Microsoft powerpoint - sept 2011 falls prevention for pt (1)

Prevention of Falls in the Person with PD Prevention of Falls in Course Description 70 % of persons with Parkinson's Disease (PD) fall annually. Postural Instability is one the the 4 primary symptoms of PD. Persons with PD have unique intrinsic risk factors that by Maria Walde-Douglas, PT put them at risk for falls. Learn about evidence-based assessment tools and Struthers Parkinson's Center, practical intervention strategies to an NPF Center of Excellence reduce fall risk in this patient population. Course Objectives 1. Identify appropriate assessment tools to assess balance and fall risk in the Parkinson's population 2. Describe risk factors for falls unique to the person with Parkinson's Disease (PD) 3. Design intervention and treatment strategies to reduce falls risk for the person with PD Parkinson's Review: Basic Pathology in Parkinson's 4 Primary Symptoms • Loss of brain cells in the substantia • Tremor-resting nigra that produce the neurotransmitter dopamine • Rigidity: resistance to passive motion; can affect trunk/neck (axial) or limbs • Dopamine is a chemical messenger for Akinesia or bradykinesia: poverty of control of movement and coordination movement or reduced speed Hypokinesia: reduced amplitude (size) of • Affects automatic movements so person experiences loss of "automatic • Postural Instability-balance pilot" and is unable to control impairment; under-scaled balance movement normally This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author Prevention of Falls in the Person with PD Medications in Parkinson's Common Medication Side Effects That May Influence PT Plan of Care • Pharmacologic treatment is aimed at • Orthostatic hypotension dopamine replacement : • Hallucinations • Most potent, "gold standard"medication is carbidopa/levadopa (trade name Sinemet) • Nausea or vomiting • Dopamine agonists: stimulate parts of the • Agonists linked with sedation/sleep attacks brain influenced by dopamine-pramipexole and compulsive behaviors (Mirapex) and ropinirole (Requip) • Dyskinesia: writhing, twisting involuntary • Many others: anticholinergics, MAO-B movements caused by PD medication side Inhibitors, COMT Inhibitors, tremor-control * only a problem if interferes with function Modified Hoehn and Yahr Scale Motor Fluctuations • Stage 1: Unilateral Symptoms • The longer the duration on levadopa • Stage 1.5: Unilateral plus axial involvement therapy, the greater the change of • Stage 2: Bilateral symptoms, without balance variability in motor function: • Stage 2.5: Mild bilateral symptoms with – ON: optimal motor function on meds; recovery on Pull Test may have dyskinesia • Stage 3: Mild to mod bilateral symptoms; some postural instability; physically – OFF: wearing off of meds or suboptimal • Stage 4: Severe disability; still able to walk functioning with increase in PD or stand unassisted symptoms such as bradykinesia, rigidity, • Stage 5: Wheelchair bound or bedridden Research Synthesis (Dr. Meg Morris, PT- World Parkinson Congress 2006) • Fall: unexpected descent into a • Fall incidence 60% in PD support surface (floor, chair, steps) • 20% resulting in a fracture • Near fall: situation in which a fall • Near falls 60-75% almost occurs but a person catches themselves, regains stability with a • 60% in ON phase support surface (wall, furniture) or is caught • Dynamic activities (walking, turning) This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author Prevention of Falls in the Person with PD PD Falls and Injuries Falls and Parkinson's Struthers Parkinson's Center Movement Disorders Journal April 2005 • Age-related changes contribute to falls but persons with Parkinson's • 1131 responses (79% response rate) have twice the fall risk of their peers • Median disease duration of 7 years• 55.9% had at least one fall in past 2 • Extra intrinsic risk-factors because of • 65% sustained an injury• 33% sustained a fracture• 75% required health care service • More risk factors=more falls Gait and Balance Initiative (GABI) Struthers Parkinson's Center supported by a grant from the National Parkinson Foundation Publication pending • Cross-sectional study of 453 people with • Near-falls more frequent than falls • Direction of falls: 45% forward, 26% backward, • Applies a multidisciplinary strategy to address relationship between number of falls and demographic and clinical measures • Associated symptoms: Wearing off (27%), • Involved assessments by Neurologists/RNs, PT, fatigue (24%), freezing (21%), dizziness (15%) OT, Speech and patient self-assessment tools and falls diary • Associated activities: Walking (41%), Standing (27%), Reaching (22%), getting up/down (15%) Physical Therapy "Those who fail to study history are for Balance, Gait and Falls doomed to repeat it" Risk in the Person with Winston Churchhill Parkinson's Disease ***View every fall as a learning experience*** This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author Prevention of Falls in the Person with PD The WHY of Falling: Fall/Near Fall Event Log Keeping a Falls Diary • Greater clarity about the frequency, • Record time of day and where you were cause