Download Evaluation and Treatment of Balance Disorders

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
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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:
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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