Expert Briefing: Freezing or Sweating Falls When Walking

Heather Cianci 00:00:04
Welcome, everyone, to the third talk in the Parkinson's Foundation ninth Expert Briefing series, Freezing, Sweating and Falls When Walking with Parkinson's Disease. We are very excited to announce that we have over 2,500 people registered from 36 countries, all 50 states, Puerto Rico and D.C. In addition, our Ohio chapter is having a viewing party, and we want to give them a shout-out. My name is Heather Cianci, and I am your guest host for today's discussion.

I am a physical therapist at the Dan Aaron Parkinson's Rehabilitation Center in Philadelphia, Pennsylvania, part of the University of Pennsylvania's Parkinson's Disease and Movement Disorders Center, a Parkinson's Foundation Center of Excellence. Please know that these webinars are not created in isolation, which is why I am very pleased to announce that this series has been designed in collaboration with our partner Parkinson's organizations, who are members of the Alliance of Independent Regional Parkinson Organizations.

I would also like to acknowledge our sponsors for this series: AbbVie, Sunovion and Lundbeck. Without their generous support, these webinars would not be possible. Thank you so much.

Remember that this PowerPoint slide deck can be downloaded on the viewing page that you are looking at right now. Look at the bottom left for the Download Slides link, and you can download a PDF file at any time during this webinar. Health professionals can earn one free CEU through the American Society on Aging.

If you are registered as a health professional and indicated that you would like CEUs, you will receive an email by the end of today with steps on how to collect your one CEU. Remember, you have just 30 days, until February 16, to collect this free CEU.

It is now my pleasure to welcome our guest speaker, Dr. Fay Horak. Dr. Horak is a professor of neurology and director of the Balance Disorders Laboratory at Oregon Health & Science University, a Parkinson's Foundation Center of Excellence, and the Portland VA Healthcare System. Dr. Horak is a physical therapist and neuroscientist who is internationally known for her research on the physiology and rehabilitation of balance disorders in Parkinson's.

Dr. Horak's laboratory is considered the premier Balance Disorders Laboratory in the world. Dr. Horak has several patents for new technology to measure and rehabilitate balance disorders. She has developed a popular new clinical balance assessment tool called the BESTest, and her novel instrumented mobility system called Mobility Lab allows clinicians and researchers to quantify balance and gait disorders using wireless wearable sensors. I've had the personal pleasure of hearing Dr. Horak speak on numerous occasions, and I know that you will really enjoy today's presentation. And now, Dr. Horak.

Fay Horak 00:03:19
Thank you very much. Today we're going to be thinking about freezing, not the kind of freezing you see here, of course, and sweating and falls. But we will be thinking about sweating both for exercise and because of fear of falling.

I need to mention that I have a potential conflict of interest because you may be seeing slides that include some of the wireless body-worn sensor technology we use to measure balance and gait.

What we're going to focus on today are three things. First, to understand how the brain controls walking and balance. Second, to discover what kinds of balance impairments or problems result in freezing and falls, because balance is really the underlying reason for both freezing and falls. And third, to explore what can be done to minimize freezing and falls. We'll talk about new things that are coming, as well as what we know about exercise and rehabilitation.

First of all, control of balance and walking by the brain is a very complicated concept because so many parts of the brain are involved in balance control. The basal ganglia, which is in the middle of the brain, is the part that's affected by Parkinson's disease. Normally, it can affect balance and walking both by going up through the cortical areas and down to the spinal cord, and then more directly to the brainstem and spinal cord.

However, what happens with Parkinson's disease is the basal ganglia has too much inhibition on both the pathways going up to the cortex and the pathways going down to the brainstem. As a consequence of this problem, people with Parkinson's disease use other parts of the brain to control balance, primarily the frontal cortex in the front of the brain, which normally we use for thinking. They have to use the thinking or cognitive part of the brain, the voluntary part of the brain, more because these automatic pathways from the basal ganglia down to the brainstem are inhibited too much.

We'll talk about the consequences of this soon. But first, let's think about freezing. What do we mean when we say a person has freezing of gait? It's been described as a brief, episodic absence or marked reduction of forward movement of the feet despite the intention to walk. Most people who have this have the feeling that their feet are glued to the floor. They're trying to move forward, but their brain doesn't connect to their muscles and their legs to allow them to walk.

Usually, it's not really frozen in terms of no movement at all, but associated with some rapid trembling or movement of the knees. I'm going to show you how that's really associated with rapid weight shifting or balance adjustments. We know that there are quite a few tricks that people can use to overcome freezing.

Fay Horak 00:06:44
I'm going to show you a movie of this person freezing now. Here he is coming toward a doorway, which is a place where many people freeze, either before an elevator or a narrow space. What he's going to do now is use some tricks. He makes a voluntary sideways movement, a voluntary large marching movement, and these things can help overcome a freezing event. But the freezing is marked by very small movements and this rapid trembling of the lower legs.

You'll notice that making a turn to his left is causing even more freezing than straight walking. He's using a couple more of these voluntary tricks to get going.

