We honestly don't know why freezing of gait happens. Sadly, even the greatest minds out there in clinical research with Parkinson's disease still don't have an explanation of exactly why freezing episodes happen. What we do know is that there's a correlation between freezing of gait and off times when it comes to medication dosages for Parkinson's, off-times being the the peaks and valleys of medication effectiveness. Basically, there are peaks and valleys in the dosage levels of carbidopa/levodopa and the dopamine levels in the bloodstream. During off times folks with PD have difficulty moving or other symptoms between doses. Freezing does tend to happen more often during those off times and they are also unpredictble. So the best thing to know is to be empowered with the knowledge to do something about those freezing episodes when they do happen. We will cover that shortly. Before we do it is important to note that freezing episodes do tend to happen or can happen when there is a noticeable change in surfaces; for example, if somebody is walking down a hallway and it is  a tile floor and then it changes to carpet, or you go from a single monochromatic floor to a floor with a checkered pattern, or anything that may be off visually, that can trigger a freezing episode. It's transitions. And a lot of times in clinical practice, I've noted that turns while walking, approaching a chair to turn to sit in a chair, etc. can be times that will induce a freezing episode.

Now, if you are a care partner of a PwP, it is very important to remember is that trying to force somebody to move or take a step when they're having a freezing episode can be very dangerous as it can really increase their risk of having a fall. This is also why it's important also for you to know what to do as well as the person with Parkinson's.

But anyway, what to do about that when it happens. These are the best tips and cues that I am aware of or have seen success with in clinical practice:

March in place
So trying to just take high steps and stomp the feet in place, that can be very helpful in breaking out of a freezing episode. Even just shifting the weight from one leg to the other while in standing can do some good. Essentially, that's the same thing as marching in place, as you have to put weight on one leg and then the other. 

Play music with a really good BEAT
Auditory cues can be very helpful. Trying to take a step or march to the rhythm can break you out of a freezing episode.

Step over an object
Taking a cane or a stick or some kind of object that's small enough to step over and physically stepping over it can be very helpful to break out of a freezing episode.

Visualize stepping over something
Even picturing taking steps in your mind's-eye, particularly stepping over an object can be just as effective as literally stepping over something.

Use an Assistive Device (If you need one)
 I'm not saying you need to use an assisted device if you don't already have one, but if you are using a walker, you may consider getting a specialized walker, like a U-Step. Some of them have built-in lasers, and there's a company called Laser Cane that makes a cane that you can use to project a laser beam out in the form of a line on the floor so you can step over it. So it's kind of nifty, but obviously that would be if you really truly need a device. Generally speaking, folks that have really bad freezing episodes tend to be in more advanced stages of PD. So, somebody like that might be a better candidate for something like a U-Step walker just because of the stability of the device and it's built specifically for people with Parkinson's.

BREATHE and SLOW DOWN
Something just to keep in mind when experiencing a freezing episode is to take a deep breath and don't get in a hurry. Stress, anxiety, and trying to really rush can actually make the freezing episode worse and can actually increase your risk of falling due to the freezing.

Combining these all or some of these recommendations with BIG steps is very important. I'm certified in the LSVT BIG program for Parkinson's disease, and in that program we focus on high amplitude, meaning LARGE, high intensity movements. I often tell people if they're having a freezing episode while trying to turn while walking or trying to sit down to stomp the feet loud enough to actually hear a stomp. And if they're not hearing a stomp or feeling a stomp, they're not moving their feet big enough. Often that's enough of a cue to get their feet moving better so that they can complete that transition.

I'd love to know what your experiences have been with this, and whether you have Parkinson's or know somebody that does in your family or perhaps a loved one with PD. I'd also like to know what other tips that you've found to be helpful with freezing episodes that I may not know about. 

Next on the list is akathisia. This refers to the inability to become comfortable or the inability to get rid of a sensation. And so, that's essentially the same as restless leg syndrome and things like that. It can be experienced as an "icky" feeling, with jerky movements in the legs. That's also associated with Parkinson's, and there are various causes of restless leg syndrome that I have discussed on our YouTube Channel in a past video.

Sexual dysfunction is a very real thing for people with Parkinson's disease and you're going to be learning today about the connection with Parkinson's disease in this area, as well as what treatments are available. 

