04georgy-upr

European Journal of Adapted Physical Activity, 3(1), 49–59 European Federation of Adapted Physical Activity, 2010 FREEZING OF GAIT IN PARKINSON'S DISEASE: IMPACT ON FALLS RISK,
WALKING AIDS UTILIZATION, AND ASSISTANCE-SEEKING BEHAVIOUR
Ehab Georgy
Senior Physiotherapist, Hampshire Community Health Care, United Kingdom Freezing of Gait (FOG) is one of the most disturbing symptoms in advanced stage of Parkinson's disease (PD) that is strongly associated with recurrent falls and reduced functional independence. The purpose of the study was to determine the impact of FOG on mobility in terms of risk of falls, walking aids utilization and assistance-seeking behaviour by comparing freezers (FRs) and non-freezers (NFRs). Clinical and demographic data, including disease duration, stage and characteristics, cognition, medication, history of falls, walking aids utilization, and assistance-seeking behaviour was collected from 102 subjects with PD from three medical centres in Belgium, Israel, and UK. Association between FOG and other disease characteristics, medication, falls, walking aids, and need for carers' assistance was investigated. Comparing FRs and NFRs showed significant difference in history of previous falls, walking aids utilization, and need for carers' assistance. More than half of the FRs reported previous fall and a need for walking aids for mobility compared to 20% in NFRs group. A vicious cycle exists among subjects with PD who experience FOG. Gait freezing induces increased risk and frequency of falls as well as increased fear of falling, which in turn increases the tendency towards higher reliance on carers' assistance and more utilization of walking aids. KEYWORDS: Parkinson's disease, gait freezing, falls, walking aids, assistance. such as doorways, reaching destination, or even spontaneously whilst walking in open Freezing of gait (FOG) is a frequent space (Schaafsma et al., 2003). It has been phenomenon in subjects with Parkinson's suggested that FOG should be added to the disease (PD), with prevalence rates ranging list of cardinal symptoms of PD (Fahn, 1995; from 7% in the early stages of PD to about Giladi et al., 2001b), in part because of its 60% in the more advanced stages (Bartels, important independent effects on function and Balash, Gurevich, Schaafsma, Hausdorff, & quality of life in PD (Hausdorff, Schaafsma, Giladi, 2003; Giladi et al., 2001a; Giladi et Balash, Bartels, Gurevich & Giladi, 2003), al., 2001b; Lamberti et al., 1997). Giladi et al. (2001a) stated that 53% of those with disease pathophysiologic mechanisms seem to be duration of more than five years develop different from those of other features of PD FOG. Typically, FOG is a transient halt of (Bartels et al., 2003; Hausdorff et al., 2003). gait, lasting <1 min, during which the subject Gait disturbances in general, and FOG complains that his feet are suddenly "glued to more specifically, may partly develop as a the floor" (Schaafsma, Balash, Gurevich, result of both the complex effect of the Bartels, Hausdorff, & Giladi, 2003). During a progression of the disease in conjunction with typical FOG episode, such feeling exists for a long term side effects of antiparkinsonian few seconds (Giladi et al., 2001a). When medication (Giladi et al., 2001a; Giladi et al., starting to walk, subjects with PD may 2001b). FOG is rarely the presenting experience FOG as a sudden inability to symptom of PD (Lamberti et al., 1997); initiate walking or a temporary difficulty in however, at the advanced stages of the continuation of walking (Bartels et al., 2003). disease, FOG is a very disabling symptom, Other situations that elicit FOG include lasting seconds to minutes, frequently turning hesitation, approaching narrow spaces EUJAPA, Vol. 3, No. 1 Freezing of gait in Parkinson´s disease associated with falls and injuries, and may as SUBJECTS AND METHODS
