Dan Keller (00:08)
Welcome to this episode of Substantial Matters: Life and Science of Parkinson's. I'm your host, Dan Keller at the Parkinson's Foundation. We want all people with Parkinson's and their families to get the care and support they need. Better care starts with better research and leads to better lives. In this podcast series, we highlight the fruits of that research, the treatments and techniques that can help you live a better life now, as well as research that can bring a better tomorrow. Falls are a major risk for people with Parkinson's and can result in significant injury. People who have already experienced a fall are at greater risk of repeat falls, and this can have a big impact on your quality of life. The good news is that there is a variety of things that can be done to prevent falls. Dr. Sotirios Parashos, director of research at the Struthers Parkinson's Center in Golden Valley, Minnesota, a Parkinson's Foundation Center of Excellence, discusses what can be done to minimize the risk of falls and what types of healthcare professionals should be involved in the process. He begins by describing the extent of the problem.

Dr. Sotirios Parashos (01:25)
Approximately 50% of people with Parkinson's disease will experience at least one fall per year. And if we look at how often that happens, is that if you look at people with Parkinson's disease who have not yet fallen, about 10% will start falling within the following year.

Dan Keller (01:46)
And do you know the causes, or is it multiple, multifactorial?

Dr. Sotirios Parashos (01:51)
Not only the causes, but the actual falls are very different from person to person. And we believe that there are many different types of falls, and of course many different reasons why people with Parkinson's disease fall. The simplest thing is, of course, that they are a certain age, that people tend to fall. About one in four or one in five people over the age of 60 may experience repeated falls without even having Parkinson's disease. However, people with Parkinson's disease may fall either just because of some of their symptoms directly with the Parkinson's. They may be falling because of some of the side effects of medications that they take. They may be falling because they're tripping, because they're shuffling. They don't lift their feet; they don't have this good clearance. They may develop a symptom that's called freezing of gait, where their feet get stuck to the ground and then they tumble over. Or they may just start falling because they lose their balance with no particular reason.

Dan Keller (02:43)
Well, that gives you a lot to work on. So how do you approach this, and what is the success of treatments or interventions?

Dr. Sotirios Parashos (02:52)
Unfortunately, there is no systematic look on what prevents falls. In the last two to three years, there have been some studies that have started that are trying to identify what interventions, what strategies, what exercises, what therapists, what types of therapy might reduce the risk of falling. There has been a lot of work done generally with falling and what can prevent falls. And there are certain centers in the United States and abroad that have made that the purpose of their research. And they have worked for a long time, and they have developed very good strategies to reduce the frequency of falling. However, the most common-sense thing is for the doctor and the physical therapist, if a physical therapist is involved, to sit down with the person with Parkinson's and figure out exactly how do they fall, what are the circumstances of their falling. So they can figure out what are the best strategies to help them, and help can be given both through adjustments of the medications, but also through physical therapy, through occupational therapy, and through targeted exercise.

Dan Keller (03:55)
Is the exercise directed in any specific part of the body, or is it individualized based on the physical therapy findings and things like this?

Dr. Sotirios Parashos (04:03)
There's a number of exercises that have been shown to have a good effect on improving balance in Parkinson's disease. The most commonly recommended one is Tai Chi. My recommendation to my patients with Parkinson's disease is to start working on their balance even before they start falling, because Tai Chi does help improve one's own awareness of their body and improve their balance in general. So I would rather have them prepared even before falls or loss of balance becomes a problem. There are specific physical therapy protocols that have been developed, and there are also a number of different exercise protocols that have been developed and that have been tested in, unfortunately, pretty small studies. The unfortunate thing with falls is that we have difficulty in studying them for many reasons. One very simple reason is, of course, that falls are different from person to person, so we have to develop a way to classify them before we can study them more systematically. And the second big problem is that we don't know how to measure falls. We can start counting falls, but that doesn't give us a very good answer, because we don't know how much a person is exposed to risk of falling. If you're sitting watching TV on the couch all day long, you're not going to be likely to fall. On the other hand, if you are out and very active biking and climbing mountains, you might be at a higher risk for falling. And right now, we don't really have a very good way of measuring what is the exposure, as we call it in epidemiology, to the risk of falling, so that we can have a better idea of what we look at when we start counting falls in some person.

Dan Keller (05:35)
What is the effect of core body strength and, on the other side, frailty?

