Overview of the cholinergic contribution to gait, balance and falls in Parkinson's disease

Mobility deficits, including gait disturbance, balance impairments and falls, are common features of Parkinson's disease (PD) that negatively impact quality of life. Mobility deficits respond poorly to dopaminergic medications, indicating a role for additional neurotransmitters. Due to the critical role of cortical input to gait and balance, acetylcholine—an essential neurotransmitter system for attention—has become an area of interest for mobility. This review aimed to identify the role of cholinergic function on gait, balance, and falls in PD using three techniques; pharmacological, imaging, and electrophysiological. Studies supported the role of the cholinergic system for mobility in PD, with the most promising evidence indicating a role in falls. Imaging studies demonstrated involvement of anterior cholinergic (basal forebrain) systems in gait, and posterior (brainstem) systems in balance. However, this review identified a small number of studies which used varying protocols, making comparisons difficult. Further studies are warranted, measuring comprehensive gait and balance characteristics as well as gold standard falls detection to further quantify the relationship between ACh and mobility in PD. •ACh is thought to modulate mobility (gait, falls and balance) in PD.•This Review examined pharmacological, imaging, and electrophysiological measures of ACh with mobility.•Evidence supports the role of ACh in gait, balance and falls.•The strongest evidence implicates a role for ACh and falls in PD.•Evidence is limited due to small number of studies and varying protocols of gait, balance and falls.