Falls Risk and People with Parkinson's

1. Sue McDowall Physiotherapist March 2017 Falls Risk and People with Parkinson's

2. Falls Risk in People with Parkinson's Age related change Rigidity Freezing Dyskinesia Fatigue Restless legs Medication Activity Footwear Eyesight Fear of falling Dizziness

3. Age Related Change It is normal in an older person to find Reduced ankle reflexes Reduced vibratory sense Reduced eye movements/visual acuity Reduced flexibility Reduced limb power These can all contribute to us being less effective when receiving threats to our balance

4. Rigidity Muscles can become less flexible causing rigidity, this can cause stooping as muscles become tired, affecting posture and walking Overtime the muscles can shorten in length It is advisable to do regular stretching to prevent/slow down muscle shortening Be aware of posture Avoid slump sitting, sit on your sit bones rather than the base of your spine Don't sit for long periods, rotate your trunk, swing your arms, get up for frequent short walks inside the house

5. Freezing Feet 'frozen'/stuck to the ground (disruption in normal sequence of movement) Often happens in walking if centre of gravity is displaced forwards causing increased weight bearing on the front of the foot and heels become raised. Don't try to keep walking STOP PUSH HEELS BACK DOWN TO THE FLOOR STAND TALL STEP FOWARDS/BACKWARDS/SIDEWAYS Sometimes counting helps, singing to a beat, use of a metronome

6. Freezing • Usual triggers are turning or approach to doorways/obstacles/distraction when walking • Turning is a very complex movement and is often when people fall. • If room allows turn in a wide arc • In a confined space count to yourself, or out loud and use a marching action to turn round • Swing your arms if you can • At doorways try to focus on something beyond the doorway and count out your steps

7. How to assist someone when freezing Walk beside them at a steady pace, encourage them to match their footsteps to yours, with a heel strike if possible Count in a steady rhythm to encourage regular longer steps. If you can avoid the shuffle the less likely they are to freeze -- having difficulty initiating a step or freezes Encourage them to stand tall with feet hip width apart. Use stand tall technique in slide 5. A steady count to sway to can help to unlock/marching on the spot Give a target to step over, e.g. your foot/ point to a pattern on the carpet. To assist in turning give as much room as possible, don't stand too close, turn together in an arc

8. Safe approach to a chair Get as close to the chair as you can If room do a wide arc turn so you have your back to the chair If you can feel the edge of the chair on the back of your legs your in a good position Place hands onto arms of chair and control your descent until you are seated, keeping your feet in contact with the ground at all times Bending forwards and sticking out your bottom with knees bent while descending helps keep control NEVER DIVE FOR THE CHAIR NEVER OVER REACH FOR THE CHAIR DON'T TRY AND DESCEND WHILE IN MID TURN OR WITHOUT TURNING

9. Dyskinesia Dyskinesia -unpredictable involuntary movements which can affect balance and safety In advanced Parkinson's the benefits of the 'on' phase between medication times can be affected by dyskinesia Monitoring by a professional is required to maximise medication and minimise side effects Walking at a slightly increased speed in time to a beat may help in restricting time available for the involuntary movements to disrupt gait. Use of pattern visual cues to help guide your feet to aid direction

10. Bradykinesia Slowness of movement Allow for extra time Focus on one thing, single tasking. Avoid distractions Keep the environment free of clutter/paraphernalia Can use a music beat to assist movement- working to the beat. Mental rehearsal,useful for a difficult task,acts as a primer and prepares the body.

11. Fatigue Avoid caffeine in the evenings or alcohol and too much stimulation before bedtime Planning- spread out any heavy or repetitive tasks evenly through out the day or several days - pace yourself Take regular breaks Fatigue is a very common symptom of Parkinson's MEND=Management of Energy in Neurological Disorders Help group based at AAH- 0131 537 9065 Aim to help understand and manage fatigue

12. Restless legs Can be distressing and fatiguing as can be more evident at night effecting sleep, resulting tiredness can increase the falls risk Massage legs Walking/stretching Relaxation exs Taking a hot bath in the evenings Avoiding alcohol,caffeine and smoking at night Attempt a regular sleeping pattern Cool comfortable sleeping environment Can sometimes be related to iron deficiency

13. Medication Important to take on time Take the right dose prescribed. Don't stop taking medication unless advised by an appropriate professional involved in your care. Don't crush your medication Works better on an empty stomach ideally 20 mins before food but if new to the medication it is recommended to take with food initially Infection can increase symptoms temporarily therefore don't rush to change meds Constipation can cause medication to be less effective. If constipation is an issue - increase fluid intake, review diet. Your Doctor may introduce a laxative.

14. Activity Symptoms in Parkinson's disease are generally less evident the more active you are. If you have the mobility join a walking group, group classes for general exs, pilates Often there are local specialist exs classes for People with Parkinson's disease. If you have been issued with an exercise regime from a physiotherapist stick with it on a regular basis. It is recommended that we perform 30 mins of activity 5 days a week- doesn't have to be in one session, can be spilt throughout the day, doesn't have to be strenuous, gardening, housework counts. TV watchers, get up and walk around when the adverts are on or stand up sit down 10 times, march in the chair or on the spot. Do some of the stretches shown earlier.

