Postural Instability, Gait Disorders and Falls in Parkinson’s Disease

Authors: P. Valkovič1ihash2 ,2 ,3
Authors‘ workplace: II. neurologická klinika LF UK a UN Bratislava, Nemocnica akad. L. Dérera 1;  Laboratórium regulácie motoriky, Ústav normálnej a patologickej fyziológie SAV, Bratislava 2;  Oddelenie fyziatrie a liečebnej rehabilitácie, Falck Healthcare, a. s., Bratislava 3
Published in: Cesk Slov Neurol N 2012; 75/108(2): 141-151
Category: Minimonography


Postural instability (PI) is a cardinal sign of Parkinson’s disease (PD). Its importance increases with the disease progression. The most serious consequences of PI are recurrent falls that extremely worsen patients‘ quality of life and complications of which increase healthcare expenditure. The majority of falls occur in the patient’s home environment and in a state of good mobility. Targeted history-taking and a specific clinical neurological assessment is needed to detect and follow-up PI. Pharmacotherapy has only a limited effect. Drugs working predominantly through the noradrenergic and cholinergic neurotransmitter system seem to be promising. Continuous “tailored” physiotherapy plays a key role in the treatment of PI and fall prevention in PD. 

Key words:
postural instability – Parkinson’s disease – gait disorders – falls – treatment


1. Hughes AJ, Daniel SE, Kilford L, Lees AJ. Accuracy of clinical diagnosis of idiopathic Parkinson’s disease: a clinico-pathological study of 100 cases. J Neurol Neurosurg Psychiatry 1992; 55(3): 181–184.

2. Bloem BR, van Vugt JP, Beckley DJ. Postural instability and falls in Parkinson’s disease. Adv Neurol 2001; 87: 209–223.

3. Valkovič P. Posturálna instabilita u pacientov s Parkinsonovou chorobou a jej liečba. Neurol Prax 2009; 10(6): 348–353.

4. Stolze H, Klebe S, Zechlin C, Baecker C, Friege L, Deuschl G. Falls in frequent neurological diseases-prevalence, risk factors and aetiology. J Neurol 2004; 251(1): 79–84.

5. Pickering RM, Grimbergen YA, Rigney U, Ashburn A, Mazibrada G, Wood B et al. A meta-analysis of six prospective studies of falling in Parkinson’s disease. Mov Disord 2007; 22(13): 1892–1900.

6. Schrag A, Selai C, Jahanshahi M, Quinn NP. The EQ-5D a generic quality of life measure-is a useful instrument to measure quality of life in patients with Parkinson’s disease. J Neurol Neurosurg Psychiatry 2000; 69(1): 67–73.

7. Rahman S, Griffin HJ, Quinn NP, Jahanshahi M. Quality of life in Parkinson’s disease: the relative importance of the symptoms. Mov Disord 2008; 23(10): 1428–1434.

8. Jankovic J, McDermott M, Carter J, Gauthier S, Goetz C, Golbe L et al. Variable expression of Parkinson’s disease: a base-line analysis of the DATATOP cohort. The Parkinson Study Group. Neurology 1990; 40(10): 1529–1534.

9. Bloem BR, Grimbergen YA, Cramer M, Willemsen M, Zwinderman AH. Prospective assessment of falls in Parkinson’s disease. J Neurol 2001; 248(11): 950–958.

10. Bloem BR, Hausdorff JM, Visser JE, Giladi N. Falls and freezing of gait in Parkinson’s disease: a review of two interconnected, episodic phenomena. Mov Dis­ord 2004; 19(8): 871–884.

11. Ashburn A, Stack E, Pickering RM, Ward CD. Predicting fallers in a community-based sample of people with Parkinson’s disease. Gerontology 2001; 47(5): 277–281.

12. Farníková K, Bareš M, Nestrašil I, Kaňovský P. Parkinsonské fenotypy – na cestě k nové nozologii atypických parkinsonských syndromů. Cesk Slov Neurol N 2011; 74/107(6): 641–653.

13. Schrag A, Quinn NP, Ben-Shlomo Y. Heterogeneity of Parkinson’s disease. J Neurol Neurosurg Psy­chiatry 2006; 77(2): 275–276.

