I think, therefore I fall

October 07, 2005

The patient came into the doctor's office in a wheelchair, weighted down by a diagnosis of Parkinson's disease, taking medication for the disorder and insisting she was unable to stand or walk. Thirty minutes later, after jogging down the hallway, she strolled out the door.

No Parkinson's patient was she. Rather, she was a perfect example of a person with "fear of falling gait," said neurologist and Parkinson's expert Roger Kurlan, M.D., of the University of Rochester Medical Center. Kurlan has seen enough cases of the condition, where a person is so afraid of falling that the mind actually affects the ability to walk, that he wrote about the disorder in the September issue of Cognitive and Behavioral Neurology to cue other physicians about the condition.

In the case reported in the journal, Kurlan describes an elderly woman who had an increasingly difficult time walking. The difficulties began shortly after her husband died, when she tripped and fell, breaking a wrist and bruising her leg. Her inability to walk led her doctor to diagnose Parkinson's disease, and she was prescribed the Parkinson's medication levodopa to treat her symptoms. Despite treatment, she ended up in a wheelchair, unable to walk, and she was sent to Kurlan, an expert in movement disorders like Parkinson's.

A thorough physical exam turned up nothing abnormal, but the woman refused to try to stand up on her own, even pushing herself down into her chair as Kurlan and a nurse tried to convince her to attempt to stand up. With enough persuasion, though, and with several people available to help her up, the woman finally did rise.

At first she took short, tentative steps, sure that she was going to fall. Upon hearing that she did not appear to have Parkinson's or any other serious neurological condition, however - and that her problem was psychological, reflecting her fear of falling - the woman's bearing improved markedly. With more encouragement and offers of help, the woman began walking around the room and even jogging down the hallway.

Doctors subsequently referred her to a physical therapist to build her confidence on her feet, and they also gradually stopped her Parkinson's medications. Her ability to walk unassisted continued for the six months the team followed her progress.

Kurlan estimates that he has seen at least 30 patients with "fear of falling gait" over the years, and that most neurologists who treat Parkinson's disease have seen such patients too, though not a lot has been written about the condition. People who have Alzheimer's disease or who have had several strokes also sometimes have a similar disorder, he said.

The abnormal gait sometimes begins, as it did with this patient, shortly after a fall, though many patients have never fallen but are literally paralyzed by the fear that they might fall. Patients shuffle or slide their feet along the floor and hold onto something constantly for support. Soon the abnormal gait itself becomes a problem, even to the point that a person doesn't walk for months or years.

To treat the disorder, persuading patients to try to walk and convincing them they can is crucial. Physical therapy is also useful to improve the person's balance and ability to walk, and to build their confidence. Kurlan said the treatment is similar to that for any "psychogenic gait disorder," where the condition of a patient's mind, not any physical cause, affects the patient's ability to walk.

"The results can be pretty dramatic when psychogenic gait disorders are treated appropriately," said Kurlan, professor of Neurology and a scientist in the Center for Aging and Developmental Biology. "People literally come in in a wheelchair, and walk out of the office after one appointment. It's very satisfying as a physician to treat this condition. Symptoms often reverse quickly."

Kurlan said most patients are thrilled to learn that their problems walking have more to do with their mind than their bodies. In his experience about half of such patients walk out of his office when the appointment is over, though for many the hard work - working out psychological problems through ongoing counseling - is just beginning.

A psychogenic gait disorder is similar to other neurological symptoms that have their roots in causes that have nothing to do with a patient's physical health, Kurlan said. Some patients experience hysterical blindness - they think they can't see - when there is absolutely nothing wrong with their eyes or their nervous system, for instance. Other people at times can feel weak, or can even lose their ability to speak - and all these symptoms can sometimes be due to the mind, not the body. Usually, treatment that focuses on the patient's psychological well-being helps ease symptoms.

"For a lot of patients, we simply help them get over their fear of falling by getting them into physical therapy and getting them more confident about being on their feet. Some patients never get over the fear, though, and they spend the rest of their lives not walking."

University of Rochester Medical Center

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