So does Parkinson's disease cause erectile dysfunction in men? The answer is yes. However, it's not always the case that Parkinson's is the primary cause of ED. The reason why this is the case is that PD directly results in damage to the autonomic nervous system. This, in turn, can result in issues of sexual function or result in sexual dysfunction because it is primarily a brain function. This is why anything that affects the brain can affect this area as well.

And so with that being said, Parkinson's can result directly in issues with ED. And if that's the case, it can be treated basically the same way it would be if it was any other cause. The one thing that I would stipulate here is that you need to be cautious to have your primary care physician and probably a urologist to do a consultation with you and to do a thorough workup to make sure that there are not other physiological causes of the ED. Examples would include conditions such as diabetes, which can result in nerve damage that can cause issues with this area. Peripheral vascular disease affects the blood flow and could also be a cause. You could have problems with enlarged prostate as well. Psychologically, even depression can result in issues with erection. Other medical conditions that aren't listed may also be causes and that root cause needs to be ruled in or out before treatment. In other words, another condition or conditions may need to be treated in addition to medication for the ED. 

The Parkinson's Foundation website has a page on male sexual health that I will link here. There's a list of common medications, though with the oral medications there's really not really any reason to introduce those. I feel like pretty much everybody has heard of these, but there are also a list of injectables and other alternative treatment options. Please note that the injectable treatments are directly into the penis, which is quite alarming to hear about and think about as a man, though if you are having issues in this department you will probably do whatever it takes. This is especially understandable if you are in an intimate relationship. I would hope that your physician is going to have a much more individualized recommendation rather than just a cursory look at the medications we're talking about. One other side note too is that there are some heart conditions which may be a contraindication or maybe preventing you from taking medications for ED. Outside of that they tend to be safe alongside Parkinson's medication. And as a matter of fact, I've had clients that are taking ED medication at the same time as their Parkinson's meds and they're doing fine.
​
So, in summary, ED can be linked to Parkinson's disease, even though the other causes may result in the problem. One way or the other, getting it treated is going to make a big difference in your life. 

If you have learned a lot from this blog post, please consider supporting us on Patreon as a co-producer. This also supports our YouTube channel and efforts on the Parkinson's Warrior Podcast. 

Many physicians may dismiss this question, but a well trained neurologist and/or movement disorders specialist should immediately recognize that there could be a connection between neuropathy and PD. The symptoms of neuropathy include tingling, burning, numbness, and pain in the hands, feet, or both. Peripheral neuropathy in PD is actually distinct from diabetic neuropathy in that with DM the damage done to nerves is due to high blood sugars and resultant fatty infiltrates that damage the blood vessels that feed the nerves. With Parkinson's Disease there is no known mechanism; however, there is a correlation between Parkinson's related neuropathy and deficiencies in Vitamin B6 and Vitamin B12. Why are these important? B6 is directly responsible for the health of nerve cells in the brain, spinal cord, and peripheral nerves. B12 not only helps B6 to do this job, but is also responsible for the health of myelin sheath building and maintenance. For a reminder of why myelin sheaths are important, just think Mutiple Sclerosis (MS). MS is a demyelinating disease, which results in nerve conduction becoming faulty and in some instances unable to happen at all. Specific supplemental treatment with these vitamins* can reduce the pain, numbness, and tingling that can come with neuropathy when in conjunction with PD and could help prevent the worsening of the symptoms. *Please NOTE: Vitamin B6 should not be taken when on Levodopa ALONE, but is safe with Carbidopa/Levodopa (Sinemet). 

This next bit is speculation on my part, but knowing what we know about PD and the gut-brain connection it makes me wonder if the connection between PD and vitamin B6 and B12 deficiency could be some form of absorption disorder in the gut that is associated with PD. If adequate gut health and normal flora of bacteria spell warding off such diseases as Parkinson's, then perhaps the opposite means higher likelihood of developing PD and also vitamin absorption issues? Recent research studies have suggested the possibility of such connections between the gut and developing PD, such as this one at University of Florida. 