Next, you'll see him after he takes his levodopa. It's true that for most people with Parkinson's disease who have freezing, the freezing almost goes away or is much better when they're on their levodopa. But that doesn't mean his balance is perfect, because even people on their levodopa fall quite often. Sometimes it even makes their balance worse, even if it improves their freezing.

How do you know if you have freezing or not? One thing to do is to do what's very difficult for people who have freezing of gait, and that is to make a turn in place, like a 360-degree turn. This subject in our study is going to be turning. Turning is important because if you fall while you're turning, it's very dangerous because you could land on your hip and fracture a hip.

You'll see a video of her trying to turn and how it induces freezing and balance problems. That's why we're standing so close to her. She's turning in one direction, 360 degrees, and then the other direction. We're measuring with the sensors how much freezing she has.

This is the easiest way to elicit freezing, even in people who don't freeze when they're just walking straight ahead. Turning is special. It requires a lot of dynamic balance control, and it requires movement of your head, then your upper body and then your lower body. If you have rigidity, this is difficult to do, and it's involved in many different tasks of daily life.

What we did is we put a camera on people's belts, looking at their feet, and asked the question: how often do people turn in a day? You'll see a movie of a person's feet as they're getting around their apartment. We were surprised to see that people turn over 100 times an hour, or up to 1,000 times a day.

In fact, we all do more turning than we do walking straight. We think turning is something people need to be practicing in rehabilitation, and when we think about exercise to improve balance and reduce falls, we have to think about including turning in those exercises.

Fay Horak 00:10:10
Of course, this makes you a little dizzy looking at her turning around in her small kitchen. But you can see how important turning is. In fact, we did a study where we looked at 30 people at home with Parkinson's disease and 30 people without Parkinson's disease, and found that people with Parkinson's turn significantly slower than people without Parkinson's. They take many more steps, like up to four or five steps instead of one or two steps, to make a turn. Then we looked at how the quality of turning was affected by the severity of Parkinson's disease.

In the bottom graphs, you can see that the number of turns per every 30 minutes was smaller and smaller the worse the Parkinson's disease. People start avoiding turns as they get more severe, and their turning velocity gets slower and slower.

When we looked at falls, we found that what could predict falls was how people turned. The variability of the number of steps that they used to turn was more predictive of falls than anything else. I believe that this variability might reflect less automatic turning and more turning that has to come from the frontal cortex, or more voluntary part of the brain.

Why are balance and walking less automatic in people with Parkinson's disease, especially people who have freezing of gait, or what we call FOG? As I mentioned before, in people without Parkinson's disease, balance and gait are usually very automatic because the basal ganglia can communicate directly with the brainstem and the motor cortex to control balance and walking. You don't have to think about it.

However, as the basal ganglia starts to degenerate and people, in this case, are not taking their medication or are in their off state or they have freezing, they begin to use the front part of the brain, the frontal cortex, the more cognitive part of the brain, to control balance and walking. When they take levodopa, studies have shown that this helps them go back to using the more automatic parts of the brain for balance control. That's why, probably, there's less freezing.

Now, all of us have trouble trying to do two things at once. For example, here's a man who's trying to cross a busy street while he's texting, right next to a sign that says, 'Caution texters.' It looks like he's going to get into trouble shortly. What we know is that walking slows down when talking, and thinking slows down when walking. This is even more true for people with Parkinson's disease, and even more true for people with freezing.

Fay Horak 00:13:08
What we call the dual task cost -- that is, how much your walking and balance change when you're trying to think of something else -- is even higher in people with Parkinson's disease than people without Parkinson's disease. That tells us that they're using more attention and more cognitive control for balance and gait.

Here's two people walking, and they may both be using a lot of cognitive attention for balance because how much attention is required for balance really depends on how difficult the task is. The task in this athlete walking on a wire above the city is definitely challenging for anyone, but sometimes just walking, even with a walker, could be quite challenging and require a lot of attention for somebody with Parkinson's disease.

One thing to think about is you're not going to be asking people to talk to you or discuss what they want for lunch when they're trying to cross a busy street if they need to have all their attention on thinking about balance and thinking about walking, because that could be quite dangerous in these situations.

We did a study in which we showed that not only is walking affected by dual tasking, or trying to think about something at the same time as walking, but also balance is affected by dual tasking. Here we have a man on the left side who is going to be tripped by a moving surface. The platform underneath him is going to move backward, like pulling the rug out from under him, and he's going to have to take a step forward to keep himself from falling. It's an automatic stepping response for balance. On the right side, the same man will be doing this, but we're asking him to make a list of all the food he had to eat yesterday.

As he's thinking about all these different foods, then we pull the rug out from under him, and you'll see how much more difficult and dangerous it is for him. Here he is, thinking about balance, and he's able to take a step when he falls forward. In the next movie, you'll see that now he's thinking about his food and he falls into the harness, and we have to catch him.

The same situation, a slip or trip, can be recovered when you're using your cognition and attention to help improve your balance control. Yet it could result in a fall when you're thinking about something else.

