PD ExpertBriefing Gait, Balance and Falls in …...PD ExpertBriefing: Understanding the Progression...
Transcript of PD ExpertBriefing Gait, Balance and Falls in …...PD ExpertBriefing: Understanding the Progression...
Parkinson’s Disease Foundation
PD ExpertBriefing: Understanding the Progression of Parkinson’s
Led By: Ronald F. Pfeiffer, M.D.
To hear the session live on: Tuesday, June 26, 2012
at 1:00 PM EDT.
DIAL: 1 (888) 272-8710 and enter the passcode 6323567#.
To also view the session live on the computer by visiting:
http://www.pdf.org/parkinson_briefing_progression
If you have any questions, please email [email protected]
or call (212) 923-4700
Parkinson’s Disease Foundation
PD ExpertBriefing: Gait, Balance and Falls in Parkinson’s Disease
Led By: Terry Ellis, Ph.D., P.T., N.C.S.
To hear the session live on: Tuesday, January 15, 2013
at 1:00 PM ET.
DIAL: 1 (888) 272-8710 and enter the passcode 6323567#.
To also view the session live on the computer by visiting:
http://event.netbriefings.com/event/pdeb/Live/falls
If you have any questions, please contact
Valerie Holt at [email protected] or call (212) 923-4700
Introduction
Robin Anthony Elliott Executive Director
Parkinson’s Disease Foundation
PD ExpertBriefing: Gait, Balance and Falls in
Parkinson Disease
Terry Ellis, Ph.D., P.T., N.C.S. Director, Center for Neurorehabilitation Boston University College of Health and Rehabilitation Sciences: Sargent College
Goals for PD ExpertBriefing
• Gain a better understanding of the nature of walking and balance problems experienced by people living with Parkinson's disease.
• Learn about research that demonstrates the benefits of
rehabilitation and exercise to improve walking and balance in Parkinson’s disease.
• Learn practical strategies to help improve walking and
reduce fall risk as it applies to you, or a loved one or a patient living with Parkinson's disease.
• Slow walking • Short, shuffling steps • Foot drags or “catches” • Arms swing less • Stooped posture • Difficulty initiating walking • Difficulty turning
Problems with Walking in Parkinson’s Disease
• Hypokinesia (small size of movements) • Rigidity (stiffness) • Freezing • Weakness in the lower extremity muscles • Reduced mobility of the joints in the lower
extremity and the spine
Why is Walking Problematic in Parkinson’s Disease?
Walking and Disability in Parkinson’s Disease:
Is There a Link?
Walking and Disability in PD
Difficulty with “ambulation”
is “Clinical Red Flag”
that marks emerging disability
Shulman L. Movement Disorders , 2010; 25 (1):S131-135
WALKING DISTANCE: 6 MINUTE WALK TEST
Patients Park-net trial
Controls Aging study
N 699 1959
Men 409 (58.5%) 921 (47.0%)
Age 68.6 (±7.7)
65.8 (±7.0)
Time since diagnosis
5.3 (±4.7)
Nimwegen MV. Physical Inactivity in Parkinson’s disease. J Neurol. 2011;258(12):2214-21
77 327 243 34 11% 47% 35% 5%
People with PD were about 1/3 less active (29%) compared to healthy elders.
Variable Baseline
Mean (SD) [95% confidence interval]
One year
Mean (SD) [95% confidence interval]
Magnitude of Change
(% change / Effect size#)
Age (years)" 67.06 (8.75) [64.01-‐70.11]" " "
Years with PD" 4.44 (4.24) [2.97-‐5.91]" " "
Hoehn and Yahr Stage (median)" 2.0 (1-‐3)" 2.0 (1.5-‐3)" "
LEDD (mg)" 303.03 (294.38) [197.77-‐408.29]" 423.49 (359.66) [296.13-‐550.84]" 28 / 0.37"
Steps*" 10,261.15 (4332) [8625-‐11,645]"
9159.44 (3534) [7887-‐10,325]"
-‐12 / 0.28"
Moderate intensity minutes*" 22.5 (24.2) [13.7-‐30.4]"
16.1 (18.7) [9.2-‐22.1]"
-‐40 / 0.30"
MDS-‐UPDRS Motor subsecYon" 28.18 (8.56) [25.15-‐31.22]" 28.52 (11.71) [24.36-‐32.67]" -‐1 / 0.03"
MDS-‐UPDRS Item 3.10 (median)" 1 (0-‐2)" 1 (0-‐2)" "
6 minute walk (meters)" 480.52 (135.61) [432.43-‐528.60]" 495.96 (154.60) [440.23-‐551.71]" 3 / 0.11"
Maximal Gait Speed (meters/sec)" 1.77 (.50) [1.56-‐1.95]" 1.74 (.53) [1.60-‐1.96]" -‐2 / 0.06"
Changes in Ambulatory Activity in People with PD Over One Year
Cavanaugh JT, Ellis T, Earhart GM et al. JNPT;2012:36:51
• Slow progression of disability • Optimize independence and participation in
home, work and leisure activities • Improve walking
– Speed – Distance – Size of movements – Turning ability
Goals for People with Parkinson’s Disease
• Practicing walking can improve walking • Walking with a metronome or music can
help improve coordination, timing, speed and efficiency of walking
• Using a pedometer can help with setting
goals and providing feedback about progress
Solutions
• Auditory • Visual • Tactile • Verbal • Attention (thinking about the movement) • Combination of Above
Solutions: Cueing
• Replace the lost internal cueing mechanism with an external cueing mechanism
• Acts as an internal “cue” or “trigger” to enable movement sequences to be carried out implicitly, automatically and without attention
How Does Cueing Work?
