Transcript Park-Assessment - plaza

Assessment of
Balance Disorders and Falls Risk
in Persons with
Parkinson’s 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
Acknowledgements
Foundation for Physical Therapy
VA Brain Rehabilitation and Research Center
Kathye Light, PhD, PT
William Friedman, MD
James Cauraugh, PhD
Dawn Bowers, PhD
William Triggs, MD
Philip Teitelbaum, PhD
Sheryl Flynn, PT, MHS
Mary Thigpen, PT, MHS, NCS
Jung Chang, PT, MHS
Balance Difficulties
Intrinsic
Inherent
to PD
1° Balance
Disorder
Non-PD
Related
Associated with
Movement/Cognitive
Disorders-
Extrinsic
Environment
ADL,
Taskdependent
Medications
Inherent
to PD
1° Balance
Disorder
• Stage III Hoehn & Yahr,
balance disorder
• Mid-Late in disease progression
• 38% fall (Koller et al., 1989):
person’s body involuntarily
contacts the ground
• 13% fall more than 1x/week
• 18% suffer fractures
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.
• 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)
Inherent
to PD
Associated
with
Movement
Disorders
• Decreased walking speed, if <
0.6 m/sec
decreased
ground clearance
trips
FALLS
• Shuffling gait, decreased step length and ground
clearance (< 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,
> 20 steps in 360 degree turn (Lipsitz et al., 1991)
• Difficulty terminating locomotion
• Context-dependent/environment (ex. visual array: tile pattern
change, door width / hallway / outdoors, barriers to movement,
corners or furniture requiring change in direction)
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.
Non-PD
Related
• Age-related changes
Sensory impairments:
visual, vestibular,
proprioceptive
• Weakness; inability to stand up from a chair without
using one’s 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
Extrinsic
Medications
• Depress NS (sedatives, antidepressants)
• Lead to postural hypotension: a postural
systolic BP decline > 20 mm Hg at one or
three minutes of standing or an absolute
systolic BP below 90 mm Hg
(antihypertensives, antidepressants,
diuretics)
Extrinsic
ADL,
Taskdependent
• OVERALL. Minimize balance requirements while
performing ADLs and minimize cognitive tasks
/conversation. Diminish balance requirement, focus on
task. Break down task into steps.
• 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.
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
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?
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
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
1) persons with PD and no hx of falls and from
2) control subjects (no hx of falls)
Distance Reached (cm)
Functional Reach Group Means
50
45
40
35
30
25
20
15
10
5
0
PD + Falls
(Behrman et al, 2002)
PD - Falls
Control
% subjects reaching < 25.4 cm
% subjects reaching = or > 25.4 cm
100
Percent
80
60
40
20
0
PD + Falls
PD - Falls
Control
Criterion for falls risk: reach < 25.4 cm (Duncan et al., 1992)
FR test validity: sensitivity, specificity, predictive value
Falls History in Individuals with PD
Screening Test
Hx of Falls (+)
Total
Reach < 25.4*
(+ Falls Risk)
9
Reach >/= 25.4*
(- Falls Risk)
21
c
12
d
33
Total
30
13
43
a
Sensitivity = a / (a + c) = 30%
+ Predictive value = a / (a + b) = 90%
a
No Falls Hx (-)
b
1
10
Specificity = d / (b + d) = 92%
- Predictive value = d / (c + d) = 36%
= 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)
Standing, transitional movements, and functional tasks:
Berg Balance test
Bogle Thorbahn & Newton, 1996
Residents of 2 independent life-care communities (n=66), M = 79.2 yrs
Mixed diagnoses: 38% orthopedic or neurologic impairment (n=5, 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,
n=18 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
Berg Balance Test Items
1.
2.
3.
Sitting to standing
Standing unsupported
Sitting unsupported
4.
5.
6.
7.
8.
Standing to sitting
Transfers
Standing with eyes closed
Standing with feet together
Reaching forward with an outstretched arm
9.
10.
11.
12.
Retrieving object from floor
Turning to look behind
Turning 360°
Placing alternate foot on stool
*
13. Standing with one foot in front of the other foot
(tandem stance)
14. Standing on one foot
*
*
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 clinician’s arms.
• Patient in stance with feet 10 cm apart.
• “I am going to tap you off balance, and I won’t let you
fall.”
Use to quantify baseline performance and outcome of
stepping training.
0
1
2
3
4
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
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
> 20 steps in 360° turn (Lipsitz et al., 1991)
Falls Records (Yekutiel, 1993 – 2 case studies)
• Context-dependent vs. lab/clinic-based assessments
• Individual’s 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 individual’s particular problem
Plan intervention accordingly.
Continual assessment over time, % reduction of falls.
Factors accounting for falls may change.
Balance Difficulties
Intrinsic
Inherent
to PD
Extrinsic
Non-PD
Related
Associated with
Movement/Cognitive
DisordersContext-dependent
Environment
Fear
of
Falling
ADL,
Taskdependent
Medications
Falls Efficacy Scale (Tinetti)
Measures a person’s confidence in doing
ADL without falling.
Fear
of
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?
1.
3.
5.
7.
9.
Clean house (e.g. sweep or dust)
Prepare simple meals (no carrying)
Simple shopping
Go up and down stairs
Reach into cabinets or closets
2. Get dressed/undressed
4. Take a bath/shower
6. Get in/out of car
8. Walk around neighborhood
10. Hurry to answer the phone
Self-efficacy has a strong correlation with
1) frailty: person self-limits activities and 2) incidence of falls.
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
Visualization/verbal cues
Visual cues
Stepping response
Maintain musculoskeletal and cardiovascular
systems in good condition.
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
Intervention: 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.
Prieto N & Light KE. (1999). Balance, Frailty,
and Falls Assessment, and Intervention: Case
study of a client with Parkinson’s disease.
Balance Difficulties
Intrinsic
Inherent
to PD
Extrinsic
Non-PD
Related
Associated with
Movement/Cognitive
DisordersContext-dependent
Environment
Fear
of
Falling
ADL,
Taskdependent
Medications
“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 lifesaving 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)
“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 one’s equal, one’s coexplorer…one may find ways, tactics, which can
be modified as occasion requires.”
(Sacks, 1982)
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
End of the day:
Controversy or new
BWS-locomotor training
Locomotor training with BWS, treadmill, and
manual assistance
Functional Walking:
Control Requirements by the Nervous System
Equilibrium
during
propulsive
movement
Basic
movement
synergy
Adaptation to
behavioral
goals and external
constraints
Adapted from
Forssberg, 1982;
Barbeau et al., 1999
“Rehabilitation’s 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
Will I walk again?
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)
Rehabilitation of Walking After SCI
Compensation
Recovery
Apply
“Recovery” to
Rehabilitation for Walking
after SCI
Specificity of Training
Activity-Dependent Plasticity
Locomotor-Specific Stimuli
VIDEO
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)
Discovery
• Volitional motor control is not a
prerequisite for the generation of
stepping.
(Wernig et al., 1992, 1995; Behrman & Harkema, 2000)
National Center for Medical Rehabilitation Research, NIH,
PI: Andrea L. Behrman, PhD, PT
• ASIA C or D, UMN
• < 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
“Rehabilitation’s 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 rehabilitation’s jobs is to optimize
your body’s capacity for plasticity in order
to maximize recovery from injury.
Discovery
Recovery
SCI