Fay Horak 00:15:44
Why is that? One thing we know about these stepping responses is they require a lot of balance control. You have to shift your weight over to one leg so you can lift the other leg and take a step. On the right side here, you see the increased force in blue on one leg before the person takes a step.

Here you see what it looks like when this healthy person without Parkinson's disease is forced to do a postural stepping response. He shifts his weight to the left, and he's able to take a quick, large, single step to keep himself from falling. These are automatic balance responses that occur very rapidly and automatically.

This is what it looks like if you look at the forces under his feet. In the healthy person here without Parkinson's, the green force goes up, and then he takes a step. Whereas a person with Parkinson's disease that I'll show you next, he shifts his weight to the right and then to the left and then to the right and then to the left, and then finally takes a step later. There's too much balance control going back and forth, and he's not able to stop balance and start initiating a step.

Here you see a fellow who was off his medication with Parkinson's disease, who has freezing that makes him freeze even when he's falling, and he's not able to take a normal balanced step. In this case, because of that, he would fall into the harness when we move the platform under him and he falls forward.

When we looked at the brains of people with Parkinson's disease and healthy people with imaging, what we found is that the connections between the frontal part of the brain and down to the brainstem, where this balance center is, were stronger than normal in freezers compared to non-freezers.

You can see that in the graph on the right, in which the bar for the freezers is larger, showing that there are more connections. That is, the brain is talking more -- the cortical part of the brain, the higher-level parts, are talking more to the balance and walking parts than they are in people without Parkinson's or without freezing. Freezing involves too much cognitive control of balance and gait, so it's less automatic.

Fay Horak 00:18:36
The other thing that we found that's associated with freezing are some cognitive deficits, thinking differences. I think it tells us something about how the brain controls balance: that it's not just a sensory and a motor control issue. It's also a cognitive issue, and we're finding a mood issue.

Let's look at this task on the right that's called the Stroop inhibition test. In this task, we ask people who see these different words of colors to not say the word, but just say the colors. Try it yourself. Start from the left and go to the right on the top, and just say the colors, but not the words. You have to inhibit the word in order to say the color. You'd say red, blue, red, blue, green, pink, yellow, red, blue, pink, black, green.

Everybody's a little slower when there's not an agreement between the color and the word because you have to inhibit what you want to say automatically. But we found that the worse people were on the Stroop test, this cognitive task of inhibition, the worse was their freezing of gait. The better they did the test, the less freezing they had. I think that the kind of inhibition we need to stop shifting our weight, to stop balance and to then release the gait, is reflected in this same kind of inhibition.

That means the parts of the circuits in the brain that control this kind of cognitive inhibition are probably also involved in step initiation and in balance control.

In fact, when we looked at the right graph, you see the dual task cost, how much people slow down when they're talking. On the left graph, we're looking at the Stroop test. We see that both of these are related to how much connectivity there is from this inhibition pathway from the top of the brain, the thinking part of the brain, down to the automatic brainstem part of the brain. We believe that they share circuitry for both thinking as well as balance and gait.

Fay Horak 00:21:02
Luckily, lots of studies have also shown that these kinds of balance problems, and perhaps some of these cognitive problems, can be improved with practice in people with Parkinson's disease. For example, we did a study in which we had people standing on a movable surface, and the surface would move very quickly, which would force them to take a step. They started off taking two smaller steps, and with practice over an hour with rest breaks, we found that people with Parkinson's could improve.

On the right is a graph that shows how much their body's center of mass moves backward or falls backward. You can see that the dark line is people who have taken their levodopa medication, and they're not falling as far with practice over the blocks. Then we bring them back the next day, and they still can remember and are better than they were the day before.

However, what we did find is that when we had people try to do this kind of practice when they were in the off state, when they didn't take their medication that morning, they didn't learn as well. That learning was impaired. There was some improvement, but not nearly as much as when they were taking their medication.

There have been animal studies showing that levodopa is important for balance, for motor learning. It tells us that before we go to exercise or do any kind of practice where we want to improve our movements, it's best to be in the optimal on state and take your medication. We also learned, though, that practicing stepping backward did not improve their ability to step sideways or other directions. So we need to exercise with a variety of different movements.

Fay Horak 00:23:02
Here you see a woman with Parkinson's disease. First, on the left in the first video, you'll see her when she just starts to practice these stepping responses. Then in the next video, you'll see after an hour of practice. Here she is in our laboratory trying to keep her balance, and she had to take a lot of small backward steps. These automatic stepping responses were not very efficient because they weren't strong enough or large enough.

However, in the next video, you'll see after just practicing for less than an hour, she looks like she has normal stepping responses. She's able to stop her body from falling backward with a large step. Even though these things are fast and automatic, they are something you learn. By practice, you can learn to do them better.

How about freezing? What do we know about freezing and whether it can be improved? Here you see, when we have sensors on people's right and left foot, on the left a control subject without Parkinson's disease walking, and you can see his angular velocity of his lower leg in pink and blue as he walks along, compared to a person with freezing, where he's walking fine at first and then has a freezing episode where you get that trembling of the lower legs.

