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Stepping out of harm's way: Minimizing falls risk in patients with dizziness and other movement disorders Peggy R. Trueblood, PhD, PT Professor and Chair, Physical Therapy California State University, Fresno Learning Objectives • Recognize the prevalence of falls in people with vestibular disorders (e.g. dizziness) and movement disorders (e.g. Parkinson's). • Identify common clinical manifestations/impairments that may affect the postural control system in persons with vestibular disorders and movement disorders. • Describe the basic components of a physical examination for a person experiencing a vestibular disorder/movement disorder. • Propose at least two clinical interventions for a person experiencing problems with balance and/or gait impairments. • Discuss current evidence for common interventions designed to improve balance problems and/or gait impairments. • List at least three self‐care strategies or resources for a person experiencing dizziness/movement disorders. Two reasons we fall: 1) We do not sense or realize that we are tipping (sensory problems including vestibular disorders) 2) We cannot stop ourselves while tipping (movement disorders such as Parkinson’s Disease) • Most common causes of falls is DIZZINESS, VERTIGO, or LOSS OF BALANCE….. • Not the same, however dizziness, in any form, often leads to loss of balance sense and therefore has the potential for a FALL! Dizziness and Vertigo • Vestibular and non-vestibular causes • It has been estimated that 65% of individuals > 60 years of age experience dizziness or loss of balance, often on a daily basis. • Prevalence 31% in older adults (vs 1.8% in young adults); most common symptom causing patients to visit their primary care physician (70% of elderly patients present with dizziness) • Accounts for 2.5% of emergency room visits Association between Vestibular Dysfunction, Dizziness, and Falling • Participants with a vestibular dysfunction and self reported dizziness were 12 X more likely to fall. • Researchers also found that individuals who fell because of dizziness and vertigo were more likely to fall two or more times, vs. experience a single fall. • Patients with bilateral vestibular dysfunction were shown to have a significant increase in falls when compared to the general population. • People who were chronically dizzy (3.5% elderly) were found to be at an increased risk of falling. • Common disorder due to TBI from falls in elderly Movement Disorders and Falls • Movement Disorder refers to a motor impairment resulting in an inability to move the body properly (does not refer to an impairment in the sensory systems) and will cause a fall when the ability to walk with a normal gait is impaired such as: 1) Stroke – Fall almost 2 X as often as people without stroke; 37% fall within 6 months of their stroke 2) Parkinson’s Disease – 38% patients with PD fall each year; 13% fall more than X1/week Vestibular Disorders: 3 categories UVL (neuronitis; labyrinthitis; Acoustic Neuroma; BVL (ototoxicity Complaints of unsteadiness, instability (may increase with head movement); Complaints of visual blurring and “dizziness” Inputs present, but disturbed (BPPV, TBI; Brainstem Stroke) Vertigo; Instability increases in the presence of inappropriate sensory signals (particularly vision) Meniere’s Disease, Migraine – associated Dizziness and Vertigo There are two parts to the vestibular system: • Peripheral Vestibular System (inner ear) • Central Vestibular System (brainstem and brain) Older adults can have disorders affecting either the peripheral or central systems. Problems in the peripheral system are much more common; often undetected; but respond well to treatment. Review: Anatomy of Vestibular System Bony Labyrinth surrounds the membranous labyrinth, both filled with fluid. Peripheral System 1) Semicircular canals 2) Otolith organs (utricle and saccule) 3) Vestibular Nerve Semicircular Canals Vestibular Nerves Utricle Auditory Saccule Nerve Cochlea Central System Central System Two Major roles: Gaze Stability Balance Stability The ability