Loss of Balance and Falls in Parkinson’s Disease

Balance is the control of body weight distribution and is a normal reflex in people without Parkinson’s disease. Several factors associated with Parkinson’s disease contribute to a loss of balance and falls.

1. Loss of balance reflex

   The degeneration of the grey nuclei neurons characteristic of Parkinson’s disease causes a loss of balance. Posture control then becomes managed by the cerebral cortex, or the “thinking” part of our brain. Balance therefore becomes a conscious and voluntary process rather than an automatic reflex.

   Any external disturbance while managing your balance (ex. a freezing episode during which you are thinking about the strategy to get out of it, or someone calling out your name) can cause a loss of balance.

2. Forward shift of center of gravity and rigidity

   The stooped posture resulting from a loss of postural reflex shifts the center of gravity forward, which increases the likelihood of falling forward, especially during freezing episodes.

   The contraction of the extensor and flexor muscles makes patients vulnerable to loss of balance and falls. The rigidity of certain leg muscles can also contribute to the loss of balance that leads to backward falls.

3. Decreased ability to anticipate new stabilizing positions

   Maintaining balance during unexpected position changes and movements requires rapid adaptation.

   The feet muscles that control balance and the muscles in the pelvis and legs that allow you to change position (ex. throwing a leg forward) are slower in people with Parkinson’s disease.

   Patients’ ability to anticipate new positions is also reduced. For example, when initiating walking (taking a step), the lateral movement of the body towards the leg in action is insufficient to shift the weight of the body. In this case, the slowness of preparatory adjustments leads to hesitation in initiating the movement or to freezing, especially in bigger steps. Levodopa intake and external clues can help these preparatory adjustments.

   This is also associated with weakened muscles, so make sure to stay active and exercise daily.

   A decreased range of motion, such as in arm swings or step length, contributes to a decreased ability to maintain balance and can lead to falls.

4. Decreased mental processing of external signals

   To maintain balance, your brain must process information from the eyes, the sensory nerves and the vestibular apparatus that controls balance from our ear.

   People living with Parkinson’s disease have a poor perception of the movements of different body parts and their sense of positioning of each body part is not as accurate as it used to be. For example, people find it more difficult to feel a slope in the ground. This is mainly due to muscle sense and inner ear stimulation.

   Patients then compensate for this deficit by overconfidence in the visual signals to which they are exposed.

5. Low blood pressure

   Parkinson’s disease can cause hypotension, especially during changes of position. Sudden drops in pressure can lead to dizziness, loss of balance, and eventually to falls.

   Some medication, such as levodopa in the first months, can contribute to lowering blood pressure. Speak to your neurologist and pharmacist.

6. Fluctuations in the effectiveness of antiparkinsonian drugs

   Medication effectiveness varies throughout the day, so you may feel that your medication is no longer working at certain times. These are called off periods, during which you may be at greater risk of losing your balance.

Exercise and physiotherapy can help you better control freezing episodes, turn without difficulty, walk more normally and improve your balance.

During the sessions, the physiotherapist will help you work on your balance by suggesting, for example, exercises to maintain your balance on one foot (with assistance), extend your range of motion or improve flexibility.

You can implement several strategies in your daily life to improve your balance:

• Follow a rhythm when walking, whether visual (with ground markings) or auditory (walking to the beat of a song or a metronome), to help you concentrate on your walk.
• Consciously exaggerate your range of motion by taking larger steps or swinging your arms as you walk, for example.
• Don’t get distracted. Don’t turn your head quickly to look at a distraction.
• Don’t attempt to keep a conversation going while walking. If you want to talk, stop walking and rest on something solid, such as a bench, pole or fence, to keep your balance.
• Slow down when turning.
• Stay active. Exercise daily to keep your muscles strong.

Here are some other ways to reduce your risk of falls:

• Remove decorative rugs or other objects from the floor to prevent tripping and falling.
• Make sure that your house is bright enough to properly see around you.
• Install grab bars in bathrooms and other small rooms.
• Put a non-slip mat in your shower.
• Keep regularly used items close at hand, not deep in the cupboards.
• If you fall regularly, a walking stick, cane or walker can help increase your ground support points.
• Purchase good shoes. High heels, flip flops or shoes that are too big can contribute to loss of balance.
• Occupational therapists can also help you adapt your living space or suggest outpatient care if needed.

• Most of the time, people fall in the bathroom.
• Large open spaces, such an unfurnished living rooms, also increase the risk of falls.
• Staircases are not likely places for falls, because climbing each step, especially the first and last, requires a conscious effort from people living with Parkinson’s disease.
• Falls during physical activity are infrequent. Your fear of falling should not prevent you from exercising.

The STAND UP! program was specifically designed to improve balance and reduce the risk of falls for people over 65 years of age. It is a safe, personalized and free program offered by healthcare professionals.

• 12-week exercise program
• Two hour-long exercise sessions per week to improve balance and strength
• Information messages to prevent falls and adopt safe behaviours
• Three at-home exercise programs
• A group of around 15 participants
• An opportunity to meet new people and socialize

Ask your local CLSC where the STAND UP! program closest to you is located.

Physical activity is the only treatment available to improve balance. Personalized activities help you increase your range of motion and develop postural strategies that compensate for loss of balance.

There is no medication to directly improve balance, but your neurologist can review your Parkinson’s medication dosages to increase your mobility and natural postural adaptation. Your doctor can also review the medications you are taking and reduce the doses of those that cause low blood pressure or dizziness.

You need to reduce the dangers that could cause your loved one to fall in their immediate environment, such as at home.

• Remove decorative rugs or other objects from the floor to prevent tripping and falling.
• Make sure that their house is bright enough so they can properly see around them.
• Install grab bars in bathrooms and other small rooms.
• Put a non-slip mat in the shower.
• Keep regularly used items close at hand, not deep in the cupboards.

It is difficult for people living with Parkinson’s disease to do several things at the same time, so don’t try to maintain a conversation when you walk with your loved one. This increases the risk of falls.

If you notice that your loved one is falling more frequently, discuss the use of a walking stick, cane or walker. This equipment increases support points and reduces balance loss.

Loss of balance and falls are symptoms that usually appear in the later stages of Parkinson’s disease and become more frequent as the disease progresses. This is due to the degeneration of other systems in the brain that manage the body’s cognitive and perceptual functions.