well become the most disabling symptom This study build its basis on a larger study which forces the patient to stay at home or use (Nieuwboer et al., 2009), which aimed at a wheelchair (Giladi et al., 2001a). FOG is investigating and establishing the validity and associated with increased risk of falls and reliability of the New Freezing of Gait hospitalization, Questionnaire (NFOG-Q); data from this independence, impaired health-related quality bigger study was used as basis of the current of life, and even higher risk of mortality (Bloem, Hausdorff, Visser, & Giladi, 2004; Cubo, Leurgans & Goetz, 2004; Giladi et al., Study population 2001a; Gray & Hildebrand, 2000; Hely, Participants were one hundred and two Morris, Traficante, Reid, O'Sullivan & subjects from three different medical centres: Williamson, 1999). Gait disturbance, reduced Tel-Aviv Sourasky Medical Centre, Israel (n mobility, falls risk and social isolation are the = 23); University Hospital Leuven, Belgium major contributors that might negatively (n = 40); and Northumbria University, United influence the patients' physical and mental Kingdom (n = 39). Data collection was health, social interaction, and quality of life completed by February 2007 with all required (Bloem et al., 2004; Davis, Lyons, & Pahwa, demographic and clinical data being collected 2006). The fear of additional falls due to FOG from all participants from the three medical leads to restriction of activities and reduced centres and gathered in Belgium for analysis. mobility, which in turn can lead to a higher All patients attending neurology outpatient likelihood of osteoporosis and accordingly clinic and fulfilling the inclusion criteria were higher risk of fractures (Bloem et al., 2004; asked to participate in the study over a 9- Davis et al., 2006). Health care systems are month period. Eligible participants were always striving to reduce hospital admission identified by a consultant neurologist during due to its anticipated devastating impact and the hospital visit according to the following negative effects on patients' health as well as inclusion criteria: diagnosis of PD using the its economical and financial burden. Previous Brain Bank criteria (Hughes, Daniel, Kilford, falls history or high risk of falls are among the & Lees, 1992), a Mini Mental State Exam leading reasons for hospital admission; (MMSE) score of at least 24 and were therefore, studies investigating causes and clinically non-demented. Subjects were taking possible predictors of falls in different their regular medication during testing. patients' groups are significantly important in Design and procedure order to design rehabilitation approaches and The study adopted a prospective cross- interventions that can tackle and modify such sectional correlational design. Demographic precipitating risk factors. Based on the and clinical data was collected for all subjects, reviewed literature that suggests a link including years since the onset of disease, between FOG and falls risk, this study previous brain surgery, cognition (MMSE), provides further exploration of this aspect by and the Hoehn & Yahr disease stage scale investigating the association between FOG (H&Y) (Hoehn & Yahr, 1967). Subject- and risk of falls, walking confidence and level reported history of falls, in terms of number of independence. The current study aims to and type of previous falls within the last six investigate the impact of FOG on mobility in months, as well as subject-reported walking terms of falls risk, walking aids utilization, aids utilization were recorded. Assistance- assistance-seeking seeking behaviour, i.e. the need for carers mobilising in subjects with PD by comparing help (spouse, relative or other), was also freezers (FRs) and non-freezers (NFRs). reported by asking the subjects to identify the Further analysis of the association between range of functional activities they might need gait freezing and disease stage, characteristics help with. Disease characteristics were and medication is also reported. explored by completing part three of the EUJAPA, Vol. 3, No. 1 