and circumstances of falls and in medication cycle (ON, OFF) • What you doing at the time; • Useful tool to determine what changes in activity, behavior, environment need to happen • Direction of fall • Useful info for PT to issue on Day • Witness's perspective or unwitnessed One of assessment-have • Symptoms: dizziness, freezing, patient/carepartner complete for 1-2 dyskinesia, confusion • Injuries, Medical Attention Unified Parkinson's Disease Ask Pertinent Questions Rating Scale (UPDRS) • Interview patient /carepartner Currently the most widely used carefully including questions listed in and accepted scale • "Describe the most recent falls/near Developed to assess effects of falls you have had" medications and/or surgery • Gives insight into some of the Can be long and cumbersome causes/reasons and PD symptoms for purposes of PT examination that are leading to falls *How could it have been prevented?* Unified Parkinson's Disease UPDRS Motor Examination Rating Scale (UPDRS) Numerical system provides Components may be useful common language/rating for during PT examination to Parkinson's primary and quantify Parkinson's symptoms secondary symptoms at impairment level: Not sensitive for assessing progress of PT treatment Designed for neurologists not PT; not a functional measure Postural instability This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author Prevention of Falls in the Person with PD UPDRS Pull Test-for postural Postural Stability / Pull Test Scoring from UPDRS • Patient stands with feet slightly apart and eyes open and is prepared 0 = Normal1 = Retropulsion but recovers unaided • Examiner is behind the patient (and is 2 = Absence of postural response, would also prepared to catch the patient!) if not caught by examiner.
• A sudden, strong posterior 3 = Very unstable, tends to lose balance displacement is produced by pull on patient's shoulders 4 = Unable to stand without assistance Reactive Postural Response ( Push Release Test ) Postural Response Scoring Fay Horak-BESTest Journal of Phys Ther, May 2009 • (3) Recovers stability with ankles, no One component of BESTest (Balance Evaluation added arms or hips motion • (2) Recovers stability with arm or hip In Place Response forwardIsometric push on anterior shoulders In Place Response backwardIsometric push on scapulae • (1) Takes a step to recover stability Patient stands with feet shoulder width apart, arms • (0) Would fall if not caught OR requires assist OR will not attempt Instructions: Don't let me push you. When I let go, keep your balance without taking a step Pushing or Pulling to Detect Berg Balance Test Berg, K et al Physiotherapy Canada 1989 Nature Clinical Practice-Neurology Bloehm, Okun oct 2008 • 2 groups of PD patients: prior fallers and non- • 14 items, scored 0-4, (56 max score) • Pull Test and Push Release (PR) Test performed in dopaminergic On and OFF state • Self-initiated tasks related to • Similar diagnostic accuracy but in ON state PR everyday function (sit to stand, more accurate in classifying retrospective forward reach, picking up item on "Patients with abnormal PR Test should be floor, 360 degree turn) candidates for an intensive, multifactorialintervention program, including optimization • Designed for frail, community of Parkinson medication, physical therapy and education" This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author Prevention of Falls in the Person with PD Percent Probability of Falling Limitations of Berg Based on Berg & Fall History Grid of falls probability • Documented ceiling effect; fails to calculated by Diane Wrisley identify more subtle balance deficits MS, PT, NCS (from equation in Shumway-Cook et al, Phys Ther 1997 77:812 -819) • Less sensitivity to identify Based on Berg score abnormalities in postural responses combined with reports of seen in persons with PD number of falls within the Balance Assessment Tool: The Mini-BESTest (Dr. Fay Horak) • Condensed version of Balance • Identifies more subtle deficits and Evaluation Systems Test (Phys Ther Vol 89, changes with therapy; less of a • 14 item, 32 point test-less cumbersome ceiling effect than Berg and time-consuming; more clinically relevant • Includes Anticipatory, Sensory, Postural • Found to be as reliable as the BEST • Contains elements of the Functional and slightly greater discriminitive Gait Assessment and includes a Timed properties for identifying fallers in Up and Go (TUG) with divided attention individuals with PD (JNPT, June 2011, Vol 35 ) Research on Best Tool to ID Balance Resource Website Fallers in Persons with PD PT Journal Jan 2011 • Developed by Fay Horak, PhD, PT • Functional Gait Assessment and BESTest have reliability and validity • Contains copies of BESTest MiniBEST for balance assessment in PD and various other clinical balance • BESTest is most sensitive for identifying fallers • Cutoff scores for identifying fallers: – Berg 47/56; 15/30 FGA; 69% BESTest This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author Prevention of Falls in the Person with PD Timed Up and Go (TUG) Posiadlo et al, JAGs • Subject walks a distance of 3 meters • Arm chair 18 inches high (approximately 10 feet).
