Assessment of Balance Disorders and Falls Risk in Persons with Parkinson

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Assessment of Balance Disorders and Falls Risk
in Persons with Parkinsons Disease(Intervention
and Prevention)

• Andrea L. Behrman, PhD, PT
• Department of Physical Therapy, College of Public
  Health and Health Professions McKnight Brain
  Institute at UF
• VA Brain Rehabilitation Research Center
• University of Florida

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Acknowledgements Foundation for Physical
Therapy VA Brain Rehabilitation and Research
Center Kathye Light, PhD, PT Dawn Bowers, PhD
William Friedman, MD William Triggs, MD
James Cauraugh, PhD Philip Teitelbaum,
PhD Sheryl Flynn, PT, MHS Mary Thigpen, PT,
MHS, NCS Jung Chang, PT, MHS
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Balance Difficulties
Intrinsic
Extrinsic
Environment
Inherent to PD
Non-PD Related
ADL, Task- dependent
1 Balance Disorder

Associated with Movement/Cognitive
Disorders-
Medications
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Inherent to PD

• Stage III Hoehn Yahr, balance disorder

• Mid-Late in disease progression

• 38 fall (Koller et al., 1989) persons body
  involuntarily contacts the ground

1 Balance Disorder

• 13 fall more than 1x/week

• 18 suffer fractures

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Nature of inherent postural disorder in PD (Horak
et al. 1992 Pastor et al., 1993 Schieppati and
Nardone, 1991)

• Appropriate use of sensory information for
  postural orientation Sensory Organization Test
  - (reduced sway relative to cohort
  performance/M-L)

• Appropriate coordination of postural movement
  patterns in response to displacements (hip vs.
  ankle strategy) Program is intact.

• Inflexibility of postural response patterns
  adapting to changes in support conditions.
  Planning is impaired.

• Excessive antagonist activity.

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• Precue/focus attention when change in
  environment expected (i.e. see crowd ahead,
  change from tile to carpet)

• Plan route if obstacles ahead, including stops
  if
• a long distance or expect you will need to change
  direction

• Prepare mentally to recover balance by stepping
  teach stepping response

• Prepare for probable events that will disturb
  balance (bus stops, elevator stops, train starts)

• Adapt environment to diminish changes (i.e.
  stripes on floor at areas that pose difficulty)

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Inherent to PD

• Decreased walking speed, if lt 0.6 m/sec
  decreased ground clearance
  trips FALLS

Associated with Movement Disorders

• Shuffling gait, decreased step length and
  ground clearance (lt 0.8 cm)

• Sudden cessations of walking freezing

• Turning difficulty (Thigpen et al., 2000)
• strategies freezing during turn, progressively
  smaller steps and decreased ground
  clearance,
• gt 20 steps in 360 degree turn (Lipsitz et al.,
  1991)

• Difficulty terminating locomotion

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• Context-dependent/environment (ex. visual
  array tile pattern change, door width / hallway
  / outdoors, barriers to movement, corners or
  furniture requiring change in direction)

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Inherent to PD
Associated with Cognitive Disorders

• Difficulty performing 2 tasks at once (turn and
  talk Bond et al., 2000)

• Impairment in problem-solving and planning. May
  increase incidence of behavior that is high-risk
  for persons with PD.

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Non-PD Related

• Age-related changes
• Sensory impairments
• visual, vestibular, proprioceptive

• Weakness inability to stand up from a chair
  without using ones arms to push off (LE
  strength)

• Gender Females have greater frequency of
• falls than males.

• Muscle tightness / inflexibility

• Pre-existing level of dependency higher rate
  for falls institutions vs. community

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Extrinsic
Medications

• Depress NS (sedatives, antidepressants)

• Lead to postural hypotension a postural
  systolic BP decline gt 20 mm Hg at one or three
  minutes of standing or an absolute systolic BP
  below 90 mm Hg
• (antihypertensives, antidepressants, diuretics)

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Extrinsic
ADL, Task- dependent

• OVERALL. Minimize balance requirements while
  performing ADLs and minimize cognitive tasks
  /conversation. Diminish balance requirement,
  focus on task. Break down task into steps.

