Dr Nancy Low Choy, Bond University, Gold Coast. Paige Hooper, Physiotherapist, Bond University, Gold Coast

Transcription

1 Associations between vestibular system function, perceived confidence, falls efficacy, balance and mobility in older fallers undertaking home rehabilitation Dr Nancy Low Choy, Bond University, Gold Coast Paige Hooper, Physiotherapist, Bond University, Gold Coast Helen Weston, Physiotherapist, Mobile Rehabilitation, Brisbane

2 Introduction Vestibular system underpins Gaze stability Postural stability (Herdman 2007) Ageing processes reduce function of VS Vestibular contributions to balance problems linked to fallers (Murray et al, 2005; Whitney et al, 2000) Clinical measures routinely used to identify balance and mobility problems after falls (Herdman 2007) Studies have demonstrated prevalence of VOR problems in older adults who fall using laboratory measures (Herdman et al 1998; Hiroven et al 1998; Pothula 2004) Few studies have used clinical measures to monitor VOR control in older adults (Herdman et al, 1998). Clinicians do not routinely use available clinical measures to identify and monitor gaze instability

3 Intro cont. Vestibular asymmetry has been linked to injurious falls hip (Kristinsdottir et al, 2000; Zur et al 2006) wrist (Kristinsdottir et al 2001) Cause of vestibular asymmetry not specified BPPV and/or UVL could underpin this asymmetry (Murray et al, 2005) These deficits could also contribute to reduced confidence / fear of falling when undertaking everyday tasks

4 Research Question What is the prevalence of Gaze instability BPPV when clinical methods are used to examine older fallers? Are these deficits associated with reported Dizziness handicap Confidence to undertake everyday tasks Fear of falling, or Current measures of balance and mobility?

5 Aims Establish status of Visual Acuity (ECS / HCVA) Tactile Acuity Gaze stability (PHM / Head Thrust / Dynamic Visual Acuity (DVA) BPPV - Intermittent Dizziness reported Motion Sensitivity (Rolling/Sitting up/standing up/bending/turning) Self reported Dizziness Handicap (DHI) Perceived confidence to perform everyday tasks & fear of falling Current balance & mobility status for a cohort of fallers undertaking home-based rehabilitation Test associations between vestibular system function, dizziness handicap, perceived confidence, falls efficacy, balance and mobility for fallers undertaking rehabilitation

6 Participants A mail-out to current patients receiving physiotherapy through Mobile Rehab was undertaken (n=54) 18 participants volunteered / admitted to the study to date Participants attended GP (n=8) or Hospital A&E (n=10) following a fall Head abrasions (n=6) / Trunk haematoma (n=4) Bruising (n=8) X-Ray / Cat Scan review of those attending A & E No UL / LL #s or ligamentous damage No CNS Signs & Symptoms Discharged to home from A & E with spouse / family not admitted for observations Two lived alone who presented to GP with bruising All referred for home-based rehabilitation 12 walk aid for community ambulation Mixed group of older adults (10 males; 8 females).

7 Measures Age / History of Dizziness / Medications / Co-morbidities Reported dizziness handicap, confidence & fear of falling Activities, Balance & Confidence (ABC) Scale Falls Efficacy Scale Dizziness Handicap (DHI) Postural stability tests 14 Item Berg Balance Scale (BBS) / 56 TUG test (s) Motion sensitivity rated (1-10) during motor tasks

8 Measures impairments Sensory system function Visual acuity (ECS / HCVA) Tactile Acuity PHM / Head thrust (left/right) Dynamic Visual Acuity (DVA) Hall-Pike Dix (HPD) BPPV (no Goggles)

9 Results - Prevalence N=18 Mean (SD or Range ) Age N o Medications N o Co-morbidities ECS Score (1-24 Db) High Contrast VA Score (1-13) Tactile Acuity (Monofil Size 1-8 ) N o Report history of dizziness (%) Motion sensitivity (Rated 0 10) (Roll, Sit-up, Bend FWD, Stand-up, Turn, R/L HPD Pos) N o Diag BPPV (L / R HPD test) N o +ve Head Thrust test (L/ R/ Bilat) DVA No Line diff Hd S / Hd M (4.42) 4.67 (2.24) 2.11 (1-3) (2.28) 7.39 (5.1) 6.89 (1.05) 16 (89%) 2-3 (1-3) 4 / 6 ( Dizz HPD position) 4 / 4 / (3.34)

10 Results cont. Balance, Mobility & Function Bilat St (feet apart) Firm EO / EC (30s) Foam EO / EC (30s) Bilat St (feet tog) Firm EO / EC (30s) Foam EO / EC (30s) % (Pass) 89 / / / / 0 Healthy Elderly / Lower Falls Risk 100% Bohannon et al, % Bohannon et al, % Lord et al,

