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Falls

Some people with Parkinson’s find their pattern of walking (gait) changes; you may walk more slowly, shuffle, or you may experience freezing of gait when you stop and are unable to move for a few seconds or minutes. These changes in walking pattern can affect your balance and make falls more likely, particularly as Parkinson’s progresses.

But not everyone with Parkinson’s is susceptible to falls, although statistically people with Parkinson's are more likely to fall over than people without. Falls tend to happen most when movement changes suddenly, for example when you turn around, or when you do more than one thing at a time, such as carrying an item whilst walking.

Falls tends to be forwards, and occasionally sideways, and can lead to bruises, cuts, or even fractures and broken bones, so it is important to be aware of the likely causes of falls and understand how to minimise the risks.

People with and without Parkinson’s may be more susceptible to falls if they have limited movement, are old or frail, have dementia or depression or if they take medications that cause drowsiness.

What causes falls in Parkinson’s?

Poor balance (postural instability) and freezing are probably the most common causes but there may be many contributing factors.

  • Stooped posture - the stooped posture that often occurs as Parkinson’s progresses increases the risk of falling forwards.
  • Postural instability - because Parkinson’ affects the area of the brain (the basal ganglia and brainstem) that controls walking and plays an important part in adjusting balance as you move, you may not have the normal reflexes to quickly adjust position and save yourself from falling, or to maintain balance when you shift your weight. For example, you may be unable to put your arms out to balance yourself when walking on an uneven surface or unable take an additional short step to avoid falling when tripping.
  • Reduced muscle tone - muscle weakness may make posture more stooped (bent forwards) which also increases the risk of falling. If is therefore important to stay as active as possible so as to prevent muscle weakening and to stop joints from getting weak or stiff.
  • Freezing of gait – freezing - when you involuntarily suddenly stop walking or are unable to initiate a movement as your feet feel ‘glued’ to the floor - may last just a few seconds or for several minutes. This can make you feel unsteady and therefore more likely to fall. See also Freezing.
  • Low blood pressure (orthostatic or postural hypotension) - when we move from lying or sitting to standing up our blood vessels should automatically adjust to keep our blood pressure even. But sometimes this does not happen - perhaps as a result of dehydration, illness or medication side effects – and we feel light-headed as blood flow to the brain is reduced. This can lead to fainting and falls. So it is important to get up slowly – and don’t try to start walking immediately - and be aware that there is an increased risk of falls when you get up. Blood pressure problems can be a side effect of Parkinson’s medications. Other drugs, such as those used to treat high blood pressure, can also increase dizziness on standing. Make sure you discuss any faintness you feel with your doctor as your medication may need to be adjusted.
  • Eyesight – in some people Parkinson’s can cause eye problems such as blurred vision or difficulty judging spaces. This can make it more difficult to safely move past objects or through narrow spaces and so the risk of falling is increased. It is important to discuss any eye problems with your doctor as these could be a side effect of medication. Always have regular eye check-ups so that your vision is as clear as possible.
  • Hazards in your home or at work - many falls can be avoided with careful planning and organisation. Even the smallest hazard, like laundry left on the floor, can lead to a fall and injury. Falls are more likely to occur if you experience incontinence and have to rush to the bathroom, particularly during the night. An occupational therapist will be able to advise on ways to reduce risks in your home or at work.

Reducing the risk of falls

It is important that you take all your Parkinson’s medications as prescribed so that symptoms such as poor gait and freezing are well controlled.

Some Parkinson’s medications may, unintentionally, lower blood pressure and this can cause dizziness and increase the risk of falling. If this happens you should ask your doctor or nurse to check your blood pressure both when standing and sitting. Your doctor may be able to advise on medication to help with low blood pressure and dizziness, although this can be complicated because of possible interference with Parkinson’s medications.

Some dizziness can be avoided. For example, when getting out of bed let your feet dangle over the side of the bed for a few minutes before standing and then rise slowly. When getting up from a chair, pause for a few moments and only start walking when you feel steady.

Some Parkinson’s medications can actually aggravate falls by causing dyskinesias and freezing. Again, it is important to tell your doctor if you fall so that medication can be adjusted if necessary.

Caution! 

You are more likely to fracture a bone if you fall frequently, particularly if you have osteoporosis. If you fall frequently, ask your doctor for an osteoporosis assessment. If osteoporosis is diagnosed, he or she will be able to give you s advice on minimising its effects or refer you to another professional who can help.

If you have recently had a fall then, statistically, you are much more likely to have another within the next six months. So it is important that you tell your doctor and carer if you fall so that you can together do all you can to prevent falls.

Reducing the risk of falls

It is important that you take all your Parkinson’s medications as prescribed so that symptoms such as poor gait and freezing are well controlled.