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• DRESSING. Organize closet/drawers for
  safety/access to clothes (diminish amount of
  reaching while standing). Sit down on stable
  chair when dressing, focus on buttons, etc. Clock
  turn out of closet.

• BATHING. Sit or support with rail while bathing
  / showering (remove balance as a factor, than can
  concentrate on bathing/drying, etc.) Use wash
  mitt.

• TOILETTING,compounded by urgency.
• Walking in/out bathroom. Grab rails, raised
  toilet seats. Mark floor for consistency of steps
• through doorway and in BR. Clock turn in BR.
• Night light.
• Bedside commode/urinal.
• Bedside cues for getting out of bed.

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Extrinsic
Environment

• Support surface on which person is standing
  uneven, cracks, slippery, carpeted
• Environment free of obstacles clutter
• Adequate lighting, night light in bedroom/halls
• Appropriate shoes low broad heel, lace up
• Stairs differentiation of edges and stairs
• Home Safety Check List

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Balance and Falls Risk Falls Assessment
Performance in the clinic/lab on motor tasks vs.
Assessment under real-life circumstances

• Does performance in the clinic correlate with
  performance at home or in the community?

• Does performance in the clinic predict
  performance in the home?

• Are assessment tests reliable, sensitive,
  predictive?

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Clinical Assessments of Balance

• Standing balance (Smithson, Morris, Iansek,
  1998)
• Steady standing feet apart, feet together,
  tandem stance, single limb stance
• Self-initiated movements arm raise, functional
  reach (1 reach), bend-reach, step test
• External perturbation to upright stance
  shoulder tug

• Differentiated persons with PD who have a hx of
  falls from 1) persons with PD and no hx of falls
  and from 2) control subjects (no hx of falls)
• Reliable measures 1 week later
• Stage II and III, peak-dose of meds

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Standing balance
Functional reach (Behrman et al., 2002)

• 1 practice with average of 3 test trials as test
  score
• 1 practice with 1st test trial as test score

• Both scores differentiated persons with PD who
  have a hx of falls from
• persons with PD and no hx of falls and from
• control subjects (no hx of falls)

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(Behrman et al, 2002)
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Criterion for falls risk reach lt 25.4 cm (Duncan
et al., 1992)
FR test validity sensitivity, specificity,
predictive value
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Sensitivity a / (a c) 30
Specificity d / (b d) 92
Predictive value a / (a b) 90 -
Predictive value d / (c d) 36 a true
positives, persons with a history of falls
correctly identified as at risk b false
positives, persons incorrectly identified as at
risk for falls c false negatives, persons who
are incorrectly identified as not at risk for
falls d true negatives, persons with no
history of falls correctly identified as not at
risk.
(adapted from Behrman et al., 2002)
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Standing, transitional movements, and functional
tasks Berg Balance test

• Bogle Thorbahn Newton, 1996
• Residents of 2 independent life-care communities
  (n66), M 79.2 yrs
• Mixed diagnoses 38 orthopedic or neurologic
  impairment (n5, PD)
• 53 test sensitivity for predicting positive
  falls history with 45 / 56 as cutoff or
  criterion score for risk of falls
• 96 test specificity

• (Behrman et. al, unpublished data)
• Community-dwelling population, n 66 with PD
  (reported incidence of falls, n18 controls (-
  falls history)
• Test scores discriminated overall group with PD
  ( 48. 8) from controls (M 55.7)
• Test scores discriminated group with PD/falls
  hx (M 47.2) from
• 1) group with PD/-falls hx (M 52.4) and 2)
  controls (55.7)
• Comparing balance scores for individual items
  across the three groups
• determined a significant group effect for only 3
  / 14 test items

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Berg Balance Test Items

• Sitting to standing
• Standing unsupported
• Sitting unsupported
• Standing to sitting
• Transfers
• Standing with eyes closed
• Standing with feet together
• Reaching forward with an outstretched arm
• Retrieving object from floor
• Turning to look behind
• Turning 360
• Placing alternate foot on stool
• Standing with one foot in front of the other foot
  
• (tandem stance)
• 14. Standing on one foot

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Postural response test (Pastor et al., 1996)

• If clinician pull backwards on patient at
  shoulders, typical response is lack of a
  posterior stepping response and a rigid fall
  backwards into clinicians arms.
• Patient in stance with feet 10 cm apart.
• I am going to tap you off balance, and I wont
  let you fall.

