Falls in Parkinson's disease

Current Opinion in Neurology

Volumn 17, Issue 4, 2004, Pages 405-415

  Grimbergen, Yvette A M ^a   Munneke, Marten ^b   Bloem, Bastiaan R ^b  

^a LEIDEN UNIVERSITY MEDICAL CENTER   (Netherlands)

^b RADBOUD UNIVERSITY MEDICAL CENTER   (Netherlands)

Author keywords

Falls; Freezing; Parkinson's disease; Posture; Posturography; Stereotactic neurosurgery

Indexed keywords

ANTIPARKINSON AGENT; FLUMAZENIL; FLUPIRTINE;

ARM MOVEMENT; BALANCE DISORDER; BODY POSTURE; BRAIN DEPTH STIMULATION; CLINICAL FEATURE; CLINICAL TRIAL; COST OF ILLNESS; DISEASE PREDISPOSITION; FALLING; FEAR; GAIT DISORDER; HIGH RISK POPULATION; HIP FRACTURE; HUMAN; MEDICAL EXAMINATION; META ANALYSIS; NONHUMAN; PALLIDOTOMY; PARKINSON DISEASE; PATHOPHYSIOLOGY; PATIENT MOBILITY; PHYSIOTHERAPY; PROPRIOCEPTION; RETROPULSION TEST; REVIEW; RIGIDITY; SCORING SYSTEM; STABILOGRAPHY; STEREOTAXIC SURGERY; SUBTHALAMIC NUCLEUS; TASK PERFORMANCE;

ACCIDENTAL FALLS; ARM; GAIT DISORDERS, NEUROLOGIC; HUMANS; MOVEMENT; MUSCLE HYPERTONIA; MUSCULOSKELETAL EQUILIBRIUM; PARKINSON DISEASE;

EID: 4043175432     PISSN: 13507540     EISSN: None     Source Type: Journal    
DOI: 10.1097/01.wco.0000137530.68867.93     Document Type: Review

References (74)

