Update Update from the Chair Spring 2008

Transcription

1 Inside this issue: Balance and Falls SIG Update 2 Initiatives and Articles 2 Hooked on Evidence 4 Neurology Section Roundtables Balance and Falls SIG Officers: Chair: Kris Legters, PT, DSc, NCS legters001@gannon.edu Vice Chair: Kathy Brown, MS, PT, NCS brownk@upmc.edu Secretary: Linda Csiza, PT, DSc, NCS Linda.csiza@uchsc.edu Nominating Committee: Chair: Cecelia Griffith, PT, DPT cece_griff@yahoo.com Leslie Allison, PT, PhD allisonl@ecu.edu Newsletter Editor: Steven Allred, MS, PT steven.allred@gentiva.com Balance and Falls SIG Update Update from the Chair Spring 2008 The Neurology Section Balance and Falls SIG continues to strive for increased awareness of the issues related to balance dysfunction and fall risk among clinicians, but also with the public that we serve. APTA CSM 2008 in Nashville was a huge success for our SIG! Our membership participated in the Balance and Falls Hotline held on February 8, There were 28 physical therapist volunteers who answered 60 phone calls from consumers in Arizona, California, Florida, New Jersey, New York, Pennsylvania, Tennessee, Utah and Washington. The most common reasons for the consumer s calls were having experienced multiple falls and wanting to improve balance. We had a great educational meeting/presentation by Rose Marie Rine on Vestibular Dysfunction in children. This was jointly sponsored by the Vestibular SIG and the Balance and Falls SIG with very nice attendance and interest. The SIG Roundtable generated even more dialogue with lively discussion about a decision tree for evaluation of balance and the tools that we choose to use. The discussion of the roundtable, in addition to the strategic plan of the Neurology Section, are pushing the SIG in the direction of reaching consensus on a definition of balance and the tools that we use to assess it. Please review the material included in the Newsletter related to this. We have already started the planning for APTA CSM 2009 in Las Vegas! Watch the fall newsletter for the final offerings of our SIG and our roundtable discussion. Also make sure that you cast your vote for those who will serve you in the upcoming years on behalf of the SIG. This is my last message to you as Chair of the Balance and Falls SIG as I will be turning over the reins to someone else who will move forward with our efforts. It has been a very important journey to re-establish this SIG. My thanks for your support! Please continue to express your support for the importance of this SIG within the Neurology Section! There is much yet to do on this journey! Spring 2008 Page 1

2 Initiatives and Articles Quarterly Newsletter: Spring 2008 CDC Initiative Help Seniors Live Better, Longer: Prevent Brain Injury On March 6, 2008 the CDC launched its Help Seniors Live Better, Longer: Prevent Brain Injury initiative. The initiative was developed to raise awareness about preventing, recognizing, and responding to fall-related traumatic brain injury in older adults. The initiative reaches out to children and caregivers of adults 75 and older with messages to help them understand ways to prevent falls, the leading cause of TBI among older adults, learn the symptoms of TBI in older adults, and how to respond to a TBI should one occur. Nationally: More than one third of the adults 65 years and older in the United States fall each year. Twenty to 30 percent of people in this age group who fall suffer moderate to sever injuries such as bruises, hip fractures, or head traumas. These injuries can make it hard to move around and limit independent living. They can also increase the risk of early death. Falls are the most common cause of TBI. In 2000, TBI occurred in 46% of fatal falls among older adults. Among older adults, falls are the leading cause of injury deaths. They are also the most common cause of nonfatal injuries and hospital admissions for trauma. Approximately 85% of deaths caused by falls in 2004 were among people age 75 years and older. People 75 years and older who fall are 4 to 5 times more likely than younger people to be hospitalized in a long-term care facility for a year or longer. To learn more about the CDC initiative or to view or order the FREE materials developed for the campaign, visit The CDC has developed two booklets that provide detailed information about effective fall prevention interventions and guidelines for fall prevention program planning, development, implementation, and evaluation. 1. Preventing Falls: What Works: A CDC Compendium of Effective Community-based Fall Prevention Interventions from Around the World 2. Preventing Falls: How to Develop Communitybased Fall Prevention Programs To download these booklets, please visit: Gene Defect Causes Immune Deficiency and Balance Disorder A genetic defect that causes a severe immune deficiency in humans may also produce balance disorders, according to a new study by researchers at the Iowa City based University of Iowa; The Jackson laboratory in Bar Harbor Maine and Greenville, NC based East Carolina University. The study, published in a recent issue of the Journal of Clinical Investigation, examines a specialized strain of Jackson laboratory mice with a mutation that eliminated the production of a protein call p22phox. Disruption of this protein causes a form of chronic granulomatous disease (CGD) a severe immune deficiency in humans. The researchers found that mice without p22phox develop an immune deficiency that mimics human CGD. They also discovered that the gene defect produces a severe balance disorder in the mice caused by loss of gravity-sensing crystals in the inner ear. Unlike normal mice that quickly learned how to walk on a rotating rod without falling off, the mutant mice always fell off within a few seconds. Additionally, the study showed that activity of nerve cells in the inner ear responsible Spring 2008 Page 2