to maintain gaze or visual focus on an external target during movement . The ability to maintain the body’s center of gravity (COG) over the base of support in a given sensory environment. A function of an intact VOR (vestibulo-ocular reflex) at speeds > 85 degrees/second. Common Vestibular Deficits in Older Adults Peripheral Central • Benign Paroxysmal • Brainstem concussion Positional Vertigo or TBI (BPPV) most common • Vertebrobasilar Ischemic • Vestibular neuritis Stroke or TIA • Viral Labrynthitis • Migraine-Related Dizziness • Labyrinthine concussion (following a fall) • Ototoxicity due to medications • Aging: loss of hair cells Vestibular Disorders: 3 categories UVL (neuronitis; labyrinthitis; Acoustic Neuroma; BVL (ototoxicity) Complaints of unsteadiness, instability (may increase with head movement) Complaints of visual blurring and “dizziness” Inputs present, but disturbed (BPPV, TBI, Brainstem Stroke) Vertigo Instability increases in the presence of inappropriate sensory signals (particularly vision) Meniere’s Disease, Migraine – associated Dizziness and Vertigo UVL from Vestibular Neuronitis or Viral Labyrinthitis Neuronitis • Inflammation of the vestibular nerve • Hearing NOT impaired • May spontaneously resolve (compensate) • IF doesn’t compensate in 4-6 weeks, needs PT • Often associated with BPPV • Can occur sequentially R – L (resulting in BVL) Labyrinthitis • Inflammation of the vestibular labyrinth • Hearing impaired • Symptoms similar to neuronitis Deficiency: UVL Unilateral Vestibular Loss •ACUTE (< 3 days) – Imbalance – Needs assistance with gait – Increased imbalance with head movement – Complaints of blurred vision with head movement – Nystagmus and vertigo – (+) Romberg; unable to do sharpened romberg – Unable to stand on one leg – Can’t walk with head mvts •CHRONIC (> 3 days) – Decreased head movement and activity – Decreased endurance – Visual Dependence – Blurred vision with head mvt – (-) Romberg; (+) Sharpened – Normal gait – Sensory Organization Test may be o.k. if compensated – *Vestibular Rehab excellent prognosis for uncompensated peripheral UVL Deficiency: BVL Bilateral Vestibular Loss •ACUTE (< 3 days) – – – – – – – – Decreased static balance High risk for falls Needs assistance for gait (+) Romberg; unable to do Sharpened Romberg Unable to stand on one leg SOT unable #5,6 (dead fall) Visual blurring with head movement Can’t walk with head movements •CHRONIC (> 3 days) – Blurred vision and imbalance with head mvts – Visual dependence – Decreased endurance – (+) Sharpened Romberg – LOB #5,6 on SOT – Decreased trunk rotation with gait; wide base gait BVL from Ototoxic Medications Aminoglycoside Antineoplastics Antiobiotics Diuretics Environmental Toxins Gentamycin Amidacin Streptomycin Kanamycin Tobramycin Dihydrostreptomysin Furosemide Bumetanide Mannitol Toluene Mercury Tin Lead Carbon monoxide Cisplatin Bleomycin Vincristine Vinblastine Other Medications Medications that may impair attention, slow reaction times, & interact with falls Antidepressants Sedative hypnotics Anti-anxiety meds Muscle relaxants Vestibular Pain Meds Suppressants Alcohol Antihypertensives Umphred 2002; Adapted from J. Dewane Distortion: Causes of Central Vestibular Deficits • Brainstem and cerebellar lesions resulting in central positional vertigo (downbeat nystagmus when in provoking position without vertigo) • Root entry zone lesion (Anterior Inferior Cerebellar Artery (AICA) vascular lesion (vertigo lasts hrs) • Lateral Medullary Syndrome (Posterior Inferior Cerebellar Artery) (PICA) (transient vertigo lasting minutes to hours) • Recovery much longer (vs peripheral lesions) (6 months vs 6 weeks) Distortion: BPPV • Positional Vertigo = movement related vertigo – BPPV or BPPN (benign paroxysmal positional vertigo or nystagmus) is an example – Treatment is canalith repositioning (e.g. Epley maneuver) – Some believe BPPV can respond well to “habituation exercises” - Brandt-Daroff Exercises • (based on rationale that through repeated exposure to specific stimulus causing vertigo, the brain will habituate or attenuate the vertigo response) Fluctuation: Migraine related dizziness or vertigo • ~35% of migraine patients have some associated vestibular syndrome • The clinical presentation may inclue dizziness: – motion intolerance with respect to head, eyes, and/or body – spontaneous vertigo attacks (often accompanied by nausea and vomiting) – diminished eye focus with photosensitivity – sound sensitivity and tinnitus Fluctuation: Migraine related dizziness or vertigo – – – – – balance loss and ataxia cervicalgia with associated muscle spasms confusion with altered cognition spatial disorientation anxiety/panic • Treatment is medical management (Do not respond to vestibular rehab) and education Vestibular System Screening • History • Hearing Test (any unexplained loss or asymmetric loss that has not been “worked up” for acoustic neuroma) • Nystagmus (under video goggles to eliminate vision) – Spontaneous – Gaze-evoked nystagmus – High Frequency head shake • Head Thrust • Hallpike (for BPPV) • Bedside Balance Tests – Romberg and Sharpened Romberg – Standing on foam (clinical test for SOT) – Walk with head turns History • Patient’s age; living situation; family support • Prior and current functional status • Fall history and circumstances (eg what environments or always when moving?) • Course of the disease/symptoms – Patient’s Symptoms: • Imbalance or Disequilibrium (static vs dynamic) (numerous causes) • Dizziness (lightheaded, swimming sensation in the head or sense of giddiness) (non-vestibular more often) • Vertigo (illusory sensation of motion of either self or surroundings (sense of spinning; world is spinning or tilting; sense of rising) (vestibular) History – Patient’s Symptoms: (cont) • Oscillopsia (illusion of visual motion); spontaneous (words bounce with reading) (cerebellar) or induced by head mvt (world bouncing with walking) (bilateral loss VOR) • Changes in strength or sensation (neruological) • Hearing loss, tinnitus (peripheral vestibular vs central) • Blurred vision; diplopia (ocular exam) • Clumsiness or incoordination (cerebellar) • Nausea and vomiting (stimulation to centers in medulla) (Wallenburg stroke common) • Course of the disease/symptoms (cont) – Tempo (duration of problem/disease) • Acute (peripheral vestibular disorders such as labyrinthitis, vestibular neuritis; strokes) • Chronic (most neurological disorders) – Progressive – Stable • Spells (BPPV, orthostatic hypotension; migraines; panic attack; TIA’s;) – Circumstances (spontaneous, exacerbated by head movements, exacerbated when walking in the dark or on uneven surfaces) Chronic Disequilibrium Disorders Symptoms Bilateral Vest or > 3 Dizzy, Disequilibrium days unilateral vest defect (peripheral) Fear of Falling (disuse Disequilibrium disequilibrium) Cerebellar disorder Disequilibrium; may have oscillopsia from nystagmus Basal ganglia disorder Disequilibrium Anxiety/depression Chronic brainstem stroke Circumstances (+) with head mvts, walking; worse in dark or uneven surface Whenever on feet Disequilibrium while on feet; oscillopsia while reading Whenever on feet Lightheaded, floating Induced by eye mvts, head still Vertigo, Spontaneous, disequilibrium, exacerbated by head lateropulsion, ataxia, mvts oscillopsia, sensory loss Spells/transient symptoms Disorders Symptoms Circumstances Benign Paroxysmal Positional Vertigo (BPPV) Vertigo, lightheaded, nause (secs) Orthostatic hypotension TIAs Lightheaded (secs) Positional; lying down, sitting up or turning over in bed, bending forward Positional; standing up Migraine Panic attack Meniere’s disease Vertigo, lightheaded, dysequilibrium (mins) Vertigo, dizziness, motion sickness Dizzy, nausea, diaphoresis, fear, palpitations, paresthesias (mins) Vertigo, dysequilibrium, ear fullness from hearing loss and tinnitus (hrs) Spontaneous Usually movementinduced Spontaneous or situational Spontaneous, exacerbated by head mvts Subjective History • Past Medical History - Significant co-morbidities – Diabetes – Orthostatic Hypotension – Vestibular Disorders – Osteoporosis – Peripheral Neuropathy – Vision disorders (glaucoma, macular degeneration, cataracts) – Orthopedic