What Is Parkinsons Disease
Parkinsons disease was named after the British doctor James Parkinson, who, in 1817, first described the disorder as shaking palsy. You may be surprised to learn that it is the second most common neurodegenerative disorder in the world. It is most known for the degree of impairment that it causes, most often leading to fall-related issues due to the progressive loss of muscle control that causes trembling of the limbs and head, stiffness, slowness, and impaired balance, making it gradually more difficult to walk, climb stairs, complete simple tasks or even talk.
Most individuals who develop Parkinsons disease are 60 years of age or older, but early-onset Parkinsons disease can occur.
The Role Of Levodopa In Pd Gait Progression
Although the precise mechanisms of non-dopaminergic gait control are unclear, emerging evidence suggests the importance of the cholinergic system . Cholinergic neurons in the pedunculopontine nucleus influence gait and postural control , and slower walking speed in PD is associated with increases in short-latency afferent inhibition and cholinergic denervation . Also, deep brain stimulation within the PPN may improve step velocity suggesting interventions that target brain regions not primarily dependent on dopamine may therefore help to mitigate gait impairment in PD. The benefits of drugs targeting the cholinergic system on PD gait are also being explored . Overall, interpretation of the relationship between dopamine and gait progression is limited as gait was not assessed off medication, nor were biomarkers of dopaminergic activity such as DAT imaging used. Nevertheless, our findings indicate that discrete gait characteristics progress irrespective of levodopa, suggesting the importance of non-dopaminergic mechanisms in gait impairment.
Surveying People With Parkinsons
The researchers surveyed 4,324 people with Parkinsons disease who had disabling gait impairments. Of those surveyed, 52% reported having fallen at least once in the last year, and 35% said their gait interfered with their ability to do their usual daily activities.
Individuals with Parkinsons often report difficulties with balance, falling, shuffling, staggering, and freezing of gait, the team noted. Freezing may result from a challenging course, anxiousness, or being distracted by a secondary task, such as carrying a tray.
While the surveys revealed that many people regularly use gait compensation strategies, they were often unaware of all the different types. Only 4% were familiar with all seven, and on average, respondents knew of about three.
Among the respondents, 23% had never tried any gait compensation strategies, and 17% had never heard of them.
The strategy with which most participants were familiar 47% was external cueing, and 45% were familiar with internal cueing. Only 14% had heard of action observation and motor imagery.
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What Is Parkinsonian Gait
In contrast to normal adult gait, Parkinsonian Gait also called Parkinsons Walk is characterized by very short, shuffling steps, in which the feet do not lift far from the floor. There is little to no flexion in the knee, ankle or foot, so the foot is placed flat on the ground, resulting in extremely short stride length.
The ability to bend the knee, flex the foot and roll onto the ball of the foot is critical to the ability to begin moving. Because Parkinsonian Gait lacks the knee and foot flexion of our normal movement, its often difficult for those who experience it to start walking. Uneven surfaces, slopes and steps can prove almost impossible to navigate and the inability to swing or turn the leg can make turning slow and awkward.
Instead of the body being upright, those with Parkinsonian Gait often lean slightly forward, with a hunched posture. To avoid overbalancing, its common to see rapid, short steps that seem to propel the individual forward, and reduced arm movement is often noticeable.
How Parkinsons Disease Affects The Autonomic Nervous System And The Heart
In PD, there are two major reasons why the automatic control of the cardiac system is impaired. First, areas of the brain that control this system often contain Lewy bodies and have undergone neurodegeneration. In addition, the autonomic nervous system itself is directly affected by Lewy body-like accumulations and neurodegeneration. This means, when the baroreceptors in the heart and carotid artery sense a drop in blood pressure and try to generate a signal to the heart and blood vessels to increase the blood pressure, the message may not get through. This results in neurogenic orthostatic hypotension , or drops in blood pressure upon standing due to autonomic nervous system dysfunction. There are no medications that can cure nOH by restoring the autonomic nervous system in PD. nOH however, can be treated. Read more about nOH and its treatments here.
Structural problems of the heart such as coronary artery disease or cardiomyopathy are not thought to be part of the pathology of PD, although of course, could co-exist with PD.
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What Are The Causes And Symptoms Of Parkinsons Disease
As a neurodegenerative disorder, Parkinsons Disease leads to the progressive deterioration of motor function due to loss of dopamine-producing brain cells. While the cause of Parkinsons Disease is unknown, researchers speculate that both genetic and environmental factors are involved. Studies also show that men are 50% more likely to develop the disorder than women.
Primary symptoms of Parkinsons Disease:
Balance And The Brain
Difficulties with balance and walking are linked to the brain changes that take place with PD. For people who dont have PD, balance is automatic, a reflex. But Parkinsons affects the basal ganglia . To compensate, the brain assigns another brain area an area used for thinking to take over. The thinking part of the brain, mainly the frontal cortex, cant control balance automatically. The result: for many people with PD, balance becomes less automatic.