3 for sending gravity signals to the brain was absent in the mutant mice. Although inner ear cells looked normal in the mutant mice, the researchers discovered that otoconia do not form in the inner ears of these mice. The implication is that human patients with CGD caused by defects in this gene may also have balance disorders, says Botond Banfi, MD PhD. If that is the case, this would be the first patient population where we could study the consequences of losing the sensation of gravity. In addition, Banfi says, We hope that clinicians will test the balance capacity of those patients with this rare form of CGD. Although it is hard to say what the consequences might be of not sensing gravity, these patients may be more prone to accidents like falling. P22phox is emerging as a critical subunit of a family of enzymes that produce reactive oxygen species (ROS). For many years, ROS were simply though of as destructive molecules that can kill infecting bacteria but also damage human cells. More recently, however, ROS have been shown to play an important role in many normal cell processes, including development and blood pressure regulation. The family of enzymes that produce ROS are called NADPH oxidases (Nox), and disruption of these enzymes has been implicated in a range of diseases, including cardiovascular and neurodegenerative disease, as well as immune deficiencies like CGD. -excerpted from therapytimes Magazine Spring 2008 Page 3

4 Hooked on Evidence for Balance and Fall-related Research Have you recently looked at APTA s Hooked on Evidence for balance and fall-related research in the neurologically involved? We are seeing strong increases in the number of research articles! A recent look revealed the following: Cerebral Palsy and balance 6 reviews Cerebral Palsy and falls 0 reviews Multiple Sclerosis and balance 14 reviews Parkinson s and balance 10 review Article Review - By Laurie Otis Parkinson s and falls 6 reviews Multiple Sclerosis and falls 1 reviews Stroke and balance 40 reviews Stroke and falls 7 reviews TBI and balance 1 review TBI and falls 0 reviews Lavery, L. A., D. P. Murdoch, et al. (2008). Does Anodyne Light Therapy Improve Peripheral Neuropathy in Diabetes?: A double-blind, shamcontrolled, randomized trial to evaluate monochromatic infrared photoenergy /dc Diabetes Care 31(2): OBJECTIVE: The purpose of this study was to determine the efficacy of anodyne monochromatic infrared photo energy (MIRE) inhome treatments over a 90-day period to improve peripheral sensation and self-reported quality of life in individuals with diabetes. Study Design: Randomly assigned 69 subjects of whom 60 (120 limbs) completed the 3 month evaluation period. Initially screened 174 subjects 33 active therapy patients and 27 sham control subjects; 13 males years; 47 females years Inclusion criteria o Subjects with diabetes o Mentally competent and able to understand and comply with study protocol o Vibration perception threshold (VPT) 20 and 45V Exclusion criteria: o Uncontrolled HTN of >180 mmhg systolic or >110mmHg diastolic o Pregnancy or breast feeding or likely to become to become pregnant during the study o Malignancy on Les o Nerve damage as a result of: prior reconstructive or replacement knee surgery, back surgery, spinal stenosis, spinal compression or radiculopathy o Nonambulatory o Hx of neuromuscular disease, leprosy, chronic alcoholism, sarcoidosis o Foot ulcerations or transmit or higher amputation Anodyne Therapy Professional System 480 applied to 33 patients. Sham unit created with identical appearance of active units; diodes inactivated; heaters were added and preset to 37 C to provide local warmth. Pad placement: two on plantar surface in T formation; one pad medial and lateral calf. Application duration: 40 min daily using preset and locked power setting; 7 days a week for 90 days. Subjects kept a daily treatment log indicating time and length of therapy. Spring 2008 Page 4

5 Sensory Evaluation: Semmes-Weinstein monofilament (SWM): sizes 4.56, 5.07, 5.26 and 5.88 at 10 sites on each foot VPT: tested distal aspect of great toe and 5 th MT head Nerve conduction velocity Michigan Neuropathy Screening Instrument (MNSI): QoL instrument; 35 items 10 cm visual analog scale Results: At baseline there were no statistically significant changes in SWM, VPT, nerve conduction velocity, MNSI, VAS or QoL scores for active compared with sham therapy. Overall, there was no statistical evidence that the anodyne treatment was effective in improving sensory perception compared with the sham treatment. Not only was there no clear benefit from the treatment, but there was also a large placebo effect in which sham therapy showed double the number of improvements in effect size compared with the anodyne treatment. Conclusions: Results demonstrate that anodyne MIRE therapy provided no more improvement in peripheral sensation, balance, pain or quality of life than sham therapy. Study Outcomes: strong placebo effect in this study as well as previous RCTs. Cliff et al (2005), Arnall et al (2006) and Leonard et al (2004) demonstrated improved sensation with SWMs in the sham group. One main limitation in evaluating neuropathy is the accuracy and reliability of the tools for longitudinal testing. Pain and balance were not the primary objectives in this study but were included because they were outcomes in a previous study (Leonard 2004). The results of this study should be generalized to individuals with diabetes with loss of protective sensation. At present there is no compelling evidence that MIRE can improve loss of protective sensation such that high-risk people with diabetes have a decreased risk of foot complications. QoL self report functional status sham results showed larger increase than anodyne. One statistically significant treatment-time interaction, Limited home and leisure activities, but it was significant because the sham group improvement was much greater than anodyne group. Balance assessed using two questions from QoL: evaluated unsteadiness with standing and walking. Significant improvement in self-reported unsteadiness with walking in the sham group (P = 0.05) Pain Neither group demonstrated significant change during the treatment period Spring 2008 Page 5

