How We Improve Balance for People with Parkinson's Disease
- Educate: There are typical changes to walking and balance when you have Parkinson’s disease. We will educate you on what you can expect and provide you with the strategies to improve your gait and balance.
- Involve: We will show how to engage all your senses to learn how to take bigger and fasters steps to improve your mobility. By retraining the appropriate components of your balance systems and using the strategies we teach you, your gait can be optimal for you.
- Empower: Knowledge empowers you. Understand your balance and the rationale for your individualized exercise prescription to start making changes today!
Gait abnormalities, postural instability, and bradykinesia can lead to falls and decreased quality of life for individuals with Parkinson’s disease (PD)1-4. Difficulty with ambulation is a clinical ‘‘red flag’’ that is an early indicator of emerging disability5.
- 68% of people with PD sustain at least 1 fall per year which is 2x more than the fall rate in healthy older adults.
- 50.5% of fallers with PD report recurrent falls (at least 2) over a 1-year period6-7.
Typical Gait Changes in People with Parkinson’s Disease
- Temporal Parameters
- Gait speed and symmetry are reduced by the impairments of longer double limb support time8-10 and poor interlimb timing (one leg moves faster than the other leg during swing phase of gait)
- Spatial parameters
- Decreased step and stride length
- Decreased foot clearance during swing
- Narrower base of support (BOS)12-15
- Decreased arm swing
- Decreased maximal hip extension in terminal stance16 reduces force generation by the gastrocnemius in pre-swing¹⁷ which negatively affects gait speed
- Gait variability
- Common in people with PD and is evident by variability in stride time, step length asymmetry, and interlimb coordination18-21.
- Closely associated with risk of falls in the elderly, particularly in step length and double-support phase22,23.
- Supported by a meta-analysis by Königa which determined 2.4% of stride time variability distinguishes healthy walking from pathological walking23-24.
- People with PD are unstable with 90° turns when asked to walk and turn faster than their preferred speed 11.
Typical Balance Changes
- Reactions are slower. If a foot catches or an individual is bumped, equilibrium strategies are slower.
- Anticipatory postural adjustments (APAs) that precede and stabilize balance are also hypometric (reduced amplitude) and bradykinetic (delayed onset timing)25. In preparation for stepping, people with PD have:
- Smaller than normal APAs with insufficient adjustments in the mediolateral direction
- Longer duration of unloading phase 26
- Inability to modify the amplitude of APAs when required with wider stance stepping 25-27.
- Sensory problems negatively impact motor function 28-32.
- Excessive reliance on vision for postural orientation and walking 30,33.
- Inability to rapidly change sensory weighting for different balance situations (e.g. switching sensory processing of information from vision to the vestibular when standing on moving or tilted surfaces in poorly lit areas 34. Re-weighting (the ability to rapidly choose the correct sensory input to determine balance reactions) and sensory processing are both critical for balance.
- Impaired proprioception results in additional problems with sensory orientation which is required for balance. Proprioception provides limb and body position information, which is basic information necessary for the kinesthetic body mapping and is essentials to executing accurate movement 31,35.
- Meta-analyses show that Physical Therapy is effective in decreasing fall risk and improving gait and balance 37-46,14.
- Several recent programs such as Parkinson’s disease Boot Camp 44 have focused on restoration with encouraging results. Therapists improved neuroplasticity using challenging tasks, attentional strategies, increased intensity of practice, and augmented feedback to enhance learning.
- Due to the progressive neural degeneration of PD, several researchers 37, 39 emphasize the need for long-term treatment programs in PD patients.
- The recent shift in rehabilitative training to focus on enhancing sensorial input is promising. Programs such as PD SAFEx™ (a sensory and attention focused rehabilitation program) and Blindfolded Balance Training in Patients with Parkinson's Disease emphasize sensory training and both report positive results in both motor deficits and balance control 47-48.