What we are doing is we're developing some new wireless technology. Of course, here's a wired prototype that's not very practical yet, in which we measure a person's walking, and then when their foot is on the ground, we give them a vibration to enhance the information to the brain that the right foot is on the ground or the left foot is on the ground.

Then we measured the percent of time people freeze. As you can see on the right, whether they do a single task or a dual task, there's a lot of freezing. Percent of time freezing was like 45% of the time when they didn't use this new biofeedback device, and it was much less when they used this biofeedback device. In fact, it improved as much as using a metronome to give them a cue, an external cue like marching.

Fay Horak 00:25:15
Now I'll show you a video of one of our subjects who had Parkinson's disease walking before we turned the biofeedback vibration on and after we turned the vibration on.

Here he is walking in the lab, and it's mostly in the turns that he freezes. Here you see a typical freezing type of a turn, which is dangerous because there's a lot of weight on one foot, and he has a hard time shifting his weight and takes a lot of small steps. He's wearing the device, but it's not turned on right now. This is his normal amount of freezing when he's off his medication.

He does also state that his freezing is much worse when he's anxious, and that freezing causes a lot of anxiety.

Now you see him a minute later when we turn the vibration on. It vibrates when his right foot is on the ground on his right side, and vibrates on the left when his left foot is on the ground. Immediately, it really helped him quite a bit. We're still trying to understand why this kind of biofeedback approach helps some people more than others. It's likely that some people benefit from one type of cue, like an auditory cue; other people more from vision; and in this case, from somatosensory information from the vibration. It might depend on the person which is going to benefit people the most.

This is still in the process of being studied. While we do this biofeedback, we can also look at brain activation. Here's a person who has a special kind of system in which we can look at how much the frontal part of their brain is active. We can see that before people freeze, the frontal part of the brain becomes very, very active right before and during a freezing event. Normally, it's less active during a turn. But with biofeedback, we're able to decrease the amount that the frontal part of the brain is used and make that turn more automatic.

We're hoping when the turn becomes more automatic, that's why it becomes less of a freezing type of turn.

Fay Horak 00:27:38
The other thing that we know can really help freezing, and especially fall prevention, is exercise. In fact, exercise is the only intervention that significantly reduces risk of falling, both in older people without Parkinson's and people with Parkinson's. Medication has not been shown to reduce freezing or falls, except, of course, levodopa improves freezing, but not necessarily falls.

People who have exercises that are focused on balance were 20% less likely to fall.

What kind of exercise is the best kind? People are always asking, and I'm going to say it's a complicated answer. But the best kind of exercise is really the kind of exercise you're actually going to do. That is, you can't just think about doing it. You have to actually do it, and several times a week or several times a day. A variety of types of exercises have been shown to reduce falls in people with Parkinson's. I'm going to show you examples of studies that include tai chi, dance and an aerobic type of exercise that involves agility training.

First, tai chi. There's a large study that was published recently showing that tai chi, like this, where a person is learning to shift their body center of mass forward and backward over their feet, helps them get to know their body better and get to know where their center of balance is. She's not looking at her body, but her brain knows her body better, and this improves this kinesthetic sense. The study has shown a significant reduction in falls in people who study tai chi three times a week for several weeks or months.

The other thing that can be improved with practice is dual task walking. That is, the ability to walk and chew gum at the same time or to talk and walk at the same time. Here's a study with just a few people with Parkinson's disease looking at their gait speed and how much it slowed down before they practiced. After four weeks of practice, they were walking much faster while they were talking. Then a month later, they retained that ability to do dual task at once. Even this automaticity of walking and balance can be improved by practicing it.

Fay Horak 00:30:14
There's also a series of studies from Gammon Earhart's laboratory at Washington University where they show that dance can improve balance and reduce falls in people with Parkinson's disease. They tried different kinds of dancing, ballroom dancing like waltzes and foxtrots and tango, and they found that tango that was adapted for people who never did it before and people with Parkinson's disease can really improve their balance.

On the right, you see the balance, the mini-BESTest. You can see that in the beginning, the tango dancers and the people who didn't do tango had the same score. But then after three months, six months, nine months and 12 months of doing tango lessons, you see balance improving more and more in the tango people, and balance gradually getting worse over a year in people who did not exercise by doing the tango.

This little video will show you what I mean by tango. You can see why it might be good for improving balance because the person has to walk backward and sideways, take big steps, and not let their upper body tip or fall. They have to follow a partner, and sometimes they are the leader, sometimes the follower. There's a lot of good practice of balance control by taking dance lessons like this.

I'm sure you probably heard about boxing because now it's becoming popular for people with balance problems to box. Why should boxing be good for balance? One thing is when you rapidly move your arms when you're standing, you're throwing your balance off, and your brain has to anticipate every arm movement you make and every time you hit a punching ball in order to compensate for the destabilization that comes with rapid arm movements or with hitting something.

I'm going to show you this video of this man who practiced with a trainer for four weeks boxing. You see in the beginning, when he throws a punch, he kind of loses his balance, and he's not rotating his trunk very well. He looks like his balance is not very good in the beginning, and after four weeks, you'll see improvements.