14. Schieppati M, Nardone A. Free and supported stance in Parkinson’s disease. The effect of posture and ‚postural set‘ on leg muscle responses to perturbation, and its relation to the severity of the disease. Brain 1991; 114(Pt 3): 1227–1244.

15. Bloem BR, Bhatia KP. Gait and balance in basal ganglia disorders. In: Bronstein AM, Brandt T, Woollacott MH et al (eds). Clinical disorders of balance, posture and gait. London: Arnold 2004: 173–206.

16. Azher SN, Jankovic J. Camptocormia: pathogenesis, classification, and response to therapy. Neurology 2005; 65(3): 355–359.

17. Anastasopoulos D, Ziavra N, Savvidou E, Bain P, Bronstein AM. Altered eye-to-foot coordination in standing parkinsonian patients during large gaze and whole-body reorientations. Mov Disord. 2011; 26(12): 2201–2211.

18. Schlesinger I, Erikh I, Yarnitsky D. Paradoxical kinesia at war. Mov Disord 2007; 22(16): 2394–2397.

19. Giladi N, Balash Y. The clinical approach to gait disturbances in Parkinson’s disease; maintaining independent mobility. J Neural Transm Suppl 2006; 70: 327–332.

20. Giladi N, Nieuwboer A. Understanding and treating freezing of gait in parkinsonism, proposed working definition, and setting the stage. Mov Disord 2008; 23 (Suppl 2): S423–S425.

21. Factor SA. The clinical spectrum of freezing of gait in atypical parkinsonism. Mov Disord 2008; 23 (Suppl 2): S431–S438.

22. Giladi N, Treves TA, Simon ES, Shabtai H, Orlov Y, Kandinov B et al. Freezing of gait in patients with advanced Parkinson’s disease. J Neural Transm 2001; 108(1): 53–61.

23. Giladi N, McDermott MP, Fahn S, Przedborski S, Jankovic J, Stern M et al. Freezing of gait in PD: prospective assessment in the DATATOP cohort. Neurology 2001; 56(12): 1712–1721.

24. Schaafsma JD, Balash Y, Gurevich T, Bartels AL, Hausdorff JM, Giladi N. Characterization of freezing of gait subtypes and the response of each to levodopa in Parkinson’s disease. Eur J Neurol 2003; 10(4): 391–398.

25. Snijders AH, Nijkrake MJ, Bakker M, Munneke M, Wind C, Bloem BR. Clinimetrics of freezing of gait. Mov Disord 2008; 23 (Suppl 2): S468–S474.

26. Bloem BR, Grimbergen YA, van Dijk JG, Munneke M. The „posture second“ strategy: a review of wrong priorities in Parkinson’s disease. J Neurol Sci 2006; 248(1–2): 196–204.

27. Matinolli M, Korpelainen JT, Korpelainen R, Sotaniemi KA, Myllylä VV. Orthostatic hypotension, balance and falls in Parkinson’s disease. Mov Disord 2009; 24(5): 745–751.

28. Goetz CG, Tilley BC, Shaftman SR, Stebbins GT, Fahn S, Martinez-Martin P et al. Movement Disorder Society-sponsored revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS): scale presentation and clinimetric testing results. Mov Disord 2008; 23(15): 2129–2170.

29. Valkovič P, Brožová H, Bötzel K, Růžička E, Benetin J. Push-and-release test predicts Parkinson fallers and nonfallers better than the pull test: comparison in OFF and ON medication states. Mov Disord 2008; 23(10): 1453–1457.

30. Morris S, Morris ME, Iansek R. Reliability of measurements obtained with the Timed „Up & Go“ test in people with Parkinson disease. Phys Ther 2001; 81(2): 810–818.

31. Franchignoni F, Horak F, Godi M, Nardone A, Gior­dano A. Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest. J Rehabil Med 2010; 42(4): 323–331.

32. Abdo WF, Borm GF, Munneke M, Verbeek MM, Esselink RA, Bloem BR. Ten steps to identify atypical parkinsonism. J Neurol Neurosurg Psychiatry 2006; 77(12): 1367–1369.

