Treatment options for postural instability and gait difficulties in Parkinson’s disease

ABSTRACT

Introduction: Gait and balance disorders in Parkinson’s disease (PD) represent a major therapeutic challenge as frequent falls and freezing of gait impair quality of life and predict mortality. Limited dopaminergic therapy responses implicate non-dopaminergic mechanisms calling for alternative therapies.

Areas covered: The authors provide a review that encompasses pathophysiological changes involved in axial motor impairments in PD, pharmacological approaches, exercise, and physical therapy, improving physical activity levels, invasive and non-invasive neurostimulation, cueing interventions and wearable technology, and cognitive interventions.

Expert opinion: There are many promising therapies available that, to a variable degree, affect gait and balance disorders in PD. However, not one therapy is the ‘silver bullet’ that provides full relief and ultimately meaningfully improves the patient’s quality of life. Sedentariness, apathy, and emergence of frailty in advancing PD, especially in the setting of medical comorbidities, are perhaps the biggest threats to experience sustained benefits with any of the available therapeutic options and therefore need to be aggressively treated as early as possible. Multimodal or combination therapies may provide complementary benefits to manage axial motor features in PD, but selection of treatment modalities should be tailored to the individual patient’s needs.

KEYWORDS:

• Cognition
• cueing
• exercise
• falls
• frailty
• freezing of gait
• neurostimulation
• Parkinson’s disease
• pharmacotherapy
• physical therapy

Article highlights

• Multimodal or combination therapies may provide complementary benefits to manage PIGD motor features in PD but selection of treatment modalities should be tailored to the individual patient’s needs, with a pivotal role for physical therapists.

• Physical therapy has shown short-term benefits in persons with PD and PIGD motor features. However, new care delivery models are needed to either offer PT maintenance or post-PT physical activity therapies.

• Aerobic and progressive resistance exercise training provide complementary benefits for persons with PD but will require long-term adherence in order to have sustained benefits.

• Cholinesterase inhibitor drugs can reduce the number of falls at least in a subset of patients with frequent recurrent falls.

• De-prescribing of benzodiazepines and anticholinergic drugs may be one of the easiest therapeutic interventions in PD patients at risk of PIGD motor features.

• Droxidopa can reduce falls in PD, at least in the setting of symptomatic neurogenic hypotension; there is some evidence that it may have beneficial effects on FoG.

• Although DBS generally may have no or even worsening effects on PIGD motor features in some patients, novel trends with selective electrode programming and/or low-frequency strategies may provide clinical benefit.

• Non-invasive neurostimulation approaches, such as transcranial direct current and vagal nerve stimulation show promise for future management of PIGD motor features.

• Virtual reality and exergaming therapy is safe, feasible and (cost-)effective in PD.

• Closed loop cueing technology that is less dependent on attentional focus is a promising novel treatment modality to help FoG.

• Active ‘stand-up, sit-less, move-more’ intervention strategies deserve further studies to reduce the sedentary lifestyle and improve patient functionality in PD.

• ‘Start early’ physical activity and PT to prevent frailty and neuro-muscular weakness is highly recommended. An in-home therapy plan may offer significant advantages in terms of quality of life and reducing barriers to physical activity, especially in more frail patients. This, however, will require further study to assess the safety of an unsupervised home program.

Acknowledgments

The authors gratefully acknowledge research support from the NIH-NINDS, the Department of Veterans Affairs and the Michael J. Fox Foundation.

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.