Fay Horak 00:32:52
Now here he is four weeks later. Walking backward is difficult, and he's learned to do that at the same time he's dual tasking by having to think and use his arms to punch the object there.

We're doing studies currently with training both balance and gait, as well as thinking. We call it an agility boot camp. In this case, a boot camp is where you go from station to station doing different tasks. People are doing first fast walks with large arm swings and large steps, and then power moves, which is more of an aerobic training with thinking big, and lunges, which would help to take big steps. Then obstacle course, walking sideways and through circles and turns and narrow spaces. Some boxing and some tai chi.

Then we make it even more challenging by adding cognitive tests on top of this, by doing a Stroop task, for example, while people are doing lunges, or doing a dual task by saying every other letter of the alphabet while they're going over obstacles. Or when they're boxing, telling them to do a no-go/go task so that they have to inhibit their movements, which is sometimes difficult.

Here's an example of a video of a person. In the beginning, he had very mild early-onset Parkinson's disease, still working full-time, but he felt like his balance was getting worse. When we pushed him with very challenging skipping and using his arms, we could induce freezing when he went through doorways.

Then after a few weeks working with the trainer, you'll see how much better he gets. Of course, not everybody is able to tap their knee and skip and turn their head and talk at the same time. But he said that this kind of training with this trainer for four weeks made a huge difference in how tired he was at work as a ranger out on uneven surfaces.

Fay Horak 00:35:40
What we're doing now is we're looking at whether exercise can change the brain. There are many studies that are showing that it not only improves your muscle, but it also changes your brain for the better. Here, what we did is half the people did an exercise agility boot camp -- those are the people in red -- first, and the other half did an education class about Parkinson's disease first. Then we switched, and they went into the exercise class and the other ones went into education.

The dual task cost on gait speed, that is how much people slowed down, improved with the exercise but not with the education. Then when we looked in their brains, we found that the exercise group also reduced the amount they depended on that frontal part of the brain for cognitive thinking and were able to do it more automatically. The exercise group reduced that cognitive control of the balance centers, but the education class did much less. Here you see before exercise, the frontal part of the brain is active, and after exercise it's not. It's just the automatic parts, the basal ganglia and the brainstem.

What is good exercise for people with Parkinson's? It has to be exercise that's really difficult and makes you sweat. You should do it at least three times a week, at least 30 minutes. As you get better, you should make it more difficult and more challenging. Join other people, because lots of studies have shown that people don't stick with exercise unless they do it with a friend, a partner or a group. People expect you to show up. The kind of exercise that you see here is not the kind that's probably good for us to do. These are some street children in India I took a picture of who had really good balance.

In summary, balance and gait are supposed to be automatically controlled by the brain. But when you have Parkinson's disease, and especially if you have freezing of gait, it results in less automatic control of balance and gait. When people have freezing and they start to fall, one of the problems is too-small stepping responses, lack of automaticity and inability to stop inhibition.

They're inhibiting their walking when they need to be able to take a step. But we know that exercise can help reduce falls, and we're hoping that new interventions can help reduce freezing as well. This is our group in the Balance Disorders Laboratory in Portland, Oregon, where it's not too bad for winter weather. You see Mount Hood in the background there, and our sponsors for our research are listed down below. I want to thank you for your attention. I'd be happy to answer any questions you might have.

Heather Cianci 00:38:34
Thank you so much, Dr. Horak.

We are certainly getting a great amount of questions. Remember, if we are not able to get to your questions today and are not able to get those answered, please remember that you can always call into our Helpline, which is 1-800-4PD-INFO. 1-800-4PD-INFO.

Dr. Horak, one of the questions that we have here mentions that you talked about studies showing that exercise does help with reducing falls and improving balance. But how about actually reducing freezing of gait?

Fay Horak 00:39:11
Yes, that is more difficult. There have been some studies that are specifically focused on freezing, that is, where physical therapists work with people to give them tricks to use to overcome their freezing. For example, teaching them to use external cues, like people will take a laser pointer and use it to step up over, or they'll have auditory cues, or they'll just stop, take a deep breath so they're less anxious, and teach them how to take a big step and to shift their weight.

Using these kinds of internal and external cues has been shown to reduce freezing, but it does require thinking and cognition, so you can't do that at the same time you're having a conversation, for example. I don't know of any studies yet, although some are going on, that show that practicing doing an aerobic exercise, for example, will necessarily improve freezing. But it does reduce falls.

Heather Cianci 00:40:22
Great. Thank you. We have a question from a person with Parkinson's in Michigan who wants to know: why does the freezing get worse when people are looking at me or I'm walking in a crowd?

Fay Horak 00:40:33
That's really interesting. We just published a study this month about the relationship of anxiety to freezing. There's a part of the brain that controls mood and anxiety, and we found that it was much more active and connected to the gait and balance centers in freezers compared to non-freezers. So the anxiety center can actually change the way your balance and gait work.

We don't know exactly why, but we know that it's a real physiological change in the brain, in which anxiety can induce freezing and freezing can induce anxiety. That's where trying to reduce your anxiety may be helpful to reduce freezing.