• Instructions: "When I say go, I • Performs a practice test first.
want you to stand up and walk to the line, then walk back to this • Uses customary walking aid.
chair and sit down again. Walk at your normal pace." • Performance is timed.
TUG Research in PD PT Journal Jan. 2011 • Older subjects who took 13.5 seconds or longer were classified as fallers.
• Minimal detectable change (MDC): • Scores >30 seconds identified patients smallest amount of difference in to have significant difficulties with scores that represent true change • Normal ranges for young adults were around 10 seconds.
• Found to sensitive and specific indicator *MDC in TUG score in persons with PD of whether falls occur in community was found to be 3.5 sec dwelling adults.
• Reliable tool for PD (Meg Morris, et al) Divided Attention TUG (Shumway-Cook, et al PT Journal, Sept. 2000) Can add secondary task to TUG • Performance in persons with PD Motor: carrying tray with water deteriorates with divided attention (dual tasks).
Cognitive: subtract by 3s from 50 or male/female names through • Cognitive vs. motor tasks proved equally Combined cognitive and motor task*more relevance to real-life Need to assess under dual task This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author Prevention of Falls in the Person with PD Blood Pressure Screening Assessing Mental/Emotional Orthostatic Hypotension Factors Impacting Fall Risk Fainting when upright or just upon standing may be cause for falls in PD Individuals who fall develop a risk May occur as a result of ANS impairment for fear of falling, which adds especially in atypical Parkinsonism or as PD spiraling risk for additional falling, greater fear and functional decline Screen blood pressures in both sitting and standing (wait one minute between position (Friedman et al, J Am Geri Soc 2002 Aug) Drop of more than 20 mm Hg systolic or 10 46% fear of falling (self-report mm Hg diastolic considered orthostatic hypotension tools) in persons with PD Patient may be asymptomatic Fear of Falling and PD Modified Falls Efficacy Scale Mov Disorders Journal, May 2003 Arch Phys Med Rehab 1996; 77 14 daily activities self rated on 10 point scale to address confidence with various • Studied Fear of Falling ( FOF) with qualitative and quantitative measures of postural control Updated: Yardley, L et al: Age and Aging 2005) 9 are within home and 5 are in • FOF an important, independent risk factor in persons with PD copies available on www.bestest.us/resources Activities Specific Balance Confidence Scale Psychosocial Impact of Falling Powell et al J Gerentol Med Sci 50A(1) M28-M34 16 item self rated scale from 0% (no) • Reduction in community outings social to 100% (complete) confidence to isolation decreased activity , decreased complete each daily task strength, and endurance • Issues of pride Contains more community ambulation – Reluctance to use assistive device tasks with 7 activities within the home – Difficulty accepting assistance • Embarrassment of PWP or carepartner Copies available at • Frequent injury; need to seek medical This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author Prevention of Falls in the Person with PD Functional Gait Assessment Wrisley, DM, Marchetti, GF, Kuharsky, DK and • Course of known distance.
