Clinical approach when the risk to fall is low and mobility is well preserved

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The clinical approach to the parkinsonian patient at the early stages of the disease when there are objective gait disturbances but their impact on daily function is still minor or moderate should be conservative. All patients at these stages are fully independent but are understandably worried about the future. The most common problems at the early stages are complaints of slow walk, shuffling gait and decreased arm swing, mainly on the more affected side of the body. These symptoms develop slowly and, as a result, most patients are not aware of the functional deterioration. It is frequently the spouse who first notices such changes and organizes the first appointment with the doctor. The fact that there is no significant disability and that the patient can adjust his/her daily activities according to the difficulties, can give the treating physician and the family the options if to treat the gait disturbances medically or physically. If medically, all antiparkinsonian drugs can ease some of the burden at this stage. If physically, a daily walk and exercise can give significant benefit and some times postpone the need for medications. Observing a disciplined regimen of daily exercise has many positive outcomes, several of which were mentioned above. It is a common belief that exercise during the early stages of PD will delay or slow down physical deterioration and loss of mobility, even though such data has never been published base on class IA evidenced based research. The recommendation to exercise daily has additional benefits like paying attention to the general fitness and weight, building the muscles, and strengthening the bones. Furthermore, daily exercise is an active self dependent task which leaves some control in the patient's hands in addition to its positive effect on mood and cognition.

Based on the general knowledge that as PD will progress and that gait and balance problems will inevitably develop, a ''delaying'' approach should be taken from the time of diagnosis. The therapeutic plan should be geared to deal with the patient's general physical condition, general affective and cognitive aspects, strategies for the prevention of falls and associated injuries, as well as adopting a positive attitude of being active and taking responsibility in the fight for independency and mobility.

Many non-neurological problems can affect mobility and balance among these adult patients. They should be urged to aggressively treat any existing hyperlipidemia, diabetes mellitus, cardiac problems and hypertension (Skoog and Gustafson, 2003). They should be encouraged from the very early stages of the disease to keep their body weight down to BMI = 25 or less, considering the deleterious contribution of overweight to instability and immobilization (Mc Graw et al., 2000) as well as to brain dysfunction and the development of dementia (Gustafson et al., 2003). Special attention should be given to the feet, joints and spinal column because of the significant role of the musculoskeletal system in mobility and gait. In general, patients in the early stages of the disease do not realize the extent to which their general health status will effect their future mobility, and it is the responsibility of the neurologist to make the patient aware of these preventive aspects. This approach should be maintained throughout the course of the disease, and every visit should start with a discussion on the assessment and control of non-neurological issues.

Gait disturbances and falls are closely related to the individual's affective state and cognition (Hoehn and Yahr, 1967; Adkin et al., 2003; Jantti et al., 1995; Whooley et al., 1999; Lenze et al., 2004). Depressed people fall and break bones as a result of their falls more frequently than non-depressed people (Jantti et al., 1995; Whooley et al., 1999; Lenze et al., 2004). Aggressive treatment of depression can have a significant impact on the willingness of the PD patient to exercise and take steps to enhance his/her physical fitness. It is vitally important to treat depression either medically or by psychosocial support or both. Among its many benefits, physical activity can also improve mood with its recognized positive consequences.

Dementia is a widespread complication of advanced PD and a significant contributing factor to the occurrence of falls. Dementia is the end result of many slowly progressive pathological processes, such as atherosclerosis, obesity, depression, lack of cognitive stimulation or head trauma. Treating all secondary risk factors can delay or slow down the rate of cognitive decline, with significant impact on the mental performance of PD patients at the more advanced stages of the disease.

Another aspect of delaying potential consequences of PD is the early detection and aggressive treatment of osteoporosis. Osteoporotic bone is significantly more vulnerable to injury, and even minor trauma can sometimes cause fractures that require surgery and lead to loss of mobility. All PD patients in all stages of the disease should be educated to assess their bone density regularly throughout the course of the disease and follow professional advice how to protect or treat osteoporosis.

Symptomatic medical treatment aimed specifically for gait disturbances should be given at the early stages only if it causes sig nificant disability or may lead to fall. A mild to moderate gait slowness or a decreased arm swing do not justify the use of drugs. In contrast, a history of frequent falls or shuffling gait with low ground clearance are danger and should be treat aggressively.

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