Freezing of gait in Parkinson´s disease Unified Parkinson's Disease Rating Scale Pergolide, Pramipexole, or Cabergoline; 5 mg (UPDRS-III), which investigates the impact of Ropinirole; and 10 mg of Bromocriptine of PD on the motor function, in addition to (Deuschl, Schade-Brittinger, Krack et al., question 14 (Q-14) of part two of the scale (UPDRS-II), which investigates the frequency All subjects provided informed consent of occurrence of FOG and its impact on according to the Declaration of Helsinki and walking and falls (Fahn & Elton, 1987). approved by the Ethics Committee University The NFOG-Q, a valid and reliable tool for Hospital Leuven, Tel Aviv Sourasky Medical measuring FOG (Nieuwboer et al., 2009), was Centre Ethics Committee and Sunderland used to distinguish between FRs and NFRs. Local Research Ethics Committee. The Part I of the questionnaire detected the NFOG-Q was written in English and presence of FOG using a dichotomous item in translated to Dutch and Hebrew. Data which individuals were classified as a FRs or collection procedures were standardized and a NFRs if they had experienced FOG- harmonized across centres by means of a episodes during the past month. Part II mainly detailed data collection booklet summarizing investigates the severity of FOG in terms of data collection techniques and procedures as the duration and frequency of the episodes in well as all spreadsheets and data collection its most common manifestation, i.e. during forms and templates to be used. turning and initiation of gait (items 2-6). Statistical analysis While Part III is concerned with the impact of FOG on daily life activities and function Distinguishing FRs and NFRs. Kappa
(items 7-9). To enhance the description of statistic for agreement was calculated between FOG, all participants watched a video to NFOG-Q and Q-14 scores to ensure accurate clarify different types and duration of FOG episodes; this 70-second video segment participants and to investigate the ability of contained one general example of FOG in a the NFOG-Q to distinguish between FRs and doorway, then 3 more examples were shown: two of turning-FOG (11 seconds and 1 Comparison between FRs and NFRs.
second) and one of initiation-FOG (5 Chi-Square test was used to investigate seconds). Each subject was allowed to watch differences in falls risk, walking aids the video for a maximum of two times before utilization, and assistance-seeking behaviour completing the questionnaire. Patients were between FRs and NFRs. Further analysis was asked to complete the NFOG-Q in general; done to investigate possible aggravating i.e. not distinguishing between on and off factors by exploring the differences between states; the "off" state is when the effect of FRs and NFRs in terms of age, cognitive medication starts to wear off and the function (MMSE) and disease duration using symptoms of PD start to worsen before the unpaired t-test. Mann-Whitney U test was next dose of medication is administered. This used to investigate the difference in disease is likely to affect the severity of FOG and its stage by comparing the H&Y scores between impact on gait and function. the two subgroups. To investigate the Antiparkinsonian difference in disease characteristics between recorded in a separate medication spreadsheet. FRs and NFRs, a single score for the UPDRS To investigate the relationship between FOG items including multiple body parts was and different antiparkinsonian medication, the generated based on the worst function in case of asymmetry between right and left. The calculated so that a 100mg daily dose of total scores on the UPDRS were compared standard Levodopa was equivalent to the between FRs and NFRs using unpaired t-test. following doses of other medications: 133 mg Correlation between FOG and other
of controlled-release Levodopa; 75 mg of disease characteristics. Further elaboration