Dr. Sotirios Parashos (05:41)
Well, you know, this goes along with the age component in Parkinson's disease. But of course, people with Parkinson's disease do lose a significant amount of their muscle strength and a significant amount of their muscle power. We do know from studies that have been done that although when the doctor examines you, they cannot perceive any loss of strength, people with Parkinson's disease in general have about a 10 to 20, sometimes even 25% loss of their muscular strength. So naturally, improving core strength primarily will also improve core balance, and therefore will reduce the risk of falling.

Dan Keller (06:15)
Besides exercises, are there specific techniques people can use, adjusting their gait, their stance, various other things?

Dr. Sotirios Parashos (06:23)
There are many things that a person can do with the help of the therapist, but also there are many lifestyle changes that a person can do also with the help of an occupational therapist. Quite often, I will have my occupational therapist visit people's homes and working areas, and they will make recommendations. For example, we have to remove any loose rugs that might trip you. The type of footwear that you're using is important. There are ways to work around the freezing phenomenon that the therapist can work with a person with Parkinson's disease to minimize that problem. So there are many ways, besides just straightforward exercise, that the therapist can help a person with Parkinson's disease prevent falling.

Dan Keller (07:04)
Can you gauge the effectiveness of these interventions? Since it's hard, as you said, to measure the kind of fall someone has, you can only count them. How do you know you're doing any good?

Dr. Sotirios Parashos (07:15)
There is good research from the general population about some very standardized techniques that work. And there has been some early work that was done out in the Netherlands and also in Israel that has demonstrated benefit, not only in Parkinson's disease but also in the general population, for some of these techniques. However, if we want to hone down to what works and what doesn't work, then we're going to have to develop better ways of actually measuring falls.

Dan Keller (07:41)
What should patients expect and what should they ask for so they can minimize their risks?

Dr. Sotirios Parashos (07:47)
It is important, in my opinion, for them to see somebody who is experienced with assessing and treating falling in Parkinson's disease. My experience has been that a lot of people with Parkinson's will see their family physicians. They will tell them that they're falling. The family physicians will refer them to a physical therapist who may or may not have much experience with Parkinson's disease, and they will receive a generic type of balance training, which may or may not help their particular problem. For example, if your particular problem is that you have some dizziness or low blood pressure and you fall because of the low blood pressure, then there's going to be no help from just doing balance exercises. You may need to have your medications adjusted. So it will be important for a physician who is familiar with the problem of falling to take a very, very good history and try to figure out the exact circumstances of falling so they can classify what type of falls this person has, which will, of course, direct what's the best approach to prevent any further falling.

Dan Keller (08:44)
What's coming along in research, as well as new interventions, whether physical or medical?

Dr. Sotirios Parashos (08:52)
There has been a lot of interest in reducing falls, not just with medications but also with changing targets in Deep Brain Stimulation surgery. Although we haven't been successful yet, there have been some very interesting results that helped us understand what kind of chemicals are involved in the brain of people with Parkinson's disease who are falling. And there have been some smaller studies that were done with medications that are actually being used for treatment of Alzheimer's disease. And now there are more studies that are being designed to try and see if these medications will reduce falling in Parkinson's disease. Even if these medications don't work as well, this whole area of research opens a new direction of research in trying to figure out what might help besides just traditional falls prevention strategies.

Dan Keller (09:39)
Are these medications mainly cholinesterase inhibitors or other Alzheimer's drugs?

Dr. Sotirios Parashos (09:45)
These are cholinesterase inhibitors. But there are also some medications that have been used for orthostatic hypotension that have shown some benefit. There's also some medications that seem to enhance the effect of cholinesterase drugs that seem to be also encouraging. So again, as I said, so far the only medications that have shown some benefits are cholinesterase inhibitors, central cholinesterase inhibitors. But I think, again, this is a whole new area that is just opening up for further research.

Dan Keller (10:14)
What have we missed, or what is important to add for patient safety and patient well-being?

Dr. Sotirios Parashos (10:19)
I believe that falling is one of the biggest problems that people with Parkinson's disease will ever face. I think that it should be a red flag when this happens, not only for the person with Parkinson's disease and their loved ones, but also for their treating physicians and therapists. In our center, when a person with Parkinson's starts to fall, this is a showstopper, where we have to stop everything else and address that problem, and we have to bring the full power of our knowledge and our understanding to help them. So it is very important for people with Parkinson's disease to understand that this is not a trivial issue. If they have this problem, they should seek help, and they should advocate for getting the appropriate help that they need.