Reference Intensity Intervention________ • Nieuwboer (2007) 3x / week Auditory, vibration or visual cue
E=153 30 mins at preferred frequency 3 weeks
PRACTICE TASKS » starting and stopping walking
stepping sideways & backward walking – dual task
walking over uneven surfaces
Home Cueing Program
Results • + step length • + velocity • decreased freezing • no carry over effects at 6 wks
• Rhythmic Auditory Stimulus (RAS) – Metronome – Tone embedded into instrumental music
• 80 beats / min • 100 beats / min • 116 beats / min
– Music with a specific tempo
Delivery of Auditory Cues
Video Demonstrations
NO CUES WITH CUES
People with PD can improve their walking
ability by using visual cues
A B C D E
EFFECTIVE CUES INEFFECTIVE CUES
1 foot
6 feet
Adapted from Martin, 1967 Orientation of Lines
Can People with Parkinson’s Improve Balance? … Lessen Risk of Falls?
Frequency of Falling
• One third of healthy older adults over 65 experience a fall
• Two thirds of people with PD living in the
community report falling in the past 12 months
Ashburn et al. Age Ageing (2001)
When, Where, How Do Falls Happen?
• N = 124 (age = 72; disease duration = eight years) • 639 falls occurred • 80% occurred at home
– Bedrooms – Living areas – Kitchens – Gardens
• 45% of falls during walking • 32% during standing • 21% during transferring
Ashburn et al. Disabil Rehabil 2008;30(16)
Allen et al. Balance & Falls in PD: A Meta-analysis of the Effect of Exercise and Motor Training. Movement Disorders. 26(9):1605-1615.
Effects of Tai Chi on Falling in PD
• 195 persons with Parkinson’s disease • Assigned to one of three groups:
– Tai Chi – Resistance training – stretching
• Twice a week for 60 minutes over 24 weeks • Incidence rate of falls was significantly lower in the Tai
Chi group compared to the stretching group • No significant difference was found between the Tai
Chi and strengthening group
Fuzhong Li et al. N Engl J Med 2012;366:511-9
Effects of Balance and Strengthening on Falling
Goodwin VA et al. J Neurol Neurosurg Psychiatry 2011;82:1232-1238
• N=130 • Subjects: PD with
history of >2 falls in past year
• RCT • 10 wk group Rx vs
usual care • Strength and balance
training • Led by PT • Differences in fall rate
between groups not stat sig but clin relevant?
• 32% difference in fall rates between groups during Rx
• 26% difference 10-wks post Rx
Example Exercises
Recommendations
• Be Active! • Take action to reduce disability and optimize
independence and quality of life • Treatment focusing on walking and balance can help
reduce disability • Think prevention: Get treatment for walking and
balance even before you notice a problem • Consult with a physical therapist who is knowledgeable
about Parkinson’s disease
• Walk More: – Use a pedometer – Keep track of steps: write it down – Set goals: # of steps per day – Walk better: use a metronome or music to “entrain” to the beat
• Improve Balance: – Practice balance exercises (visit a physical therapist) – Strengthening exercises (practice standing up from a chair)
• Reduce Fall Risk: – When standing still ... widen your base of support by standing with your feet
apart and not together – Avoid multi-tasking … this will result in more attention directed at walking
and keeping your balance – Reduce clutter in your house … crowded environments contribute to freezing – Fall diary … write down the time of day, direction, activity, environment
where the fall occurred and look for patterns
Things You Can Do Today
Resources • APDA Rehab Resource Center at Boston
University Exercise Helpline • (888) 606-1688 or [email protected]
• PDF General Helpline • (800) 457-6676 or [email protected]
Questions About Exercise?
Resources from PDF Fact Sheets • Falls Prevention • Physical Therapy
and Parkinson’s
Parkinson’s Disease Resource List • 750 Resources
PD ExpertBriefings: • Physical Therapy & Parkinson’s: What You Need to Know • Also available as DVD
Professional Education: • Online course.
PTs, rehab specialists can earn .8 CEUs.
Questions & Answers
Upcoming PD ExpertBriefings Under-recognized Non-Motor Symptoms of Parkinson's Disease Tuesday, March 12, 1:00 PM – 2:00 PM ET K. Ray Chaudhuri, D.Sc., M.D., Kings College London, London, UK Medical Therapies: What's in the Parkinson's Pipeline? Tuesday, April 16, 1:00 PM – 2:00 PM ET Kapil D. Sethi, M.D., F.R.C.P., Georgia Health Sciences System, Augusta, GA Improving Communication in Parkinson’s: One Voice, Many Listeners Tuesday, June 4, 1:00 PM – 2:00 PM ET Angela Roberts-South, M.A., C.C.C.-S.L.P., C.A.S.L.P.O .(Reg.), Ph.D. Candidate, Western University, Ontario, Canada
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