Heather Cianci 00:41:26
And we're getting lots of questions from people with Parkinson's disease. I'm just going to kind of dovetail off of this for Dr. Horak, where they're asking about: is freezing completely mental? I think she talked about that a little bit, but what they also want to know is how much of freezing is due to the medications.

Fay Horak 00:41:45
Right. That's difficult. Like I said, about 10% of freezers don't benefit from levodopa medication, or 90% do have less freezing. Some people have less freezing after deep brain stimulation, and some of them start to get freezing after deep brain stimulation. So it's pretty complicated. I believe that all of balance control is more mental than we used to think. Freezing and balance problems do involve the parts of the brain that are usually thought of as cognitive parts of the brain.

Whatever they do for thinking, they also do for controlling our balance and walking. Those two things often go together: cognitive problems and balance and gait problems.

Heather Cianci 00:42:37
This question leads perfectly into what you were just talking about. A person from California is saying that they imagine that people with Parkinson's who develop dementia or even possibly Alzheimer's would have more problems with freezing and balance. Is this true?

Fay Horak 00:42:53
It's really interesting. It's true that people with Alzheimer's disease have more falls.

They have a different kind of balance problem, though, than people with Parkinson's disease, because they don't get the rigidity that can contribute to falls. They don't necessarily get the bradykinesia. Sometimes they do, but sometimes they don't. Sometimes they actually walk fast, but because of their poor balance and they're too much dependent on vision, they fall when they slip or trip.

I think it's true, though, that people with Parkinson's disease who begin to get more and more cognitive problems and develop dementia are more likely to fall than people who don't have the cognitive problems. People who have more tremor tend to have fewer balance problems and fewer falls as well.

Heather Cianci 00:43:45
This question actually comes from a physician with Parkinson's disease in Colorado. He was diagnosed about 12 years ago and said that he's pretty much fully disabled now, but because of his athletic background, he's able to catch himself where he thinks other people might actually fall. His question is: when his doctor asks if he had a fall, what really constitutes a fall and what should he tell them?

Fay Horak 00:44:07
That's really interesting and really cool. That means that your athletic background has helped improve your balance control system, your automatic stepping responses, your automatic balance responses.

It's not good when people walk or run that they're tripping a lot. That says they're maybe not picking up their feet high enough, or they're shuffling. But it is good that when you do fall, when the body center of mass is going outside of its base of support, that you can recover your equilibrium using a balance response. I would say, 'Well, I'm tripping more or slipping more, but I'm not actually falling because I have a pretty good balance response.' Falls are usually defined by unintended landing on a lower surface. If you end up on a bed or a chair or the floor, then it's a fall.

But if you're slipping and tripping more often, it could be because your walking is such that you're more likely to trip. I would separate in my mind the part where you're losing your balance and the part where you're recovering your balance.

Heather Cianci 00:45:21
Thank you, Dr. Horak. I just want to take a moment to remind everyone, take a look at this slide here. We do have upcoming educational programs for health professionals, so feel free to take a look at that. Our next question, Dr. Horak, comes from a care partner and spouse in Maryland, and they want to know: are there any specific ways to prevent festination?

Fay Horak 00:45:43
Okay. Festination is the rapid, short stepping that can occur either in the forward direction or the backward direction. Often, people can't stop festinating until they get caught, or they run into a wall or something. The way I think of festination is where your body center of mass, which is what your balance control system is trying to control, gets ahead of your feet, for example. Your feet can't catch up with it because the steps you take are too weak and too short. You keep on falling, and then you keep on trying to take another step, and you're falling, you take another step, but each step is too small to catch up.

It's best not to get into that situation, because what you want to do is stop leaning forward. It's that lean forward that causes this automatic little festination. It's better to stop, take a deep breath and take a big step. You have to think really big, and it might require imagining a point on the ground or a line that you're stepping over. External cues can help people with Parkinson's, whether they're freezers or not, take bigger, larger steps. Even sometimes imagining that point on the ground can help.

If the step is large enough, there won't be festination. Festination only comes from taking too-short steps. So thinking big, I think, would be helpful in that situation.

Heather Cianci 00:47:14
We have some similar questions from care partners and people with Parkinson's disease in both Maryland and Virginia. They're asking about different situations where freezing can happen. Can it happen while driving? Can you have a full-body freeze? Can it happen in the mouth?

Fay Horak 00:47:29
That's interesting. There are studies now showing that freezing-type events can occur with your use of your hands. When you're trying to do something with your hands that's a coordinated action, you could have a period in which your hands kind of stop moving and do a little trembling before you can move on. That can be helped with levodopa, and it's associated in people who have freezing of gait as well.

I have not heard of people freezing or doing complex tasks like driving, but I think it can occur also with speech as well. When people find themselves unable to think of the next word or to articulate the next word, it can be associated with a freezing event. But remember, freezing isn't just like stopping moving. You're not driving along and you suddenly don't move. It just means that your movements are no longer smooth and coordinated.

Heather Cianci 00:48:41
Right. We have a question from a care partner in New Jersey who wants to know: is treadmill training helpful for balance and gait?