Some Parkinson’s medications may, unintentionally, lower blood pressure and this can cause dizziness and increase the risk of falling. If this happens you should ask your doctor or nurse to check your blood pressure both when standing and sitting. Your doctor may be able to advise on medication to help with low blood pressure and dizziness, although this can be complicated because of possible interference with Parkinson’s medications.

Some dizziness can be avoided. For example, when getting out of bed let your feet dangle over the side of the bed for a few minutes before standing and then rise slowly. When getting up from a chair, pause for a few moments and only start walking when you feel steady.

Some Parkinson’s medications can actually aggravate falls by causing dyskinesias and freezing. Again, it is important to tell your doctor if you fall so that medication can be adjusted if necessary.

Caution! 

You are more likely to fracture a bone if you fall frequently, particularly if you have osteoporosis. If you fall frequently, ask your doctor for an osteoporosis assessment. If osteoporosis is diagnosed, he or she will be able to give you s advice on minimising its effects or refer you to another professional who can help.

If you have recently had a fall then, statistically, you are much more likely to have another within the next six months. So it is important that you tell your doctor and carer if you fall so that you can together do all you can to prevent falls.

Who can help?

There are a lot of things you can do to help yourself but there are also experienced professionals who can provide useful advice. Depending on where you live, your doctor may be your first contact and they may refer you to another expert. In some countries a Parkinson’s Disease Nurse Specialist or nurse who specialises in neurology will also be able to advise.

Physiotherapists

A physiotherapist will address specific problems related to:

  • posture
  • gait (and freezing of gait)
  • balance and falls
  • transfers (ie moving from a chair or bed)
  • reaching and grasping.

He or she will be able to suggest an exercise programme and teach you different movement strategies to make everyday tasks as easy and safe as possible. Exercises are very important in preventing or reducing muscle stiffness, which will in turn reduce the risks of instability and falling. Good posture is important in keeping your balance and you may be advised on exercises to help with maintaining or improving your physical fitness and posture. You may find out Coping Strategies: Posture videos helpful.

A physiotherapist can also advise your carer and suggest appropriate ways of helping you to move, for example getting out of bed safely. If you fall frequently, a physiotherapist can teach you different ways to get yourself up and moving again, and help restore your confidence. The following strategies may also be helpful:

  • Getting up from lying on the floor - watch our video
  • Getting up from the floor after falling - watch our video.

Occupational therapists

An occupational therapist will be able to help you maintain as much independence as possible in your everyday life. He or she will be able to assess your home and daily routine then suggest ways of making activities as safe and as manageable as possible. Often very simple adjustments to the set-up of your kitchen or bathroom, for example, can make a big difference to your mobility, quality of life and risk of falling. They can also advise on practical aids, equipment or adaptations that might help you, as well as suggestions to improve your ability to carry out specific tasks such as dressing or cooking.

Podiatrists

A podiatrist (also known as a chiropodist) will be able to advise if you have a foot problem that may be causing you to fall. He or she will also be able to suggest the most suitable types of footwear to prevent falls.

See also: Footcare.

How can I help myself?

It is important that you do not allow a fear of falling to stop you doing things, provided that you are sensible. Keeping active is good for your mobility and independence, and doing the things you like is good for your morale. Try not to let falls curb your activities too much as this can have a negative impact on your quality of life.

The following information and practical suggestions may help you in adapting your daily routine so as to minimise the risk of falls: 

Exercise and posture

  • Try to exercise daily to keep muscles strong. Muscles need regular physical activity to prevent them from becoming stiff and weak
  • Stretching and strengthening exercises can help maintain mobility, which will minimise the likelihood of falling. Tai Chi is particularly beneficial as well as other complementary therapies that help maintain mobility such as yoga, Pilates, hydrotherapy and the Alexander technique.

Equipment and footwear

  • Various walking aids are available, but not all are suitable for people with Parkinson’s and some can increase the risk of falls, so it is important to get advice from a physiotherapist or occupational therapist
  • Try to avoid unsupportive, floppy shoes - supportive shoes with low heels or flat soles are usually more sensible. A physiotherapist, occupational therapist or podiatrist (depending where you live) will be able to advise on suitable footwear. He or she can also advise on hip pads which help to prevent fractures if you do fall
  • Walking aids may help if balance is problem, but they must be the correct height for you. They can also be a hindrance and cause you to trip so it is best to get advice from a physiotherapist.

Freezing

  • For information and tips to overcome involuntary stopping or an inability to initiate movement (which may cause falls), see Freezing.