6 Neurology Section Roundtables 2008: Outcome Measures in Balance and Falls Quarterly Newsletter: Spring 2008 What are the current outcome measures used in the assessment of balance and falls? Facilitators: Cece Griffith, Sharan Zirges Scribe: Marcia Thompson Present: Kris Legters, Kathy Brown, Marcia Thompson, Dave Taylor, Darren Martin, Deborah Alleyne, Cristiane Zampieri, Karey Ledbetter, Rene Crumley, Jeanne Nelson, Chrystal Browning, Carolyn Holman, Erika Frauzen Members were from multiple clinical locations, including Balance &Falls SIG leadership, academia, industry, home health, hospital based, outpatient orthopedics, and cross all experience levels. Summary of Discussions: Group discussions identified the challenges faced across settings and the variability with which tools are selected, applied and interpreted. The overriding goal is consistency and appropriateness of practice across all practice settings through easy access to the best guiding information at any time at the clinic level. This could and should be a valuable benefit of belonging (membership in the APTA, section and SIG). The long term goal is to provide web-based access to APTA members of the current tests and measures for balance that is framed within the ICF model, searchable by setting, population, and level of function, and provides the actual tool (where able) with instructions and key references. The following action plan is suggested to achieve this goal. All initiatives taken by the SIG will provide input to complement the APTA s current and ongoing initiatives in the area of Balance and Falls. All actions will be accomplished using best evidence from these initiatives, Hooked on Evidence, and expert clinical resources and opinion from clinicians in the field. The analysis, prioritization, and process will be managed by the Balance & Falls SIG. Implications to programming will be determined by the Balance & Falls SIG leadership. Action Plan: 1. The current definition of balance is extremely variable, effecting clinical and clinical research decisions and outcomes. Goal: Consensus on a working clinical definition of postural control in neurologic physical therapy. Reference: Perspectives on postural control shape assessment & rehabilitation of balance Horak, FB. Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? Age and Ageing. 2006; 35(Suppl 2):ii7-ii Update the list of available tests and measures of balance and gaze control in the Guide to Physical Therapist practice for the patient with balance and/or vestibular dysfunction. Goal: A current and complete list of reliable and reference-able tests and measures Input on this area has already been forwarded from the SIG leadership to the committee preparing a Neuro Toolbox. 3. Determine where within the ICF/International Classification of Function each tests fits Use this opportunity to determine if there are holes i.e. do we have the tests we need to address each area of function based upon ICF. 4. What tests can be used where and for who based upon the evidence? Determine the best test(s) at each ICF level for each care setting, including all physical therapist practice settings o Include all other settings in which balance screenings are performed Spring 2008 Page 6

7 within the continuum (e.g. ED, physician office, inpatient acute screenings, community level screens) to determine the need for physical therapy evaluation. Determine the best test(s) by patient population and acuity level within each care setting Place tests in a hierarchy based upon the evidence within the list 5. History is a key component to test selection. Although intuitive for experienced clinicians focused on the issues of balance/vestibular, it is not so for clinicians in the field. necessary. 7. There is a need to provide guidelines and instruction for non-physical therapists screening for fall risk and need for referral, based upon # 3, 4 The Balance and Falls SIG leadership has already begun to address the above items, including programming for CSM 2009, a draft of appropriate tests and measures to be included in the Neuro Tool Box, and a potential schematic for an algorithm that corresponds to the ICF model. Comments and feedback on this initiative are welcome and can be forwarded to the SIG leadership, or sent to: Cece Griffith at cece_griff@yahoo.com There is a need for a history form that is sectioned by body systems in such a way as to be directive to thought. 6. There is a need for vestibular screening tools, guidelines and instruction for the non-vestibular therapist to rule in or out involvement of the vestibular system, for appropriate referral when If you are interested in being involved in a committee of the SIG, please legters001@gannon.edu. Possible committee involvement includes: practice issues, research, newsletter and web page, Falls Free Coalition, programming, etc. Spring 2008 Page 7