33. Valkovič P, Krafczyk S, Benetin J, Šaling M, Bötzel K. Deteriorácia posturálnej stability v progresii Parkinsonovej choroby: posturografická štúdia. Cesk Slov Neurol N 2004; 67/100(5): 347–353.

34. Horak FB, MacPherson JM. Postural orientation and equilibrium. In: Rowell LB, Shepard JT (eds). Handbook of Physiology. Section 12: Exercise: Regulation and Integration of Multiple Systems. New York: Oxford University Press 1996: 255–292.

35. Horak FB, Dimitrova D, Nutt JG. Direction-specific postural instability in subjects with Parkinson’s disease. Exp Neurol 2005; 193(2): 504–521.

36. Alexandrov A, Aurenty R, Massion J, Mesure S, Viallet F. Axial synergies in parkinsonian patients during voluntary trunk bending. Gait Posture 1998; 8(2): 124–135.

37. Bronstein AM, Hood JD, Gresty MA, Panagi C. Visual control of balance in cerebellar and parkinsonian syndromes. Brain 1990; 113(Pt 3): 767–779.

38. Bronstein AM, Yardley L, Moore AP, Cleeves L. Visually and posturally mediated tilt illusion in Parkinson’s disease and in labyrinthine defective subjects. Neurology 1996; 47(3): 651–656.

39. Pastor MA, Day BL, Marsden CD. Vestibular induced postural responses in Parkinson’s disease. Brain 1993; 116(Pt 5): 1177–1190.

40. Valkovič P, Krafczyk S, Bötzel K. Postural reactions to soleus muscle vibration in Parkinson’s disease: scaling deteriorates as disease progresses. Neurosci Lett 2006; 401(1–2): 92–96.

41. Valkovič P, Krafczyk S, Šaling M, Benetin J, Bötzel K. Postural reactions to neck vibration in Parkinson’s disease. Mov Disord 2006; 21(1): 59–65.

42. Braak H, Del Tredici K, Rüb U, de Vos RA, Jansen Steur EN, Braak E. Staging of brain pathology related to sporadic Parkinson’s disease. Neurobiol Aging 2003; 24(2): 197–211.

43. Gdowski GT, McCrea RA. Neck proprioceptive inputs to primate vestibular nucleus neurons. Exp Brain Res 2000; 135(4): 511–526.

44. Jacobs JV, Horak FB. Abnormal proprioceptive-motor integration contributes to hypometric postural responses of subjects with Parkinson’s disease. Neuroscience 2006; 141(2): 999–1009.

45. Mille ML, Johnson Hilliard M, Martinez KM, Simuni T, Rogers MW. Acute effects of a lateral postural assist on voluntary step initiation in patients with Parkinson’s disease. Mov Disord 2007; 22(1): 20–27.

46. Carpenter MG, Allum JH, Honegger F, Adkin AL, Bloem BR. Postural abnormalities to multidirectional stance perturbations in Parkinson’s disease. J Neurol Neurosurg Psychiatry 2004; 75(9): 1245–1254.

47. Hausdorff JM, Schaafsma JD, Balash Y, Bartels AL, Gurevich T, Giladi N. Impaired regulation of stride variability in Parkinson’s disease subjects with freezing of gait. Exp Brain Res 2003; 149(2): 187–194.

48. Nutt JG, Bloem BR, Giladi N, Hallett M, Horak FB, Nieuwboer A. Freezing of gait: moving forward on a mysterious clinical phenomenon. Lancet Neurol 2011; 10(8): 734–744.

49. Kuo SH, Kenney C, Jankovic J. Bilateral pedunculopontine nuclei strokes presenting as freezing of gait. Mov Disord 2008; 23(4): 616–619.

50. Oertel WH, Berardelli A, Bloem BR, Bonuccelli U, Burn D, Deuschl G et al. Joint EFNS/MDS-ES Guidelines on late (complicated) Parkinson’s disease. In: Gilhus NE, Barnes MP, Brainin M (eds). European Handbook of Neurological Management: Volume 1. 2nd ed. Chichester, UK: Blackwell Publishing Ltd. 2011: 237–267.