Hazards in the home

  • Minimise clutter so there are fewer obstacles to negotiate when moving around. Position furniture to make your path as easy as possible and keep things in the same place so that your path stays familiar.
  • Either avoid loose rugs or ensure that they are securely anchored. Wall-to-wall carpeting is generally safer than rugs, although care should be taken over carpets with a pattern or pile that can be visually misleading. Whilst some patterns can help by providing a visual cue when walking, others can give the impression of a step when there isn’t one. Two different but adjacent carpets can also be confusing visually.
  • Remove loose wires or ensure that they are safely tucked away, for example behind furniture close to walls.
  • Make sure that there is good lighting, especially on stairs, in halls or around any entrances. You should have a light switch at the top and bottom of any stairs, and a light switch within easy reach of your bed in case you need to get up in the night.
  • Stick coloured tape to the edge of steps to make them more visible and less slippery.
  • Tape or plastic footsteps may be helpful as ‘stepping stones’ in places where carpet patterns are confusing or where falls are most likely, such as in doorways or on stairs. An occupational therapist or physiotherapist (depending on where you live) will be able to advise on appropriate placing of such visual aids.
  • Fit a rail on both sides of the stairs and keep frequently used items in pockets to reduce the number of times you need to climb the stairs.
  • Install grab bars and non-slip tape in the bath. Use non-slip mats on the bathroom floor if it is not carpeted. Grab bars may also be helpful near the toilet.
  • In the kitchen use non-slip mats on the floor under the sink and cooker and clean any spills immediately.
  • Remove or replace swinging doors which may knock you over.
  • It may be helpful to have an alarm system installed so that you can call for help if needed. Various types are available - some can be worn as a pendant or bracelet, some clip onto shirts - and at the press of a button you can call for help in an emergency.
  • Don’t rush! If the phone or doorbell rings, take your time to answer it.

Tips for walking well

A physiotherapist will be able to advise on any specific problems you have with walking but the following general tips may be helpful, both to you and to your carer or family.

  • When walking, concentrate on each step and minimise any distractions. You may need to ask those with you not to talk to you whilst walking.
  • Don’t try to do two things at once, such as carrying something, talking on a mobile phone or watching the television as you walk. Your carer or family should be aware of this too so that they know not to distract you.
  • Force yourself to swing your arms when walking as this will help your balance.
  • Consciously lift your feet and don’t let them drag or shuffle. With each step put your foot back on the ground from heel to toe.
  • Try to walk with your feet slightly wider apart and with longer strides as this will help with your centre of gravity.
  • Get into an even rhythm when walking. Try counting in your head with each step, singing, stepping over patterns in the floor or simply marching on the spot before setting off. Using a musician’s metronome that provides a regular tick or beat may also help. Make sure you keep an even pace and if you speed up, consciously slow back to a gentle, even pace.
  • If you freeze and someone is with you they can help by putting their foot in front of yours for you to carefully step over (raising your foot high off the ground so you do not trip). The stepping motion can trigger walking again and may avoid stumbling and falling. If you are alone, imagine an object in front of you to step over.
  • If you need to turn, do so slowly. Do not pivot on the spot as you are more likely to tilt and fall sideways. Instead walk in a wide, semicircle; try imagining that you are walking around the numerals on a clock face. If you want to reverse, do not walk backwards but turn in a u-shape, again using a semi-circular path.
  • To change direction, look the way you now want to go, pause and orientate yourself before setting off.
  • If you have to carry something, take only small items that will not throw you off balance and try to carry an even load on each side.

Low blood pressure

  • If you feel faint on standing up, sit on the edge of your bed or chair for a few minutes before rising. Hold onto something sturdy until you are sure you have your balance, and do not start walking until you feel confident.

Cueing

It is easy to get distracted when walking, and steps may then get progressively smaller until you’re shuffling, or you may freeze on the spot. This tends to happen when trying to turn in tight spaces, pass through doorways or in a crowded space. Cues can be used to help you to concentrate so that it is easier to keep your feet moving at a steady, even pace.

There are various types of cue, all of which use a part of the brain that is not affected by Parkinson’s. Such cues give information about the length and number of steps you take.

Visual cues

  • Lines on the ground or on the edges of steps can be useful as they prompt you to step over if freezing is a problem, particularly in doorways.
  • Tape across a threshold can help you to focus and step through a doorway. Alternatively concentrating on marching can help.
  • Some patterned carpets, and the cracks between tiles or paving stones, can also help to focus your attention on the quality of your walking and to keep the step size regular.  

Rhythmical cues

A steady beat from a metronome or suitable music can help. The rhythm should be a comfortable pace, the beat prompting you to lift your feet and step. The pace can be varied according to where you are, for example you will probably walk faster when outside, and slower in your home.

Attentional strategies

You may find it helpful to rehearse certain movements in your mind and focus on the sequence. For example, concentrating on putting your heel down firmly on the ground as your foot makes contact will help you to step evenly. Imagining a line to step over may help you to negotiate narrow entrances. Attentional strategies require concentration though which can be difficult if there are external distractions.

For more information on various cueing strategies see Coping Strategies - Tips & Tricks videos.

Content last reviewed: March 2016

 

Acknowledgement

Acknowledgement

Our thanks to Parkinson's UK for permission to use the following source(s) in compiling this information:

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