• 10 items; based on the Dynamic Gait • Record time (in seconds) to complete • Developed for use with vestibular disorders distance ÷ time = feet/second • Useful for clients with balance dysfunction that have a ceiling effect score on the Berg • Gait velocity <2.5 ft/s determined to be • Head turns, stop and pivot, obstacle, speed changes, eyes closed, tandem and higher fall risk (Susan Whitney, PhD, PT, retro-walking and stairs University of Pitt.) • Components of it included in the Mini-BEST• Copies available at • Useful tool at determining effectiveness of an • Count the number of steps per Parkinson's- Related Risk Factors for Falls • Useful to quantify a festinating pattern or document step Slow, Shuffling Gait Training BIG for Hypokinesia Exp Brain Res, 2005, Farley BG, Koshland, GF • Amplitude problem caused by hypokinesia • Motor Disorder: Inappropriate scaling • Reduced foot clearance common cause of trips particularly on non-level surfaces • Sensory Disorder: Sensory • Often worsens with wearing-off of proprioceptive processing problem medication or with fatigue – Mismatch between what person with PD • Treatment strategies aimed at increasing perceives their movement to be and step size to improve foot clearance how it actually appears Struthers Parkinson's Center, Golden Valley, Minnesota This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author Prevention of Falls in the Person with PD Large Amplitude Movement Large Amplitude Gait Training Dr. Becky Farley, PT • High effort, intensive training on • Treadmill and overground walking increasing SIZE of steps • Have BIG STEPS be primary focus of • Can use taped markers on floor (horizontal lines) agility ladders, footprint cutouts • Obstacle clearance (foam noodles) • Intensity is key for best results (LSVT BIG protocol was 4 • Surface transitions and uneven surface Turning Instability Turning Instability Treatment Strategies • Multi-step turns common in PD ("wind- • Focus on wide base of support with rocking • Often base of support is too narrow • Train in U Turn method for more open areas • Rock and Turns with wide base and • Incomplete weight shift exaggerated weight shift for confined spaces • Inappropriate strategies used-crossing one foot over the other • Step and turn exercise Turning Instability Treatment Strategies • Incorporate individual turning • Akinesia: absence of movement; a strategies into function temporary motor block – Build a course that incorporates large and confined space turns, pivots, 45-90-180-360 turns • May begin as a start-hesitation or be • Agility drills that involve quick direction changes without warning • Base of support usually too narrow • Navigation around cones, chairs • Incomplete weight shift This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author Prevention of Falls in the Person with PD Freezing Triggers • Sudden direction changes, turning, or • Doorways or thresholds.
• Approaching furniture / obstacles.
STOP (don't force your way through a • Turning around to sit.
• Change in floor pattern.
STAND TALL (COG over BOS) • Confined spaces.
SWAY SIDE TO SIDE STEP LONG ("sticky" foot first)-most • Stress, anxiety, hurrying.
Struthers Parkinson's Center, Golden Valley, Minnesota Rhythmic/Auditory Cues Tactile/Kinesthetic Cues • Counting aloud (in synch with weight • Touch affected foot or knee (with cane or shift) or chanting • Clapping or snapping fingers • Manual weight shift; hands on pelvis • Metronome (portable-beeps) • "Dancing" with partner • Rhythmic Auditory Stimulation (RAS): specialized technique employed by music therapists • Complex movement: marching, kick – Timing music bpm with movement Struthers Parkinson's Center, Golden Struthers Parkinson's Center, Golden Valley, Minnesota Valley, Minnesota Carepartner Instruction • Focus on object BEYOND point of • Remain calm, avoid hurrying freeze (i.e. doorway) • Taped horizontal lines on floor or X • Avoid pulling on person with PD or their AD: let them take YOUR arm if necessary • Laser device on U Step walker or • Give them space if safety permits; don't • Foot in front of patient's foot as obstacle to step over • Short, simple verbal cues given one at a • Patterns in tile Struthers Parkinson's Center, Golden Struthers Parkinson's Center, Golden Valley, Minnesota Valley, Minnesota This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author Prevention of Falls in the Person with PD • Exaggerated weight shifts in wide base of • Hastening of gait combined with support in all directions-rocking reduction in step size; "runaway train" • Step estimation technique: have patient estimate how many steps to get from Point • Often triggered when center of gravity A to Point B and count them out as they gets too far ahead of base of support • Specificity of training in areas that likely to • Common triggers: reaching into a trigger freezing; lots of repetition closet, approach to a chair ("horse sees • Externally driven locomotion-treadmill, • Can occur as a result of forcing way Retropulsion-backward balance Treatment Strategies • Focus attention on what leads up to an episode to trigger it • Backing up to sit down • Cues for upright posture and • Reaching overhead immediately STOP when shorter, quicker steps occur, widen base of • Stepping away from sink, counter support and start again with big step • Weighted walkers or U Step walker with • Carrying items close to body in both resistance control feature may be • Being approached closely/suddenly • Rhythmic