Use to quantify baseline performance and outcome
of stepping training.

• 0 Stays upright without taking a step
• Takes one step backwards but remains steady
• Takes more than one step backwards, followed by
  the need to be caught
• Takes several steps backwards, followed by the
  need to be caught
• Falls backwards without attempting to step

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Timed Up and Go (Podsiadlo and Richardson, 1991
Morris Morris, 2001)
Reliable Practice Trial, Test trials
1-3 Differentiates on/off medication performance
and Subjects with PD and adults without PD
Turning difficulty (Thigpen et al., 2000)
Fall while turning associated with increased hip
fracture in the elderly. Evaluated turning
strategy, time in turn, number of steps
Differentiated persons with turning difficulty
gt 20 steps in 360 turn (Lipsitz et al., 1991)
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Falls Records (Yekutiel, 1993 2 case studies)

• Context-dependent vs. lab/clinic-based
  assessments
• Individuals specific environment
• Falls diary
• Draw plan of home to scale and copy
• Mark each fall on the plan
• Use 1 copy / day
• Use during baseline period prior to initiating
  therapy, during therapy, and post-completion of
  therapy

• Information accumulated
• Where do falls occur?
• Under what circumstances/tasks?
• Time of day, association with meds
• Identify each individuals particular problem
• Plan intervention accordingly.
• Continual assessment over time, reduction of
  falls.
• Factors accounting for falls may change.

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Balance Difficulties
Intrinsic
Extrinsic
Environment
Inherent to PD
Non-PD Related
Fear of Falling
ADL, Task- dependent

Associated with Movement/Cognitive
Disorders- Context-dependent
Medications
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Fear of Falling
Falls Efficacy Scale (Tinetti)
Measures a persons confidence in doing ADL
without falling.
On a scale of 1 to 10 with 10 meaning NOT
confident or sure at all, 5 being FAIRLY
confident/sure, and 1 being COMPLETELY
confident/sure, how confident/sure are you that
you can do each of the following without falling?

• Clean house (e.g. sweep or dust) 2. Get
  dressed/undressed
• Prepare simple meals (no carrying) 4. Take a
  bath/shower
• Simple shopping 6. Get in/out of car
• Go up and down stairs 8. Walk around
  neighborhood
• 9. Reach into cabinets or closets 10. Hurry to
  answer the phone

Self-efficacy has a strong correlation with 1)
frailty person self-limits activities and 2)
incidence of falls.
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Progression of PD / Balance Impairments

• Early -
• Movement disorders that may affect balance
• gait pattern short steps
• gait akinesia/hypokinesia
• freezing
• Delayed stepping response to external
  perturbation in steady stance
• No incidence of falls, yet difficulty with
  balance

Intervention Attentional strategies Visualizati
on/verbal cues Visual cues Stepping
response Maintain musculoskeletal and
cardiovascular systems in good condition.

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Mid Impact of visual environment increased Gait
performance, shuffling Falls occur Assessments
TUG, Fxal Reach, tandem stance, turning, postural
response test, STS, postural hypotension, Falls
Efficacy scale, Home Safety Checklist Interventio
n Falls prevention emphasis. Restructure
environment. Review falls hx, task analysis,
impact of environment, pt/family education re
falls risk, falls diary date, time, location,
reason for fall. Maintain musculoskeletal and
cardiovascular systems in good condition. Work
within everyday tasks, home, and community. F/up
every 3 months or as necessary.
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Prieto N Light KE. (1999). Balance, Frailty,
and Falls Assessment, and Intervention Case
study of a client with Parkinsons disease.
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Balance Difficulties
Intrinsic
Extrinsic
Environment
Inherent to PD
Non-PD Related
Fear of Falling
ADL, Task- dependent