1. Bloem BR, Steijns JAG, Smits-Engelsman BCM. An update on falls. Curr Opin Neurol 2003; 16:15-26.
2. Romero DH, Stelmach GE. Changes in postural control with aging and Parkinson's disease. IEEE Eng Med Biol Mag 2003; 22:27-31.
3. Bloem BR, Bhatia KP. Gait and balance in basal ganglia disorders. In: Bronstein AM, Brandt T, Nutt JG, Woollacott MH, editors. Clinical disorders of balance, posture and gait. Arnold: London; 2004. pp. 173-206. A comprehensive review of gait and balance disorders in a variety of basal ganglia disorders, including PD, various forms of atypical parkinsonism, Huntington's disease, dystonia and orthostatic tremor. The chapter includes sections on the clinical assessment, pathophysiology and treatment of axial mobility deficits in these disorders.
4. Bloem BR, Korhan EK, de Leeuw FE. Treatment of axial mobility deficits in movement disorders. In: Hausdorff JM, Alexander NB, editors. Evaluation and management of gait disorders. New York: Marcel Dekker Inc.; 2004. In press.
5. Wood BH, Bilclough JA, Bowron A, Walker R. Incidence and prediction of falls in Parkinson's disease - a prospective multidisciplinary study. J Neurol Neurosurg Psychiatry 2002; 72:721-725.
6. Bloem BR, Grimbergen YA, Cramer M, et al. Prospective assessment of falls in Parkinson's disease. J Neurol 2001; 248:950-958.
7. Stolze H, Klebe S, Zechlin C, et al. Falls in frequent neurological diseases - prevalence, risk factors and aetiology. J Neurol 2004; 251:79-84. Although retrospective in nature, this study underscores that falls are common in PD, even when compared with other fall-prone populations.
8. Syrjala P, Luukinen H, Pyhtinen J, Tolonen U. Neurological diseases and accidental falls of the aged. J Neurol 2003; 250:1063-1069.
9. Adkin AL, Frank JS, Jog MS. Fear of falling and postural control in Parkinson's disease. Mov Disord 2003; 18:496-502. This study was the first formally to address the fear of falling in PD, using a previously validated measure of balance confidence (the Activities-specific Balance Confidence scale). The results showed that patients with PD, particularly those with greater disease severity, had a markedly reduced balance confidence compared with controls. Low balance confidence scores correlated with an increased amount of body sway during unperturbed stance, but the nature of this relationship remained unclear.
10. Pressley JC, Louis ED, Tang MX, et al. The impact of comorbid disease and injuries on resource use and expenditures in parkinsonism. Neurology 2003; 60:87-93. An interesting study that was originally undertaken to estimate the costs of PD for society, but whose results incidentally shed new light on the nature of fall-related injuries in PD. The results showed that upper extremity injuries are relatively rare compared with lower extremity injuries in PD.
11. •], this study provides some helpful recommendations regarding use of the retropulsion test in clinical practice. In particular, this paper describes the most reliable variant to examine postural instability in PD.
12. •], highlighting common errors in the current use of the retropulsion test in clinical practice.
13. Campbell F, Ashburn A, Thomas P, Amar K. An exploratory study of the consistency of balance control and the mobility of people with Parkinson's disease (PD) between medication doses. Clin Rehabil 2003; 17:318-324.
14. Behrman AL, Light KE, Miller GM. Sensitivity of the Tinetti Gait Assessment for detecting change in individuals with Parkinson's disease. Clin Rehabil 2002; 16:399-405.
15. Thomas M, Jankovic J, Suteerawattananon M, et al. Clinical gait and balance scale (GABS): validation and utilization. J Neurol Sci 2004; 217:89-99. This paper describes a comprehensive rating clinical scale for gait and balance which, after further perfection, could be used in different disorders, including PD.
16. Giladi N, Shabtai H, Simon ES, et al. Construction of freezing of gait questionnaire for patients with Parkinson's disease. Parkinsonism Relat Disord 2000; 6:165-170.
17. Bloem BR, Visser JE, Allum JH. Posturography. In: Hallett M, editor. Handbook of clinical neurophysiology. Amsterdam: Elsevier Science BV; 2003. pp. 295-336. A comprehensive and richly illustrated review of different posturography techniques, both static and dynamic, which can be used to study the pathophysiology of balance impairment in PD and other disorders.
18. Bloem BR, Munneke M, Carpenter MG, Allum JH. The impact of comorbid disease and injuries on resource use and expenditures in Parkinson's disease. Neurology 2003; 61:1023-1024.
19. Bloem BR, Munneke M, Mazibrada G, et al. The nature of falling in progressive supranuclear palsy [extended abstract]. Mov Disord 2004; 19:359-360.