Dan Keller (10:59)
Very good. I appreciate it.

Dan Keller (11:09)
If you want to find out more about reducing the risk of falls, or if you need help finding an expert care team in your area, call our toll-free helpline at 1-800-4PD-INFO. As Dr. Parashos has said, more research is needed on the various reasons that falls occur. The Parkinson's Foundation is a major funder of all aspects of Parkinson's disease research through our Centers of Excellence and through our ongoing Parkinson's Outcomes Project, the largest-ever clinical study of Parkinson's. To find out more about what research is going on in Parkinson's, call our helpline or go to parkinson.org and click on Research. If you have any questions about the topics discussed today, or if you want to leave feedback on this podcast or any other subject, you can do it at parkinson.org/feedback. At the Parkinson's Foundation, our mission is to help every person diagnosed with Parkinson's live the best possible life today. To that end, we'll be bringing you a new episode in this podcast series every other week. Next time, we'll hear the answers to some common questions about exercise. Till then, for more information and resources, visit parkinson.org or call our toll-free helpline at 1-800-4PD-INFO—that's 1-800-473-4636. A couple of our free publications might be of particular interest after today's chat with Dr. Parashos. Fitness Counts includes posture and balance tips and exercises to help with fall prevention. Managing Parkinson's Mid-Stride covers freezing and other changes in movement symptoms and how to work with your doctor to manage them. You can find both publications at parkinson.org/books. We also have a webinar on freezing and falls coming up on Tuesday, January 16, 2018, as part of our Parkinson's Expert Briefing Series. Go to parkinson.org/expertbriefings for more information and to register. Thank you for listening.

Falls can lead to fractures and other injuries, and the fear of falling can limit participation in activities. There are many causes of falls in Parkinson’s, but also many strategies to help prevent them.

Dr. Sotirios A. Parashos is a movement disorders specialist with the Minneapolis Clinic of Neurology and Clinical Research Lead at the Struthers Parkinson Center, a Parkinson’s Foundation Center of Excellence. He is also Clinical Professor of Neurology at the University of Minnesota. He completed his basic medical training at the Aristotle University in Thessaloniki, Greece; a two-year Fogarty Fellowship in Neuropharmacology at the Experimental Therapeutics Branch of the National Institute of Neurological Disorders and Stroke of the National Institutes of Health, in Bethesda, MD; a neurology residency at the University of Minnesota, in Minneapolis, MN; a PhD in Experimental Physiology of the Nervous System at the Aristotle University; and an Advanced Clinical Fellowship in Movement Disorders at the Mayo Clinic, Rochester, MN. He serves on the Community Advisory Board of the Struthers Parkinson’s Center, on the Work Group for Parkinson’s Disease Physician Performance Measure Development of the American Academy of Neurology, and on the steering committee of the Parkinson’s Outcomes Project of the Parkinson’s Foundation. His research centers on non-dopa-responsive symptoms of Parkinson’s disease, such as falls and cognitive dysfunction, the natural history of Parkinson’s and the role of multidisciplinary and interdisciplinary care in the management of Parkinson’s. He has co-authored many articles published in peer-reviewed journals and a book, Navigating Life with Parkinson Disease, and he has given numerous lectures on Parkinson’s to professional and lay audiences.

Dr. Indu Subramanian received her medical degree in 1996 from the University of Toronto, Canada. She did her neurology residency and Movement Disorders fellowship training at UCLA. Dr. Subramanian has stayed on at UCLA and is now a Clinical Professor of Neurology. She established the movement disorder clinic at the West Los Angeles Veterans Administration and has assumed the position of the Director of the South West PADRECC (Parkinson Disease Research, Education and Clinical Care) Center of Excellence in Parkinson Disease. She has developed a strong interest in integrative medicine with a special interest in Yoga and Mindfulness. She underwent a 200 hour yoga teacher training and studied mindfulness at the VA with J.G.Serpa and Christian Wolfe through Insight LA. She is designing a yoga teacher training program for yoga instructors who are interested in working with PD patients. Dr. Subramanian recently got board certified in Integrative medicine. She is also passionate about palliative care in Parkinson Disease. She is the host of a virtual support group with world experts in PD and co-edits a blog for PD patients.