Levodopa plus Entacapone; 1 mg of and analysis of the data were done to explore the association between gait freezing and EUJAPA, Vol. 3, No. 1 Freezing of gait in Parkinson´s disease other significant disease characteristics by mobility. The total NFOG-Q scores were also analysing the collected data from all correlated to the H&Y scores and the daily participants (n= 102) regardless of the dopamine dose equivalent using Spearman's coefficient. A p-value of less than 0.05 (two- relationship between FOG and disease tailed) was considered statistically significant. characteristics, all participants' NFOG-Q Statistical analysis was performed using SPSS scores were correlated with the UPDRS-III for Windows (Version 11.5). coefficient. In addition, the total NFOG-Q scores were correlated with question 29 (Q-29) of the UPDRS-III, which specifically Subjects' characteristics investigates the gait disturbance and the need Subjects' characteristics are shown in for assistance while walking for further in- depth analysis of the impact of FOG on
Table 1
Subjects' characteristics
Levodopa
UPDRS Falls
Assistance
7.5 (I), 16 (II) 65.5 (III), 16 (IV) Figures represent mean values ±SD, except for gender, falls, walking aids and assistance. M= male and F= female, DD= disease duration, MMSE= Mini Mental State Exam, H&Y = Hoehn and Yahr stage (I–IV), UPDRS= Unified Parkinson Disease Rating Scale, % Falls = percentage of patient reporting a fall over the last 6 months. relatives (4%), or professional caregivers participated in the study (68 male, 34 female), (6%). Subjects reported needing assistance with average age of 68.5 years and mean with washing and dressing (58%), gait (33%), disease duration of 9.6 years. The mean score fine motor activities (21%), rising from bed on the MMSE was 28.1 (±1.9). Ten subjects (15%), transfer activities (7%), domestic help (9.8%) had undergone deep brain stimulation. (6%), and turning in bed (5%). Ninety percent of the patients received an Distinguishing FRs and NFRs average Levodopa dose of 578.5 mg/day. Seven and half percent of the subjects were in In order to accurately identify FRs among stage I of the disease according to H&Y all participants and to examine the ability of clinical staging, 16% were in stage II, 65.5% the NFOG-Q to distinguish between FRs and were in stage III and 16% were in stage IV. NFRs, a 2x2 table for agreement was The mean UPDRS-III score was 30.4. Forty- constructed between NFOG-Q and Q-14 five percent of the subjects reported using (UPDRS-II) scores. Kappa statistic for walking aids for mobility, including walking agreement was calculated at 0.65, showing a moderate agreement. Q-14 data was not scooters. Forty-two percent reported previous available for one patient. Table 3 summarizes history of falls during the previous 6 months, the relationship between the Q-14 and the ranging from one to 360 falls. Sixty-eight NFOG-Q mean scores. percent of the subjects needed various forms of assistance. Assistance was provided by spouse in 86% of the cases; other carers included other family members (4%), distant EUJAPA, Vol. 3, No. 1 Freezing of gait in Parkinson´s disease Agreement between NFOG-Q and Q-14 Descriptive summary of the relationship between the Q-14 and NFOG-Q mean scores Kappa measure of agreement Comparing FRs and NFRs Comparing FRs and NFRs showed no Chi square was used to compare FRs and significant differences regarding age (p = NFRs in terms of falls history, walking aids 0.853) or MMSE (p = 0.762). Comparing utilization, and need for assistance (Table 5). disease profiles between FRs and NFRs There were significant differences in the use (Table 4) showed that FRs had significantly of walking aids (p = 0.0004), previous history longer disease duration (10.9 ±6.1 years of falls (p = 0.006), and need for assistance (p versus 8 ±6.2 years, p = 0.0001), more severe = 0.002). FRs used more walking aids, tended H&Y stages (median = 3 [2; 4] versus 2 [0; to fall more, and seemed to be in more need 3], p < 0.0001), and higher UPDRS-III scores for assistance by their carers. (31.9 ±15.7 versus 22.7 ±11.7, p = 0.003).
