Balance is a nearly universal issue with PD patients. And, whether it comes along early in the course of disease, or late, as it is more likely to do, it is most often a progressive problem. Bad balance can of course lead to falls. Falls lead to nothing good. This is why I always encourage people with PD to start working on balance early, even if it is not yet a problem. To know why, you should understand a little about what is going on with balance in PD.
We humans are in a precarious situation in the first place. Since we stand on only two limbs, the simple act of walking is one in which we constantly throw ourselves forward in a form of controlled falling. One step after the next propels us into space and we land in what feels like an unbroken motion to keep going. This all requires a very complex onboard system to remain upright. Our eyes give the parietal lobe of the brain a visual map of the three dimensional space. Our inner ears contain semi circular canals in which fluid filled spaces lined with tiny hair cells that click on and off like relay switches, sense the direction our heads move and feed that information back to the brainstem. Tiny nerves in the feet (and the rest of the body for that matter) send signals to the posterior column of the spinal cord about where our body parts are in space. The posterior column climbs to the brainstem and fibers converge on the cerebellum, the true master of balance, which monitors, and in many ways, governs the whole system. Sometime you have tripped over an uneven surface, maybe a root on the ground, and before you knew what happened, your feet corrected themselves in a sudden move. You had no time to react, no time to think about it, and yet reflexively, you stayed upright. You probably gave yourself a little pat on the back for being so cat-like, but that was your cerebellum at work behind the scenes, beneath conscious thought, and in a fraction of a second correcting a footfall to stop disaster. To a neurologist, it is a glimpse behind the curtain of the hidden brain.
There are also automatic procedural patterns of movement that are sometimes referred to as habit learning, such as walking or riding a bike – really any set of movements you had to train yourself to do. These are, for the most part, stored in your brain’s striatum, and are unique to you, part of the reason PD is unique to the person. The striatum is particularly important because it is the input of the basal ganglia (BG), into which dopamine is delivered from its source in the midbrain. When there is low dopamine, some automatic patterns fail. This is how people with PD lose their normal gait pattern in what Mayo neurologist Harry Lee Parker, M.D., described in the pre-dopamine drug era of the 1950’s this way: “One recognizes the loved one’s step before arrival. In this disease all is leveled to a sterile similarity” (1).
One problem with gait and balance can be explained by dopamine tone. If you think about the BG as a store of dopamine, with connections to its own parts and other brain regions, the tone, or flow of dopamine is important. In other words, dopamine may be thought of during wakeful hours as being in a state of flow, similar to water in a pipe, or current in a wire. In this case, the strength or tone of that flow is one way the BG communicates: more dopamine tone may mean “yes, that movement is being done correctly;” whereas less tone may mean “no, that movement was bad.” The BG also regulates many of the movements themselves. It is quality control and operator. Thus, the BG might, under normal circumstances, turn down the tone of dopamine messaging to signal a failure of correct movement. If the BG fails to control how high you pick up your feet, how fast you move, or how long your stride is, the abnormal low state of dopamine in the brain forces the basal ganglia to, more or less, tell a lie to the brain. This is how you find yourself walking along, unaware that one foot is not clearing the ground as high as it used to. Your toe makes contact with some uneven or elevated surface in the middle of your stride and your foot abruptly comes to a halt while your body is still in motion. Worse still, your cerebellum does not save you either, because in PD the postural reflex is also not working. Down you go.
The good news is that you may be able to do something about this, and there are some choices. Studies have shown that programmed exercise, dance, physical therapy, yoga, and Tai Chi can all help balance.
While movement disorder neurologists recognize and diagnose gait disorders, physical and occupational therapists are specialists in treating impaired balance and gait dysfunction. In the case of PD, they teach patients to understand the way balance is failing, how to correct, and carry out the movement. If this is practiced enough, it becomes a new pattern, outside of the damaged networks in the striatum. This new neural pathway is reinforced and becomes automatic, similar to learning any new skill. This is why starting early and working on repetition is important. It is not a simple process, but the work pays off. Multiple studies have supported the use of PT for improving balance in PD.
Selina Carey, MS, OTR/L notes that when seeing a person with PD, “our initial session involves a thorough evaluation. We give the patient a numerical rating on
a fall risk, complete at least one other balance assessment such as the Berg or Tinetti balance tests, timed up and go, or several other options. We are able to calculate a numerical score and assess the level of a fall risk that patient may be at pre, during, and post treatment. The great thing is that we are able to see and show the patient how much they have improved from initial measurement.” She is also LSVT BIG certified (see the spring issue article “What is LSVT?” for more details), and reports that BIG “works to improve limb and body movement.” She and her colleagues tell patients to “think big” and use “big movements,” cues to improve the amplitude and speed of movement. “With improved body movement, a person’s stability and balance inevitably improves, and therefore carries over in daily routines and patient-centered activities. A patient’s balance improves with trunk rotation, stride length, and quality of movement.” She opines that “LSVT BIG is highly effective. Patients report and show improvements with balance, stability, and independence completing their chosen functional task. I love seeing how a patient’s positive regard improves as the program progresses. Our balance assessments are able to show improvements that are indicated by higher scores that are taken at initial evaluation, after 10 visits, and at the time of discharge.” However, “the LSVT BIG program can be time demanding, and therefore not for everyone.” An alternative approach is a structured exercise program tailored to each individual patient. “Therapists can work with a patient to strengthen specific muscles, improve activity tolerance, and endurance as well as improve dynamic and static balance. Specific functional tasks and exercises can be extremely beneficial to a patient who has balance deficits.” To prolong the effects of a PT intervention, she urges, “Get exercising now! We really encourage patients to continue exercising and moving. It is highly recommended that patients complete their daily exercises to insure carry over of the progress made with therapy intervention. Incorporating ‘bigness’ in their everyday life is also very important. A focus in the program is to increase limb movement. We recommend that patients continue to use big movements during their daily routine. Selina Carey is a therapist with Coastal Rehab in Falmouth, Maine, and is the group facilitator for the PD support group at that location.