Dr. Indu Subramanian received her medical degree in 1996 from the University of Toronto, Canada. She did her neurology residency and Movement Disorders fellowship training at UCLA. Dr. Subramanian has stayed on at UCLA and is now a Clinical Professor of Neurology. She established the movement disorder clinic at the West Los Angeles Veterans Administration and has assumed the position of the Director of the South West PADRECC (Parkinson Disease Research, Education and Clinical Care) Center of Excellence in Parkinson Disease. She has developed a strong interest in integrative medicine with a special interest in Yoga and Mindfulness. She underwent a 200 hour yoga teacher training and studied mindfulness at the VA with J.G.Serpa and Christian Wolfe through Insight LA. She is designing a yoga teacher training program for yoga instructors who are interested in working with PD patients. Dr. Subramanian recently got board certified in Integrative medicine. She is also passionate about palliative care in Parkinson Disease. She is the host of a virtual support group with world experts in PD and co-edits a blog for PD patients.

Dr. Robert Hauser is a Professor of Neurology at the University of South Florida College of Medicine, in Tampa, Florida. He serves as Director of the USF Parkinson’s Disease and Movement Disorders Center, a Parkinson Foundation Center of Excellence. Dr. Hauser earned his medical degree from Temple University School of Medicine in Philadelphia, Pennsylvania, and completed neurology training at the Eastern Virginia Graduate School of Medicine, in Norfolk, Virginia.

Dr. Hauser completed a fellowship in Movement Disorders at the University of South Florida and became Center Director in 1994. He has authored or co-authored more than 300 peer-reviewed publications and is one of the world’s most cited Parkinson’s Disease investigators. He is Past Chairman of the Interventional Neurology Section of the American Academy of Neurology, has served on the executive committee of the Parkinson Study Group, and was a member of the steering committee for the NIH-sponsored Neuroprotective Exploratory Trials in Parkinson’s Disease program (NET-PD). Dr. Hauser lectures frequently at scientific meetings and served as Chairman of the 2009 World Federation of Neurology International Congress on Parkinson’s Disease and Related Disorders.

Dr. Hauser’s primary research interest is the development of new medical and surgical treatments for Parkinson’s disease and other movement disorders. He has extensive expertise in clinical trial design and execution. The outcome measures he developed have become the gold standard for use in clinical trials. He maintains an active patient practice and has been voted a Top Doctor by his peers every year since 1993.

Dr. Muhammad Nashatizadeh was born and raised in Emporia, Kansas, and completed his undergraduate biology degree in 1998 with highest honors as a University Scholar at Emporia State University. He completed his medical degree at the University of Kansas School of Medicine in 2003, internal medicine internship in Wichita in 2004, and neurology residency in Kansas City in 2007. He served as chief resident before pursuing movement disorder fellowship training at Baylor College of Medicine in Houston, Texas returning home to Kansas in 2008. He is board-certified in neurology by the American Board of Psychiatry and Neurology (ABPN).

Known as "Dr. Muhammad" by numerous patients, he worked as a community neurohospitalist for over six years while seeing clinic patients with movement or cognitive disorders. He returned to the University of Kansas School of Medicine as faculty in 2015 and has been the Director of Inpatient Movement Disorders since 2017. Primarily covering the inpatient consultation service, he works with emergency medicine, internal medicine, rehabilitation and surgical teams to help manage neurological problems affecting hospitalized patients. He educates geriatrics fellows, residents from neurology, internal medicine and psychiatry, and medical students to understand how medical disorders affect patients neurologically and how multiple problem layers cumulatively contribute to illness. For these efforts, he was voted as the Neurology Educator of the Year (Student Voice Award) by third year medical students for four years straight and selected as a top five finalist for the prestigious Rainbow Award in 2018-2019 honoring altruism, excellence, and professionalism.

La Dra. San Luciano es neuróloga especialista en trastornos del movimiento, que incluyen la enfermedad de Parkinson, distonía, temblor esencial y otras enfermedades. Es licenciada en Medicina por la Universidad de Navarra en España y realizó su residencia en Neurología en Boston University, donde fue jefa de residentes durante su último año. Realizó un fellowship clínico y de investigación en trastornos del movimiento en Beth Israel Medical Center en Nueva York (ahora pertenece a Mount Sinai) y obtuvo una maestría en métodos de investigación clínica del Albert Einstein College of Medicine. El enfoque de investigación de la Dra. San Luciano es en genética de la enfermedad de Parkinson y distonía, desarrollo de biomarcadores y estudio de resultados de tratamientos quirúrgicos de estas enfermedades. Desde 2012 es miembro de la Facultad de UCSF.