Gait disorders and balance disturbances in Parkinson’s disease. Clinical update and pathophysiology

Department of Neurology, Donders Center for Neuroscience, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
Current Opinion in Neurology (Impact Factor: 5.31). 09/2008; 21(4):461-71. DOI: 10.1097/WCO.0b013e328305bdaf
Source: PubMed

ABSTRACT Gait disorders and balance impairments are one of the most incapacitating symptoms of Parkinson's disease. Here, we discuss the latest findings regarding epidemiology, assessment, pathophysiology and treatment of gait and balance impairments in Parkinson's disease.
Recent studies have confirmed the high rate and high risk of falls of patients with Parkinson's disease. Therefore, it is crucial to detect patients who are at risk of falling and how to prevent falls. Several studies have shown that multiple balance tests improve the prediction of falls in Parkinson's disease. Difficulty turning may be caused by axial rigidity, affected interlimb coordination and asymmetries. Turning difficulties are easily assessed by timed performance and the number of steps during a turn. Impaired sensorimotor integration, inability of switching between sensory modalities and lack of compensatory stepping may all contribute to the high incidence of falls in patients with Parkinson's disease. Similarly, various studies highlighted that pharmacotherapy, neurosurgery and physiotherapy may adversely affect balance and gait in Parkinson's disease.
Insights into the pathophysiology of Parkinson's disease continue to grow. At the same time, it is becoming clear that some patients may in fact deteriorate with treatment. Future research should focus on the development and evaluation of multifactorial fall prevention strategies.

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Available from: Tjitske Boonstra, Mar 25, 2015
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    • "Fall frequency in the past three months was determined retrospectively and patients were assigned one of three fall status categories: (1) no falls or near falls, (2) no falls but at least one near fall, and (3) one fall or more in the last 3 months. A fall was defined as an event resulting in a person coming to rest unintentionally on the ground or other level and not as the result of a major intrinsic event or overwhelming hazard [13, 14]. A near fall was defined as any loss of balance without hitting the floor or other lower surface (fall arrested by seeking support) [15]. "
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    ABSTRACT: This exploratory study aimed to identify which aspects of postural control are able to distinguish between subgroups of patients with Parkinson's disease (PD) and controls. Balance was tested using static and dynamic posturography. Freezers (n = 9), nonfreezers (n = 10), and controls (n = 10) stood on a movable force platform and performed 3 randomly assigned tests: (1) sensory organization test (SOT) to evaluate the effective use of sensory information, (2) motor control test (MCT) to assess automatic postural reactions in response to platform perturbations, and (3) rhythmic weight shift test (RWS) to evaluate the ability to voluntarily move the center of gravity (COG) mediolaterally and anterior-posteriorly (AP). The respective outcome measures were equilibrium and postural strategy scores, response strength and amplitude of weight shift. Patients were in the "on" phase of the medication cycle. In general, freezers performed similarly on SOT and MCT compared to nonfreezers. Freezers showed an intact postural strategy during sensory manipulations and an appropriate response to external perturbations. However, during voluntary weight shifting, freezers showed poorer directional control compared to nonfreezers and controls. This suggests that freezers have adequate automatic postural control and sensory integration abilities in quiet stance, but show specific directional control deficits when weight shifting is voluntary.
    Parkinson's Disease 06/2013; 2013:971480. DOI:10.1155/2013/971480 · 2.01 Impact Factor
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    • "Of all neurological diseases, PD patients are at the highest risk of falling [22-24], but the pathophysiology of balance impairments in PD remains unclear [25,26]. Recently, it was suggested that one of the factors contributing to decreased balance control in PD patients, is impaired trunk control [27,28] or a decreased intersegmental coordination [29,30]. "
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    ABSTRACT: Background Human stance involves multiple segments, including the legs and trunk, and requires coordinated actions of both. A novel method was developed that reliably estimates the contribution of the left and right leg (i.e., the ankle and hip joints) to the balance control of individual subjects. Methods The method was evaluated using simulations of a double-inverted pendulum model and the applicability was demonstrated with an experiment with seven healthy and one Parkinsonian participant. Model simulations indicated that two perturbations are required to reliably estimate the dynamics of a double-inverted pendulum balance control system. In the experiment, two multisine perturbation signals were applied simultaneously. The balance control system dynamic behaviour of the participants was estimated by Frequency Response Functions (FRFs), which relate ankle and hip joint angles to joint torques, using a multivariate closed-loop system identification technique. Results In the model simulations, the FRFs were reliably estimated, also in the presence of realistic levels of noise. In the experiment, the participants responded consistently to the perturbations, indicated by low noise-to-signal ratios of the ankle angle (0.24), hip angle (0.28), ankle torque (0.07), and hip torque (0.33). The developed method could detect that the Parkinson patient controlled his balance asymmetrically, that is, the right ankle and hip joints produced more corrective torque. Conclusion The method allows for a reliable estimate of the multisegmental feedback mechanism that stabilizes stance, of individual participants and of separate legs.
    Journal of NeuroEngineering and Rehabilitation 02/2013; 10(1):23. DOI:10.1186/1743-0003-10-23 · 2.74 Impact Factor
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    • "Parkinson's disease has a progressive effect on postural control, resulting in loss of postural stability [1], especially during gait [2], which limits the performance of activities of daily living and reduces the level of independence [3]. Of the motor symptoms, postural instability responds less to medication and surgical treatment [4], but several studies have shown that physical therapy can improve the balance of patients with Parkinson's disease through exercise therapy , composed by balance and strengthening exercises [5], external cues [6] and virtual reality [7]. "
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    ABSTRACT: To investigate the effect of Nintendo Wii™-based motor cognitive training versus balance exercise therapy on activities of daily living in patients with Parkinson's disease. Parallel, prospective, single-blind, randomised clinical trial. Brazilian Parkinson Association. Thirty-two patients with Parkinson's disease (Hoehn and Yahr stages 1 and 2). Fourteen training sessions consisting of 30 minutes of stretching, strengthening and axial mobility exercises, plus 30 minutes of balance training. The control group performed balance exercises without feedback or cognitive stimulation, and the experimental group performed 10 Wii Fit™ games. Section II of the Unified Parkinson's Disease Rating Scale (UPDRS-II). RANDOMISATION: Participants were randomised into a control group (n=16) and an experimental group (n=16) through blinded drawing of names. Repeated-measures analysis of variance (RM-ANOVA). Both groups showed improvement in the UPDRS-II with assessment effect (RM-ANOVA P<0.001, observed power=0.999). There was no difference between the control group and the experimental group before training {8.9 [standard deviation (SD) 2.9] vs 10.1 (SD 3.8)}, after training [7.6 (SD 2.9) vs 8.1 (SD 3.5)] or 60 days after training [8.1 (SD 3.2) vs 8.3 (SD 3.6)]. The mean difference of the whole group between before training and after training was -0.9 (SD 2.3, 95% confidence interval -1.7 to -0.6). Patients with Parkinson's disease showed improved performance in activities of daily living after 14 sessions of balance training, with no additional advantages associated with the Wii-based motor and cognitive training. Registered on (identifier: NCT01580787).
    Physiotherapy 09/2012; 98(3):196-204. DOI:10.1016/ · 1.91 Impact Factor
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