Brief Answer:
Falls

Detailed Answer:

Hello,

It sounds as if you've been diagnosed with PARKINSON'S DISEASE or at least some type of PARKINSONIAN SYNDROME. You've been prescribed a very common medication whose brand name is SINEMET but available in generic form as Carbidopa/Levodopa. You're also on selegeline which works adjunctively (or in concert with) the levodopa component of your regimen.

There's been much written on selegeline and its effectiveness in the Parkinson's patient. Personally, I've not seen any dramatic results with this drug but there are people who claim benefits even as a standalone drug. I would think, based on the numbers of patients I've seen who've not experienced much change with this drug, that the number of people who get ACTUAL relief or improvement in symptoms is very very small.

You say that you've been falling recently. Assuming that things had been stable prior to the last few weeks that you've been falling, the first I would do if you were my private patient in the office or clinic is run some basic screening tests on your blood and urine looking for any evidence of either metabolic derangements such as:
* Electrolyte imbalances
* Exaggerated liver or renal enzyme parameters that would suggest some type of chemical stressor in the system, or infection such as in the kidney, bladder, or even bloodstream.

Increasing falls in people with Parkinson's disease or syndrome in the face of a URINARY TRACT INFECTION (which is generally not something most patients realize they have) is not an uncommon way to see this sort of change. Therefore:
* A urinalysis with a gram stain, culture and sensitivity is what I'd get.

I'd also check other less CRITICAL elements but NO LESS IMPORTANT things that have been said to be helpful when treating any type of NEURODEGENERATIVE DISEASE PROCESS. For example:
* VITAMIN D, D2, AND D3
* FT4 and TSH (thyroid hormones), and I'd also check:
* ESR (sedimentation rate) which will tell us about an inflammatory process that could be going on. I would also get:
* Vitamin B12 level and make sure those levels are at least at 400-450 since peripheral neuropathy is a very common cause of falls which again, may not be noticeable to patients until they do fall and even then, they don't necessarily know why.

Reasons for falls, though I've not seen you walk or ambulate I am going to assume that you have a parkinsonian gait which means that you likely have small steps a narrow base, stooped posture, lack of arm swing (usually one side is less XXXXXXX than the other...possibly both sides poorly move), and rather unsteady balance to the point where just standing still without much movement or other excitement can cause you to lose your balance.

You may have other attributes of gait disturbance such as difficulty initiating a first step, sudden freezing of motion in the middle of a walk, and then, something called FESTINATION whereby the center of gravity of your torso begins to get out ahead of your feet which causes you to have to try and shuffle the feet faster and faster but the end result is almost a "running" of sorts to PREVENT from falling...which of course, eventually goes awry and you fall.

Again, you probably do not have ALL OF THE ABOVE mentioned features of altered gait, especially if you're relatively early into the disease process (5-7 years since diagnosis) but as time goes on more of these features may become apparent or more noticeable to you or to others.

Now, as to PREVENTION or other forms of treatment:

1. You should have a GOOD NEUROLOGIST or at least at least a GOOD PHYSICAL THERAPIST OR KINESIOLOGIST analyze your gait and balance function in order to identify exactly the points of constraint I mentioned above. After all, how can you FIX FALLING if you don't know all the potential items or weaknesses in a person's posture or gait there are that could be contributing or causing the falls in the first place? Make sense? Therefore, THOROUGH ANALYSIS AND EVALUATION.

2. Assessment of the individual for use of ambulatory aids. For example, will a cane, walker, Ankle Foot Orthosis (AFO), or just some intense PHYSICAL THERAPY, EXERCISE THERAPY, AQUATHERAPY, OR VESTIBULOTHERAPY be sufficient to improve things?

I often send my patients for EXERCISE THERAPY....not so much PHYSICAL THERAPY since they are limited in what they can do....but EXERCISE therapy using programs such as PARKINSON'S BOOT CAMPS which more and more hospitals around the country are developing or my favorite, DELAY THE DISEASE...which emphasizes exercising and enhancing strength and stamina in LARGE MUSCLE GROUPS of the body. You can look up places in your state that may be offering this program. It's usually 6 weeks in duration and I can tell you that the patients of mine who've gone through the program and keep up at home with solid practice sessions do MARVELOUSLY WELL and improve their gait and falls risk in less than 6 weeks.

3. There is also traditional GAIT TRAINING which probably goes through some form of PHYSICAL THERAPY dept. but honestly, if you get into something like DELAY THE DISEASE....that is automatically a part of almost every other exercise routine they will offer you so you will necessarily work on your gait and mobility just be participating in the course.

Remember, gait therapy and training does little good UNLESS the patient and the caregiver are willing to go through the tedious drudgery of practicing what is taught outside the class....which isn't hard since every time you have to walk you can actually implement what you've learned. Once of the things I find patients most likely to FORGET immediately after any class is:

a. STAND UP WITH A STRAIGHT POSTURE....DON'T HUNCH

b. LOOK STRAIGHT AHEAD, NOT DOWN AT YOUR FEET....no matter how much you think looking down helps you not fall...guess what? It CONTRIBUTES IMMENSELY TO FALLING....looking straight ahead actually PREVENTS falls since it forces you to focus on a FIXED POINT OF REFERENCE that is distant and this gives you much better orientation and stabilizing power of the body as you command it to move relative to your point of distant focus. If you don't believe that....just look at people walking who don't have PARKINSON'S...where is their focus of attention while walking....Ahead? Or DOWN? I rest my case.

c. INCREASE EACH AND EVERY STRIDE LENGTH and widen the base of your feet to be shoulder width. Again, the trap that PARKINSON'S DISEASE sets for you is to somehow make you believe that by taking smaller and smaller steps that you're being more CAREFUL while walking and that will prevent you to fall.....WRONG! Taking smaller and smaller steps with narrower bases means you must distribute and EQUILIBRATE BODY WEIGHT over a smaller and smaller surface area on the floor by reducing the distance between steps and placing the center of gravity farther out in front by virtue of the STOOPED POSTURE....see (a) above. Result, you're going down.

4. FINALLY, and LEAST COMMONLY we find that by increasing the dosages or better yet, DOSING FREQUENCY during the day that gait may actually improve. But beware, this is a sword that cuts both ways. It is just as often the case that upon raising doses of your medications or adding new medications that side effects which can CONTRIBUTE or CAUSE more instability, lowered blood pressures, increased fatigue, and dizziness/vertigo can occur and make walking even worse. In my opinion, medication considerations should be one of the last considerations to improving falls risks since we really have NO medication that works to improve sheer BALANCE or BODY EQUILIBRIUM. Let me repeat: We do not have any medication on the market as of yet that improves equilibrium in PARKINSON'S DISEASE. We have medication for improving, stiffness, rigidity, and slowness of muscle response....that's what LEVODOPA does......no such medication exists for equilibrium and balance.

BUT, there is such a thing as VESTIBULOTHERAPY and I frequently send patients for this type of training.....but again, as I've said repeatedly.....once weekly sessions of this elegant form of training is only going to be as good as a patient's ability and desire to practice what is taught when not in the session, makes sense, right?

If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating? Again, many thanks for submitting your inquiry and please let me know how things turn out.

Hope I have answered your query.

Regards,
Dr. Dariush Saghafi
Neurologist

---