Fay Horak 00:48:51
Definitely for gait, probably less so for balance. Treadmill training is really good for getting aerobic conditioning. People with Parkinson's disease often get cardiovascular problems from lack of exercise, and that causes disability as well. Aerobic training on a treadmill can help improve walking and can make steps larger and faster. If you're not holding on to the handles or something, you can also be improving your balance, but that could be dangerous on a treadmill.

We did a study in which we looked at balance before and after treadmill training and didn't find improvements in balance, although we did find big improvements in gait. I think the main thing to think about with exercise is to do more than one kind. Do what you love and do it a lot, but do a variety of things. If you like the treadmill exercise, that's great, but then other times, take walks around the block or on uneven surfaces in a hike.

Or go up and down your stairs. Do a variety of things. I think that would be the best thing so that some of the exercises could be better for your balance and other ones for your walking.

Heather Cianci 00:50:13
Right. We have two questions here which are referring to the biofeedback device that you showed. We have one from Chappaqua, New York, who wants to know: how can I find out about getting into your study, or are there other studies? Then from a physician in Wisconsin, who wants to know if you've tried the biofeedback device on people who have had DBS.

Fay Horak 00:50:37
There's a way for people to get involved in research studies, and researchers really need people with Parkinson's disease, as well as other family members who don't have Parkinson's disease, to participate. There's a national program called NeuroNext.

Online, people can sign up for joining medical research for all different reasons and for neurological disorders. Whoever has research going on in their area then will be able to know that you're interested in participating. You could also look at a particular website, like the OHSU website, for research studies you can participate in if you wanted to come here.

We haven't tried the biofeedback yet with people who have had DBS, deep brain stimulation. Some people with deep brain stimulation develop freezing, or freezing gets worse. We don't know yet if it also helps them. What we're doing now, however, is trying to get it out of the clinic and laboratory and into the home. We're developing a more wireless system that you won't be able to see in the shoes, so that people can use it in the home. Then we have to measure freezing in the home with sensors in the socks or shoes to see if it's going to work in the long run, not just over a short period of time.

Heather Cianci 00:52:03
Great. As Dr. Horak was giving you some resources there, remember to take a look at our educational resources slide here. We have many different ways to stay in touch with you and help with many of your questions.

We have an interesting question here from a care partner in Rhode Island, who is asking that if you put an extra thick sole on one shoe, will it help you to focus more so that you can use the front part of your brain more?

Fay Horak 00:52:30
Oh, I don't know. It sounds like it could be dangerous, maybe. In fact, when people first get a new pair of shoes, that's probably the most dangerous time for their walking because their brain is used to automatically accounting for the properties of your shoe. You're right, when you get a new pair of shoes of any type, you probably use the less automatic and more conscious part of your brain. More attention is required for you to walk safely without tripping because you have to lift up your leg higher if you have a thicker sole, for example.

Those are the kinds of tricks you'd probably want to do with a physical therapist and not on your own because it could be dangerous.

Heather Cianci 00:53:14
Great. Thank you very much. I want to draw everyone's attention to the Expert Briefing survey. Please take a moment to complete this online survey for us. Your feedback is really important to us, and it really helps us to improve our webinars and to ensure that you get the information you need.

Let's take a look at our next question here, Dr. Horak. This actually comes from our Ohio chapter. They said that you had mentioned that you can teach a person with Parkinson's disease to use a laser. Is this one of the only ways that you can help people to take larger steps, or are there other ways to teach people to take larger steps?

Fay Horak 00:53:54
A laser is one way that's helpful, because they may be fine walking straight and then they want to go into an elevator or a doorway and they need to bring the laser out. The other thing they could do is find an app for a metronome on their phones, on their pocket phones.

They could use it if they're going to be taking a longer walk down the block or something. They could use the auditory cues coming from about one step per second, or a little slower than that, to help them take regular, larger steps. People can learn to automatically think about having those lights or the auditory cues as well. They internalize them after practicing for a while. But sometimes people still become reliant on the external cues, and they're more powerful.

What you can do in the home is put lines on the ground. For example, in a small bathroom, you could put tape on the ground at 12 o'clock and 3 o'clock, 6 o'clock and 9 o'clock that helps people make a turn in a small bathroom so that they don't fall in the bathroom while they're trying to turn. It helps them take bigger steps in that situation.

Heather Cianci 00:55:20
Right. A question from someone else in Colorado who wants to know: where is the best place to find help with Parkinson's disease? You mentioned you're a Center of Excellence. How do we find out about others?

Fay Horak 00:55:33
Well, the National Parkinson Foundation here is a good place to start. They have a Helpline and a website that can tell you about all the Parkinson Centers of Excellence in the country and how close they are to you. That would be one good place to start. I think if you're thinking that you want to see a physical therapist or a neurologist, you would need to ask them, 'How many people with Parkinson's disease do you see?' Those who see many people with Parkinson's disease are going to, of course, have more expertise than those who see very few.

Heather Cianci 00:56:13
I just want to take a moment here and say that people are really sending in the accolades, Dr. Horak. We're getting information from a health professional in Illinois and some people with Parkinson's disease in Vermont who are talking about how well done this webinar is and how much your information is truly helping them. So thank you for that.

