November/December 2022

Neurology: Fear of Falling and Freezing: Physical Therapy Is Key
By Michele Deppe
Today’s Geriatric Medicine
Vol. 15 No. 6 P. 6

People with Parkinson’s disease who experience symptoms that affect their safety and independence can benefit from physical therapy.

Parkinson’s disease (PD) is the second most common neurodegenerative disorder in the United States, following Alzheimer’s disease.1 Most of the 500,000 diagnosed with PD are 60 years of age or older. As the population ages, the number of patients is expected to double by 2040.1

“Parkinson’s is a degenerative disease that compounds the typical effects of aging,” says Jason Longhurst, PhD, PT, DPT, NCS, an assistant professor of physical therapy and athletic training at Saint Louis University in St. Louis. “Older individuals with PD often have less functional reserve and experience more impact from the disease.”

PD is characterized by dopamine loss, Longhurst explains, particularly in the basal ganglia and midbrain. “This results in the characteristic signs and symptoms of Parkinson’s disease,” he says, “including tremor, rigidity, bradykinesia, and postural instability. Additionally, Parkinson’s disease results in nonmotor symptoms; these include bowel and bladder changes, cognitive changes, and mood changes.”

According to a study authored by Longhurst and four colleagues, falling and the fear of falling (FOF) are a great concern of PD patients, with around 60% of people reporting at least one fall each year and 39% reporting multiple falls annually.2 The research revealed that FOF might develop even when a person hasn’t had a fall and that it seems to precipitate falls and negatively influences an individual’s quality of life.2 Because of the anxiety and FOF, a person with PD may begin to avoid activities and movement as much as possible.2

“Fear of falling and its related avoidance behavior occur across all stages of the disease but become somewhat more prominent as physical abilities decline in the later stages of PD,” Longhurst says. The study states that up to 75% of adults with PD aged 65 and over avoid at least one daily activity because they’re afraid they’ll fall.2 Patients often have FOF before physical abilities decline sufficiently to compromise safety, Longhurst says. He adds that intervention is of vital importance to help PD patients prevent the consequences that come with FOF and avoidance of activities.

Avoidance Activity
According to Longhurst, research has found that in individuals with PD, FOF and decreased balance confidence frequently lead to avoidance behavior, which causes people to withdraw from activity, and, over time, leads to a loss of physical conditioning. Poorer physical conditioning then results in less balance control, which Longhurst says contributes to less balance confidence or more FOF, thus creating a vicious cycle. “This can speed functional decline and disease progression in Parkinson’s disease,” he says. “However, in understanding this cycle, we believe there is hope through behavioral change interventions (to address the fear of falling and avoidance behavior) and physical exercise incorporating both aerobic (to address deconditioning) and balance training (to address decreases in balance control).”

In a study published in 2022 coauthored by Longhurst, 174 individuals replied to a questionnaire to determine which activities people with PD most frequently avoided. The results showed that walking in dimly lit, unfamiliar places and over different surfaces caused FOF. Other activities included lifting and carrying objects, walking in crowded places, and using the stairs.3

When observing patients, it may not be clear whether a patient is afraid of falling or simply doesn’t have the physical fitness needed to move in the desired way. “Clinicians should consider the overall profile of avoidance activity as it relates to physical abilities,” Longhurst says. Individuals with high physical abilities, he adds, may be avoiding more complex or risky activities, such as stair climbing, whereas, for those with lower physical abilities, it may be appropriate to avoid those more complex activities. “Ultimately, clinicians should try to judge whether the chosen activities match an individual’s physical abilities. Note situations where individuals are overavoiding activities that they can safely perform. Likewise, a person may not avoid an inappropriate activity, according to their diminished physical abilities, which risks injury.”

Freezing of Gait
The number of people who experience freezing of gait with PD varies widely, from 14% to roughly 55%, according to a review, and it isn’t clear why some people with PD experience freezing of gait and others don’t.4

“Freezing of gait is a common symptom of PD and can occur in some other neurological diseases,” Longhurst says. “It occurs when an individual is unable to step despite the intention to step. Another way of thinking about this is that freezing is a dramatic manifestation of the loss of automatic control of gait, which is typical of PD.” Freezing is often described as feeling as if your feet are glued to the floor, Longhurst says, and that it is “often a very frustrating symptom of PD as it is transient and unpredictable.”

In people with PD, their loss of automatic control (movements people make without conscious thought) is compensated for by attentional control. PD negatively affects attention and working memory and increases sensitivity to the effort of moving the body.5 “But in freezing of gait, the person’s attentional control is insufficient to adequately compensate for the loss of automatic control,” Longhurst says. “This results in freezing episodes, typically in scenarios that have higher attentional demands.”

