A Balancing Act - Freezing and Fall Prevention in Parkinson's

More than half of people with Parkinson's disease (PD) will experience a fall over the next year. While some falls might result in minor scrapes or bruises, others can be life-changing, impacting mobility and more. Keep reading for how trouble moving and walking and other PD symptoms can contribute to falls and how to lessen the risk.

This article is based A Balancing Act - Freezing and Fall Prevention in Parkinson's, a Parkinson’s Foundation Expert Briefing webinar presented by Colum MacKinnon, PhD, Professor, Department of Neurology, Institute of Translational Neuroscience, University of Minnesota. Watch the webinar now.

Breaking the Cycle

As we age, our strength can decline. Movement symptoms of Parkinson’s can impact strength, creating a frustrating cycle: gait difficulties and postural instability can lead to falls, which can create fear of falls, causing less movement. Lack of physical activity is associated with depression, apathy, constipation, sleep problems, fatigue and cognitive decline. Other complications can include cardiovascular disease and osteoporosis. This combination of challenges can further increase movement difficulties. Breaking this cycle is essential.

The extensors and flexors of the muscles of people with PD tend to be much weaker than those of the general population.

• Extensors are the muscles in areas such as the ankles, knees, glutes and hips that support us against gravity.
• Flexors, such as plantar muscles in the foot, help us bend limbs.

In PD, extensor weakness is often greater than flexor weakness. Regularly working to strengthen all these muscles can keep you safely moving forward.

People with PD who exercise regularly can move more normally than those who do not. Studies show moderate to high-level intensity exercise may be neuroprotective. Adding range of motion movements along with activities that increase postural challenge and cognitive load, as needed, can get you back to better, more stable movement.

Strength Training and Movement  

Aim for progressive resistance strength training that safely increase weight over time, two to three times per week for 20 to 60 minutes or more. Continue to increase weight as needed and target all the major muscle groups from top to bottom.

Target all major muscle groups, but focus specifically on:

• Extensors (ankle, knee, hip and back)
• Hip flexors and extensors
• Hip abductors and adductors

Progressive resistance exercise may be most beneficial when combined with:

• Instability training: using unstable surfaces to strengthen muscle groups, such as using a wobble board or stability ball.
• Flexibility exercises and tasks that focus on a large range of motion, such as stretching and yoga.

Overcoming Built-in Instability

When thinking about fall prevention, far too often we focus on the legs and feet, but controlling the upper body is the bigger struggle for people with Parkinson's.

A natural challenge to all humans is the two-thirds/two-thirds problem, which means that two-thirds of your body mass is located two-thirds of your body height above the ground. This is inherently unstable. Overcoming this is something we take for granted every time we take a step. If you are a 150-pound person, 100 pounds of your body is sitting two-thirds of the height off a small, invert-dependent, unstable base of support.

When standing, your center mass is within your base of support, but as soon as you start moving your center mass is outside your base of support. The real challenge to maintain balance and walk is controlling this big mass up high. Parkinson’s adds to this challenge.

Balance Basics and Fall Prevention Tips

A person’s body must provide vertical support against gravity to maintain balance when walking. This is critically dependent upon control of your trunk. Keep your head stable. You also want to make sure you have a clear path for your feet and good toe clearance to take a safe step.

Your center mass normally sits right behind your belly button and helps you maintain balance. If you're standing, your center mass projects downward — directly between your feet, slightly in front of your ankles. If you lean forward, your center mass moves forward. If you experience freezing or posterior instability, this moves your center mass outside of your normal base of support.

To prevent falling, use one of these simple tips to keep yourself stable:

• Widen the width of your stance to move center mass.
• Rotate your feet outwards to boost your side-to-side support and lessen dependence on your front-to-back base of support.
• Stagger your feet to increase the width and length between them.

Be sure you are stable or have nearby support when practicing any of these tips in case something bumps you or you lose your balance.

If are standing still and you want to move forward, it can require you to take a step and reestablish a new base of support. Or if you're bumped, for example, and your center of gravity goes outside your base of support, taking a big step forward can help you re-establish your balance.