Let's take a look. Here's an interesting one. This is from a person with Parkinson's disease. I'm sorry, I don't know where from, but they say: why can I always run when I cannot walk?

Fay Horak 00:56:45
Yeah, that is funny, isn't it? I wonder if running is more automatic for you than walking for some reason. When you're running, you're actually falling. Everybody who's running has their center of mass outside of their base of support, so you're actually falling and you're taking balanced steps to recover. Whereas when you're walking, you have to do a more sideways weight shifting, and maybe your sideways weight shifting isn't fast and large enough for you to unweight a leg, or maybe your walking is just not automatic enough.

It requires this cognitive system, which is slower and involves more complex interactions between balance and gait. I don't think everybody can run who can't walk, but certainly for you, that's the way it is.

Heather Cianci 00:57:41
We have a question from a person with Parkinson's in Minnesota. Can you please talk about the feeling of weakness that I get in my upper legs when I freeze?

Fay Horak 00:57:50
Hmm. So it's not only a feeling of your feet being glued to the floor, but a feeling of weakness. I wonder if that's part of it, where your brain is saying, 'Lift the leg, lift the leg,' but you still have a lot of weight on that leg. So you haven't shifted your weight off of that leg. You're trying to lift your entire body weight when you lift your foot off the ground. Yeah, I think that's the problem. I think you have to voluntarily think, 'Shift my weight to the left leg, and then lift up the right leg.' Then maybe your leg won't feel so weak because it's not having to lift as many pounds.

Heather Cianci 00:58:32
Another question from a person with Parkinson's. You mentioned many different exercise options. Can you speak about indoor cycling?

Fay Horak 00:58:42
Yes. There are some new studies showing that cycling behind somebody on a tandem bike can really improve people's walking with Parkinson's because you're forced to take really fast and large cycles. I think cycling in the home could be good for aerobic conditioning, and it may help walking. But there's not a lot of balance practice happening there. You'd also have to include another program, let's say, go take Tai Chi as well, so that you can work on balance there and work on your aerobic with the bicycle.

Heather Cianci 00:59:26
Right. A question from another care partner-spouse team in Maryland: are there any specific suggestions for avoiding retropropulsion?

Fay Horak 00:59:36
Retropropulsion can be very dangerous because people are falling backwards, and they're taking those tiny little steps rather than a big step to stop themselves. Their stepping responses are too weak and too late. One thing is to practice having good postural alignment. When people are more flexed at the hips and the knees and the ankles, they tend to shift their body center of mass too far back. If it's back near your heels, then you're really likely to start tipping backwards and then having to take a step. So the first thing is, you have to avoid tipping backwards.

You have to look in a mirror and work with a therapist to improve your body alignment so you're more upright and more weight is on the front of your feet and not back on your heels. Secondly, you need to practice walking backwards with big steps. Taking big backward steps is a necessary part of preventing retropropulsion because once you start tipping backwards, you have to take a really big step, and that can stop you from falling backward.

It might require working with a physical therapist so you don't fall, because taking backward steps is a dangerous thing to do since you can't see where you're going, and you may not be able to naturally take a big step. But with practice, I believe people can improve this backward stepping and even these automatically triggered backward steps that are needed for balance control.

Heather Cianci 01:01:09
Thank you, Dr. Horak. It looks like we have time for one more question. I want to remind everyone, if we don't get to your question and have that answered today, you can again contact us at the Helpline at 1-800-4PD-INFO. Number four PD INFO.

The question that we have here is from a person with Parkinson's in Pennsylvania, and they say that they've suffered with neuropathy and other problems with their feet and find it difficult to find exercises that don't involve pain in the feet. Would you have any other suggestions of exercises that they could try?

Fay Horak 01:01:45
In fact, we found that over 80% of people with Parkinson's disease have other things like neuropathy and arthritis and things like that that affect their balance and walking too, in addition to Parkinson's. I would think if you have pain in your feet from walking, exercises done in a pool might be useful. In a warm swimming pool, a therapeutic pool, where you can do large stepping and aerobic exercises and even practice your balance responses in a pool without endangering yourself.

With that less weight on your feet and the warmth of the pool, that might be useful to prevent pain and improve your balance and walking.

Heather Cianci 01:02:31
Wonderful. Thank you so much, Dr. Horak, for all of your wonderful information today. It was truly a pleasure to be able to moderate this today with you. We'd also like to thank our sponsors, AbbVie, Sunovion and Lundbeck, again for helping to make this series possible. Remember that an archive of today's event will be made available starting next week on Tuesday, January 23, by visiting our website at www.parkinson.org. I'd like to remind you to please join us for our next webinar entitled Parkinson's Disease Psychosis: Hallucinations, Delusions, and Paranoia.

That will be on Tuesday, February 27, again from 1 to 2 o'clock Eastern Standard Time, and that will be presented by Dr. Christopher Goetz of Rush University Medical Center, a Parkinson's Foundation Center of Excellence. We thank you for being with us today, and we hope to see you again and hear from you again at our next webinar.