Neurology: Fear of Falling and Freezing: Physical Therapy Is Key
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.
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
“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
Are Medical Therapies Effective for Freezing?
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.
“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.
Gradually Introduce Devices
Watch for Inappropriate Devices
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.
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.