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Sleep and gait problems in PD

Unlike Dolly Parton, your brainstem doesn’t just work 9 to 5; it keeps going 24/7, managing important functions like breathing, coordination, and sleep cycles. When everything is running smoothly during REM (dream) sleep, your brainstem pulls a metaphorical lever to paralyze your muscles. It's a built-in safety feature so you don't accidentally punch your nightstand (or your bed partner 😬) while dreaming about saving the world. But sometimes this machinery does not function properly, possibly due to the presence of abnormal protein accumulation in the brainstem gumming up the works. Without this safety mechanism, people start thrashing, kicking, or acting out their dreams (see the GIF above to see what this can look like) —this is called REM sleep without atonia (RSWA), and may lead to a diagnosis of RBD: REM Sleep Behavior Disorder.

Researchers at the University of Minnesota, including Dr. Colum MacKinnon, along with Drs. Sommer Amundsen-Huffmaster, Paul Tuite, and Michael Howell, wanted to look at the bigger picture. They already knew that both sleep issues and walking (gait) difficulties are common in PD. But they asked, “How do these two things change over a three-year period, and how might they be related to each other as the disease progresses?”

To answer this question, they compared three groups of people:
1. Healthy Controls: A "control" group does not receive the treatment or experimental condition. In a drug study, the control group receives a placebo (fake) pill. In this study, the control group is people without Parkinson's. If there was no control group in this study, we wouldn't be able to know if gait (walking) was getting worse over time because of Parkinson's or just because of normal aging.
2. PD patients without movement during sleep
3. PD patients with movement during sleep

Table showing study findings in healthy controls compared to PD subjects without and with REM sleep movements. Healthy controls have no muscle activity during REM sleep at baseline, with significantly more movements in the PD plus RWSA group compared to both healthy controls and PD minus RWSA group. Over time, gait gets worse in both PD groups. However, it gets even worse in the PD plus RWSA group compared both to controls and the PD minus RWSA group. The authors also found that in both PD groups, muscle activity and gait irregularities were positively correlated (the worse the gait, the more muscle activity during REM sleep or vice versa)

Why Does This Matter?

This study tells us that sleep abnormalities and walking troubles aren't just random, isolated symptoms—they are linked. Because the brainstem coordinates both, RSWA might actually be an early-warning clue that PD is progressing more quickly. This is useful because the rate of Parkinson’s symptom progression can really vary (i.e. some people’s symptoms get worse very quickly, others progress very slowly). By catching these nighttime movements early, doctors can customize better care plans; if a clinician sees a Parkinson’s patient acting out dreams, they can provide proactive mobility training and fall-prevention strategies.

If you're interested in reading the full-force science lingo version, here is the link to the original article. If you're interested in learning more about RSWA and RBD, check out this article from MJF.

(Not all movement during sleep is RBD; if you’re worried about your Parkinson’s symptoms, talk to a neurologist -- click here for a neurologist specializing in PD.)

Image of online article webpage listing a title, subtitle, and author as well as the photo used by the article author

Spotlight on exercise science at UMN

Check out this fascinating feature in the University of Minnesota's Discovery magazine -- it covers Minnesotan Jason Kopacz’s fight with early onset PD; from the unusual way Dr. Paul Tuite diagnosed him, to his quest to raise awareness and money for research on exercise for PD.

We’ve heard how frustrating it can be – coming up with the perfect medication routine is more difficult than getting Minnesotans to zipper merge. Jessica Froula, PhD, asked Natalie Heinrich, PharmD, a Medication Therapy Management specialist at MHealth Fairview, to answer a few common questions about medications for Parkinson’s and how they fit into your daily life.

Q: I’ve heard eating protein ruins Sinemet, is that true?
A: Protein in your foods can lessen the effectiveness of carbidopa-levodopa (Sinemet). To avoid this interaction, we typically recommend taking carbidopa-levodopa at least 1 hour before a meal or 2 hours after a meal, especially when you’re eating foods that are high in protein. Examples of foods that are high in protein include meat, cheese, yogurt, milk, nuts, beans. If you are eating foods that are light in protein, such as fruits and vegetables, you do not need to separate the timing of the medication from these foods.

