The Exercise Files: Standard of Care for Treatment of Balance Issues

This month, Dr. Hackney consulted Dr. Ramon Gil for his perspective on treating balance issues in PD. Dr. Gil is a Board Certified Neurologist specializing in Parkinson’s Disease and other Movement Disorders.

Dr. Madeleine Hackney:  I'm interested in what you would consider "standard of care/current practices" for the treatment of balance issues in PD. What do you do when someone has balance problems?

Dr. Ramon Gil:  First of all, when a PD patient presents with balance problems, I explain to the patient and care partner that the time to "optimize" balance is now way past due.  Actually, it would have been most important to improve physical fitness and engage in long term exercise programs (such as Tai Chi, Dance, or simply walking at moderate intensity) for at least 150 minutes/week before the disease progressed to stages III or IV Hoehn & Yahr.

Second, I make sure that the medical treatment is adequate. Patients who are undertreated, or simply experiencing too much "off" time, are bradykinetic and typically balance is worse under those circumstances (postural reflexes also seem to be deteriorated). Patients with dyskinesias may also find themselves more "off balance" and prone to falls, as their involuntary movements make it more challenging for them to maintain balance.  This also obviously applies to those with "di phasic dyskinesias", in which the movements of the legs are often "out of control" and prevent the patient from walking safely.

Third, for patients with Deep Brain Stimulation (DBS) and balance problems, it is important to remember that DBS may worsen balance.  This is often as a result of settings aiming to "stop" the tremor or "minimize off time", at the expense of speech and balance/gait. The clinician and the patient have to work together to judge and decide how to handle this often difficult dilemma.  Needless to say, placement of the lead is critical, since suboptimal placement often makes it impossible to achieve positive results without negative impact in balance/gait and/or speech.

Fourth, and this is extremely important, Orthostatic Hypotension is common and often under recognized.  This problem MUST be aggressively addressed, since it is simply impossible to improve balance in patients with untreated Neurogenic Orthostatic Hypotension (NOH).

Fifth, concomitant medications (hypnotic, narcotic and anticholinergic) are often used in PD patients, with significant impact on their motor skills. Inappropriate use of Dopamine Agonists (DAs) could also lead to worsening of NOH and/or worsening of alertness, with deterioration of balance.

In conclusion, it is critical to exercise from Day 1 and optimize before there is any significant problem to prevent and delay.  Engage in long term programs, not just 6 week courses of specialized PT.  Learn how and when adaptive equipment is necessary.  The end of the patient's effort to maintain good balance will come when their disease is cured! Until then, we must continue working as a team to keep patients from often devastating injuries.

Dr. Madeleine E. Hackney, Ph.D, is a Research Health Scientist at the Atlanta VA Center for Visual and Neurocognitive Rehabilitation and an Assistant professor of Medicine in the division of General Medicine and Geriatrics at the Emory School of Medicine. She holds a Ph.D. in Movement Science from Washington University and a BFA in Dance from NYU, Tisch School of the Arts and has also been an American Council on Exercise certified personal trainer since 2000. Dr. Hackney’s extensive research interests include inquiry into challenging exercise programs–traditional exercise, Tai Chi and partnered tango classes–designed to improve physical function and quality of life in people with PD, older adults and those with serious mental illness. In 2014, she co-founded MDT Education Solutions, which has trained dozens of fitness and allied health professionals how to develop and lead safe, evidence-based exercise programs for people with PD at all stages of the disease, including almost all instructors in the PD Gladiators Metro Atlanta Fitness Network (including the YMCA of Metro Atlanta). She is currently the Research Advisor to PD Gladiators.

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