Table 4

Comparison between FRs and NFRs for age, cognitive function (MMSE), disease duration,
characteristics (UPDRS) and stage (H&Y)
Freezers
P value
Figures represent mean values ± standard deviation, except for the disease stage, where it represents median and range, ** Significant defference. Comparing assistance-seeking behaviour FRs stated that they needed their carers to between FRs and NFRs revealed that only help them with various transfer activities three NFRs sought their carers' help for including rising from chair or bed, car mobility. The majority of activities that transfers, or getting in and out of bath. required carers' assistance were washing and Additionally, assistance for washing and dressing, bed mobility, and other domestic dressing were fairly prevalent in the FRs help. On the other hand, FRs sought help subgroup. A larger proportion of FRs (52%) more often. Eighteen FRs reported that they reported a fall over the past 6 months than required assistance while mobilising, and 15 NFRs (21%) (p = 0.003). EUJAPA, Vol. 3, No. 1 Freezing of gait in Parkinson´s disease Table 5
Comparison between FRs and NFRs for falls, walking aids utilization and need for assistance
Previous Falls
Walking aids
Assistance
X2= Chi Square Statistic More than half of the FRs (58%) needed the effect of visual and auditory stimuli, and to use different walking aids for mobility, mood influence make FOG a complex compared to 18% only of the NFRs (p = symptom to study (Giladi et al., 2001b). This 0.004). Similarly, more than two thirds of the article compared FRs and NFRs to investigate FRs (78%) needed carer assistance, while less the impact of FOG on mobility in terms of than half of the NFRs required such assistance falls risk, walking aids utilization, and (p = 0.002). Within the FRs group, significant assistance-seeking correlations were found between NFOG-Q mobilising, as well as to explore the scores and H&Y stage (R = 0.3, p = 0.03) and relationship between FOG and other PD falling (R = 0.35, p = 0.003). characteristics. In the current study, the NFOG-Q was Correlation between FOG and other disease effectively used to distinguish FRs and NFRs. characteristics The moderate agreement (Kappa = 0.65) Spearman correlation coefficient showed between NFOG-Q and Q-14 of UPDRS-II weak correlation between NFOG-Q and (frequency of FOG and its impact on walking UPDRS-III scores (R = 0.24, p = 0.018), and falls) suggests that the two scales were moderate correlation between NFOG-Q and measuring a similar construct, but it was not H&Y scores (R = 0.6, p = 0.0002), and so high as to suggest that the two scales were moderate correlation with the daily dopamine necessarily measuring the same dimensions of dose equivalent (R = 0.5, p = 0.0001). FOG. Question 14 of the UPDRS-II is mainly Spearman's coefficient also showed moderate concerned with the impact of falls and FOG correlation between NFOG-Q total scores and on the daily life activities, while NFOG-Q Q-29 of the UPDRS-III (R = 0.6, p = 0.0002). was constructed to assess the different aspects of FOG including presence, severity in terms of duration and frequency, and finally the DISCUSSION
impact on function and activities. The The freezing phenomenon has been moderate correlation between the two observed in subjects with PD for more than measures reflects the ability of NFOG-Q to 120 years, but its pathophysiology and distinguish between FRs and NFRs. clinical course remain poorly understood When comparing FRs and NFRs, there (Giladi et al., 2001b). FOG is a frequent was no significant difference regarding age (p feature associated with PD with significant = 0.853) and MMSE (p = 0.762). It was effect on patient's mobility and quality of life previously suggested that FRs are, in general, (Giladi, Shabtai, Rozenberg, & Shabtai, more motor impaired than NFRs as a result of 2001c). The episodic nature of this symptom, EUJAPA, Vol. 3, No. 1 Freezing of gait in Parkinson´s disease specific attention deficit and that such frontal maybe due to the improper use of the walking attention deficits may form the basis for FOG aids, e.g., carrying the walking frame instead in PD (Camicioli, Oken, Sexton, Kaye & of using it for support (Bloem et al., 2004). Nutt, 1998). Furthermore, strong correlation Moreover, using walking aids for mobility might