20. Carpenter MG, Allum JH, Honegger F, et al. Postural abnormalities to multidirectional stance perturbations in Parkinson's disease. J Neurol Neurosurg Psychiatry 2004; in press.
21. Maki BE, McIlroy WE. The role of limb movements in maintaining upright stance: the 'change-in-support' strategy. Phys Ther 1997; 77:488-507.
22. Allum JH, Carpenter MG, Honegger F, et al. Age-dependent variations in the directional sensitivity of balance corrections and compensatory arm movements in man. J Physiol (Lond) 2002; 542:643-663.
23. Dimitrova D, Horak FB, Nutt JG. Postural muscle responses to multidirectional translations in patients with Parkinson's disease. J Neurophysiol 2004; 91:489-501. Use of the 'multidirectional posturography' technique (with analyses restricted to electromyogram responses) showed that PD patients have a directional preponderance for falls in a backward or medial-lateral direction. This study also found new evidence for 'postural inflexibility' in PD, as patients were shown to be unable to modify their postural responses appropriately when the distance between the feet was manipulated.
24. ••], again using 'multidirectional posturography' in the same group of patients, but now with analyses restricted to the kinematics.
25. Maurer C, Mergner T, Xie J, et al. Effect of chronic bilateral subthalamic nucleus (STN) stimulation on postural control in Parkinson's disease. Brain 2003; 126:1146-1163. A comprehensive study of balance control in PD, both in terms of the techniques used (a combination of static posturography, tilting support platforms and moving visual surrounds) and in terms of treatments that were analysed (drug therapy and stereotactic neurosurgery, alone or in combination). The paper also features a scholarly written discussion that is well worth reading.
26. Ferrarin M, Rizzone M, Lopiano L, et al. Effects of subthalamic nucleus stimulation and I-dopa in trunk kinematics of patients with Parkinson's disease. Gait Posture 2004; 19:164-171.
27. Grüneberg C, Bloem BR, Honegger F, Allum JH. The influence of artificially increased hip and trunk stiffness on balance control in the pitch and roll planes. Exp Brain Res 2004; DOI: 10.1007/s00221-004-1861-x [Epub ahead of print]. Another multidirectional posturography study, but this one focused on artificially induced stiffness of the hips and trunks in young healthy subjects. No patients were studied, but the results may have direct relevance for understanding the significance of 'inflexibility' for patients with PD and other disorders characterized by axial stiffness.
28. Hagiwara N, Hashimoto T, Ikeda S. Static balance impairment and its change after pallidotomy in Parkinson's disease. Mov Disord 2004; 19:437-445. This static posturography study draws attention to the possible contribution of tremor in causing sway abnormalities in PD. The paper also reports that unilateral pallidotomy has no major therapeutic impact on unperturbed balance control in PD.
29. Maschke M, Gomez CM, Tuite PJ, Konczak J. Dysfunction of the basal ganglia, but not the cerebellum, impairs kinaesthesia. Brain 2003; 126:2312-2322. Although this was a study of passive arm movements, the observation that kinaesthesia is mediated by circuits involving the basal ganglia may indirectly influence our pathophysiology concepts of falls or postural instability.
30. •], this demonstration of abnormal proprioception-related potentials in PD patients highlights the importance of impaired kinaesthetic processing in causing motor impairment in PD.
31. Wijnberg N, Quinn NP, Bloem BR. Posture in Parkinson patients: a proprioceptive problem? In: Duysens J, Smits-Engelsman BCM, Kingma H, editors. Control of posture and gait. Maastricht: Symposium of the International Society for Postural and Gait Research; 2001. pp. 758-762.
32. Willemsen MD, Grimbergen YA, Slabbekoorn M, Bloem BR. Vallen bij de ziekte van Parkinson: vaker door houdingsinstabiliteit dan door omgevingsfactoren. Ned Tijdschr Geneeskd 2000; 144:2309-2314.
33. Vaugoyeau M, Viallet F, Mesure S, Massion J. Coordination of axial rotation and step execution: deficits in Parkinson's disease. Gait Posture 2003; 18:150-157. This gait study shows that abnormal trunk coordination contributes to walking difficulties in PD, and also underscores the difficulties with complex motor tasks in this disorder.
34. Bloem BR, Allum JH, Carpenter MG, et al. Triggering of postural responses and compensatory strategies in a patient with total leg proprioceptive loss. Exp Brain Res 2002; 142:91-107.