The bottom line is that the treatment for B6 and B12 deficiencies is relatively non-invasive and your PCP and neurologist should be able to help you to come up with solutions for dealing with this moving forward. 

Something about PD that you may not know is that it directly damages the autonomic nervous system. This is the part of your nervous system that basically runs on autopilot. Your breathing, saliva production, tear formation, blood pressure regulation, heart rate and rhythm, digestion, etc are all controlled by the autonomic nervous system. Think fight or flight or resting and digesting and there you have it. When eating food and then digesting the smooth muscles in the gut rhythmically contract in a function called peristalsis. However, in a person with Parkinson's the muscles of the gut are inhibited and therefore do not contract efficiently. This slows down the flow of fecal matter in the small intestine and hence the colon. The stool then becomes dried out and harder, resulting in constipation. There are other factors that can directly make this worse or be secondary causes to constipation when associated with PD and that is what we will list next: 

•  Parkinson's medications can also slow down peristalsis contraction
  
• Dulled sense of smell and taste can result in people craving sweets that do not contain enough fiber
• Dehydration directly results in constipation due to water being pulled out of the gut by the body to use it in more critical areas for survival. ​

• Increase dietary foods such as vegetables, beans, lentils, etc. Fiber absorbs water and bulks up the stool making it easier to pass.
• Drink. More. Water. Water helps to keep the stool moving and stops it from becoming hard and dry.
• Exercise, exercise, exercise. Getting up and down frequently, moving, and standing up help to keep the gut moving through abdominal muscle contractions and gravity aiding things along as they move down and out. 
• Consult your physician on a regimen of daily laxitives that is appropriate for you.

Please leave your comments and reach out to me at any time if you have questions. The link below will allow you to schedule a call with me for consulting. 

Let's talk about the essential first steps (these are outlined in the video below as well):

Step 1. Assess the situation - After that first *twang* in your back - stop - breathe - try to see if you can move. If you can move without increasing your pain, then go to step 2. 

Step 2. Try gently move your back in different directions and seek out movement that relieves pain and/or seek a position of comfort that reduces your pain as you remain in that position.

Step 3. Keep moving. Find that direction of motion that feels better and keep moving your back in that direction. This may be a stretch to your back muscles, it may be backward bending at the waist, etc. You will know if it isn't going to help you very quickly. 

Step 4. Keep MOVING! - Motion is lotion. Keeping your back moving will help keep the joints lubricated and the soft tissues and connective tissues from getting "sticky." Walking daily is essential to keep your entire body moving fluidly and prevent loss of muscle, including the muscle on and around your spine. Bedrest is the last thing that you need, particularly with back pain. 

The video linked below explains all of this in some more detail and is the first in the series. Take these steps now: 1) Please watch  this video next. 2) Save the playlist for future reference. 3) Subscribe to my YouTube channel to get notified of even more self-help tools, and 4) Like and SHARE this with others! You never know how impactful an action that small can be and it is an act of kindness for the one you share with. 

Thanks for reading my post today. Be empowered, and you'll be hearing from me next week!

Hyland Physical Therapy offers free discovery visit/consultation. We see clients in our clinic, at their home/office, or online via telehealth calls. 
918-251-7199

The following exercises are found in the video that you just saw above. If you are looking for an exercise ball and yoga mat like used in the video you can get them via the links in this post. * For the following exercises, I recommend 5-10 repetitions of each immediately prior to sitting down on the piano bench. *As an Amazon Associate I earn from qualifying purchases

1. Standing pectoralis doorway stretch - This will help to open up the chest, stretch the pectoralis muscles, and to encourage erect posture.

2.  Standing pectoralis/biceps stretch  - Again,  this encourages opening up the chest and bringing the shoulders and arms back. Tightness in pectoralis major and minor can result in neural tension of the brachial plexus (this is the bundle of nerves that exit the neck, under the collar bone, and into the shoulder and arm).

3. Standing upper limb prayer stretch/neural glide - This exercise moves the entire upper limb through a range of motion that encourages lengthening the nerves of the upper body through all of the bends in the limb. This is not as specific, but is a great warm up exercise.

4. Median nerve glide - This is a specific stretch for the median nerve of the upper limb. This is the culprit in carpal tunnel syndrome as the median nerve is often compressed at the wrist. 

