Clinical approach when the risk to fall is high and mobility is compromised

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Disturbed gait and postural control represent major and very disabling aspects of advanced parkinsonism affecting most if not all patients (Hoehn and Yahr, 1967). Gait disturbances initially appear at the ''Off'' state, when dopaminergic treatment is less effective. As the disease progresses, even the ''On'' state is associated with gait and postural disturbances which classically manifest as short stride, low speed, shuffling gait as well as stooped posture and freezing of gait (FOG) or propulsion and festinations (Morris et al., 1994, 1996; Baatile et al., 2000; Giladi et al., 1992, 2001). In addition, significant gait dysrhyth-micity with increased stride-to-stride variations (Schaafsma et al., 2003) and left/right steps asymmetry (Plotnik et al., 2005) has been recorded by sensitive gait assessment tools. The importance of those sub clinical measures is their predictability for FOG and falls (Bloem et al., 2004). Most gait disturbances can initially be improved up to the level of a normal gait during the ''On'' state when medications are effective. Other common problems of advanced parkinsonian stages are involuntary leg movements in the form of ''Off'' dystonia and ''On'' dyskinesia. At the advanced stages of parkinsonism, cognitive disturbances play a major role in the fight for mobility and independence without falls. Dementia can significantly influence the therapeutic options as well as the risk to fall.

Fine-tuning of the anti-parkinsonian medications can decrease the total daily ''Off'' time and ''On'' dyskinesia with a direct and immediate effect on secured mobility and stability.

Aside from optimal control and fine-tuning of ''Off'' and ''On'' periods, specific treatments can improve specific problems and non-motor disturbances that might have a significant impact on gait. Orthostatic hypotension, depression, and dementia should all be treated aggressively medically and behav-iorally. All can be improved by medications and appropriate exercise and support with significant impact on patients mobilization safely.

At the most advanced stages of PD when ''Offs'' are very frequent and very disabling with dyskinesias which can cause major disability, functional neurosurgery at the level of the basal ganglia should be considered (Giladi and Melamed, 2000). Pallidotomy and deep brain stimulation of the sub-thalamic nucleus (STN) or the internal globus palli-dum (GPi) have been very effective in avoiding motor response fluctuations with the elimination of ''Off'' periods and dyskinesias (Allert et al., 2001; Ferrarin et al., 2004).

Posture, balance, gait and transfers could be targeted by physiotherapists (Rubinstein et al., 2002; Plant et al., 1997). Physical therapy may induce small but significant improvements in gait speed and stride length (Plant et al., 1997). A sensory, cue-enhanced physical therapy program showed improvements lasting up to 3 months after the therapy had ended (Rubinstein et al., 2002; Nieuwboer et al., 1997).

General fitness can be maintained by daily exercise which should be recommended to every patient but even more persuasively to those at the more advanced stages of PD. A daily walk for 30-45 minutes during the ''On'' period is highly recommended for general health as well as for specific physical and mental needs. Daily walking has been shown to improve stride length and walking speed with a carryover effect of several months, even when the exercise was stopped (Sunvisson, 1997; Lokk, 2000; Scandalis et al., 2001).

Mobilization should be maintained for as long as possible but not at the price of risking the individual to dangerous falls. Walking aids should be considered if drugs and behavioral treatment cannot maintain safe walking. Only rarely will the patient be the first to suggest the use of walking aids, so the obligation of raising this issue falls upon the doctor or the physical therapist. When walking becomes extremely difficult and dangerous and demands much effort and energy but does not substantially improve the patient's quality of life, it is time to switch the patient's mindset to now regard walking as an exercise without any mobilization goal. This is the time to introduce the use of wheelchair for actual mobilization and represents the end of the fight for ambulatory independence. When instability becomes a major risk for falls, walking aids can decrease the risk and preserve mobility. Use of a wheelchair is a practical and effective option when all others possible interventions have failed. Beside its stigma and lost of independency the wheelchair can let the patient get out of home and get every where in a safe and easy way.

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