- Lyons KE, Pahwa R, Troster Al, Koller WC. A Comparison of Parkinson's Disease Symptoms and Self-reported Functioning and Well Being. Parkinsonism Relat Disorders. 1997;3:207-209.
- Scalzo Paula Luciana, Flores, Carolina Reis, Marques, Juliana Rúbia, Robini, Simone Cristina de Oliveira, & Teixeira, Antônio Lúcio. Impact of changes in balance and walking capacity on the quality of life in patients with Parkinson's disease. Arquivos de Neuro-Psiquiatria.2012;70(2), 119-124
- Schrag A, Jahanshahi M, Quinn N. How does Parkinson’s disease affect quality of life? A comparison with quality of life in the general population. Mov Disord. 2000;15(6):1112-1118.4.
- Ellis T., Cavanaugh J. T., Earhart G. M., Ford M. P., Foreman K. B., Dibble L. E. Which measures of physical function and motor impairment best predict quality of life in Parkinson's disease? Parkinsonism Relat. Disord.2011; 17, 693–697.
- Shulman L. Understanding Disability in Parkinson’s Disease. Movement Disorders Vol. 25, Suppl. 1, 2010, pp. S131–S135
- Campbell AJ, Robertson MC, Gardner MM. Elderly people who fall: Identifying and managing the causes. Br J Hosp Med. 1995;54(10):520-523
- Wood BH, Bilclough JA, Bowron A, Walker RW. Incidence and prediction of falls in Parkinson’s disease: a prospective multidisciplinary study. JNeurol Neurosurg Psychiatry. 2002;72(6):721-725).
- Ebersbach G., Heijmenberg M., Kindermann L., Trottenberg T., Wissel J., Poewe W. Interference of Rhythmic Constraint on Gait in Healthy Subjects and Patients With Early Parkinson's Disease: Evidence for Impaired Locomotor Pattern Generation in Early Parkinson's Disease. Mov Disord. 1999 Jul;14(4):619-25
- Sofuwa O, Nieuwboer A, Desloovere K, Willems AM, Chavret F, Jonkers I. Quantitative gait analysis in Parkinson’s disease: comparison with a healthy control group. Arch Phys Med Rehabil 2005;86:1007–1013
- Morris M. E., Iansek R., Matyas T. A., and Summers J. J., “The pathogenesis of gait hypokinesia in Parkinson’s disease,” Brain(1994) 117, 1169
- Mellone S., Mancini M., King L, Horak FB and Chiari L. The quality of turning in Parkinson’s disease: a compensatory strategy to prevent postural instability? Journal of NeuroEngineering and Rehabilitation 2016 13:39
- Morris ME, Huxham F, McGinley J, Dodd K, Iansek R. The biomechanics and motor control of gait in Parkinson disease. Clin Biomech. 2001; 16(6):459–470.
- Morris M. E., Huxham F. E., McGinley J., and Iansek R., “Gait disorders and gait rehabilitation in Parkinson’s disease,” Adv. Neurol. 87, 347 (2001).
- Morris, M, Martin, C., Schenkman M. Striding out with Parkinson Disease: Evidence-based physical therapy for gait disorders. Physical Therapy. 2010;90(2):280-288.