5. Radial nerve glide - Another specific stretch for the radial nerve. This supplies the sensation for the back of your hands and is the motor nerve for the muscles that extend the fingers and wrist.

6. Ulnar nerve glide - A specific stretch for the ulnar nerve. This supplies the sensation for the half of the palm near the ring and pinky fingers. This nerve can be compressed at the elbow (where your funny bone is) as well as at the wrist (Guyon's tunnel). Guitarists may need to worry about this one more than the medial nerve, but both are important to stretch for the keyboardist. 

7. Cervical/neck rotation, side bending, and flexion/extension - These are combined due to the fact that they are all the same area of the spine. These are great for general flexibility for the joints of the neck while turning the head right and left, bending to the side, and looking up/down. This is important for limbering up the joints of the neck as well as warming up the muscles that will be working to hold your head up while playing. 

8. Standing trunk rotation - General flexibility exercise for the upper and lower back to loosen up the joints of the spine and warm up the muscles of the trunk

9. Back extension - General flexibility exercise for the lumbar spine to encourage good sitting posture and to move the spine in the opposite direction of slouching. This can alleviate soreness in the back as well.  

10. Lower trunk rotation with legs on ball - Good general flexibility exercise for the lower back muscles and joints. This can be a great one for relieving stiffness and soreness in the lower back as well. If you are looking for an exercise ball you can purchase one here.*

*As an Amazon Associate I earn from qualifying purchases

 In this case, I mean in the LITERAL sense! 

So, here's the thing, there are a TON of exercises that you can do with an exercise ball.*​ If you have worked with me as a client before, or if you plan to in the future, there are so many ways you can prescribe exercise, even a home exercise program, with a ball* such as this. Why? Well, they are light weight, relatively easy to store, and you can do so many exercises without even using weights and you will really get a workout! I thought I would put together a list of exercises that would be really useful if you obtain a therapy ball. Any of the links found in this post will take you to a ball that I recommend in particular*. The GoFit professional stability ball is the one that I use in the clinic and in my videos, because its not expensive and it even comes with printed exercises on the side to give you an extra challenge and ideas of what to do. WARNING, I would NOT start with the ones printed on the side of this particular ball. But I am going to give you even MORE ideas so you can get started now! ( Wave your mouse over images for caption). These particular exercises would be helpful for back pain. *As an Amazon Associate I earn from qualifying purchases

​So here goes: 

                                         Prone Glut Sets                                                                                      Bridges on ball

                                         Wall Ball Squats                                                                                   Ball passes

                             Lower abdominal sets                                                                                 Ball crunches

                                        Arm lifts on ​ball                                                                                    Leg lifts on ​ball

Alternating arm/leg marches seated on ball                                            Alternating arm/leg lift on ​ball

I hope you find these exercises helpful and that this gives you an idea of how you might manage back pain by obtaining a therapy ball. This one tool could save you lots of time and money due to space savings and versatility. For more information, please call me today to discuss other ideas for treating your back pain. 918-251-7199. 

P.S. If you are looking for a soft spot to lay this yoga mat is the one I use and I love it because of its extra cushioning! Be empowered!

*As an Amazon Associate I earn from qualifying purchases 

Osteoporosis (OP) is a condition effecting the bones and is associated with very low bone mineral density (BMD). The name itself means "porous bones" and results in the bones becoming brittle and leading to fractures due to bone fragility. This is typically associated with women, but men can also have the condition as sex hormones diminish over the decades. Most, if not all people with OP, started out with osteopenia (low BMD, but not yet progressed to osteoporosis). This is the best time to prevent onset of OP, but even those with OP can prevent worsening of the condition, prevent fractures, and prevent falls that lead to fractures. Osteoporosis Canada has great resources on the condition. The full list of "fast facts" can be found here, but to me one of the most profound listed is that 80% of fractures in those 50+ are due to OP. Many of these folks will not be diagnosed with OP and will not be prescribed the correct preventative treatment. Medications and supplements are very important, but exercise is a crucial medicine for OP. 