There are other ways to improve your balance, as has been shown in many studies published in peer-reviewed medical journals. One well-publicized, randomized, controlled trial funded by the National Institute of Neurological Disorders and Stroke, included 195 mild-to-moderate PD patients who were sorted into one of three groups: Tai Chi, resistance training, or stretching. Participants met for an hour, two times a week, over the course of 24 weeks. The Tai Chi group performed consistently better than the resistance-training and stretching groups in terms of maximum excursion, directional control, stride length, and functional reach. Tai Chi lowered the incidence of falls as compared with stretching and was about equal with resistance training. The benefits of Tai Chi training were still present three months after the 24-week period (2). However, a six-month course may not be enough. Generally, the interventions described here should be performed long term. Bill Milan would agree. He has taught Tai Chi at the YMCA in Bath for over eight years, and has been involved in the practice for three decades. He is now also teaching at the Landing YMCA in Brunswick, and notes that in Tai Chi, one has to focus on center of gravity, breathing, centering and making the body posture more upright. This is done through a lot of guidance. Moreover, he notes that it is “not an easy activity. It takes patience, but if one engages, it can really help.”
Yoga is another means to better balance. A randomized, controlled, trial of 41 PD patients with an average age of 72, met over a 12-week period to compare the effects of power training and a high-speed yoga program on physical performances, and to test the hypothesis that both training interventions would lessen PD symptoms and improve physical performance. Raters in the study measured standardized PD and balance scales, which were improved significantly, compared with a non-exercise control group (3).
Elizabeth Burd is a Maine Parkinson Society Board member, certified personal 
trainer, and certified Kripalu yoga instructor who has worked with PD patients in Maine since 2006 in various capacities. She finds that high-speed yoga may not be ideal for the moderate to advanced PD patient, though in some cases a fast-paced interval training with higher heart rate while using a variety of exercises is helpful. Often, a slower pace is more conducive to good results. Elizabeth has worked with patients at all stages of disease and has found at seminars and PD support group meetings that for patients with advanced disease, especially those on a first foray into yoga, fear of falling may be a major impediment to balance. With a yoga intervention, “the biggest thing I hear is that they feel more confident, which definitely contributes to being able to move around. You’re working on balance, core, and leg strength at the same time. When people realize they can practice safely, they are more likely to do it on their own.” Still, some patients use a walker or a wheelchair. “I may modify the yoga poses to make them more accessible for everyone. They think, ‘I have terrible balance, I can’t do that.’ Well, here is a way you can.” She has produced a 45 minute video, mostly seated home practice, though there are some standing options which help strengthen the legs and core (visit her website for details http://www.pdyogaforme.com/). She also notes, “I also really try to encourage the caregivers, who sometimes don’t look after their own health.” She is currently a trainer at Natural Fitness in Portland and conducts private yoga training.
Various forms of dance have also been investigated in PD. Though there are several published studies showing improvement of balance with programmed dancing, most are with mild or moderate PD patients. In one study, patients with severe PD who primarily used a wheelchair for transportation were enrolled in a 10-week trial with 20 one-hour tango classes (4) The results included improved balance and balance confidence. Patients also demonstrated increased endurance and reported improved quality of life.
Another popular intervention of late is boxing training. In one study, 31 people with PD were randomly assigned to boxing training or traditional exercise for 24-36 sessions, each lasting 90 minutes, over 12 weeks. Boxing training included stretching, boxing (punching bags but not people), resistance exercises, and aerobic training. Traditional exercise included stretching, resistance exercises, aerobic training, and balance activities. Before and after completion of training, tests were taken of balance, balance confidence, mobility, gait velocity, gait endurance, and quality of life. Only the boxing group demonstrated significant improvements in gait velocity and endurance. Both groups demonstrated significant improvements with the balance, mobility, and quality of life (5).
For more, see the upcoming fall issue of Maine PD News, in which Dr. Kleinman will discuss the data on exercise in PD.
1. Harry Lee Parker, M.S., M.D., F.R.C.P.I., Clinical Studies in Neurology 1956, p21-24.
2. Li et al., Tai chi and postural stability in patients with Parkinson’s disease. N Engl J Med. 2012;366(6):511-9.
3. Ni et al., Comparative Effect of Power Training and High-Speed Yoga on Motor Function in Older Patients with Parkinson Disease. Arch Phys Med Rehabil. 2016;97(3):345-354.
4. Hackney M, Earhart G. Effects of dance on balance and gait in severe Parkinson disease: a case study. Rehabil. 2010;32(8):679-84.
5. Combs et al., Community-based group exercise for persons with Parkinson disease: a randomized controlled trial. NeuroRehabilitation. 2013;32(1):117-24.