- Morris M. E., Iansek R., Matyas T. A., and Summers J. J., “Stride length regulation in Parkinson’s disease: Normalization strategies and underlying mechanisms,” Brain (1996), 119, 551-568
- Roiz, Roberta de Melo et al . Gait analysis comparing Parkinson's disease with healthy elderly subjects. Arq. Neuro-Psiquiatr., São Paulo 2010;68, n. 1, p. 81-86,
- Morris ME, McGinley J, Huxham F, et al: Constraints on the kinetic, kinematic, and spatiotemporal parameters of gait in Parkinson’s disease. Hum Mov Sci. 1999;18:461–483
- Blin O, Ferrandez AM, Serratrice G. Quantitative analysis of gait in Parkinson patients: increased variability of stride length. J Neurol Sci. 1990;98:91–97
- Hausdorff J. M., Cudkowicz M. E., Firtion R., Wei J. Y., and Goldberger A. L., Gait variability and basal ganglia disorders: stride-to-stride variations of gait cycle timing in Parkinson’s disease and Huntington’s disease. Mov Disord.1998; 13:428
- Schaafsma JD, Giladi N, Balash Y, Bartels AL, Gurevich T, Hausdorff JM. Gait dynamics in Parkinson’s disease: relationship to Parkinsonian features, falls and response to levodopa. J Neurol Sci .2003;212:47–53
- Baltadjieva R., Giladi N., Gruendlinger L., Peretz C., and Hausdorff J. M., “Marked alterations in the gait timing and rhythmicity of patients with de novo Parkinson’s disease,” European Journal of Neuroscience 2006;24:1815–1820
- Warlop T, Detrembleur C., PT, Bollens B., Temporal organization of stride duration variability as a marker of gait instability in parkinson’s disease J Rehabil Med 2016; 48: 865–871
- König N, Singh NB, Baumann CR, Taylor WR. Can Gait Signatures Provide Quantitative Measures for Aiding Clinical Decision-Making? A Systematic Meta-Analysis of Gait Variability Behavior in Patients with Parkinson’s Disease. Front. Human Neurosci. 2016;10:319.
- Callisaya ML., Leigh Blizzard, Michael D. Schmidt, Kara L. Martin, Jennifer L. McGinley, Lauren M. Sanders, and Velandai K. Srikanth. Gait, gait variability and the risk of multiple incident falls in older people: a population-based study. Age Ageing 2011;40 (4): 481-487
- Blouse S, Cassim F, Blatt JL, et al. Anticipatory postural adjustments associated with arm movement in Parkinson's disease: a biomechanical analysis. J. Neurol. Neurosurg. Psychiatry.2008;79(8), 881-887.
- Banora G, Mancini M, Carpinella I, Chiari L, Horak FB, Ferrarin M. Gait initiation is impaired in subjects with Parkinson's disease in the OFF state: Evidence from the analysis of the anticipatory postural adjustments through wearable inertial sensors. Gait Posture. 2017;51:218-221.
- Lin CC, Creath RA, Rogers MW. Variability of Anticipatory Postural Adjustments During Gait Initiation in Individuals With Parkinson Disease. J Neurol Phys Ther. 2016 Jan;40(1):40-6.
- Huh YE, Hwang S, Kim K, Chung WH, Youn J5, Cho JW. Postural sensory correlates of freezing of gait in Parkinson's disease. Parkinsonism Relat Disord. 2016 Apr;25:72-7
- Pereira MP, Gobbi LT, Almeida QJ. Freezing of gait in Parkinson's disease: Evidence of sensory rather than attentional mechanisms through muscle vibration. Parkinsonism Relat Disord. 2016 Aug;29:78-82
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- Pilgram LM, Gammon M. Earhart, and Kristen A. Pickett. Impact of limiting visual input on gait: Individuals with Parkinson disease, age-matched controls, and healthy young participants. Somatosen. Motor Res.2016; 33(1).
- Schoneburg B, Mancini M, Horak F, Nutt JG. Framework for Understanding Balance Dysfunction in Parkinson’s Disease. Movement disorders : official journal of the Movement Disorder Society. 2013;28(11):1474-1482.
- Carpentera M.G., Bloem B.R. Postural control in Parkinson patients: A proprioceptive problem? Experimental Neurology Volume 227, Issue 1, January 2011;26–30
- Bloem BR, Beckley DJ, van Dijk JG, Zwinderman AH, Remler MP,Roos RA. Inﬂuence of dopaminergic medication on automatic postural responses and balance impairment in Parkinson’s disease. Mov Disord.1996;11(5):509-521
- Kwakkel, G. et al. Impact of physical therapy for Parkinson's disease: A critical review of the literature. Parkinsonism Relat Disord. 2007;13 Suppl 3:S478-8
- Goodwin, V. A., Richards, S. H., Taylor, R. S., Taylor, A. H. and Campbell, J. L. The effectiveness of exercise interventions for people with Parkinson's disease: A systematic review and meta-analysis. Mov. Disord.2008;23:631–640.