Q: There’s a lot of crazy stuff on the internet, do you see people changing their medication routines based on what they see online?
A: I find that when people hear about medications on the internet, they bring their questions to their provider or pharmacist and we are able to address them. There are a lot of different Parkinson’s disease medications on the market and we want to be able to offer people the best possible treatment regimen, so if they are interested in trying something new, we will have a conversation about the risks, benefits, and possible cost. Sometimes after hearing from their clinic team, they decide it is not worth the risks or costs to try a new medication. It’s also important to know that each person’s experience with Parkinson’s disease is unique, so when reading about a person’s experience with symptoms or medications online, that experience may not be the same for other people living with Parkinson’s disease.

Q: Alphabet soup: What is the difference between IR vs ER vs CR forms of levodopa?
A: “IR” is short for immediate-release, “ER” is short for extended-release, and “CR” is short for controlled release. These are each different formulations of carbidopa-levodopa available on the market. Traditionally, the IR formulation is prescribed first and used most commonly due to the low cost and quick-acting effect. When a person begins to experience wearing off of carbidopa-levodopa, meaning the medication is not lasting from one dosing time to the next, we may consider switching to a CR or ER formulation. The CR tablet formulation is typically inexpensive but it can have a more unpredictable effect throughout the day. We more often use the CR formulation before bedtime. The ER formulations can include Rytary or Crexont, which are the longest-lasting medications and these are available in a capsule form.

Q: Are there any hot new meds for PD?
A: There are two relatively new medications on the market for PD. Both are different formulations of carbidopa-levodopa. The first is called Crexont and it is a long-acting formulation of carbidopa-levodopa in an oral capsule. If you are familiar with Rytary, Crexont is similar to Rytary but slightly longer-acting than Rytary. Typically, Crexont is dosed 2-4 times daily and provides more even medication distribution over the course of the day. The other new medication is Vyalev, which is a subcutaneous pump containing liquid carbidopa-levodopa which is administered continuously over 24 hours. Because the pump provides continuous medication, typically “off” periods are much less; however, there is a risk of infection and skin sensitivity due to the administration of medication through a small needle under the skin.

Free Parkinson's Events in July

1. M Health Fairview PD Support Group
This group meets the first Wednesday of every month except February and August. There is also a virtual option. Contact facilitator Margie Kron for more info: Margie.Kron@fairview.org or 651-326-3629.
🕒 Wednesday July 1, 10:00am CT
📌 1925 Woodwinds Dr., St Paul, MN 55125

2. Parkinson's or Something Else? Understanding Parkinsonisms
On the third Thursday of every month at 11 a.m. CT, the MJF Foundation hosts a webinar on various PD topics.
🕒 Thursday July 16, 11:00am CT
📌 Online (Registration)

3. Why Falls Happen in Parkinson's: Changes in Balance & Movement
In this educational event from the Parkinson's Foundation, experts will share practical strategies and safety precautions to improve safety and minimize fall risk to support balance and mobility in everyday life.
🕒 Wednesday July 29, 12:00pm CT
📌 Online (Registration)

4. APDA Summer Parkinson's Symposium
Our own Dr. Vitek will be speaking at this event! Register here.
🕒 Friday July 31, 10:00am - 2:00pm
📌 Pier B Resort Hotel
800 W Railroad St., Duluth, MN 55802
(Note from the editor: Pier B has a great restaurant, I’m sure the lunch will be top notch! Also, I’m from Duluth, and you can't go wrong with Duluth in late summer; highly recommend!!)

Medical School

Sleep and gait problems in PD

Spotlight on exercise science at UMN

Free Parkinson's Events in July

This newsletter is a service of the MnDRIVE Neuromodulation Core at the University of Minnesota. If you would like to support Parkinson's research at the University of Minnesota, you can donate here!