51. Litvinenko IV, Odinak MM, Mogiľnaya VI, Emelin AY. Efficacy and safety of galantamine (reminyl) for dementia in patients with Parkinson’s disease (an open controlled trial). Neurosci Behav Physiol 2008; 38(9): 937–945.

52. Bohnen NI, Albin RL. The cholinergic system and Parkinson disease. Behav Brain Res 2011; 221(2): 564–573.

53. Rascol O, Brooks DJ, Melamed E, Oertel W, Poewe W, Stocchi F et al. Rasagiline as an adjunct to levodopa in patients with Parkinson’s disease and motor fluctuations (LARGO, Lasting effect in Adjunct therapy with Rasagiline Given Once daily, study): a randomised, double-blind, parallel-group trial. Lancet 2005; 365(9463): 947–954.

54. Giladi N, Rascol O, Melamed E, Oertel W, Poewe W, Stocchi F et al. Rasagiline treatment can improve freezing of gait in advanced Parkinson’s disease: A prospective randomized, double blind, placebo and entacapone controlled study. Mov Disord 2004; 19 (Suppl): S191–S192.

55. Coria F, Cozar-Santiago Mdel P. Rasagiline improves freezing in a patient with primary progressive freezing gait. Mov Disord 2008; 23(3): 449–451.

56. Boonstra TA, van der Kooij H, Munneke M, Bloem BR. Gait disorders and balance disturbances in Parkinson’s disease: clinical update and pathophysiology. Curr Opin Neurol 2008; 21(4): 461–471.

57. Devos D, Krystkowiak P, Clement F, Dujardin K, Cottencin O, Waucquier N et al. Improvement of gait by chronic, high doses of methylphenidate in patients with advanced Parkinson’s disease. J Neurol Neurosurg Psychiatry 2007; 78(5): 470–475.

58. Espay AJ, Dwivedi AK, Payne M, Gaines L, Vaughan JE, Maddux BN et al. Methylphenidate for gait impairment in Parkinson disease: a randomized clinical trial. Neurology 2011; 76(14): 1256–1262.

59. Baláž M, Bočková M, Bareš M, Rektorová I, Dírerová V, Rektor I. Kvalita života po hluboké mozkové stimulaci u pacientů s pokročilou Parkinsonovou nemocí. Cesk Slov Neurol N 2011; 74/107(5): 564–568.

60. Snijders AH, Nonnekes J, Bloem BR. Recent advances in the assessment and treatment of falls in Parkinson’s disease. F1000 Med Rep 2010; 2: 76.

61. Ferraye MU, Debû B, Fraix V, Goetz L, Ardouin C, Yelnik J et al. Effects of pedunculopontine nucleus area stimulation on gait disorders in Parkinson’s disease. Brain 2010; 133(Pt 1): 205–214.

62. Oertel WH, Berardelli A, Bloem BR, Bonuccelli U, Burn D, Deuschl G et al. Joint EFNS/MDS-ES Guidelines on early (uncomplicated) Parkinson’s disease. In: Gilhus NE, Barnes MP, Brainin M (eds). European Handbook of Neurological Management: Volume 1. 2nd ed. Chichester: Blackwell Publishing Ltd. 2011: 217–236.

63. Keus SH, Bloem BR, Hendriks EJ, Bredero-Cohen AB, Munneke M. Evidence-based analysis of physical therapy in Parkinson’s disease with recommendations for practice and research. Mov Disord 2007; 22(4): 451–460.

64. Valkovič P, Schmidt F. Princípy liečebnej rehabilitácie. In: Benetin J, Valkovič P (eds). Parkinsonova choroba. Herba 2009: 204–212.

65. Morris ME, Perry A, Bilney B, Curran A, Dodd K, Wittwer JE et al. Outcomes of physical therapy, speech pathology, and occupational therapy for people with motor neuron disease: a systematic review. Neurorehabil Neural Repair 2006; 20(3): 424–434.

66. Nieuwboer A. Cueing for freezing of gait in patients with Parkinson’s disease: a rehabilitation perspective. Mov Disord 2008; 23 (Suppl 2): S475–S481.

Paediatric neurology Neurosurgery Neurology

Article was published in

Czech and Slovak Neurology and Neurosurgery

Issue 2

2012 Issue 2

Most read in this issue
Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account