Why Exercise Is Important With OP
Reason 1: Preserving bone density.
With aging we all start to lose bone density as young as our thirties. The amount of exercise and physical activity that you challenge your body with, as well as the amount of calcium that you consume in youth, have a direct impact upon the health of your bones as you age. Think of it as a bank where you make deposits over time. The more you store up for the future, the more healthy your bones are. But again, why is exercise so important? Two words: Wolff's Law. Wolff's Law states that bone will adapt to the stresses placed upon it. The more stress, the more the bone will grow. The lower the stress, the less bone will grow. The bone that is particularly susceptible to becoming brittle and fracturing is called trabecular bone, or cancellous bone. Let's look at the anatomy for a moment. Trabeculae are bony projections within the bone that result in a matrix or lattice work that supports load bearing. The long bones of the body such as the humerus and femur have trabecular bone in the ends where the load is particularly important, for example the shoulder and hip. The vertebrae of the spine also contain trabecular bone. While the cortex of the bone, the outer wall, is also thick in the ends of long bones due to load bearing, trabeculae provide even more support for tension or compression forces in the bone. Think of them as little columns or buttresses supporting the large outer walls. These structures are the first to go with OP and literally make the trabecular bone disappear. Without this extra support fragility fractures are highly likely. Weight bearing activity and resistance training places stress upon the bone and results in bone building that can protect from losing bone density over time. Even if you already have OP when you start exercising, these types of exercises will still help to prevent fractures. 
Reason 2:  Preventing Falls
As we age our muscle tissue will slowly deteriorate if nothing is done to prevent it. Last week, we discussed sarcopenia, or progressive muscle tissue loss, as a preventable disease of advanced age. Preserving muscle strength is not only important for bone health, as the bone at the musculotendinous junction is thickened by the pull of muscle placed upon it, but also just as important for preventing onset of weakness in the lower body and trunk. This weakness results in poor balance reactions to prevent falls and inability to stop fall once a loss of balance occurs. Falls are a source of many of the fractures that occur with OP. Remember the statisic we saw earlier about 80% of fractures in the aging adult being the result of OP? If we can prevent the falls that lead to the fractures through exercise we can also prevent the loss of bone mineral density that leads to OP at the same time. 1 in 4 adults over the age of 65 will fall in 2018. How many will break a hip or a wrist, even a vertebrae? How many will not return home after they fall? Our easy chairs are more deadly than most people realize. It's time to get moving!

What Exercises Are Safe with Osteoporosis?
As a physical therapist, exercise prescription is a daily part of my job. With aging adults this takes more skill and adaptation. There are many ways to strengthen the muscles and to preserve flexibility without stressing the spine in a dangerous way. This is where a PT is so valuable and why we need to be training more people that are not therapists in exercise programs that encourage bone health without danger of fractures. There are programs out there that are very valuable that I will provide links to below. The guidelines of the ACSM state the following for recommendation of exercise for people with OP:

Frequency: Weight bearing aerobics 3-5x/wk (if not daily) and resistance training 2-3 days per week
Intensity: For aerobics, moderate exercise starting at 40% and working up to 60-80% of heart rate reserve. For resistance training, moderate intensity at 10-13 on Borg Rating of Perceived Exertion and 60-80% of 1 rep maximum.
Time: 30-60 minutes total each day of exercise
Type: Weight bearing aerobics such as walking,  jogging, or elliptical. Water aerobics also valuable. Resistance training with bands, weight machines, or anti-gravity with supervision of a physical therapist.

Here is what to look out for ->

• No twisting the spine (rotation is not the same as twisting and there are safe ways to do this).
• No bending forward such as in crunches, sit ups, etc. There are safe excellent core strengthening exercises that to not require spinal flexion. 

There are great resources out there for OP and these guidelines are great for preventing fractures as well as options for community based exercise programs for bone health. The following list is short, but valuable:

• Do It Right! And Prevent Fractures! - Sponsored by the Academy of Geriatric Physical Therapy
• Too Fit to Fracture - Sponsored by Osteoporosis Canada

At Hyland Physical Therapy and Wellness we are developing an exercise class for people with osteoporosis that is based upon the guidelines we have discussed today. This would be available in group format, but at any point I am available to consult with you individually to develop a safe program specifically for you. Contact me today to find out more. The links below will help you to get in touch with me.