gait training with metronome to slow cadence; pacing activities Compensatory strategies Treatment Techniques • Weight shift activities in Power Stance; add resistance as able (Theraband, • Power Stance: martial arts split stance with wide base • Sidestepping vs. backing away from • Retro-walking on treadmill (if high objects like countertops level) or over-ground with emphasis on • Heavy duty walker such as U Step big steps-can add resistance as able may be necessary to counterbalance • Backward alternating lunges- using/near support if needed Struthers Parkinson's Center, Golden Valley, Minnesota This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author Prevention of Falls in the Person with PD Assistive Devices in PD • 5 inch swivel casters for front of standard • Axial (core muscle) rigidity creates altered trunk mechanics and loss of • 4 wheeled walker with hand brakes segmental rotation • Difficulty moving in multiple planes • Laser cane-www. U Step.com • Difficulty initiating and completing • U Step walker-www. U Step.com protective responses during activities • All contribute to increased risk of • Dashaway Walker-www.dashaway.net Concepts from Parkinsons Wellness Recovery Training, Dr. Treatment Strategies • Multi-plane, reciprocal, rhythmical rotational Can be major contributor to falls: movements in varying postures • Active stretching of flexor musculature • Exhaustion from sleep disorder or poor • Yoga Poses: spinal twist, modified revolving triangle using a chair • Vicious cycle of feeling tired>becoming • Transitions from varied positions more sedentary >muscle atrophy>loss exaggerating axial rotation and extension – 4 point to side-sitting to long-sitting with arms positioned in extension behind trunk • Imbalance between rest and activity• Fatigue of PD different than ordinary – Concepts from Parkinsons Wellness Recovery Training, Dr. Orthostatic Hypotension Patient Education Patient Education • Ankle pumps and leg kicks in seated • Balance rest and activity: take short rest periods, position prior to standing to increase break projects into smaller tasks, one short daytime nap if needed • Keep legs moving/weight shifting if • Healthy sleep habits: avoid excessive daytime • Encourage regular fluid intake- sleeping, consistent bedtimes and waking hydration to increase blood volume • May need to wear support hose • Frequent bouts of activity throughout the day: • Report back to MD for further medical develop an activity schedule This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author Prevention of Falls in the Person with PD Vision and Perceptual Changes: Vision and Perceptual Changes Patient Education Strategies Rick Vandendolder, OT Struthers Parkinsons Center Rick Vandendolder, OT Struthers Parkinsons Center • Mark edge of stairs, armrests, walker handles with brightly colored tape • Reduced contrast sensitivity • Bright lighting; especially path to • Impaired visual spatial perception bathroom at night or dark stairways • Slower speed of eye scanning • Taped markers (X) on floor for movements in walking path proper positioning in front of toilet or chair Impaired Cognitive Function: Impaired Cognitive Function Patient Education Strategies Marjorie Johnson, SLP, CCC Struthers Parkinsons Center Marjorie Johnson, SLP, CCC Struthers Parkinsons Center • Lack of attention; selective, dividing, alternating • Enlist help of carepartner for gentle reminders and supervision if needed • Impaired short-term memory • Post visual cue cards to jog memory – Remembering to use safety devices and strategies taught in OT or PT • Simplify tasks; do one piece at a time – Do not bombard patient with multiple verbal cues • Reduced executive function: Plan>Act>Assess Outcome>Revise Plan – Problem- solving in novel situations, generalize **consult Occupational and Speech Therapist for more specific learning, recognize risky situations, learn from recommendations and training past mistakes, "motor recklessness" Divided Attention Treatment Strategies Work on building blocks of floor transfers: Early Stage PD: Focus on training with motor and cognitive secondary tasks – Prone to sidelying Ideas: category naming, backward spelling – Sidelying to sidesitting Perform while walking through obstacle – Sidesitting to 4 point course, on "stepping stones", or – 4 point to half kneel with/without support retrowalking to increase complexity – Supported ½ stand with wide base Add to exercise: forward, sideways, – Pivot to sit in chair safely This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author Prevention of Falls in the Person with PD Interdisciplinary Team Community Programs • Comprehensive team approach • Study of 10 wk comm ex class 2X/wk works best in area of fall prevention – Improved grip strength and 6 min walk– Long-term participants (14 mo) showed similar improvement and NO DECLINE • Important for compliance and accountability upon discharge from PT • PT, OT, SLP, SW, MD, RN collaboration • Exercise groups: Silver Sneakers, Modified yoga, Tai Chi, NeuroFit • Develop an integrated network of • Each member addresses their scope providers-education about PD and when to refer back to PT "Our greatest glory lies not in never falling but in rising every time we fall" This information is property of Maria Walde-Douglas and should not be copied or otherwise used without express written permission of author

Source: http://www.mnapta.org/associations/11650/files/Parkinsons%20Disease%20and%20Falls%20Prevention.pdf