THE FOX FOCUS...
ON LIVING WITH PARKINSON’S
DR. DOLHUN
TALKS PD
POSTURAL INSTABILITY
AND GAIT DIFFICULTY
Not everyone with Parkinson’s
experiences postural instability and gait
difficulty (PIGD). But for those who do,
these symptoms can be some of the most
frustrating.
•G
ait disturbances may include
shuffling, trouble getting started
(hesitation), sudden inability to move
(freezing), or short, quick steps that are
difficult to stop (festination).
•P
ostural instability refers to imbalance
or unsteadiness.
Balance and walking problems may
become more noticeable as Parkinson’s
disease (PD) progresses, or, as with a
subgroup of people with “PIGD
phenotype,” these symptoms may be
relatively prominent from the outset.
PIGD is concerning because it increases
the risk of falls, which can lead to injury
and/or hospitalization, limit social activities
and independence, and therefore lessen
quality of life. Unfortunately, walking and
balance problems are among the most
challenging symptoms to treat in PD. Many
people with PIGD are not highly responsive
to the presently available medications and
surgical techniques.
Until new and better strategies are
realized (see opposite page), management
of PIGD relies on fall prevention, optimization of Parkinson’s drugs, and physical
exercises and therapies. Being cautious to
avoid falls is of utmost importance — use
care with movements like turning around,
bending over and reaching forward, which
commonly trigger falls. Always hold the
staircase handrail, don’t multitask or rush
while walking, and stay off ladders. Try not
to get discouraged — take control of your
care, build a team of doctors and physical
or occupational therapists, and know that
there is a lot you can do to manage PIGD.
QUESTIONS AND ANSWERS ABOUT PIGD
1. H
ow do doctors evaluate for
walking and balance problems?
Physicians rely on your medical history and
physical examination to assess these issues.
If you feel unsteady, or your walking is in any
way impaired, make sure you bring this up
during the office visit, even if your doctor
doesn’t ask. In addition to performing the
standard neurological exam, your doctor
may:
O
bserve your gait pattern. By watching
you stand up, move through a doorway,
walk a short distance and turn around,
the doctor collects information on your
strength, walking speed, step length,
stance width and arm swing. He or she will
see if you shuffle, hesitate, freeze or tend
not to swing one arm.
C
heck for postural instability using the
“pull test.” The doctor will stand behind
you and tug backward on your shoulders
to determine if you can maintain your
balance.
Evaluate fall risk by asking about or
looking for certain factors that can be
predictive of falls, such as a previous fall,
fear of falling, the duration of Parkinson’s
disease and the severity of disease. He or
she will also take into account associated
symptoms like decreased leg strength
and/or sensation, freezing, dyskinesia,
imbalance, and cognitive impairment, all of
which can increase the chances of falling.
RESEARCH TO HELP THOSE WITH PIGD
Treatments for PIGD are a significant unmet need, and investigations, including several funded
by The Michael J. Fox Foundation, are ongoing toward novel treatments to address these
issues. Early clinical studies of drugs that affect the brain chemical acetylcholine have shown
promise for gait improvements and fewer falls. A trial of deep brain stimulation (DBS) in the
pedunculopontine nucleus (PPN) — an area of the brainstem that plays a key role in control of
gait and posture — is evaluating whether stimulating this new target might alleviate freezing
and decrease falls. If you are interested in participating in clinical trials to speed the
development of new treatments, visit foxtrialfinder.org.
12 THE FOX FOCUS
2. H
ow do physical and
occupational therapists treat
postural instability and gait
difficulty?
D
esign specialized programs that
improve posture, balance and mobility, and
lessen falls
T
each techniques to fall in ways that
mi