related problems (arthritis, etc) • Medications (potential side-effects) Standardized Self-Report Tests • (Dizziness Handicap Inventory) (Jacobson and Newman, 1990) • Evaluates self-perceived physical, functional and emotional effects imposed by vestibular system disease • 25 questions; maximum score 100 • Reliable test (.97 test-retest) • No correlation with caloric or rotary chair testing • ` Standardized Self-Report Tests – ABC (Activities-specific Balance Confidence Scale) (Powell and Myers, 1995) • Level of confidence scale (self or clinician administered) • Developed for use with elderly at risk for falling • Reliable (.92 test-re-test) • Questionnaire measuring perception of performance in 16 activities in and outside the house • Maximum score of 160 • (Whitney et al 1999) Tested in patients (N=71) with vestibular impairments (negative correlation with DHI) Standardized Self-Report Tests – BES (Balance Efficacy Scale) (Rose DJ, 2003) • Subject rates level of confidence (0-100%) during daily life tasks • 18 Questions • Maximum score of 180 • Less than 50% confidence considered significant • Includes environmental impact • Vestibular System (Gaze Stability and Balance) –Physical Exam 1. Spontaneous Nystagmus Peripheral (acute unilateral vestibular loss) vs Central lesions (brainstem/cerebellum lesion) 2. VOR (Vestibular Ocular Reflex) Slow VOR – horizontal and vertical – head movement with eyes fixed on stationary target DVA (Vestibular Dynamic Visual Acuity) - head oscillated at 2 Hz - should not lose more than 3 lines • Head thrust - small thrust of head to each side as subject fixates a distant visual target refixation saccade indicates decreased VOR • Head Shaking nystagmus - pitch head 30 deg and oscillate horizontally X 20 - nystagmus indicates vest imbalance *NOTE: clear the neck first for either test; more difficult to perform in older adults VOR Testing • DVA (Dynamic Visual Acuity) - head oscillated at 2 Hz – young adult should not lose more than 2 lines (identifies the extent of acuity loss during active head movement) Log Mar Chart for Dynamic Visual Acuity VOR Testing • Head Thrust while patient fixes gaze on clinicians nose • Thrust to the side of normal vestibular function: gaze remains fixed • Thrust to side of vestibular loss: eyes slip with quick saccade to return to target Compuerized Dynamic Visual Acuity (DVA) and Gaze Stabilization test (GST) • Testing function of the VOR • Determines maximum speed of head movement subject can still maintain accurate visual acuity (GST) • Determines visual acuity loss with head movement (DVA) • Isolate gaze impairments Normal performance < 0.12 + 0.08 LogMar 3. Visual tracking (central problem) • Smooth pursuits - slow tracking; head still, moving object • VOR cancellation - head and object moves together • Saccades- fast changes in eye position - look at speed, initiation and accuracy (hypermetric vs hypometric are overshoot and undershoot) 4. Positional Tests • Hallpike-Dix test for BPPV nystagmus from BPPV should begin within 30 secs and last less than 30 secs • Motion Sensitivity Testing 16 changes in position (includes Hallpike-Dix) 5. Pressure testing (Hennebert sign)- nystagmus or drift of eyes after positive and negative pressure directed to the external auditory canal (perilymphatic fistula, hypermobile stapes, sometimes with Meniere’s disease or hydrops) Hallpike Test for BPPV 1) 2) 3) Clear C-spine Patient keeps eyes open Patient long-sits on the table so head will clear table when supine 4) Stand in front and to the right of the patient, grasping head in hands 5) Rotate patient’s head to right 45 degrees 6) Move patient to supine with 30 degrees of cervical extension 7) Maintain head-hanging 45-60 seconds 8) Note latency, direction and duration of nystagmus 9) Slowly return patient with head still rotated, sitting 10) Note latency, direction and duration of nystagmus 11) Repeat opposite side 5. Balance Tests • Standing on foam (part of mCTSIB (Shumway-Cook A., Horak F. 1986) Left UVL secondary to labyrinthitis 5. Balance Tests • Computerized Dynamic Posturography (more sensitive) (Nashner, 