Parkinson’s and Falling [Avoid falling and injuries!]

Parkinson’s and falling, unfortunately, go hand in hand.

Most patients with Parkinson’s disease have some imbalance. In uncomplicated Parkinson’s disease, falls are less common.

But:

  • If you have recurrent falls or
  • If you are falling backwards, Parkinson’s disease may not be the right diagnosis.

If you do have Parkinson’s disease, adequate treatment helps you move properly. This prevents falls.

In addition, a few general measures may also help to prevent falls and avoid serious injuries.

Let us learn more.

How do we maintain our balance?

When the joints in your legs move, the nerves in your legs send signals to the spinal cord, from where they go to the Brain.

If this system is working, then the Brain knows *exactly* where your legs are, even when your eyes are closed!

This ability is called “Joint Position Sense”.

“Joint position” signals going from the ankle joints to the brain are very important for balance.
There are many nerves in the arms and legs (blue). These send joint position signals to the spinal cord (red), which in turn sends them to the brain (pink). A problem anywhere in this pathway can cause problems in maintaining balance.

A second device is important as well:

Our inner ears contain tiny circular canals filled with fluid.

When your head moves, the liquid inside these canals moves, and the ears immediately send signals to the brain, informing it of this movement.

The internal ear has delicate canals filled with fluid which detect head movement.

Finally, your eyes.

This one is obvious.

When you tend to fall, you can see that you are falling.

The eyes almost instantaneously send this information to the Brain, so that corrective action can be taken.

Our eyes send signals to our brain almost instantaneously.

The Brain is supposed to act immediately when it gets signals from any of these organs (joints/ears/eyes) that you are going to fall down.

These reflex movements are called “Postural reflexes”.

With this understanding, let us see now why we fall.

Why do patients with Parkinson’s disease fall?

In simple terms, patients with Parkinson’s disease fall down because of 3 reasons: Poor input, Poor postural reflexes, Freezing.

1. Poor input:

This problem is often overlooked.

When thinking about Parkinson’s and falling, we need to remember that Parkinson’s patients can also have other diseases.

Let us say you have a problem with your eyes. Everything is blurred.

Now, you start to walk.

But…. your brain is not getting any input. It does not know where your limbs are! So, you become unsteady!

Proper eyeglasses enable you to see clearly and reduce falls.

So:

  • Problems in your joints, muscles or leg nerves – e.g. Diabetes, Vitamin D deficiency
  • Problems in your spinal cord – e.g. compression, vitamin B12 deficiency
  • Problems in your ears – e.g. infections
  • Problems in your eyes – e.g. improper glasses, cataracts

Increase the risk of falling tremendously. This is true even if you do not have Parkinson’s disease!

But let us look at 2 reasons specific to Parkinson’s disease:

2. Poor postural reflexes:

Let us say your brain is getting all the inputs it needs.

It now knows where your limbs are.

But in Parkinson’s disease, the brain becomes slow. For unclear reasons, it does not respond to these inputs immediately.

This problem is called “Poor Postural Reflexes”.

Poor postural reflexes: The brain is slow in processing inputs and outputs needed for balancing.
Poor postural reflexes: The brain is slow in processing inputs and outputs needed for balancing.

Let’s imagine you catch your foot in the carpet.

When you start to fall, your brain is too slow to take corrective measures. It does nothing. So you fall.

This is one of the reasons for Parkinson’s and falling.

3. Freezing:

When walking, you may sometimes feel like you are stuck to the ground.

This is called “Freezing”.

If this happens suddenly, your upper body may continue moving and you may fall forwards.

If your movement problems are incompletely treated, you can “Freeze” suddenly while walking and fall forwards.
Is freezing really the reason for falling?
Some people believe that “freezing” while walking can lead to falls. In contrast, other people believe that the freezing before falling is an erroneous reflex by the Brain, which is just trying to prevent a process of falling which has already started happening. Regardless of what comes first, it is clear that making movements more rapid with proper treatment helps to prevent falls.

So, how can you prevent falls?

The first step is to identify why you are falling.

The relative contribution of these factors to falling is different in different patients.

Thoughtful collaboration with your neurologist should help to identify your most critical problems. We will look at each of these things in detail, one by one.

