In early October 2023, the American Parkinson Disease Association (APDA) provided a webinar on reducing the frequency of falls for people with PD, using exercise to practice balance. Teresa Baker, a physical therapist at Boston University, shared why falls are so hazardous for people with PD. She summarized the findings of review papers on the impact of exercise on the rate of falls in those with PD, and offered recommendations for exercise based on research. This webinar is part of the APDA’s “Let’s Keep Moving” series.
The most effective exercise for reducing falls makes use of a variety of movements, and is difficult enough to challenge your body but not so strenuous that you’re in danger of falling. Overall, any exercise someone with PD finds enjoyable is good exercise!
A recording of the webinar is available on the APDA’s YouTube channel
There are currently 25 videos posted to the “Let’s Keep Moving” playlist on the APDA’s YouTube channel
See our list of virtual PD exercise classes and PD exercise videos (many of which include balance training components):
If you are lucky enough to live in Northern or Central California, see our lists of fall prevention programs and in-person PD exercise classes:
To find a physical therapist knowledgeable about PD, contact the APDA information and referral center in your area
Below is my summary of the talk and the question and answer session.
“Balance Training to Reduce Falls with PD”
Speaker: Teresa Baker, PT, DPT, Center for Neurorehabilitation, Boston University
Webinar Host: American Parkinson Disease Association (APDA)
Webinar Date: October 3, 2023
Summary by: Jordan Dagan, Stanford Parkinson’s Community Outreach
People living with Parkinson’s disease (PD) have a greater number of falls per person per year (rate of falls), and greater rates of injury and disability, than those of the same age without PD. Multiple characteristics of the motor symptoms of the disease contribute to a high risk of falling. Postural instability makes maintaining balance difficult. Slowness and stiffness prevent the person’s reflexes from catching them when they lose their balance, and prevent them from breaking their fall safely. The body is less responsive to changes in balance, and has a slower reaction time. People are often especially unsteady when they stand up, when walking, and at transitions between surfaces and/or rooms.
Changes to the body’s ability to balance can begin early in PD. The “Norwegian Park West” study by Hiarth in 2017 compared those newly diagnosed with PD, and those without PD. They measured the frequency and timing of falls both groups experienced, over 7 years time. Among the group with PD, 15% had fallen even before their diagnosis. Though both groups had an increase in falls over 7 years, the group with PD had consistently greater instances of falls, and more than 60% fell over the course of the study.
A review paper by Allen in 2022 (published in the Cochrane Review) reviewed 14 studies on whether exercise reduced the rate of falls, and what types of exercise interventions reduced the rate of falls, in people with PD. Exercise overall reduced the rate of falls by 26%. All but one study favored exercise, compared to the control group.
Allen et. al. reviewed the type of exercise that was most effective, using data from those same 14 papers. They found that gait and balance exercises, resistance exercises, and tai chi were the most effective. This offers options for exercise people with PD can use to maintain their physical stability and overall health! All of these types of exercise challenge movement control, and all use a variety of movements, rather than repetition.
The final measure Allen et. al. reviewed across the papers they studied was supervision of the exercise people with PD had. They compared whether the exercise intervention was entirely supervised, or not. Entirely supervised interventions were more effective than those that were not entirely supervised. Teresa said this may be because these interventions were more challenging with a supervisor, because the supervisor offered encouragement and motivation to participate, because the supervisor offered more specific attention to individuals’ needs, or due to some other factors.
Balance training works best when it’s challenging the participant’s current comfort zone, and when it’s multidimensional and uses the whole body. In order to be challenging, walking should be practiced on uneven terrains, narrow surfaces, and in everyday environments which contain distractions.
Balance training can be combined with cognitive exercises, such as reciting the alphabet backwards, using the left foot or right foot separately, or responding to prompts from a coach or partner to stop and start movement. Movement games and virtual reality may be especially helpful for combining balance exercises with cognitive tasks.
Community exercise programs, such as those for tai chi and dance, can increase motivation and participation. These offer a lot of variety of exercise, as well as valuable social time.
It’s very important to choose exercise that you and/or your loved one find engaging and enjoyable! Ideally, exercise would be practiced for about 30 minutes at a time, 2 to 3 times per week. You can supplement outdoor or organized activities with safe and challenging home exercises, especially if you’re consulting a physical therapist.
Teresa recommends starting physical therapy as early as possible, especially if there is any concern that someone might fall. Finding a physical therapist is important if there are significant developments to symptoms affecting balance and movement. The physical therapist can assess what exercises are safe and challenging for you, which is vital to creating a safe and effective exercise plan.
QUESTIONS AND ANSWERS
Tim Nordahl, PT, DPT, also with Boston University, joined for the question and answer section.
(23:10) What do you think of sports like boxing or table tennis?
Boxing requires quick and coordinated movements, following the instructor’s prompts, and provides both challenge and supervision. Table tennis practices hand-eye coordination, quick and complex movements, and provides connection with a partner to play with. Both of these options sound like excellent choices for someone with PD!
(25:45) Freezing of gait, small steps, “concrete feet” and getting stuck.
Freezing is a significant concern for people with PD. A balance training program which includes strategies to initiate movement is often helpful. The APDA has another presentation which details strategies for freezing, including counting or using music or a mantra, placing visual cues on the floor (for example, lines of tape), and imagining marching or stepping over a small object. All of these can help initiate movement.
(27:30) Is walking considered a balance exercise?
Walking can improve speed and endurance, but walking on a level surface might not be challenging your balance enough for you to see a benefit. For extra benefits from walking, try talking while you walk, turning your head to look at the scenery, and/or practice walking uphill or on uneven terrain. You may need to slow down your pace while your balance is being challenged, in order to stay safe. Consult with a physical therapist if you have safety concerns, and walk with company or in populated areas in order to have help if you do fall!
(29:15) What do you mean by “challenging?” Does this imply an element of failure to our exercise?
“Challenging” means the movement requires effort and adjustment. If you give the movement a rating, where zero (0) is easy, and ten (10) is so difficult that you might fall, aim for a difficulty rating of four to six (4-6). You shouldn’t be at risk of losing your balance!
(31:05) I’m nervous that I might lose my balance and fall. How can I stay safe?
Most importantly, start gradually, and increase the difficulty of your exercises slowly! Do your exercises in a place that you can catch yourself, such as next to a wall, or a table at a convenient height to put your hand onto. Make sure the floor where you’re exercising is clear of clutter, loose rugs, and other tripping hazards. There shouldn’t be furniture or objects nearby that you could hit your head on if you fall.
(33:50) How can I make sure I have the time to add balance exercises to my existing routine?
The most important part is doing exercise that you enjoy! Teresa and Tim frequently hear concerns about managing scheduling and time with exercise routines. People often want to make sure they’re covering all the different types of exercise which could benefit their PD symptoms. Try doing exercises that combine different movements, rather than prioritizing repetition or strength building. Exercising frequently for short periods is preferable to exercising for a long time. When in doubt, consult a physical therapist, who can help you make an everyday balance exercise that fits into your day.