will be coming out soon, hopefully. It's called the RESPOND trial, which I mentioned in my slide. It's a huge randomized trial of rivastigmine, which is a cognitively based medication that can be added to patients' dopaminergic regimen that might be helpful in specifically improving gait and balance.

Dr. James Beck 00:52:41
Got it. Oh, sorry, I didn't mean to cut you off.

Dr. Mitra Afshari 00:52:43
No, go ahead.

Dr. James Beck 00:52:44
I was going to ask, where does DBS fit into this realm of things? Because if we talk about people with more advanced PD, DBS is often something that's utilized for some of them. Is that a way that's also able to help with the gait and balance issue?

Dr. Mitra Afshari 00:53:01
Absolutely. That's not something that I touched on in this lecture, but it's really important to talk about DBS because DBS is no longer an elective procedure. DBS is being offered more and more to patients, and it should be offered honestly to more and more early patients as well because what DBS does, it essentially can treat those cardinal features of Parkinson's disease outside of medication.

It treats bradykinesia. It treats rigidity. It reduces bradykinesia and rigidity, and in reducing bradykinesia and rigidity, it can help with that shuffling gait pattern that contributes to gait difficulties. DBS definitely has a role in gait and balance, and especially early in the disease, it can work on those aspects very well. Again, with DBS, you're not changing the course of the disease. It's just a symptomatic therapy similar to levodopa.

Adjustments have to be made over time with DBS stimulation. The newer DBS platforms that are out there allow so many different perturbations of stimulation that could potentially be helpful for gait and balance. There's actually a lot of research going on out there of different ways to stimulate the brain that might be specifically helpful for gait and balance. A lot of that work is happening out at Stanford University with Helen Bronte-Stewart. DBS definitely has a role in gait and balance, and if used correctly, it can definitely be helpful.

Dr. James Beck 00:54:45
When we also think about the cognitive aspects regarding gait and balance, I would suspect sleep plays a key role, getting a good night's sleep to be able to do that, and nutrition. Are those things that come up?

Dr. Mitra Afshari 00:55:01
Absolutely. I think exercise, nutrition, lifestyle, all of these things go hand in hand. There's a lot of great research out there on nutrition. There was some really interesting work that was just presented at our international conference on different ways people are testing different types of diets that can be inflammatory versus non-inflammatory.

There was actually a study that was presented where patients were compared under the Western diet, which is essentially an inflammatory diet, versus a more kind of non-inflammatory quote-unquote heritage diet, and they were able to show that the patients who underwent the more non-inflammatory diet essentially did better with respect to their Parkinson's symptoms. I think all of these things go hand in hand in terms of overall lifestyle. There are certain diets out there that tend to be more non-inflammatory.

One of the most common ones is called the MIND diet, which is essentially a combination of the Mediterranean and the DASH diet, and it essentially maximizes anti-inflammatory foods like blueberries and olive oil and things like that. All of these things work hand in hand.

Dr. James Beck 00:56:29
Fantastic. Yeah, that's a good point. One of the questions that has come through here is, I think, a real practical one. We've talked about medications and how they can help. What about when you're not on medication? You first wake up in the morning. How do you advise patients to help with their gait and address these issues until their meds kick in? I mean, during this lull time or the chance that someone does go off because maybe they have missed a dosage and they're out.

Dr. Mitra Afshari 00:57:00
Absolutely. This is a common thing that we see with patients. If the patient is at least having a moderate level of Parkinson's disease where they're at risk for falls, we address this in our patients by giving patients low levels of long-acting levodopa at night so that there can be a steady level of levodopa in their system. It allows them to move better in the bed and wake up in a better state, as you mentioned, because there's a little bit of dopamine still left in their system.

These long-acting formulations are not meant to be used really during the daytime because they don't provide a robust levodopa peak, but they can help with sleep at night and waking up in a better state. We have strategies to overcome that. Another thing that I always recommend to my patients who are definitely at risk for falls is to potentially set an alarm and have their medication at bedside so that they can take their medication about 30 minutes right at bedside, just kind of pop their levodopa about 30 minutes before they're ready to actually get out of bed and start their day, so it's really in their system.

Dr. James Beck 00:58:18
Got it. That gives them a chance to snooze a little longer, perhaps.

Dr. Mitra Afshari 00:58:21
Right.

Dr. James Beck 00:58:22
That works. One of the things that we talk about with people at risk of falls, and I've seen this in Nijmegen in the Netherlands with Bas Bloem, is they had programs that teach people to fall. Are there things like that here in the U.S. where you can teach people who are at risk of falling how to fall properly and minimize risks?

Dr. Mitra Afshari 00:58:44
It's really important. This actually came up at our conference recently, that people don't know how to fall well. To some extent, our physical therapists haven't been trained in that either. I don't think the training is extensive, or it's not rocket science really, but I think it is important that our providers not only focus on preventing falls, but also, in case a fall does occur, that our physical therapists actually teach people how to fall well so they don't sustain those hip fractures that may put them out and cause secondary immobility.

I think it's important for us, as some of the experts and the educators, to develop educational programs for a lot of our physical therapists to teach patients, but also even just educational programs for our patients and their providers that may even be able to be administered over telemedicine, a simple video. These sorts of things are low-hanging fruit, but they can make a huge difference, which is a lot of what my research is about.

Dr. James Beck 01:00:06
Yeah, that's fantastic. On that note, I want to thank you very much, Dr. Afshari, for offering your time today for an Expert Briefing on improving gait and balance in Parkinson's disease. And a big thank you to every one of you who joined us today. I know we had a significant response during our question-and-answer session, and unfortunately, I couldn't quite get to them all in our timeframe.

Please be aware that your question won't go unanswered. You can call our Helpline, 1-800-473-4636, 1-800-4PD-INFO, and you can also send an email at Helpline@Parkinson.org as part of that process. This is number five of six Expert Briefings. Our next one is going to be on November 12, and we'll focus on managing Parkinson's disease symptoms beyond traditional medications. We're going to explore functional medicine and focus on whole-body wellness here. You can learn more about our future topics and register at the webpage listed here on screen, Parkinson.org/ExpertBriefings.

You're probably familiar with it because you've already registered in order to get to this point so far, so congratulations on that. In addition to our Expert Briefing sessions, the Parkinson's Foundation, as you may know, offers a wide range of virtual education and wellness programs each week through our PD Health @ Home series. You can learn more and register for those also by visiting this website on the screen, Parkinson.org/PDHealth. These are hopefully pretty easy to remember, and you can go to that yourself or search on our website. Nevertheless, beyond all this, we're here for you. Please do not hesitate to reach out to the Foundation.

Dr. James Beck 01:01:42
We have a comprehensive website available. As Dr. Afshari pointed out, one of our resources on exercise, we have tons of resources that are available, really dedicated to everything related to Parkinson's disease and developed in conjunction with people living with PD as part of the process. Feel free to again reach out to our Helpline and email or call one of our staff members who can be there to really help you and spend time with you. Until next Expert Briefing in November, I wish everyone a happy fall.