If you have Parkinson’s and falling backwards, a very important possibility arises. Your doctor should carefully examine you for signs of PSP.

PSP is described in another article [Click here].

 

Careful examination & collaboration usually identifies 1-3 critical problems causing falls.

 

Prevent a drop in Blood Pressure on standing

When you get up suddenly from a chair or bed, your blood rushes into your legs.

This causes blood pressure to drop. You may become light-headed & fall.

This is called Orthostatic Hypotension. It is very common in Parkinson’s disease.

You can read more in another article, but here is a quick summary:

Prevent Orthostatic Hypotension
1. Avoid medications that may worsen this problem.

2. Drink enough water

3. If your doctor agrees, slightly increase salt in your diet

4. Stand up gradually

5. Exercise & develop better muscle tone

6. Ask your doctor for medications.

Adequate sensory input

A neurological examination can test the input organs (nerves, spinal cord, ear, eyes).

For example, your may ask you to close your eyes and move your big toe up and down. If you are unable to tell whether it is up or down, it indicates there is something wrong with your “joint position sense”.

Your neurologist may ask you do some tests:

 

Tests to check sensory organs (input)
1. Nerve conduction studies

2. MRI of the spine

3. Blood tests – Vitamin B12, Folic acid, E & Copper, Syphilis & HIV

4. Ear examination

5. Eye examination

Adequate treatment of Freezing

You can fall down if you have sudden “freezing” while walking. You can also fall if your body’s corrective movements occur too late or too slowly to prevent a fall.

Therefore, adequate treatment of your movements so that slowness (bradykinesia) and freezing while walking are treated is absolutely essential in preventing falls.

Medications used to treat movement problems are described in a different set of articles. It is important to select these judiciously. In most cases, the best medication happens to be levodopa.

Once it enters the Brain, Levodopa is converted into Dopamine.

Training your Brain

YES! This can be done.

Think about the time when you learnt to ride a bike. As you kept practising, it became automatic.

In the same way, balance training can prevent falls.

Multiple studies have proven this. You can take my word for it. You could also read these 2 studies, to extinguish any residual excuses!

Any exercise is better than no exercise.

However, exercise methods that focus on balance, e.g. Yoga or Tai Chi can be more helpful to improve your balance (Hackney 2008 and Roland 2013).

I believe these traditional methods help in instability.

Their low-impact nature and emphasis on balance is especially interesting.

Yoga and Tai Chi can improve your balance & prevent falls.

What changes should I make to my home?

Remove all loose-fitting rugs or unstable pieces of furniture that you can trip over.

Excessive clutter or furniture can cause Freezing. So, make sure your home is as tidy and clutter-free as possible.

Patients frequently fall in the bathroom. Take the measures below to avoid falls.

This living room looks nice. But removing the rug, and the low tables in the centre would help to prevent freezing and falls.

 

Make these changes to your home
1. Remove rugs.

2. Reduce furniture & clutter.

3. Avoid using the bathtub.

4. Use anti-skid rugs in the bathroom.

5. Sit down while taking a bath.

6. Install support rods to help you get up.

Make sure any support rods you install are firmly attached and rounded.
If possible, install support rods to help you to get up from your commode and after taking a bath.

How can I prevent injuries after falling?

Make sure your furniture is not sharp. You can buy foam padding for corners online.

Even more importantly make sure that your bones are adequately dense so that they do not break if you fall. This can be done by measuring the bone density using a test called a DEXA scan.

A DEXA scan measures bone density. If your bones are not adequately dense, they can break easily.

The medical term for less dense bones is “Osteoporosis”. Bones can be made denser and stronger by giving you medications.


Caution:
This information is for educational purposes. It is not a substitute for professional medical diagnosis & treatment. Do not change your medications, supplements or other treatments without your doctor's permission.

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Dr. Siddharth Kharkar

Dr. Siddharth Kharkar is a board certified (American Board of Psychiatry & Neurology certified) Neurologist. He is a Epilepsy specialist & Parkinson's specialist in Mumbai, Maharashtra, India.

He has trained in the best institutions in India, US and UK including KEM hospital in Mumbai, Johns Hopkins University in Baltimore, University of California at San Francisco (UCSF), USA & Kings College in London.

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