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- Tomlinson CL, Patel S, Meek C, et al. Physiotherapy intervention in Parkinson’s disease: systematic review and meta-analysis . The BMJ. 2012;345:e5004.
- Shen Xia., Wong-Yu Irene S. K., Mak Margaret K. Y. Effects of exercise on falls, balance, and gait ability in Parkinson’s disease. Neurorehab. Neural Repair 2016;30(6):512 – 527
- Yitayeh A, Teshome A. The effectiveness of physiotherapy treatment on balance dysfunction and postural instability in persons with Parkinson’s disease: a systematic review and meta-analysis. BMC Sports Sci., Med. Rehab. 2016;8:17.
- Klamroth S1, Steib S, Devan S, Pfeifer K. Effects of Exercise Therapy on Postural Instability in Parkinson Disease: A Meta-analysis. J Neurol Phys Ther. 2016 Jan;40(1):3-14
- King LA, Horak FB. Delaying Mobility Disability in People With Parkinson Disease Using a Sensorimotor Agility Exercise Program. Phys. Ther. 2009;89(4):384-393.
- Dibble LE, Addison O, Papa E: The effects of exercise on balance in persons with Parkinson's disease: a systematic review across the disability spectrum. JNPT.2009; 33(1), 14-26
- Sparrow D., DeAngelis TR., Hendron K, Ellis T. Highly Challenging Balance Program Reduces Fall Rate in Parkinson Disease. Journal of neurologic physical therapy: JNPT 40(1):24-30 · January 2016
- Lefaivre SC., Q. J. Almeida, “Can sensory attention focused exercise facilitate the utilization of proprioception for improved balance control in PD?” Gait & Post.; 41(2):630–633, 2015.
- M. Tramontano, S. Bonnì, A. Martino Cinnera, et al., “Blindfolded Balance Training in Patients with Parkinson’s Disease: A Sensory-Motor Strategy to Improve the Gait,” Parkinson’s Disease, 2016, Article ID 7536862, 6 pages, 2016
Reduce the Risk of Falling
- Improve the safety of your home and environment (see resources).
- Have your vision and medications checked.
- Have your balance and gait assessed by a specialized balance expert.
- Educate yourself on balance (link to How you balance handout) and how it affects everyday activities.
- Learn tips to overcome freezing.
- Exercise! Stay active! Understand which specific exercises are best for you!
Step and Connect wants to be a resource for medical professionals and clients offering the most updated education, appropriate programs in your community, and balance specialists that can optimally decrease fall risk and improve people’s balance. We developed Balance Matters™ as an additional tool to help clinicians and clients to improve their balance programs in the clinic or home.
Balance Matters™ was designed to offer a wide variety of training options. It allows specific sensory training of one or more impaired systems, encourages anticipatory postural adjustments, improves gait mechanics, improves spatial and temporal parameters, enhances kinesthetic awareness, varies equilibrium retraining, and offers cognitive reconditioning. It is easy to set up in the clinic and or home environment. Clients can obtain their Balance Matters™ system to replicate the multisensory, real-time feedback that skilled health care professionals provide in the clinic. This will facilitate progress achieved while actively receiving therapy and also preserve progress after therapy has been completed.
Balance, gait and freezing worksheet
Davis Phinney Foundation
Parkinson’s Association of the Rockies
Michael J. Fox Foundation for Parkinson's Research
American Parkinson’s Association
National Parkinson’s Association
Parkinson's Creative Collective