Associated with Movement/Cognitive
Disorders- Context-dependent
Medications
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A phenomenon like this makes me wonder May
psychological attitudes somehow influence the
severity of Parkinsonian disabilities? Or,
alternatively, may some nerve circuit situated
deep in the more primitive part of our nervous
system be capable when called upon under certain
circumstances, of bypassing malfunctional
striatal linkages, thereby making possible an
instinctive, semi-automatic life-saving ability
to walk? All of this forces another difficult
question. If the skills for walking can be
reactivated to serve a thoroughly disabled
Parkinsonian patient, even if transiently, and
under specific circumstances, can some way be
discovered---whether by a trick of the will or by
repetitive conditioning---of bringing still other
neuronal pathways and connections back into
dependable service? (McGoon, 1990)
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One must cease to regard all patients as
replicas, and honour each one with individual
attention, attention to how he is doing, to his
individual reactions and propensities and, in
this way, with the patient as ones equal, ones
co-explorerone may find ways, tactics, which can
be modified as occasion requires. (Sacks, 1982)

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Correlates for Home-based Standardized
Assessments Problem Specific
Timed Functional Movement Battery (Light et
al., self-selected, fast pace) adapt to
functional activities in home
Time to dress
Distance walking / day
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End of the day Controversy or new BWS-locomotor
training
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Locomotor training with BWS, treadmill, and
manual assistance
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Functional Walking Control Requirements by the
Nervous System
Adapted from Forssberg, 1982 Barbeau et al.,
1999
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Rehabilitations job is to take your body as
it is and to maximize your capabilities within
recognized limitations. This is a difficult
acknowledgement. Rehabilitation seems only
second best. To fully accept rehabilitation, for
most of us, it is to effectively abandon
recovery. Rehabilitation can give you strength,
reeducation, skills and real improvement, but no
cure. Corbet, 1980 Editor, New Mobility,
Spinal Network
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Will I walk again?
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LOCOMOTOR-SPECIFIC STIMULI

• Loading
  (Conway et al., 1987 de Guzman et al.,
  1987 Edgerton et al., 1991 Harkema et al.,
  1987 Visintin Barbeau, 1994)
• Speed
  (Conway et al., 1987 de Guzman et al.,
  1987 --- Patel et al., 1998 Visintin Barbeau,
  1994)
• Hip position
  (Conway et al., 1987 Andersson et
  al., 1978 Grillner et al., 1978 Duysens et al.,
  1980)

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Rehabilitation of Walking After SCI
Compensation
Recovery
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Apply Recovery to Rehabilitation for Walking
after SCI
Specificity of Training Activity-Dependent
Plasticity Locomotor-Specific Stimuli VIDEO
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DISCOVERY Improvements in Walking Function in
Individuals with Incomplete SCI Following
Experimental Locomotor Training

• Developed the ability to walk overground
• Improved their overground walking velocity and
  kinematics
• Some regained the ability to climb stairs
• (Visintin Barbeau, 1989 Wernig et al.,
  1992, 1995, 1999 Trimble et al., 1998 Behrman
  Harkema, 2000)

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Discovery

• Volitional motor control is not a prerequisite
  for the generation of stepping.
  
• (Wernig et al., 1992, 1995 Behrman Harkema,
  2000)

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National Center for Medical Rehabilitation
Research, NIH, PI Andrea L. Behrman, PhD, PT

• ASIA C or D, UMN
• lt 3 yrs. post-SCI
• Can walk minimum of 40
• Walks minimum of 30/day
• Randomized to 1 of 2 training speeds with BWS
  and trainers
• 45 sessions
• Overground gait velocity
• Reflex modulation

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Rehabilitations job is to take your body as it
is and to maximize your capabilities within
recognized limitations. This is a difficult
acknowledgement. Rehabilitation seems only
second best. To fully accept rehabilitation, for
most of us, it is to effectively abandon
recovery. Rehabilitation can give you strength,
reeducation, skills and real improvement, but no
cure.
One of rehabilitations jobs is to optimize your
bodys capacity for plasticity in order to
maximize recovery from injury.
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