1982) sway referencing of the platform sway referencing of the visual surround • Sensory Organization - Modified Clinical Test for Sensory Interaction on Balance – mCTSIB (Shumway Cook and Horak 86) assumed to reflect sensory integration deficits • standing on foam may provide biomechanical as well as sensory challenge • Smart Balance SOT more valid CTSIB SOT Firm, EO Firm, EO Firm, EC Firm, EC Firm, SV Foam, EO SS, EO Foam, EC SS, EC SS, SV 5. Balance Tests (cont) • Romberg and Sharpened Romberg • Single Limb Support • Walking with head turns Normal Staggers when turning left Goals of Vestibular Rehabilitation • Resolve/decrease positional related symptoms • Reduce dizziness/spatial disorientation • Improve gaze stability • Improve visual vestibular interaction during head movements • Normalize static and dynamic balance • Decrease anxiety/fear/depression Vestibular Physical Therapy • • • • • • • Treatment of BPPV Eye Exercises Gaze Stability Training Eye-head motion Balance Retraining Coordination Conditioning/Fitness BPPV • Most common cause of vertigo due to a peripheral vestibular disorder • Characterized by brief episodes of vertigo when the head is moved into certain positions • Mechanism may be – canalithiasis - degenerative debris floating freely in the endolymph of the canal – cupulolithiasis - degenerative debris adhering to the cupula of canal • Treatment depends on canal and mechanism (most common post canal canalithiasis) Canalith Repositioning for PC Canalithiasis • Non-invasive • 85% - 98% success rate Also called: • Epley Maneuver • Particle Repositioning • Modified Liberatory Maneuver Gaze Stabilization Exercises • Functional complaints: – Dizziness with head motion – Decreased DVA – Movement of visual world with head motion • Treatment Goals – Decrease or eliminate symptoms of dizziness – Trying to promote function • safely crossing busy street while turning head to check traffic • Shopping in grocery store and recognize items • Perform household chores Treatment of Vestibular Deficits based on mechanisms of recovery • ADAPTATION = ability of vestibular system to make long-term changes in the neuronal response to head movement with the goal of decreasing retinal slip – Retinal slip during head movements is the error signal that induces adaptation. . . . – Vestibular Adaptation Exercises = exercises to improve gaze stability – VOR training (gaze stabilization exercises) X 1 viewing X 2 viewing VOR Exercises: Progression • Progress via increasing: • Speed (remember stimulus for adaptation is retinal sip during head movement) • Duration (work up to 1-2 min; 4x/day) • Complexity of Background (progress to busy background) • Posture (feet together vs one leg) • Progress via change in: • Position (sit to stand to walking to sport specific) • Surface (firm to compliant) • Treatment Strategies for poor oculomotor control (poor tracking, convergence/ divergence, saccades) – Oculomotor Exercises (on foam wedge or during walking; add busy background to challenge) • Looking from near to far object • Looking at different objects on busy background • Tracking objects across midline 3 8 4 9 1 7 6 2 1 0 5 Changing the surface to increase the challenge Looking at different objects on busy background Central Sensory Impairments • Prognosis may not be as good (compared to peripheral impairments) • Types of Disorders – Geriatric Patient who is visually dependent during movement secondary to poor integration of 3 senses; unable to resolve conflict • limit head motion during walking • problems going down stairs, escalators, elevators, walking on uneven ground, making quick turns (failure to select appropriate sensory inputs to adapt to changes in sensory environment) • Post-concussion with residual vestibular dysfunction – Visual preference or visual motion sensitivity – Dysequilibrium – Dizziness/vertigo with head movements • Central Vestibular Lesions (failure to use inputs) (pontine infarct or aneurysm) – Primary Problems • Lateropulsion • Perception of tilt - subjective visual vertical • Oculomotor abnormalities • Positional vertigo in