35. Henderson JM, Watson S, Halliday GM, et al. Relationships between various behavioural abnormalities and nigrostriatal dopamine depletion in the unilateral 6-OHDA-lesioned rat. Behav Brain Res 2003; 139:105-113. An interesting analysis of axial mobility deficits in rats with unilateral nigrostriatal lesions induced by 6-hydroxydopamine. The observed correlation between the depth of the dopamine depletion and the appearance of particular postural deficits provides a rationale for the hitherto poorly understood therapeutic inefficacy of dopaminergic drugs in patients with balance impairment. The results also suggest the involvement of dopaminergic mechanisms in causing abnormal sensorimotor integration in PD.
36. Bloem BR, Hausdorff JM, Visser JE, Giladi N. Falls and freezing in Parkinson's disease: a review of two interconnected, episodic phenomena. Mov Disord 2004; DOI: 10.1002/mds.20115 [Epub ahead of print]. A comprehensive review of falls and freezing of gait in PD, covering many publications that fell outside the review period for the present paper.
37. Schaafsma JD, Balash Y, Gurevich T, et al. Characterization of freezing of gait subtypes and the response of each to levodopa in Parkinson's disease. Eur J Neurol 2003; 10:391-398. This paper carefully describes the different phenotypes of FOG in PD. Incidentally, the study also introduces a gait/obstacle trajectory that apparently seems effective in eliciting freezing episodes.
38. Hausdorff JM, Balash Y, Giladi N. Time series analysis of leg movements during freezing of gait in Parkinson's disease: akinesia, rhyme or reason? Physica A 2003; 321:565-570.
39. Hausdorff JM, Schaafsma JD, Balash Y, et al. Impaired regulation of stride variability in Parkinson's disease subjects with freezing of gait. Exp Brain Res 2003; 149:187-194. An interesting study that used pressure-sensitive insoles to characterize further FOG in PD. A new and thought-provoking finding was that patients with freezing also have an abnormal gait pattern outside overt freezing episodes, suggesting that FOG is more than a pure 'paroxysmal' gait disorder. The 'interictal' gait abnormality observed in freezers consisted of an increased stride variability, a feature previously shown to correlate with falls in other populations.
40. ••]. The aforementioned increase in stride variability is here shown to correlate with a history of previous falls.
41. Giladi N, Shabtai H, Rozenberg E, Shabtai E. Gait festination in Parkinson's disease. Parkinsonism Relat Disord 2001; 7:135-138.
42. Bishop MD, Brunt D, Kukulka C, et al. Braking impulse and muscle activation during unplanned gait termination in human subjects with parkinsonism. Neurosci Lett 2003; 348:89-92. The approach chosen in this brief report (analysis of stopping mechanisms during walking) could open up a new line of studies that might help to clarify the causes of forward falls in PD.
43. Stack E, Ashburn A. Fall events described by people with Parkinson's disease: implications for clinical interviewing and the research agenda. Physiother Res Int 1999; 4:190-200.
44. •]).
45. •]).
46. Hirsch MA, Toole T, Maitland CG, Rider RA. The effects of balance training and high-intensity resistance training on persons with idiopathic Parkinson's disease. Arch Phys Med Rehabil 2003; 84:1109-1117. A randomized controlled trial, comparing combined balance and resistance training with balance training only.
47. Keus SHJ, Hendriks HJM, Bloem BR, et al. KNGF-richtlijn Ziekte van Parkinson [Dutch Guideline for Physiotherapy in Parkinson's Disease]. Amersfoort: KNGF, 2004 (www.kngf.nl). These Dutch guidelines provide an evidence-based 'menu' of exercises for practicing physiotherapists to deal with specific mobility deficits in PD. An English translation of these guidelines will also appear shortly (see www.kngf.nl).
48. Kamsma YP, Brouwer WH, Lakke JPWF. Training of compensation strategies for impaired gross motor skills in Parkinson's disease. Physiother Theory Pract 1995; 11:209-229.
49. Lundin-Olsson L, Nyberg L, Gustafson Y. "Stops walking when talking" as a predictor of falls in elderly people. Lancet 1997; 349:617.
50. Bloem BR, Grimbergen YA, Cramer M, Valkenburg W, "Stops walking when talking" does not predict falls in Parkinson's disease. Ann Neurol 2000; 48:268.
51. Bootsma-van der Wiel A, Gussekloo J, de Craen AJM, et al. Single versus dual task walking performance as predictor of falls in the general population of oldest old. Results of the Leiden 85-plus Study. J Am Geriatr Soc 2003; 51:1466-1471.
52. Marchese R, Bove M, Abbruzzese G. Effect of cognitive and motor tasks on postural stability in Parkinson's disease: a posturographic study. Mov Disord 2003; 18:652-658. This study confirms earlier work by showing an increased instability when PD patients perform a secondary motor or cognitive task while standing. A new finding was that this dual task impairment is particularly prominent in patients with previous falls.
53. Hausdorff JM, Balash J, Giladi N. Effects of cognitive challenge on gait variability in patients with Parkinson's disease. J Geriatr Psychiatry Neurol 2003; 16:53-58.