When your center mass moves forward and your step is not big enough — which can often happen when people experience freezing — your center mass continues to be outside your base of support and you're still in a state of falling, even though you took a step. This requires you to take a second step (or more) to reestablish a new base of support. That must be done very quickly.

Recognize Falls Risks

Falls in Parkinson's disease can cause significant disability and loss of independence. While aging may put us all at an increased risk for falling, the risk of hip fracture is four times higher in people with PD. About 60% of people with PD fall each year — two-thirds of these people fall several times throughout the year. The severity of and frequency of falls can increase as Parkinson’s progresses.

The consequences can include fear of future falls, injury, reduced quality of life and high levels of stress for care partners and loved ones.

About 80% of the falls in PD are due to postural instability (difficulty maintaining balance while standing or walking) and episodes of “freezing” of gait, which is the temporary, involuntary inability to move.

Freezing initially responds well to levodopa dopamine replacement therapy but can become medication resistant over time. Deep brain stimulation (DBS), which involves surgically implanting small electrodes into specific brain regions, can also reduce or eliminate freezing, but for many, freezing eventually returns. Establishing early exercise habits is critical.

People with PD fall most frequently during:

• Turns
• Bending forward
• Standing up
• Initiating walking or trying to avoid an obstacle

Self-induced movements of the center mass are the dominant cause of PD-related falls. The first step of people with Parkinson's is often too short and even shorter for those experiencing freezing. This combination shrinks the base of support for your body’s trunk. When your trunk gets ahead of your feet and your step is too small to balance it all, the likelihood of a fall is higher.

Physical and occupational therapy can improve balance, posture and sense of position to minimize freezing and falls. LSVT BIG is a PD-specific treatment that focuses on making big movements with vigor and intensity and practicing awareness of your legs, trunk and feet.

Proceed with Care

About half of people with Parkinson's will experience a freezing episode. As PD advances, the likelihood of freezing increases. Knowing how to spot the features and causes of freezing episodes can help you take action to prevent falls:

• At the onset of an episode, the foot or the toes do not leave the ground, or barely clear the supporting surface.
• Freezing features can include faster, shorter shuffling steps (known as hastening).
• Depending on the severity, knee trembling or a complete lack of movement lasting anywhere from one to 30 seconds, can accompany freezing.
• Some people will freeze in one direction and not in the other. Freezing can also be asymmetric — different on one side of the body than another.
• Freezing episodes and falls typically happen during transitions, when moving from one state of movement to another. Even stepping into a darkened room can make freezing more pronounced. Exercise caution when attempting to turn, when you're passing through narrow or congested pathways, such as approaching a doorway, or while approaching your destination, such as a chair.
• Anxiety, stress and dual tasking (such as talking on the phone or to a friend while trying to walk at the same time) can also increase the severity and frequency of freezing.
• “Off” freezing, which can occur when someone is due for their next dose of dopaminergic medications, usually lessens after taking the medicine.

After a freeze has occurred, there's often a period of alternating trembling of the legs at a frequency somewhere around 3 to 8 times per second. Any further attempt to step during this time is unlikely to be successful and the likelihood of a fall is higher. At this point, before moving forward, it’s important to:

• Stop.
• Get yourself back to a stable, balanced, standing posture.

Using a visual cue, such as “step over my foot” can help some people take the next step. Counting or clapping a rhythmic beat can also be helpful.

Slowing down, reducing your rate of movement, being aware of where your limbs are and making large movements with intensity are very important steps in improving your balance, creating stability and preventing falls.

Learn More

Consider a clinical trial from the comfort of home. People with Parkinson's have a higher risk of fractures from falls. The TOPAZ study, led by doctors who are experts in bone health, is testing if a medicine called zoledronate can prevent fractures in people with PD. If you live with PD or parkinsonism and are 60 years old or older, you may be able to join. Learn more here.

The Parkinson’s Foundation believes in empowering the Parkinson’s community through education. Learn more about optimizing movement in PD with our below resources, or by calling our free Helpline at 1-800-4PD-INFO (1-800-473-4636).

• Read Walking with Parkinson’s: Freezing, Balance and Falls for more tips on moving well.
• Get moving with our PD Health @ Home Fitness Fridays.