brainstem and cerebellar lesions • Functional Complaints – LOB/falling in crowds or challenging environments – Difficulty going down stairs; spatial demands – Difficulty with timing demands; making quick turns – Dizziness/vertigo especially with head movement – Veering – Visual complaints (blurred vision) • POSTURAL STABILITY stimulate Vestibular via disadvantage vision and somatosensory – What if primarily loss of balance during #4,5 (or EC/foam) – Absent vision with unstable or compliant surface (eyes closed on rocker board or foam) – Destabilize vision with unstable or compliant surface – Confuse /distract vision while on unstable or compliant surface (moving visual surround while on rocker board or foam) • Treatment Strategies for persons with VISUAL PREFERENCE – Treat in distracting environments – Place in conflict situations to challenge system (but want success so can’t make too challenging) – Give them a visual “target” in the environment to help compensate • Balance/Gait Training with disrupted somatosensory (foam, floor mats, grass, gravel, sand, etc) • Balance/Gait Training with disrupted vestibular - head turning, quick pivots, abrupt starts and stops • Combined disruptions Self Help Strategies to Prevent Falls in People with Vestibular Deficits • • • • • • Keep moving Use of assistive device in acute stage Do not reach up or tip head back Avoid multi-tasking Do not bend over especially on soft surfaces “Safe-walk” (avoid quick turns; avoid rushing; waiting to walk after first standing; walk where there is good light) • Find stationary vertical target when walking Movement Disorders Parkinson’s Disease • 38% of patients with PD experience falls • 18% sustain fractures as a result of falling • 13% fall more than 1 x per week Pathomechanism • Death of dopamine producing cells in the substantia nigra compacta • Death of Ach producing cells in the pedunculopontine nucleus (PPN) Loss of dopamine to the putamen reduces activity in motor areas of the cerebral cortex, decreasing voluntary movements. • BRADYKINESIA • Decreased trunk rotation and arm swing • Slowed postural reactions/reaction time • Deficits in strategy selection • Decreased movement time or time it takes to complete a task (bed mobility, transfers, etc) • Difficulty initiating movement, changing directions or stopping once movement begins Loss of dopamine to the putamen reduces activity in the midbrain locomotor region to the CPG, decreasing stepping/walking control. • • • • Postural Instability & Gait Dysfunction (PIGD) Decreased gait initiation, akinetic gait Decreased step height/length, shuffling gait Decreased gait velocity and cadence • Freezing of Gait (FOG) • Festinating gait Loss of PPN cells, combined with increased inhibition of the PPN, disinhibits the reticulospinal tracts, producing excessive contraction of postural muscles. • • • • Movement rigidity Truncal and neck rigidity Decreased axial rotation Decreased postural alignment (progressive forward flexed posture) • Decreased postural control (decreased postural extension) Other disease manifestations that affect movement control: Visuospatial or Visuoperceptual Impairment Visual blocks (doorways, elevators, obstacles) Autonomic Impairment: Orthostatic Hypotension Cognitive Increased dementia Inability to access working memory Poor procedural learning (learning with practice) Difficulty shifting attention Decreased dual tasking ability Measure of Fall Risk Timed Up and Go (TUG) >13.5 secs high risk for falls Time it takes to stand up, walk 10 feet (3 meters) and return to the chair and sit down. for falls Tinetti Balance and Gait (Mary Tinetti, 1986) • Uses a 3 point scale; separate balance and gait portion (video balance portion only) • Reliable (.85 inter-rater) • Scores less than 12/16 on balance portion at risk for falls; less than 8/12 on gait portion significant • Scores less than 22/28 risk for falling • Used as screening Significance of Gait Change and Difficulty Performing Dual Tasks • Gait disorders and decline in gait performance while dual tasking are closely associated with increased falls risks in people