54. Goldstein DS, Holmes CS, Dendi R, et al. Orthostatic hypotension from sympathetic denervation in Parkinson's disease. Neurology 2002; 58:1247-1255.
55. Bloem BR, Overeem S, van Dijk JG. Syncopal falls, drop attacks and their mimics. In: Bronstein AM, Brandt T, Nutt JG, Woollacott MH, editors. Clinical disorders of balance, posture and gait. London: Arnold; 2004. pp. 286-316. This chapter contains practical clinical 'tips and tricks' for recognizing and treating falls that are preceded by a loss of consciousness. Topics covered include syncopal falls sustained by patients with PD or multiple system atrophy.
56. Bloem BR, van Vugt JP, Beckley DJ. Postural instability and falls in Parkinson's disease. Adv Neurol 2001; 87:209-223.
57. Putzki N, Maschke M, Drepper J, et al. Effect of functional NMDA-antagonist flupirtine on automatic postural responses in Parkinson's disease. J Neurol 2002; 249:824-828.
58. Ondo WG, Hunter C. Flumazenil, a GABA antagonist, may improve features of Parkinson's disease. Mov Disord 2003; 18:683-685. Although flumazenil failed to improve balance, this trial is an example of much needed studies aimed to identify new treatment approaches to reduce falls in PD.
59. Bakker M, Esselink RA, Munneke M, et al. Effects of stereotactic neurosurgery on postural instability and gait in Parkinson's disease. Mov Disord 2004; DOI: 10.1002/mds.20116 [Epub ahead of print]. This meta-analysis shows that stereotactic neurosurgery - and particularly bilateral stimulation of the globus pallidus or subthalamic nucleus - can lead to significant improvements in clinical scores for balance, gait and posture.
60. Vitek JL, Bakay RA, Freeman A, et al. Randomized trial of pallidotomy versus medical therapy for Parkinson's disease. Ann Neurol 2003; 53:558-569. A randomized trial of unilateral pallidotomy versus optimal drug therapy, with a 2-year follow-up of clinical gait and balance scores.
61. Bastian AJ, Kelly VE, Perlmutter JS, Mink JW. Effects of pallidotomy and levodopa on walking and reaching movements in Parkinson's disease. Mov Disord 2003; 18:1008-1017.
62. Krack P, Batir A, Van Blercom N, et al. Five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinson's disease. N Engl J Med 2003; 349:1925-1934. This is the first long-term follow-up study of a large group of patients with bilateral stimulation of the STN. The effects on posture and gait were only studied using standard clinical assessments. The results showed a lasting improvement in 'OFF' state scores, but 'ON' state scores started to deteriorate after the first postoperative year.
63. Krystkowiak P, Blatt JL, Bourriez JL, et al. Effects of subthalamic nucleus stimulation and levodopa treatment on gait abnormalities in Parkinson disease. Arch Neurol 2003; 60:80-84.
64. Rocchi L, Chiari L, Cappello A, et al. Comparison between subthalamic nucleus and globus pallidus internus stimulation for postural performance in Parkinson's disease. Gait Posture 2004; 19:172-183. One of few studies that will eventually be able directly to compare the effects of different types of stereotactic neurosurgery (bilateral stimulation of the globus pallidus or STN). The present paper is a preliminary report of a subset of patients involved in a much larger comparative study.
65. Keus SHJ, Bloem BR, De Jonge P, et al. Physiotherapy in Parkinson's disease: referral rate, characteristics of treatment and patient's view. J Neurol 2004; in press.
66. de Goede CJT, Keus SHJ, Kwakkel G, Wagenaar RC. The effects of physical therapy in Parkinson's disease: a research synthesis. Arch Phys Med Rehabil 2001; 82:509-515.
67. Deane KH, Ellis-Hill C, Jones D, et al. Systematic review of paramedical therapies for Parkinson's disease. Mov Disord 2002; 17:984-991.
68. Rubinstein TC, Giladi N, Hausdorff JM. The power of cueing to circumvent dopamine deficits: a review of physical therapy treatment of gait disturbances in Parkinson's disease. Mov Disord 2002; 17:1148-1160.
69. ••].
70. Moreland J, Richardson J, Chan DH, et al. Evidence-based guidelines for the secondary prevention of falls in older adults. Gerontology 2003; 49:93-116.
71. ••].
72. •].
73. van Vaerenbergh J, Vranken R, Baro F. The influence of rotational exercises on freezing in Parkinson's disease. Funct Neurol 2003; 18:11-16. This open-label study was not without shortcomings, but the new treatment approach for FOG (placing patients on a rapidly spinning chair until they became nauseous) is provocative and warrants further study.
74. Cubo E, Moore CG, Leurgans S, Goetz CG. Wheeled and standard walkers in Parkinson's disease patients with gait freezing. Parkinsonism Relat Disord 2003; 10:9-14. A practical reminder for clinicians that walking aids can have adverse effects if the wrong model is prescribed or if the inappropriate patient is targeted.