This means that when people experience freezing and fall, they cant adjust their balance automatically. Taking small steps to try and regain balance can make things worse, because it involves shifting weight with each step. The brain changes from PD inhibit their ability to take a big step to catch their balance and avoid a fall. For some, the drug levodopa can help prevent freezing, but does not improve balance.
A person whose balance is less automatic must pay more attention while walking. For everyone, walking slows down when were talking and thinking slows down when were walking. This is called the dual-task cost and its higher in people with PD. That tells us that people with PD are using more attention and more cognitive control for balance and gait.
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How Does This Condition Affect My Body
Parkinsons disease causes a specific area of your brain, the basal ganglia, to deteriorate. As this area deteriorates, you lose the abilities those areas once controlled. Researchers have uncovered that Parkinsons disease causes a major shift in your brain chemistry.
Under normal circumstances, your brain uses chemicals known as neurotransmitters to control how your brain cells communicate with each other. When you have Parkinsons disease, you dont have enough dopamine, one of the most important neurotransmitters.
When your brain sends activation signals that tell your muscles to move, it fine-tunes your movements using cells that require dopamine. Thats why lack of dopamine causes the slowed movements and tremors symptoms of Parkinson’s disease.
As Parkinson’s disease progresses, the symptoms expand and intensify. Later stages of the disease often affect how your brain functions, causing dementia-like symptoms and depression.
Sensory Feedback During Walking And Turning
Asymmetric proprioceptive input elicited by vibration of axial muscles produces steering and turning , whereas proprioceptive input from the leg contributes to fine adjustment of the spinal pattern generators for walking . Input from axial muscles would play the role of a servo-mechanism, whereby minor asymmetries initiated by asymmetric foot placement would affect the spinal generators to produce the necessary fine changes in leg and foot kinematics accompanying heading changes.
Whether or not continuous walking along a circular trajectory is also favored by a shift in our straight-ahead goes beyond the scope of this short review, but we would note that a shift in subjective straight-ahead occurs after a period of stepping in place on a rotating treadmill . In turn, it is not unlikely that a shift in the straight-ahead is produced by the feedback from the muscles producing the rotation of the pelvis and trunk over the standing leg when walking along a curved trajectory or when stepping in place and turning . Vision is obviously not necessary for implementing a curved trajectory , but the continuous visual field motion would nonetheless favor the fine tuning of the gait synergies underpinning the production of the circular trajectory .
What Is The Quality Of The Reviewed Studies
Overall, quality scores were mediocre for both non-intervention and intervention studies. The main points that studies scored low on were sample size justification, electrode placement procedures and signal processing techniques. Individuals with PD exhibit great heterogeneity and generally high inter- and intra- subject gait EMG variability necessitating greater sample sizes than for HOA. However, the median sample size was only twenty-two and no study in this review performed power analysis to justify their selection of participant number. Most studies included a greater proportion of males, reflecting the gender bias in PD although some studies did not specify gender. Gender differences in muscle activity during walking have previously been reported, indicating it is an important factor. Only four studies determined electrode location using validated guidelines such as the SENIAM guidelines. Identification of the optimal electrode site helps ensure the signals with higher signal to noise ratio are recorded from the selected muscle with minimal cross-talk from adjacent muscles.
Over half of the studies did not report any signal normalisation methods,,,,,,,,. Such normalisation is essential to allow comparisons of EMG between muscles, sessions and participants as factors such as thickness of adipose tissue, presence of oedema and number and orientation of muscle fibres will modify amplitude,. Excluding normalisation can invalidate subsequent results.
Ten Tips To Put The Freeze On Freezing
While these methods can be helpful to get out of a freeze that is already underway, physical therapy techniques that incorporate these types of cueing strategies are utilized to reduce freezing of gait overall. Rhythmic auditory cueing is one such technique which utilizes rhythm and music to improve gait in PD and other neurologic diseases.
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What Is Freezing Of Gait
Freezing of gait is an abnormal gait pattern that can accompany Parkinsons disease as well as other parkinsonian disorders in which there are sudden, short and temporary episodes of an inability to move the feet forward despite the intention to walk. In a sense, youre stuck. This results in the characteristic appearance of the feet making quick stepping movements in place. However, while the feet remain in place, the torso still has forward momentum which makes falls unfortunately common in the context of freezing of gait. For some, these episodes can simply be frustrating, annoying and perhaps embarrassing for others freezing of gait can become incredibly disabling and lead to injury.
Freezing of gait episodes tend to occur least often when walking on an unobstructed, straight path. Any deviation from that can induce freezing for example, when you first try to start walking, when you go to make a turn, or try to navigate around obstacles or through narrow spaces any of these can cause you to get stuck.