15. Fear Loss of confidence in mobility due to a fear of falling is a known falls risk in itself The fear of falling restricts movement and can result in long periods of sitting down, the resultant lack of activity causes reduced balance and loss of muscle strength which in turn increases the fall risk A vicious circle that impacts on confidence and independence Set small goals

16. Footwear Our feet change shape with age, what fitted in the past may not be right anymore Ill fitting shoes can cause serious foot problems and can lead to falls When buying shoes make sure they are deep enough and wide enough. Shoes should be comfortable straight away and shouldn't require 'breaking in' Ladies that can't manage without some form of heel should consider an appropriate wedge sole Make sure the heel of your foot is well supported

17. Footwear Beware of trainers with thick soles, People with Parkinson's that walk mainly on the front part of the sole of the foot are more likely to catch the tred on the floor and trip Shoes should be long enough so your toes are not touching the end and be supportive around the middle part of the foot Avoid ballet pumps, flip flops and canvas shoes that offer no support

18. GOOD

19. BAD

20. BAD GOOD

21. Eyesight Ageing can decrease contrast sensitivity, making it harder to see the edge of steps/kerbs(can place light coloured stripes edge of stair tred if an issue) also slower to react coming in from light to dark Depth of perception can also be altered As we get older we rely on vision as one of our balance mechanisms more

22. Eyesight As well as the issue of macular degeneration, cataracts and long sight which affects the ageing population, People with Parkinson's can be affected by double vision due to the rigidity affecting the eye muscles causing two images. This can be overcome by the fitting of a prism lens over one eye. Annual eye checks are recommended from 70yrs onwards If getting up during the night pop on your glasses Keep glasses well cleaned and in good condition Beware of bi or vari- focals when descending stairs

23. Dizziness Postural drop-drop in blood pressure from lying/sitting to standing Low blood pressure(BP) can be a side effect of medication If you are dizzy on rising from a bed or chair Move arms and legs prior to stand, pulse squeeze hands together Rise slowly, stand for count of 10 before movement. Light headedness, or vision going black/grey on standing usually related to BP

24. Dizziness Unsteadiness on initial stand without a light head - normally due to poor balance Room spinning/vertigo - often vestibular problem and related to balance mechanism within the inner ear/brain brought on by head movement

25. What can I do to reduce my Falls risk Have good lighting Improve visual contrast,eg brightly coloured tape on ends of steps/stairs Wear your glasses when moving Keep up to date on your eye tests If coming inside from bright light give you eyes time to adjust to the darker conditions Avoid rushing Don't spin round, increases risk of falling backwards or sideways – perform wide arc turn if space allows Don't over reach for chairs or rails

26. What can I do to reduce my Falls risk Don't overcrowd your space with furniture/clutter trailing wires Don't sit for long periods Take time to rise out of a chair(if phone rings they will wait if they know you, or phone back if important) Keep feet in good condition with regular chiropody/podiatry Wear well fitting firm shoes, no sling-backs, backless slippers or high heels, never walk in stocking feet on hard floors If possible keep regular exercise going as long as you can either in a class or home program

27. What can I do to reduce my Falls risk Scan for trip hazards when out before walking Carrying shopping bags could obstruct view of hazards, you may find a rucksack helpful Watch out for- - 'lipped' door frames - subtle changes of gradient ,esp near pedestrian crossings Keep bus pass/money at hand so all ready when boarding a bus Ask the bus driver to wait until you are seated before moving off (Saga.co.uk/falls)

28. WALKING AIDS 'Sign of getting old', 'embarrassed', 'not ready for that yet', 'if I give into a walking aid I will only get worse' Aim of a walking aid is to reduce your falls risk, give back your independence, maintain your independence as long as possible Alerts people not to invade your space in crowds Height of a stick is important - level of wrist crease when arm by your side Make sure you have a ferrule(rubber end) and replace if worn out

29. Rising off the floor

30. How to help if someone has fallen Don't help them up straight away, give them a few minutes to get over the shock Place a support under their head and try to keep them warm, get them to take slow breaths Get help/community alarm/relatives/neighbours/999 If uninjured let them get up themselves if they are able Only help if you have the physique and heath to do so,assisting only enough that risks no injury to either of you Once seated and rested check again for injuries Both review what may have caused the fall and what can be done to reduce the risk of this happening again

31. I have had a fall • Lie still for a minute, try to stay calm and check for injuries • If you know you are unable to get up or feel pain try and summon help and follow instructions “I can't get up” • If you are unhurt and think you can get up follow instructions “ I can get up” • If you can't get onto your hands and knees then you maybe able to bottom shuffle or roll to a low surface such as bottom stair or settee with your back to the surface. • Put your hands on the surface (if a settee you may need to place a cushion under your bottom to raise you up a little) and push yourself up on to the stair or settee. • If using the stairs go up onto the next step and use the stair rail to help you rise

32. Thank you for listening