with PD (Verghese et al. 2002) • Stop talking while walking may be good predictor of falls in PD. • Meta-analysis reported 3 mo fall rate of individuals with PD was 46%, 218/473 (Pickering et al 2007) • Strongest predictor of falls was prior falls in the preceding year • Disease severity was not a good predictor of falls General Treatment Principles • Intervention based on disease progression and level of handicap • General goals are to increase movement/ROM; improve equilibrium reactions; maintain or restore functional abilities • Anti-parkinson’s meds primarily decrease bradykinesia; not as effective in improving balance • Use of external stimuli based on premise that individual’s with Parkinson’s disease exhibit bradykinesia because they are unable to drive their motor output internally Meta analyses (2008): Exercise in Parkinson’s • Exercise improves: – – – – – – – physical functioning health related QOL strength and balance gait speed increases safety decreases depression Little evidence that exercise reduces falls • Exercise has proven effective for delaying or reversing functional decline • Questions remain around the optimal content of exercise interventions (dosing, component exercises) Treatment Strategies • COG control activities – Visual feedback beneficial – Emphasis on posterior direction – Emphasis on increasing speed – Dynamic wt shifts; stepping over obstacles; lunge • Postural Strategy – Facilitate hip strategies – Facilitate stepping strategies – Use of uneven surface for perturbations – Context dependent responses with varied environment • Rhythmical exercises – Swiss ball sitting activities – Music/dancing • Dynamic Gait – Auditory and visual stimuli may improve step length and speed – Stairs easier than level ground without cues – Start/stop; change speeds; turning; walking in crowds; change in stride lengths • Dual tasks (walking and counting backwards) • Music Therapy as effectual auditory cueing • Exercises to promote trunk rotation; extension; hip extension; relaxation of rigidity • General fitness to reduce fatigue Medication complications to Consider • In the beginning, the response to medication is more consistent & sustained. • Anti-parkinsons meds primarily decrease bradykinesia; not effective in improving balance • As the disease advances, the response to the medications used to treat it can become less reliable; begins to wear off before next dose. Past Studies Using External Cues • Numerous studies have demonstrated the effectiveness of visual (VC) and auditory cues (AC) on gait performance under single and dual tasks – – – – – – Azulay 1996 Azulay et al. 2007 Baker et al. 2007 Morris et al. 1996 Fernandez del Olmo et al. 2003 Suteerawattananon et al. 2004 Effect of External Cues in PD • Visual Cues – Guide movements by way of visuomotor control through the intact cerebellar pathway – Conscious/voluntary control through visual pathways • Auditory Cues – Excites spinal motor neurons through reticulospinal pathway, reducing the reaction time – Works as a pacemaker Kinesia Paradoxa • Bypassing damaged pathways can result in more normal motor output/function – Externally provided cues - Visual or Auditory Contrast is essential (dark on light; light on dark) External pacing (treadmill, cycling) Exaggerated movements Rhythm is needed (metronome, music) Loudness – Internally generated cues Rhythm Focusing attention (away from distractors; on to walking) • Dynamic Gait with External Cues – Auditory and visual stimuli may improve step length and speed Assistive Devices come with red laser light to facilitate walking in PD LVST BIG & Loud •http://www.youtube.com/watch?v=fk4Xw8PW7bk •http://www.youtube.com/watch?v=wElz9jNrqns&fe ature=related Balance-Based Torso Weighting to Improve Postural Control Cynthia Gibson-Horn Summary • Vestibular and Movement Disorders common in elderly • Screening tools include: – – – – – – Good history including previous fall Head thrust Walk with head turns Romberg/Sharpened Romberg Stand on Foam Gait (timed up and go) • Refer to Physical Therapy if at risk for fall or has balance or gait disorder