11 Results cont. Balance, Mobility & Function Mean (SD) Healthy Elderly / Lower Falls Risk BBS (0-56) TUG (s) FES (0-100) ABC (0-100) DHI (0-100) (13.38) (3.34) (22.58) (21.23) (26.94) > 46 Berg et al, 1992 < 13.5 Shumway-Cook et al, 2000 > 80 Hill et al, 1996 > 85 Powell & Myers, Jacobsen & Newman, 1990

12 Results Spearman rho correlations Low r >.2 to <.5 Moderate r >.5 to <.7 High r.7 Age Low ECS (rho = -.347) Motion sensitivity during motor tasks (rho = ) Balance in standing on firm surface EO (rho = to -.420) TUG test (rho = -.455) Moderate to high HCVA (rho =.567) Tactile Acuity (rho =.655) History of dizziness (rho = -.560) DHI total score (rho =.675) Emotional (rho=.371) Functional (rho =.701) Physical (rho =.713) Balance in standing on a soft surface EO (rho = to -.740) BBS (rho -.775)

13 Results Reported history of dizziness HPD test position (rho = -.563) BPPV DHI (rho =.550) Balance feet tog firm surface EO (rho=.500) Balance feet apart / tog firm surf EC (rho = ) Balance feet apart soft surface EO (rho = ) BBS (rho = -.274) FES (rho = -.274) ABC Scale (rho = -.274)

14 Results cont. DVA Score High associations (rho >.7) Instability - failed trials standing on foam (EO) Edge contrast sensitivity score Moderate associations (rho >.5) Motion sensitivity when rolling, bending, HPD test position, head rotation, turning around Head thrust test

15 Results cont. Motion sensitivity during rolling, bending and standing tasks showed moderate (r=.5-.6) to high associations (r>.7) with Head thrust test HPD test position DVA DHI

16 Results cont. DHI had mod to high associations with Age Medication use Motion sensitivity (rho >.5) lying down from sitting rolling over standing up turning around Falls efficacy scale (rho =.783) ABC Score (rho = -.586)

17 Discussion Care with overstating results when limited numbers included Impaired vestibular function was prevalent Low grade motion sensitivity during roll over, bending FWD, sitting & standing up, turning around HPD test BPPV (>50% cases) Increased dizziness in L / R HPD position not as easy to formally diagnose without goggles Use specific protocols (Brandt Daroff Exs or mepley) Gaze instability with head movement was prevalent (DVA test / Head Thrust / PHM Test) VOR dyscontrol Education and Gaze Stability training indicated during rehabilitation Use of substitution strategies indicated for this older group of fallers presenting with signs of bilateral vestibular hypo-function

18 Balance & mobility scores Outside established norms for those for older adults (no specific norms for those in the 80s) Reveal continued high level risk for fall Support targeting these domains in the ongoing rehabilitation program Reduced confidence / fear of falling were prevalent & required ongoing attention

19 Take home message High prevalence of BPPV & Gaze Instability BPPV presented >50% older adults tested Diagnose & Treat BPPV VOR dysfunction prevalent in older faller even after BPPV managed associated with stability & function Retrain GS / Educate about residual deficit Include education & training for entry level physiotherapy students Integrate with balance, mobility, falls efficacy & perceived confidence for holistic management of the older faller.

20 Questions?

21 Brandt Daroff Exercises 1. Start sitting on edge of bed 2. Turn head 45º to the left 3. Quickly lie onto right side 4. Stay in position until dizziness stops plus 30sec 5. Return to sitting await for dizziness to stop plus 3o sec 6. Turn head 45 to the left 7. Quickly lie onto right side await until dizziness stops plus 30sec 8. Return to sitting 1 cycle = 1 repetition

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25 Gaze stability training Focus on a stationary object near & far maintain focus while adding gentle head motion side to side & up / down for 30-60secs gradually increase speed maintain focus - Progressively integrate with more challenging postural positions

26 Place an object at arms length. 2x viewing Move head and eyes in a reciprocal pattern (out of phase) Keep object in focus during head/eye movements

27 Results cont. ABC Scores (Confidence to undertake every day activities) had mod to high associations with General health (rho =.935) Medications (rho = -.604) Support from spouse / family (rho =.686) DVA Diff Score (rho = -.519) Motion sensitivity (sit-up / stand-up) (rho =.548- to.779) DHI (rho = -.586) NB: DHI Emotional component (rho = -.608) Falls efficacy (rho =.783) Balance firm / foam surface feet apart (EO) (rho= ) TUG test (rho =.686) BBS (rho =.533)

28 Results cont. Falls efficacy was associated with General health (rho =.748) Medications (rho = -.681) Social support (rho =.624) Perceived confidence (ABC Score) (rho =.783) Motion Sensitivity Sit to supine (rho -.614) Rolling (rho =.548) Bending FWD (rho: Left =.311; Right =.548) Standing up (rho = -.734) DHI Total (rho = -.686) Standing on firm surface EO (rho =.548) TUG test (rho =.624)