reduce the patient's attention, and depression, and cognitive impairment, and it subsequently lead to FOG and falls; was suggested that those factors might set the performing a secondary task while walking stage for and increase the likelihood of FOG was suggested to trigger FOG leading to (Giladi & Hausdorff, 2006). However, the frequent falls (Bloem et al., 2004). Within the current study showed no significant difference FRs group, significant correlations were in the MMSE scores between FRs and NFRs; found between FOG and history of falling possibly, due to the fact that subjects with suggesting a close association between FOG MMSE scores of less than 23 were excluded and increased falls risk. Bloem et al. (2004) from the study. In this study context, projected that the suddenness of FOG will comparison of MMSE between FRs and lead to balance disturbance and predisposition NFRs should not be used to explain the to falls. Knowing that FOG is more common in crowded places, narrow spaces, and in development of FOG. Conversely, comparing time-restricted, stressful situations such as when the telephone or doorbell rings differences in disease duration, H&Y stage, (Schaafsma et al., 2003), it is not surprising UPDRS-III score, and daily Dopamine dose, that FRs tend to have higher rates of falls and with the FRs having longer disease duration, greater risk of balance disturbance. Moreover, higher H&Y stages, higher UPDRS-III scores, in more advanced stages of PD, FOG can and higher medication doses, which again appear more frequently and be more stresses the role of disease duration, disease prolonged, thereby severely limiting walking progression and Levodopa treatment as and creating higher risk of falls (Giladi et al., significant contributing factors for the 2001a; Giladi et al., 2001b). In addition to the presence of FOG. high prevalence of falls and the higher Comparing history of previous falls, percentage of walking aids utilization in the walking aids utilization, and need for carers' FRs group, a moderate correlation was also assistance between FRs and NFRs showed found between NFOG-Q total scores and Q- significant difference between the two groups. 29 of the UPDRS-III, which investigates the FRs tended to use walking aids more than gait disturbance and need for assistance while NFRs, yet they were still more susceptible to walking in FRs. Gait disturbance and high falls than NFRs. More than half of the FRs risk of falls seem to be the main trigger for reported between one and 360 falls within the assistance-seeking behaviour in FRs. More last six months compared to only 20% of than two thirds of the FRs needed carer NFRs reporting falls. Falls secondary to gait assistance, mainly for mobility and transfer disturbances and FOG in subjects with PD related activities, compared to less than half might be attributed to less rhythmic of the NFRs requiring such assistance. accelerations at the pelvis in the vertical and The results of the study show a weak anteroposterior planes, which creates an correlation between the NFOG-Q and the inability to control displacements of the torso UPDRS-III scores (R = 0.24), providing when walking and might impose higher further evidence that FOG is an independent predisposition to falls in this population (Latt, motor symptom of PD, caused by a Menz, Fung, & Lord, 2009). Similarly, more paroxysmal pathology that is different from than half of the FRs stated that they needed to that responsible for bradykinesia, rigidity or use different walking aids for mobility postural instability (Bartels et al., 2003). On compared to 18% only of the NFRs. The high the other hand, moderate correlation (R = 0.5) rate of falls despite the use of walking aids was found between NFOG-Q and the daily EUJAPA, Vol. 3, No. 1 Freezing of gait in Parkinson´s disease dopamine dose. This is in line with previous weakness, and eventually will result in poorer studies that investigated the relationship quality of life, more need for hospitalization, between FOG and Levodopa treatment; total and nursing home admission. An effective Levodopa daily dose and duration of way of addressing such cycle might be to Levodopa treatment were strongly associated ensure proper use of the walking aids among with the presence of FOG (Giladi et al., FRs and provision of appropriate