The particular triggers for one person may be different than for another. An episode is typically very brief, often lasting only 1-2 seconds, although they can last longer. Freezing of gait can be affected by anxiety, so if a person feels rushed , freezing may be particularly prominent.
How Does Parkinsons Walk Interact With Other Parkinsons Symptoms
Two other symptoms associated with Parkinsons Disease can make walking, and moving, even more difficult, especially as the disease progresses.
Slow movement referred to using the Greek term Bradykinesia is another of the symptoms used to diagnose Parkinsons. In addition to generally sluggish movement, a decreased blink rate, and reduced facial expression, those with Bradykinesia find the fine motor control required for writing, or doing up buttons, challenging.
Additionally, those with Parkinsonian Gait often experience freezing episodes known as Freezing of Gait during which they feel stuck in cement, and unable to lift their feet from the ground.
Parkinsons freezing in particular can make walking risky, as it significantly increases the likelihood of falling. As a result, many with Parkinsonian Gait simply limit their movement as much as possible to avoid injury.
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What Medications And Treatments Are Used
Medication treatments for Parkinsons disease fall into two categories: Direct treatments and symptom treatments. Direct treatments target Parkinsons itself. Symptom treatments only treat certain effects of the disease.
Medications that treat Parkinsons disease do so in multiple ways. Because of that, drugs that do one or more of the following are most likely:
Several medications treat specific symptoms of Parkinson’s disease. Symptoms treated often include the following:
- Erectile and sexual dysfunction.
- Hallucinations and other psychosis symptoms.
Deep brain stimulation
In years past, surgery was an option to intentionally damage and scar a part of your brain that was malfunctioning because of Parkinsons disease. Today, that same effect is possible using deep-brain stimulation, which uses an implanted device to deliver a mild electrical current to those same areas.
The major advantage is that deep-brain stimulation is reversible, while intentional scarring damage is not. This treatment approach is almost always an option in later stages of Parkinson’s disease when levodopa therapy becomes less effective, and in people who have tremor that doesnt seem to respond to the usual medications.
Researchers are exploring other possible treatments that could help with Parkinsons disease. While these arent widely available, they do offer hope to people with this condition. Some of the experimental treatment approaches include:
Walking With Parkinsons: Freezing Balance And Falls
Parkinsons disease can change the way a person walks. Movement Symptoms like stiff muscles, rigidity and slow movement make it harder to take normal steps. In fact, short, shuffling steps are a common sign of PD, as is freezing, the feeling that your feet are stuck to the floor, for people with mid-stage to advanced PD.
On their own, these changes are distressing enough. But add the fact that Parkinsons affects balance and they also become dangerous, putting people with PD at risk of falling. The good news is that with exercise and physical therapy, people with PD can improve their balance. What can you do to minimize freezing and avoid falls? Read on to find out.
The following article is based on the latest research and a Parkinsons Foundation Expert Briefings about Parkinsons-related freezing, balance and falls hosted by Fay B. Horak, PhD, PT, Professor of Neurology at the Oregon Health & Science University, a Parkinsons Foundation Center of Excellence.
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Where Can I Find Support If I Have Parkinsons Disease And Want To Exercise
You can find exercise support in your community. For example, many gyms and community centers offer seated exercise classes for people who struggle with balance. Ask your healthcare provider for ideas if you have Parkinsons disease and want to exercise.
A note from Cleveland Clinic
Exercise is an important part of managing Parkinsons disease. Talk to your healthcare provider about your exercise program and choose activities you enjoy so you stay motivated to get up and move every day.
Last reviewed by a Cleveland Clinic medical professional on 04/08/2021.
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Trouble Sleeping And Daytime Sleepiness
You may have trouble falling asleep or toss and turn throughout the night. Or you may be unable to keep your eyes open during the day.
How can I manage them?
- Step outside and get some sunshine during the day.
- Exercise regularly before 8 p.m.
- Go to bed and get up around the same time each day. Spend 7 to 8 hours in bed.
- Donât nap for more than an hour.
- Have a regular nighttime routine. Avoid screens an hour or two before bed.
- Cut back on alcohol and caffeine.
What are the treatments? Your doctor will want to rule out sleep apnea. Parkinsonâs medicines can also affect sleep, so they may need to adjust your dosage. If lifestyle changes donât work, your doctor may prescribe a sleep medicine or a drug to increase alertness.
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How Soon After Treatment Will I Feel Better And How Long Will It Take To Recover
The time it takes to recover and see the effects of Parkinson’s disease treatments depends strongly on the type of treatments, the severity of the condition and other factors. Your healthcare provider is the best person to offer more information about what you can expect from treatment. The information they give you can consider any unique factors that might affect what you experience.