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I Think, Therefore I Fall

October 10, 2005
University of Rochester Medical Center
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. She was a perfect example of a person with "fear of falling gait," says neurologist and Parkinson's expert Roger Kurlan.

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

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

In the case reported in the journal, Kurlan describes anelderly woman who had an increasingly difficult time walking. Thedifficulties began shortly after her husband died, when she tripped andfell, breaking a wrist and bruising her leg. Her inability to walk ledher doctor to diagnose Parkinson's disease, and she was prescribed theParkinson's medication levodopa to treat her symptoms. Despitetreatment, she ended up in a wheelchair, unable to walk, and she wassent to Kurlan, an expert in movement disorders like Parkinson's.

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

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

Doctors subsequently referred her to a physical therapist tobuild her confidence on her feet, and they also gradually stopped herParkinson's medications. Her ability to walk unassisted continued forthe 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 whotreat Parkinson's disease have seen such patients too, though not a lothas been written about the condition. People who have Alzheimer'sdisease or who have had several strokes also sometimes have a similardisorder, he said.

The abnormal gait sometimes begins, as it did with thispatient, shortly after a fall, though many patients have never fallenbut are literally paralyzed by the fear that they might fall. Patientsshuffle or slide their feet along the floor and hold onto somethingconstantly for support. Soon the abnormal gait itself becomes aproblem, even to the point that a person doesn't walk for months oryears.

To treat the disorder, persuading patients to try to walk andconvincing them they can is crucial. Physical therapy is also useful toimprove the person's balance and ability to walk, and to build theirconfidence. 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 gaitdisorders are treated appropriately," said Kurlan, professor ofNeurology and a scientist in the Center for Aging and DevelopmentalBiology. "People literally come in in a wheelchair, and walk out of theoffice after one appointment. It's very satisfying as a physician totreat this condition. Symptoms often reverse quickly."

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

A psychogenic gait disorder is similar to other neurologicalsymptoms that have their roots in causes that have nothing to do with apatient's physical health, Kurlan said. Some patients experiencehysterical blindness -- they think they can't see -- when there isabsolutely nothing wrong with their eyes or their nervous system, forinstance. Other people at times can feel weak, or can even lose theirability to speak -- and all these symptoms can sometimes be due to themind, not the body. Usually, treatment that focuses on the patient'spsychological well-being helps ease symptoms.

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

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