training on 2001a; Lamberti et al., 1997). FOG tends to the use of such aids in order to minimise the be mild, short lasting, and with minimal risk of falls related to the improper use of the impact on gait at the early stages of the walking aids. One of the limitations of the disease prior to the introduction of Levodopa, study is that it did not distinguish between the while at the advanced stages of PD, FOG is "on" and "off" states of medication. Further much more disabling, lasts longer, and studies should take into account testing the frequently leads to falls (Giladi et al., 2001a). subjects during the "on" and "off" states. This confirms previous reports that disease progression and Levodopa treatment are CONCLUSION
development (Giladi et al., 2001a; Lamberti et The results of the current study confirm that FOG might be an independent motor In previous investigations, higher H&Y symptom of PD that has a different stages were associated with the occurrence of underlying pathology than those of other PD FOG (Giladi et al., 2001a; Lamberti et al., symptoms. It also suggests that disease 1997). In the current study, moderate duration, medication, and disease progression correlation were observed between the might be influential predictors of the presence NFOG-Q and the H&Y scores (R = 0.6) of FOG. Comparing FRs and NFRs revealed suggesting a high association between the that FOG is associated with greater gait FOG and the disease progression as indicated disturbance and higher risk and frequency of by the H&Y stage. It was proposed that the falls, subsequently leading to more walking strong relationship between FOG and H&Y aids utilization and more need for carers to stage is not just due to the effect of the progression of the PD in general but Interventions are needed to address falls and specifically with the development of postural FOG in the PD population to ensure reflexes abnormalities in stage three of the H&Y scale (Giladi et al., 2001a). quality of life for subjects as well as The findings of this study suggests the presence of a vicious cycle among subjects with PD, where FOG constitutes a major risk factor for increased frequency of falls among PERSPECTIVE
FRs as well as increased fear of falling and The FOG-related gait disturbance and risk reduced confidence while walking, which in of falls have devastating impact on the turn increases the tendency towards higher patients' lives, as, in most cases, it will lead to reliance on carers' assistance and more utilization of walking aids. It also suggests that FOG-related gait disturbance, increased assistance, reduced independency and poor fear of falling, and reduced independency will general physical and mental well-being. From all lead to reduced mobility and functioning, research, clinical and policy perspectives, with subsequent weakness, osteoporosis, FOG and falls have recently received increasing recognition for their clinical impact deconditioning, which might raise the risk of on the patients and the financial burden on the injuries, fractures, and further postural health care systems. Most health care systems instability secondary to osteoporosis and strive now to achieve the balance between EUJAPA, Vol. 3, No. 1 Freezing of gait in Parkinson´s disease high quality heath services and cost-effective Fahn, S., & Elton, R.L. (1987). Unified health care systems. Interventions looking Parkinson's Disease Rating Scale. In: Fahn, into addressing the problem of FOG in S., Marsden, C.D., Goldstein, M., & Calne, subjects with PD will serve to reduce risk of D.B. (eds) Recent Developments in falls, improve mobility, independence and Parkinson's Disease. Macmillan, New York, quality of life, and reduce health and social Fahn, S. (1995). The freezing phenomenon in Parkinsonism. In: Fahn, S., Hallett, M., Lüders, H.O., & Marsden, C.D. (eds). Negative motor phenomena. Advances in REFERENCES
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STURZRISIKO, GEBRAUCH VON GEHHILFEN UND HILFESUCHVERHALTEN
