The balancing act of Parkinson’s fall prevention

As caregivers, the natural instinct is to help. But sometimes, helping does more harm than good, especially for people with Parkinson’s disease.

Parkinson’s disease is a progressive neurodegenerative disorder that affects the nerve cells in the part of brain responsible for organizing movement. People with Parkinson’s may have tremors, rigid or stiff limbs, balance and coordination problems or bradykinesia, a general slowness of movement.

People with Parkinson’s disease may have some difficulty getting around, but unless they ask for assistance, they should be allowed to get around on their own, says Rachel Lovati, PT, DPT, who lectured on the topic at the Cleveland Clinic. Offering too much help or babying them could further reduce muscle strength and mobility.

“People only come to us when they have a problem, so we’re used to working with people who are sick, and we are usually gentle and work to the patient’s tolerance,” Lovati says. “These people who come in with Parkinson’s come in healthy. This is not just an episode. They’re managing a chronic disease.

“We have to ask ourselves, ‘How can we set them up for success not just now but for the future?’”

There is no way to prevent or slow progression of Parkinson’s, but symptoms can be improved with medications and physical therapy. Parkinson’s disease is one of the most referred diagnoses for Lovati, who works in rehabilitation and sports therapy for the Neurological Institute at Cleveland Clinic Avon Lake Family Health Center. Lovati says success means helping people with their standing posture because that means improving balance and reducing falls.

Tips to maintain balance for people with Parkinson’s disease:

  • Keep at least one hand free at all times.
  • Swing both arms back and forward while walking.
  • Lift feet off the ground while walking. Don’t shuffle or drag feet.
  • Face forward and make a wide turn in “U” shape instead of pivoting sharply.
  • Stand with feet shoulder length apart.
  • Do one thing at a time. Trying to multitask decreases the ability of automatic reflexes and complicates motor function.
  • Avoid wearing rubber or gripping soled shoes, which could catch and the floor.
  • Change positions slowly using deliberate, concentrated movements. Count 15 seconds between each movement. Use a grab bar or walking aid, if necessary.
  • Step over a foot or imaginary object to avoid freezing.
  • Exercise within reach of a grab bar or rail if balancing is difficult.
  • Stay active by pursuing an enjoyable activity or hobby, such as water aerobics, yoga, tai chi, swimming or gardening.
  • Exercise facial muscles, jaw and voice by making faces in the mirror, chewing each piece of food for at least 20 seconds and singing or reading aloud with exaggerated lip movements.

Sources: Cleveland Clinic, Parkinson’s Disease Foundation, National Parkinson Foundation

People with Parkinson’s have a tendency to lean forward with their head bowed over their shoulders, putting more strain on the neck and back. The added weight shifts their center of gravity and reduces their ability to balance, adjust and react. Combined with the fact that people with Parkinson’s take smaller steps and shuffle, they are putting themselves at risk.

People with Parkinson’s fall about twice as often as healthy people. Half of people with Parkinson’s who fall, fall more than once a year. One-third of all falls are attributed to postural instability, people’s ability to control their balance when standing, reacting to a force placed upon them or in response to dynamic movement.

Lovati says her patients might not understand the Parkinson’s diagnosis—she often has to educate them on the disease and its progression—but they already know and fear falls. The good news is physical therapy can retrain the brain and decrease the risk of falling.

The first step to get them moving is to stop and listen. “I always ask patients what’s the problem here, what’s holding them back from taking the first step,” she says. “If they can identify that they want to roll their arm over, then you’re empowering patients to identify their problem rather than just telling them.”

Lovati trains her patients in 30-45 minute sessions, but that high-intensity exercise can be done in shorter intervals, whatever is convenient for residents and staff in a community setting. The important thing, she says, is to work out for two hours a week—and really work.

“Just because they have Parkinson’s doesn’t mean they can’t work hard,” Lovati says. “Two hours of pretty hard exercise can help improve the symptoms of Parkinson’s disease.”

She says she generally keeps her patients at 80-90 rotations per minute (RPM) on a stationary bicycle.  She pushes them on the treadmill or walking outside, too. She gives her patients wooden spoons to march and drum at the same time, teaches boxing classes and recommends tango dancing to work on coordination.

It doesn’t matter how or what devices, equipment or technology people use, the important thing is to get them moving. Lovati says a lot of the times, physical therapists do exercises in three sets of 10 and can be just as set in their ways as their patients. She recommends using the rate of perceived exertion scale instead. The Cleveland Clinic focuses on certain positions and doing several exercises in each position: rotations, extensions, rhythmic rocking and reaching.

Physical therapy is medicine, Lovati says. “We tell our patients this is their home exercise pill. This is their dose, and they have to take that if they want to get better.” For example, Lovati’s patients may practice opening their back and alignment by sitting in an upright dining room chair with hips, shoulders and chin back. She puts a tennis ball between their shoulder blades to help them keep their posture. Or she’ll prop elbows with towels on a table to raise those arms up to chest height and push shoulders back.

People with Parkinson’s tend to take small motions, so she instructs her patients to be big and take up space. She tells them to get loud, too. “If we ask them to do something, we should be willing to do that, too,” she says, yelling and bounding across the room.

They also sometimes have trouble getting started, so she offers patients visual cues to help step over a line, encourages taking one big step past the other and auditory cues like 1,2,3 step so they don’t freeze as much. At the beginning, she says she’s constantly reminding them to take longer steps. They learn pretty quick how cueing 1-2-3 can be an effective way to stop freezing.

“I think if we can show them or get them to recognize the feeling when they do their bigger steps, then once they feel safer, they’re more likely to do it,” she says. “They’ll start counting to themselves. That’s when you know they’re learning. You need to get them from where they are to where they need to be by taking little steps towards it.”

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