Stress Contributes to Freezing
Acute stress worsens motor symptoms, leading to more severe and frequent freezing; it also contributes to nonmotor symptoms, particularly anxiety and depression in people with PD.6 “A leading theory regarding this relationship is that anxiety diverts a portion of attentional capacity away from gait and postural control, thus reducing the available capacity for processing gait and postural control,” Longhurst says. “While interacting with a health care professional can be stressful for some individuals with PD, typically there is also a higher attentional focus of gait when they know their movement is being observed by a health care provider. In my experience, this may offset the effect of anxiety.” Ideally, he says, health care providers get the opportunity to observe a freezing episode; this can provide them with information that can help them better treat the individual’s freezing of gait.”

Are Medical Therapies Effective for Freezing?
“Unfortunately, there is very little evidence to support the use of any drugs for managing freezing of gait in patients with Parkinson’s disease,” Longhurst says. “There is also poor evidence to support the utility of deep brain stimulation and other medical therapies.”

Evidence points to physical therapy as the most effective nonpharmacological aid to PD patients. “Physical therapists typically provide this kind of care using cueing techniques that are effective for improving the person’s mobility,” Longhurst says. “These and other strategies are optimized as therapy continues and freezing occurrences are reduced. The patient may be able to wean away from these strategies over time.”

— Michele Deppe is a freelance writer based in South Carolina.

Tips for Helping Patients With Parkinson’s Disease

Physical therapist Melanie Lomaglio PT, DPT, MSc, is a board-certified neurologic specialist who provides care for people with Parkinson’s disease (PD) at STARS Rehab in St. Augustine, Florida. She brings more than 20 years of experience to her work and offers tips about how to help people with PD.

Specialized Therapy
Lomaglio says no two people are alike; all people with PD have their own individual freezing of gait (FOG) triggers, making it difficult, she says, to provide blanket suggestions. What works for one person may not work for the next, so she recommends consultation with a specialized therapist who has an arsenal of strategies to help the patient overcome freezing.

Slowing Down
We tend to think of people with PD as slow moving, but often people with FOG have anxiety and tend to rush their movement. This rushing—for example when the doorbell rings—can trigger freezing.

“Teaching people to take slow and mindful steps will actually help them reach their destination quicker and with less freezing,” Lomaglio says. An easy trick to get someone moving forward is to have them sing“Row, Row, Row Your Boat,” or count their steps out loud, Lomaglio says. She recommends the use of a metronome (available as a phone app) set at 80 steps per minute to help slow a person’s cadence and reduce freezing.

Penguin Turns
Help patients turn by encouraging a wide base of support, with their feet apart, and then have them begin the turn by rocking side to side. “Weight shifting is so important for initiating a step,” Lomaglio says, explaining that people with PD lose the ability to perform automatic weight shifts, and this leads to FOG. Waddling side to side, like a penguin, prevents FOG during tight turns, she says, like when turning to sit on the toilet.

Gradually Introduce Devices
Most people are resistant to using assistive devices as they see this as a sign of disease progression, so Lomaglio recommends a gradual introduction, such as using the device only at night for trips to the bathroom or only during medication “off time” when levodopa levels are low.

Watch for Inappropriate Devices
A common problem is that patients are given inappropriate assistive devices. “For example,” Lomaglio says, “some devices, like pick-up walkers, can trigger freezing. Others, such as four-wheeled rollators, can trigger gait festination (slow steps that hasten quickly into an uncontrolled half run).” It’s also important that the devices be appropriate, she says, because “Medicare won’t pay for another device for five years.”

One of her favorite devices for people with severe gait problems is the U-step walker with a laser light cue, a device specifically designed for FOG. For people who have mild gait problems, stability poles are helpful as they cue upright posture, allowing for a bigger step.

References
1. Parkinson’s disease: challenges, progress, and promise. National Institute of Neurological Disorders and Stroke website. https://www.ninds.nih.gov/health-information/patient-caregiver-education/hope-through-research/parkinsons-disease/parkinsons-disease-challenges-progress-and-promise. Updated July 25, 2022. Accessed July 26, 2022.

2. Rider JV, Longhurst JK, Lekhak N, Young DL, Landers MR. Fear of falling avoidance behavior assessment and intervention in Parkinson’s disease: a scoping review. Research and Reviews in Parkinsonism. 2022;12:1-17.

3. Rider JV, Longhurst JK, Navalta JW, Young DL, Landers MR. Fear of falling avoidance behavior in Parkinson’s disease: most frequently avoided activities [published online June 30, 2022]. OTJR. doi: 10.1177/15394492221106103.

4. Ge HL, Chen XY, Lin YX, et al. The prevalence of freezing of gait in Parkinson’s disease and in patients with different disease durations and severities. Chin Neurosurg J. 2020;6:17.

5. Cognitive changes: cognitive symptoms in Parkinson’s disease are common, though not every person experiences them. American Parkinson Disease Association website. https://www.apdaparkinson.org/what-is-parkinsons/symptoms/cognitive-changes/. Accessed July 26, 2022.

6. Common symptoms of Parkinson’s disease. American Parkinson Disease Association website. https://www.apdaparkinson.org/what-is-parkinsons/symptoms/. Accessed July 26, 2022.