Falls When Standing, Falls When Walking: Different Mechanisms, Different Outcomes in Parkinson Disease

Abstract

Our retrospective study of falls and resultant trauma in consecutive Parkinson disease (PD) patients seen in one year at the Muhammad Ali Parkinson Clinic found that multiple-fallers could be divided into patients who fell mainly when walking or those who fell mainly when standing. Patients who fell when walking were more likely to visit an emergency room or be admitted to a hospital.Of 455 consecutive patients who were evaluated over a one-year period, 51 were excluded because they had atypical Parkinson disorders, had multiple risk factors for falling, or were demented. Unified Parkinson Disease Rating Scales and Zeno Walkway results were compared among non-fallers, single-fallers, and multiple-fallers. Among multiple-fallers, comparisons were made between patients who fell mainly when standing and those who fell mainly when walking.Most patients (197, 49%) did not fall, 142 (35%) fell once, and 65 (16%) fell more than once. Multiple-fallers differed significantly from single-fallers and non-fallers: they had PD significantly longer (p<0.001), were more severely affected (p<0.001), and took shorter steps (p<0.001). Of 65 multiple-fallers, 26 (40%) fell mainly when standing, 28 (43%) fell mainly when walking, and 11 (17%) fell equally often when standing or walking. Falls when walking resulted in more severe injuries. Patients who fell mainly when standing did not realize they could fall when standing; engaged in inappropriate weight shifting, bending, reaching, and multitasking; and failed to use their assistive devices. Such patients would benefit from being counseled about falling when standing. Patients who fell mainly when walking were aware they could fall, despite using an assisted device, and were more likely to have freezing of gait (FOG). They were more likely to sustain a severe injury, and were more likely to be admitted to an emergency room or hospital. Such patients would benefit from reducing, if possible, FOG.

Future Therapeutic Strategies for Freezing of Gait in Parkinson’s Disease

“…Freezing of gait (FOG) is a disabling symptom that affects more than half of all advanced Parkinson’s disease (PD) patients ( Giladi et al, 2001b ; Forsaa et al, 2015 ; Zhang et al, 2021 ). It profoundly reduces quality of life ( Perez-Lloret et al, 2014 ; Walton et al, 2015b ), leading to falls ( Okuma et al, 2018 ; Lieberman et al, 2019 ) and a loss of independence. Patients who develop gait freezing fare poorly: falls related to gait freezing occur during walking, rather than standing, resulting in more severe injuries and increased hospitalisation ( Lieberman et al, 2019 ).…”

Assessment of Risk Factors for Falls among Patients with Parkinson’s Disease

“…Symptoms of this disease are characteristic gait disturbances, visible as small, shuffling steps, and the lack of balance [ 15 , 16 ]. These dysfunctions also concern motor coordination related to the work of the cerebellum, basal ganglia, and frontal lobes [ 17 – 19 ]. The lowest-level gait disorders result from damage to peripheral locomotor organs and sensory systems [ 20 – 23 ].…”

Novel Pharmacotherapies in Parkinson’s Disease

“…This could be achieved by administering nicotine via inhalation, or nasal spray. It is of relevance to note that a recent clinical study using oral administration of nicotine, reported positive effects of nicotine on falls and freezing gait in PD (Lieberman et al 2019 ). Furthermore, pulsatile nicotine preparations in forms of inhalers or nasal spray are available and approved by FDA for smoking cessation and could be re-purposed for PD pending evaluation of their effectiveness in clinical trials.…”