Ein starres Gangbild (Freezing of Gait – FOG) ist eines der am meisten störenden Symptome im fortgeschrittenen Stadium der Parkinson-Krankheit (Parkinson Disease – PD), das auch stark mit wiederkehrenden Stürzen und reduzierter funktionaler Unabhängigkeit verbunden ist. Die Absicht dieser Studie war es, den Einfluss dieses starren Gangs auf die Mobilität hinsichtlich Stürzen, Gehhilfen und Hilfesuchverhalten zu untersuchen, indem Betroffene mit („freezers" – FRs) und ohne starres Gangbild („non-freezers" – NFRs) verglichen wurden. Klinische und demografische Daten, einschließlich Erkennung, Dauer, Phase und Charakteristiken der Krankheit, Medikation, Sturzchronik, Gebrauch von Gehhilfen sowie auftretendes Hilfesuchverhalten, wurden von 102 Probanden mit PD von drei medizinischen Zentren in Belgien, Israel und UK gesammelt. Eine Verbindung zwischen FOG und anderen Krankheitscharakteristiken, der Medikation, Stürzen und dem Bedarf an Betreuungshilfe wurde untersucht. Der Vergleich zwischen FRs und NFRs zeigte signifikante Unterschiede in der Vorgeschichte hinsichtlich Stürzen, dem Gebrauch von Gehhilfen und dem Bedarf an Betreuungshilfe. Mehr als die Hälfte der FRs berichteten von früheren Stürzen EUJAPA, Vol. 3, No. 1 Freezing of gait in Parkinson´s disease und von Bedarf an Gehhilfen gegenüber nur 20 % in der Gruppe der NFRs. Ein Teufelskreis scheint zu existieren unter den Probanden mit PD, die ein starres Gangbild (FOG) aufweisen. Die Starrheit des Ganges induziert ein erhöhtes Risiko und höhere Häufigkeit von Stürzen sowie auch vermehrte Sturzangst, die wiederum die Tendenz zu stärkerem Vertrauen auf Betreuung und mehr Gebrauch von Gehilfen ansteigen lässt. SCHLÜSSELWÖRTER: Parkinson-Krankheit, starres Gangbild, Stürze; Gehhilfen, Assistenz. "FREEZING" LORS DE LA MARCHE CHEZ DES PERSONNES ATTEINTES DE LA
MALADIE DE PARKINSON : IMPACT SUR LES RISQUES DE CHUTE,
L'UTILISATION D'AIDE A LA MARCHE ET COMPORTEMENT DE RECHERCHE
Le « freezing » durant la marche est un des symptômes les plus perturbants lors du stade avancé de la maladie de Parkinson qui est fortement corrélé avec des risques de chute et une réduction de l'indépendance fonctionnelle. L'objectif de cette étude était de déterminer l'impact du « freezing » lors de la marche sur les risques de chute, l'utilisation d'aide à la marche et le comportement de recherche d'assistance en comparant des sujets atteints de freezing (FR) et d'autres non atteints de freezing (NFR). Des données cliniques et démographiques ont été collectées auprès de 102 patients atteints de la maladie de Parkinson provenant de centres médicaux Belges, Israélien et Anglais. Ces données incluaient la durée de la maladie, le stade et les caractéristiques, la cognition, la prise de médicaments, l'historique des chutes, l'utilisation d'aide à la marche and le comportement de recherche d'assistance. L'association entre le freezing lors de la marche et les autres caractéristiques de la maladie, la prise de médicaments, les chutes, les aides à la marche and le besoin d'assistance ont été étudiés. La comparaison des deux groupes, FR et NFR, a révélé une différence significative de l'historique des chutes, de l'utilisation d'aide à la marche et du besoin d'assistance. Plus de la moitié des sujets FR ont rapporté des chutes et l'utilisation d'aide à la marche contre 20% pour les sujets NFR. Un cercle vicieux existe chez les personnes atteintes de la maladie de Parkinson et qui sont sujets au freezing durant la marche. Freezing durant la marche augmente le risque et la fréquence de chute ainsi que la peur de tomber, ce qui par conséquent augmente la recherche d'assistance et l'utilisation d'aide à la marche. MOTS CLEFS: Maladie de Parkinson; freezing de marche; chutes; aide à la marche; assistance. EUJAPA, Vol. 3, No. 1

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UNIVERSITY OF TASMANIA Understanding Applied Pharmacology: Perceptions of undergraduate student nurses Final Report for the SNM HDR Committee Ms Juliet Sondermeyer, Dr Christine Spratt, Dr Christine Armatas and Mr Daniel Goss January 2006 FACULTY OF HEALTH SCIENCE School of Nursing and Midwifery

The first marathon runner wasn't greek, he was jewish - jewish world features israel news haaretz

The first marathon runner wasn't Greek, he was Jewish - Jewish World . SUBSCRIBE TO HAARETZ DIGITAL EDITIONS ריעה רבכע Not a member? Register now A vindication that theshow must go on Search Haaretz.com Thursday, August 07, 2014 Av 11, 5774 ARCHAEOLOGY PODCASTS NEWS BROADCAST Israel-Gaza conflict: In depth The IDF's Gaza fallen Israeli archaeology 10:04 PM Russia to ban all U.S. food, all EU fruit, vegetable imports (Reuters)