Freezing or Sweating FallsWhen Walking with Parkinson’s DiseaseFay B. Horak, Ph.D, PTProfessor of NeurologyOregon Health & Science UniversityParkinson’s Foundation Center of Excellence

January16,20181pmET

Disclosure

Dr. Horak has significant financial interest in ADPM, a company that may have a commercial interest in the results of this research and technology. This conflict has been reviewed and managed by OHSU.

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Objectives

1. Understand how the brain controls walking and balance• Balance and gait should be automatic• The basal ganglia works with the frontal cortex and brainstem

2. Discover what types of balance impairments result in freezing and falls

• Small stepping responses (multiple weight shifts)• Lack of automaticity (dual-tasks)• Inability to stop inhibition (cognitive deficit)

3. Explore what can be done to minimize freezing and falls• Biofeedback and Cueing• Exercise: Dance, Tai Chi, Agility, Cognitive

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What Is Balance?

An active brain process that controls the body center of mass over its base of support

CoM

CoM

Walkingisfallingandcatchingyourself

CoM

Brain Control of Balance and Walking:What Goes Wrong in PD?

Control Parkinson

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MotorCortex

Brainstem PD:toomuchBGinhibitionofMotorCortexandBrainstem….

SorelymoreonFrontal(cognitive)cortex.

FrontalCortex

What Is Freezing of Gait (FoG)?

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FoG:“abrief,episodicabsenceormarkedreductionofforwardprogressionofthefeetdespitetheintentiontowalk.Afeelingthefeetaregluedtothefloor…”

Usuallyassociatedwithrapidtremblingoftheknees(weightshifting)astrytostartwalking.

TrickscanhelpovercomeFoG.

Nutt,etal,MovementDisorders

Turning 360 Degrees is Best Way to Freeze

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Fallswhileturningarecommonanddangerous-

Leadtofracturedhips!

We Turn 1,000 Times a Day!

Turning at Home Is Related to Severity PD

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Mancini,etal,2017

Turning Variability at Home Predicts Falls

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Mancinietal,2016

Morevariableturnsmayreflectlessautomaticturns.

Why are Balance and Walking Less Automatic in PD (especially with FoG)?

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Gilatetal.2017

Automaticcontrol Frontal(cognitive)control

Moreautomatic

withFoG

WalkingslowswhentalkingThinkingslowswhenwalking

BalanceandWalkingNeedAttentionMoreAttentioninPD,esp.withFoG!

Walk Talk

CognitiveReserve

More Difficult the Balance Task, the More Attention is Needed

Butpracticecanmakewalkingandturningmoreandmoreautomatic

Balance Stepping Response is Impaired by Dual Tasking

NoCognitiveTask WithCognitiveTask

Jacobs,etal,JPDandRelatedDisorders,20(7),2014

Stepping to Recover Balance Requires Weight Shifts

FreezingisAssociatedwithMultiplePosturalWeightShifts:AsifCan’tInhibitBalancetoStartWalking

Jacobsetal,Exp Neurology 2009

Steponset

Steponset

Control Subject PD Subject

Freezing of postural stepping

Jacobs, ExpNeurology 2009

Freezer Using Multiple Weight Shifts with Small Steps for Stepping Response.

FoG is Associated with Too Much Frontal Cortex Control of Brainstem

FUFUNCTION

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Brainfunctio

nalcon

nectivity

FoG

noFoGNormal

FoGinvolvestoomuchcognitivecontrolofbalance/gaitsolessautomatic.

Fling,etal,2015

ScoreonFreezingofGaitQuestionnaire(FoG-Q)

Stroop

Score(s)

6 8 10 12 14 16 18

0

50

100

150

200

250 Rho=.84

Cohenetal,2014ParkandRelatedDisorders

FreezersHaveDifficultyReleasingInhibitionSoCan“Go”

StroopInhibitionTest

Flingetal. Brain2013

R²=0.85487

-10

-8

-6

-4

-2

0-0.2 0 0.2 0.4

DualTa

skSL-N

ormalSL

(cm)

PPNLateralityIndex(%)

Stroop Cognitive Task and Dual Task Cost on Gait are Both Related to Brain Inhibition Pathway from Frontal Cortex to Brainstem.

Petersonetal. 2017

BrainInhibitionPathway

BrainInhibitionPathway

• It is difficult for the brain to control balance and thinking at the same time

• Poor balance requires more attention

• Attention can be reduced by aging and PD

• As skilled tasks become more AUTOMATIC, they require less attention

Why Is it Hard to Walk and Chew Gum?

Attention is required for balance!

Freezers Require More Attention for Balance and Walking

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DualTaskCostislargerinFreezersthanNonfreezersforbalanceandwalking.

Bienvenida GaitandPosture,2017

Can PD Balance be Improved? YES!

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Improvedbackwardsteppingdoesn’ttransfertolateralsteps

Buttakeyourlevodopaforlearning!

Improved Balance Responses with Practice: Especially When ON Levodopa

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Biofeedback to Reduce Freezing of Gait

ManciniandHorak,2015

Tactile Biofeedback DuringStance Phase Reduces FoG

Mancini,etal,MDS,2016

BaselineFreezingduringTurns

LessFreezingwithVibrotactile Biofeedback

Mancini,etal,WPC,2016

Vibrotactile BiofeedbackCanReduceFoG

Frontal Brain Activity Increases Before FoGBiofeedback Can Reduce this Hyperactivity

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• The only intervention that significantly reduces risk of falling! (Gillespie et al, Cochrane Review, 2009)

• People receiving Balance Exerciseswere 20% less likely to fall.

Exercise

Exercises to Improve Balance

Dual Task Walking in People with PD Can Improve with Training!

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30days4weeks

Killane,2015

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TangoCanImproveBalanceinPD

Earhart,G,etal

Boxing Can Improve Balance

Before practice After 4 weeks practice

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Agility Boot Camp

A-C-E…

walking PWRmoves© agilitycourse boxing taichi

prioritization setshiftingdualtasking

Go!…NoGo!

inhibition

lunges

L– L– L– L- R

FoG When Challenging and Stressful

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FoG Improves with Practice

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Exercise Can Improve Dual Task Cost

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Exercise Can Improve Brain Connectivity

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Good Exercises for PD

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n Makeyousweat(>80%HR)!n Atleast3x/weekn Atleast30minutesn Getharderasyougetbetter!

n Joinotherstostickwithit!n Varietyisthespiceoflife!

Main Summary Points

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• Balance and gait should be automatic.

• PD and FoG results in less automatic control of balance/gait.

• Freezing and falls in PD:Ø Small stepping responses

Ø Lack of automaticity (dual-tasks)

Ø Inability to stop inhibition (cognitive deficit)

• Exercise can reduce falls

•TheNIH-NationalInstituteonAging•TheKineticsFoundation•TheNIH-NationalInstituteofNeurologicDisordersandStroke• NIH- NationalCenterofMedicalRehabResearch•OregonHealthandScienceUniversity•DepartmentofVeteransAffairs

OHSUBalanceDisordersLaboratory

Sponsors:

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