Winter 2003-2004

Fall Prevention in Parkinson's Disease

Falls are a frequent and hazardous complication of Parkinson's disease. Patient studies indicate that the percentage of PWPs who experience falls can run as high as 68 percent. Parkinson's patients are at an increased risk of falling because of the symptoms of Parkinson's disease - muscular stiffness, freezing, shuffling gait, balance impairment or stooped posture - and in rare cases as a result of the side effects of antiparkinson medications.

Even a minor fall can result in bruises, cuts or sprains. More serious falls can cause severe injuries such as broken bones or concussions. Furthermore, a fear of falling can also affect a PWP psychologically, resulting in a reluctance to leave the home. Fall prevention is therefore a paramount consideration in the management of Parkinson's disease, and especially so in the colder months when slippery driveways and pavements call for extra precautions. Here we outline a number of suggestions to help prevent falls.

Tell your doctor.

If you experience a fall, inform your doctor so that your medication schedule can be evaluated and adjusted to better control rigidity and slowness. When this problem is still mild, modest adjustments in medication can go a long way to prevent falling. You may need to be patient while your doctor fine-tunes the combinations, dosages and timing of drugs to ensure the best "on" time and the least-limiting "off" time.

Making Adjustments at Home

Studies have shown that PD patients are more prone to falling inside the home than outside it. Potential danger spots include tight spaces such as areas where turning or backing-up is required (e.g. in the kitchen), in doorways and on stairs. The good news about this is that there are many things that can be done in the home to help prevent falls. Here's a list of ideas.

• Use carefully-positioned and sturdy furniture such as a couch-back to provide a hand-rail to help prevent a PWP from becoming unbalanced when walking from room to room.
• Remove lightweight decorative chairs that may topple easily and any tables or furniture with glass tops.
• Loose rugs should be secured and smooth or preferably removed altogether (and never use wax on floors)
• Long hallways can be fitted with an extra handrail along one wall.
• Bathrooms can be installed with grab bars and non-skid adhesive strips in the bath or shower as well as outside the rub or shower stall.
• Safety on stairs can be improved by checking that treads are secure and fitting a handrail on both sides.
• Consider marking the first and last steps with non-slip white paint (avoid tape) to highlight where the stairs begin and end.
• Swinging doors between rooms should be replaced with regular hinge doors or eliminated altogether.
• Good lighting is important. Make sure that halls, stairways and entrances are well lit. Use night lights in your bathroom and hallway to prevent bumps and accidents if you have to get up during the night.

Occupational therapists are available for a "Home Safety Assessment" and can suggest additional ways to adapt your home to help prevent falls.

Carefully Control Movement to Help Maintain Balance

Take care when rising from a bed or chair. Once you are upright, stop, take a breath and allow yourself to be aware of your body and posture. Wait until your body is upright and balanced and only then take a step and begin walking. If you have been sitting or lying flat for any length of time, be sure to stretch before you get up, twisting or bending from the waist to improve blood flow and stretch your muscles.

A stooped posture can increase the risk of falling. Exercises to straighten the spine and keep the body upright can help to maintain the center of gravity and minimize falls. Regular exercise (minimum of 3 times a week - preferably daily) can also help to keep your muscles limber so they are better able to make postural corrections to remain upright - or if falls do occur, to get yourself up off the floor with little or no assistance.

Physical therapy can be invaluable in improving mobility and fall prevention.

Walking aids

There are many types and brands of walking aids, each of which comes with a gamut of accessories. Walking sticks of the types used by trail walkers are useful for PWPs with a stooped posture because they are deliberately designed to be taller than the person using them. Being able to grab the stick at a higher level to maintain an upright posture has an advantage over the bent posture more commonly experienced when using a regular cane. Walking sticks can also be far more decorative and sporty than the traditional grey cane, offering a jaunty accessory to the daily walk. Prices vary according to quality, decoration and finish, and can be purchased from most good outdoor sporting goods stores.

If balance is especially difficult in the morning (before taking the first dose of antiparkinson medication), it is a good idea to keep a standard cane by the bedside to assist with moving safely to the bathroom or kitchen and beginning the day. If greater stability is needed, a tripod may be of help.

Use of a cane in crowded areas, such as the grocery store, shopping mall, airport or busy park, should be encouraged. Besides helping with your balance, it is a visual cue to other people, who will be less likely to bump or knock you.

If falling becomes more frequent, a walker may be necessary. Before purchasing a walker, the patient should be evaluated by a physical therapist to determine the type of walker that is best suited to the patient's abilities. Be aware that the breaking systems on walkers can be very sensitive. Users should receive proper advance training on how to use them.

Difficulties with Gait

Two especially troublesome gait symptoms that increase the risk of falling are freezing and retropulsion. When a PWP experiences freezing, the feet are temporarily stuck to the floor, unable to move. If the upper body is moving forward and the feet are stuck, the result is a forward fall (propulsion). Freezing is especially likely to occur when starting to walk after a period of sitting, on turns, at doorways, and as the PWP approaches a target, such as a chair. Strategies to help a PWP 'un-freeze' include cueing tricks to lift a foot, such as imaging a line which must be stepped over, physical therapy to improve mobility, gait training, and an increase in the dose of anti-parkinsonian medication.

Retropulsion is the tendency to topple backwards, which results in a backward fall. The problem can occur without warning, when a PWP is standing still in the middle of an open space. Many patients with this problem seem unaware of the fact that they lean or rock backwards when they stand. It can also happen on turning, or when a patient attempts to get up from a seated position. Retropulsion cannot be helped using medication. The best strategy is physical therapy to increase awareness of stance, and to improve posture and gait. Heels lifts may help to prop a person forward slightly, to compensate for a tendency to retropulse. Walkers do not prevent a backward fall, but may reduce the opportunity for retropulsion by requiring a forward leaning position.

Healthy Eating

Be sure that your diet contains ample quantities of calcium and that you are getting enough vitamin D to keep your bones strong and thereby reduce the risk of fracture. Milk, cheese and yogurt are good sources of calcium but you should try to choose lower-fat versions where possible. Be careful to monitor your protein intake as too much protein can, for some PWPs, interact with Sinemet. Vitamin D can only be found in foods such as oily fish, e.g. sardines and tuna, and in meat. To be sure you are getting enough of these and other vitamins, consider complementing your regular diet with a vitamin supplement.

Stay safe, be careful and keep independent!