Balance and Falls in PD: Effective Interventions and Assistive Devices

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1 Balance and Falls in PD: Effective Interventions and Assistive Devices Hanan Khalil, PhD Department of Rehabilitation Sciences Jordan University of Science and Technology Irbid, Jordan

2 Overview Understand the prevalence and impact of risk of falls in people with PD Understand the contributing factors to risk of falls in people with PD Discuss the effects of rehabilitation interventions on fall risk in people with PD

3 Is Falling an Issue in PD? Hely et al, Move dis; 2008

4 Is Falling an Issue in PD? High occurrence rate of falls in PD 40% to 75% Average rate of falls per recurrent fallers per year is 20.8 Falls occur during daily activity and when patients are optimally medicated Falling in PD leads to Injuries Fear of falling Reduced mobility Deterioration of fitness Loss of independence Increasing risk of nursing admission Kerr et al, Neurology, 2010; Allen et al, Parkin Dis, 2013; Gazibara et al, Geriat nurs, 2014

5 Falling Is Not a Late Feature in PD Pickering et al, Move dis; 2007

6 Take Home Messages! Falls is very prevalent in PD It starts from an early stage

7 But What Happen when Falls Do Occur.. Previous history of falling is linked with fear of falling in PD

8 Fears Leads to Inactivity I will never fall again

9 Falls and Fear of Falls: a Vicious Cycle Falling leads to fear of fall Fear of fall leads to inactivity Further diminish muscle strength, physical fitness and motor impairments Further increases the risk of future fall

10 Take Home Message! Fewer falls is not necessarily better!

11 What Contributes to Falls in PD? Factors associated with recurrent falls include: A positive fall history Increased motor impairment Fear of falling Freezing of gait Impaired balance Reduced physical activity Treatment with dopamine agonist Increased L-dopa dosage

12 Dopamine Replacement Increases Gait-Related Mobility without Improving Reactive Responses Forman et al, Parkinsons Dis; 2012

13 DBS Increases the Exposure to Risk of Falls on the Long Term St George et al, Neurology. 2010

14 Additional Contributors to Falls in PD Autonomic dysfunction Orthostatic hypotention Urinary incontinence Sensory co-morbidities Visual, somatosensory, vestibular Attentional deficits and dual tasking

15 Take Home Messages! Falls in PD is multifactorial Several contributing factors may be amenable by PT interventions

16 Treatment: What Evidence Says..? Recommendations from the European Physiotherapy Guideline Conventional Physiotherapy Treadmill Cuing Cognitive strategies Dance; Tango Ti Chi No of falls BBS FR DGI Mini-Best FOG

and turns Large amplitude of movement Single leg stance Weight shifting Controlled displacement

17 Evidence Based Interventions Tango dance: train for a minimum of 10 weeks twice a week for 60 minutes Ti Chi: Train for a minimum of 24 weeks twice a week for 60 minutes Content: Start, stop and turns Large amplitude of movement Single leg stance Weight shifting Controlled displacement of COM over BOS Stepping in multiple directions Backward walking EU Physiotherapy guideline in PD; 2014

18 Evidence Based Interventions Earhart GM. Eur J Phys Rehabil Med. 2009

19 10 once weekly group exercise sessions with twice weekly home sessions Evidence Based Interventions

20 Evidence Based Interventions Goodwin et al. JNNP, 2011

21 Common Elements Between Successful High repetitions High challenge Dynamic in nature Interventions In dance and Ti-Chi; the possibility for attentional cues Dance and Ti-Chi have also several sources of built in cues provided by the partner and the music

22 Under Recognized Treatment Options

23 Main Results

24 Under Recognized Treatment Options Dual Task and Risk of Falls Dual task adversely affects postural control in PD. Dual tasking is linked to increased risk of falls in PD.

25 Under recognized treatment options After the intervention, the results for mediolateral sway with eyes closed were significantly better for the dual-task group.

26 What about Assistive Devices? Commonly used: Hiking poles Laser canes Wheeled walker Wheeled walker with laser pointer Laser cane Hiking poles Constantinescu et al, Parkinsonism and Rel Dis; 2007

27 Take Home Messages! Fall is common in people with PD and it may have serious consequences Falls in PD is multifactorial; it has motor and non-motor contributors PD medications and BDS surgery has the potential to increase the risk of falls in PD Risk of falls in PD is amenable; a number of rehabilitative interventions can help in reducing risk of falls in PD

28 Acknowledgement Study participants Research team Dr. Elham Alshorman, Dr. Alia Algwiri, Dr. Hikmat Hadoush, Prof. Khalid Elsalem, Prof. Monica Busse, Dr. Lori Quinn, Mr. Hassan Khawaldeh, Ms. Shada Khazaaleh, Ms. Lamees Abualfoul Funding support to Jordan University of Science and Technology

29 Balance and Falls in PD: Effective Interventions and Assistive Devices Hanan Khalil, PhD Department of Rehabilitation Sciences Jordan University of Science and Technology Irbid, Jordan

Postural instability Hypokinesia Rigidity Tremor Forward flexed posture. pain million people 50+ years old 10 most populated countries

Postural instability Hypokinesia Rigidity Tremor Forward flexed posture. pain million people 50+ years old 10 most populated countries 4.1-4.6 million people 50+ years old 10 most populated countries Cyndi Robinson, PT, PhD University of Washington Seattle, Washington, USA Progressive neurodegenerative disorder Selective neuronal loss