PD AND FALLS J U MALLYA FALLS AWARENESS MEETING

Transcription

1 PD AND FALLS J U MALLYA FALLS AWARENESS MEETING

2 PD Chronic Progressive neurodegenerative disease Motor system disorder Degeneration of Dopaminergic neurons in Substantia nigra in the midbrain. Hallmark intraneuronal inclusions - ἀ - synuclein Second most common neurological disorder.

3 CARDINAL FEATURES Bradykinesia Rigidity Tremors Loss of postural reflexes and gait problems Falls are associated with: Increased risks of fractures Mobility restriction FOF with reduced quality of life Increased mortality

4 QOL Gait and balance disorders are a major contributor to decreased QOL Determinants of Disability and Quality of Life in Mold to Moderate PD Neurology 2008;70:

5 FALLS AND PD

6 HOW COMMON IS FALLS IN PD? Falls, especially recurrent falls, are a major cause of disability. Variability in the reported prevalence of falls ranges from 11% - 68% Whether PD with specific falls risk factors are included or excluded Whether ones with serious injury are included Whether PD-plus disorders included or excluded

7 WHAT IS THE INCIDENCE OF FALLS? 401 PD subjects age years. 1 year FU 51% fell once and 11% recurrent fallers Longer duration and severity of UPDRS scores correlated well. Unable to stand on single leg < 3 seconds. Predicting falls in PD Arch Neuroscience 2016

8 FALLS ONSET IN RELATIONSHIP TO DISEASE: Disease Time to First Fall Months after onset Supranuclear Palsy 16.8 Vascular Parkinsonism 40.8 MSA 42 Lewy Body dementia 54 PD 108

9 WHAT PREDISPOSES PD TO FALL?

10 FALLS IN PD Freezing Turning Abnormality Gait abnormality Vision Falls Factors Postural Instability Cognition PD Postural abnormalities

11 1. POSTURAL ABNORMALITIES: Doherty, Karen M, MRCP, Lancet Neurology, The, Volume 10, Issue 6, Copyright 2011 Elsevier Ltd

12 2. LOSS OF POSTURAL REFLEXES Loss of postural reflexes is a characteristic feature: usually occurs in more advanced stages of the disease along with freezing of gait tendency to overestimate balance performance on functional reach testing compared to controls when concurrently performing complex motor (e.g., carrying a tray) and cognitive tasks (e.g., performing mental arithmetic)

13 3. GAIT

14 4. FREEZING Brief episodes during which a subject is unable to generate effective stepping movements

15 FREEZING MECHANISM: Exact reason for the symptom is not known Freezing occurs when something interferes with a person's normal flow of movement Walking is an automatic action without consciously thinking Walking changes automatically when Smooth to rough surface Open room into a doorway or hallway PD brain stops when has to do those changes in stride - freezes Freezing is more likely to take place when Someone is agitated or nervous Uncomfortable or unfamiliar surroundings Unable to focus Freezing situations: crowded places places where the Parkinson's disease patient has never been before narrow spaces (like aisles and doorways) changes in walking surfaces

16 A) (A)Consciously lifting one leg higher and marching like a soldier to overcome freezing. B) (B) Consciously striking the heel first on the ground may prevent shuffling forward or festinating. C) (C) To overcome the doorway effect, stepping over transverse lines drawn on the floor may help. Yasuyuki Okuma Pract Neurol 2014;14:

17 5. TURNING En Bloc Head, shoulder, trunk and pelvis turn as one unit. Normal turn: Head rotation precedes shoulder Shoulder precedes pelvic turn 180 degree turn > 4 steps ( < 2) Longer turn time (> 2 sec) Smaller turn width Less efficient Turn Types Delayed onset initial steps making negligible direction change or advance Incremental turns - multiple turning steps on the spot Larger turning arc

18 6. VISION Visual acuity, Color vision, contrast sensitivity, Contrast sensitivity Saccadic and smooth pursuit movements Visuospatial Visual hallucinations Smooth Pursuit Saccadic Hypometria

19 7. COGNITION AND GAIT Gait disorders and falls are more prevalent in dementia patients Severity of cognitive impairment correlates well with gait abnormalities. Cognitive impairment and gait abnormalities adversely affect functional independence

20 COGNITION AND GAIT Executive function Attention Motivation Judgment

21 COGNITION Movement Disorders Volume 28, Issue 11, pages , 16 OCT 2013 DOI: /mds.25674

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23 DISEASE SPECIFIC RISK FACTORS FOR FALL IN PD:

24 RISK FACTORS 1 Risk Factor Background Ascertainment intervention Slow mobility Decreased mobility increases fall risk TUGT, 6 m walk L- Dopa Shuffling and small steps Stumbling TUGT, exaamine feet L-Dopa, gait training, strength & trunk mobility Freezing gait & festination Most common cause of fall FOG questionnaire 360 degree turn ON Decrease L- Dopa, OFF increase L-Dopa Gait training Cognitive movement strategies

25 RISK FACTORS - 2 Risk Factor Background Ascertainment intervention Posture Worsens festination & forward falls Clinical Increase L-Dopa Physiotherapy Postural instability Balance impairment Pull test, Push & release Increase L Dopa Rising from chair & sit down Single leg stance Transfers Fall during transfers Examine transfers Measure OH BP Balance training Muscle strengthening Dual tasking. COM shift, turning strategies Transfer training cues or cognitive strategies OH generic measures

26 RISK FACTORS - 3 Risk Factor Background Ascertainment intervention Cognitive impairment Executive dysfunction Freezing gait Stops while talking MMSE/MOCA Avoid anticholinergics Reduce sedatives Minimize hazardous behavior Cholinesterase inhibitors Neuropsychologist input

27 RISK FACTOR 4: Risk Factor Background Ascertainment intervention Axial rigidity Reduces the ability to reduce impact on falling Clinical L-dopa Flexibility exercise Dyskinesia Balance impairment Large sway in COG Clinical Optimize drugs Education on safety strategies

28 PD AND EXECISE

29 ACSM DEFINITIONS: Exercise: subcategory of physical activity involving planned, structured, and repetitive body movements Are performed to improve or maintain one or more components of physical activity Physical activity: Any body movements that is produced by contraction of skeletal muscles Involves tasks walking, house hold chores etc. Physical therapy: Exercise as a modality to facilitate more effective movement Uses cognitive strategies

30 MOBILITY: Ability of a person to move around safely in many different conditions and environments Relies on balance and gait Ability to change strategies to task and environment

31 1. TRADITIONAL EXERCISE TO IMPROVE MOBILITY:

32 1.STRENGTH AND FLEXIBILITY Muscle Strength Consequence Falls Type of exercise Reduced muscle strength - force Reduced power force X velocity Reduced walking speed Postural instability Eccentric- focused resistance training Strength training

33 2. AEROBIC TRAINING: Aerobic Treadmill Bicycling Benefits Gait velocity Stride & step length Disadvantage No benefit balance and UPDRS No change in QOL No benefit Non Motor symptoms

34 3. BALANCE TRAINING: Poor Balance Major cause of fall in PD Association Postural Instability Combining with other training modalities strength, gait and flexibility Benefit balance, freezing, physical functioning

35 2. EXERCISE TARGETING IMPAIRMENT: THAT AFFECT MOBILITY:

36 INTEGRATIVE FUNCTIONS FOR OPTIMAL MOBILITY Cognition Intent Mood Attention Biomechanics Strength ROM Proper alignment Motor coordination Activation Pattern Timing Scaling Environment Surface Contact Lightening Noise External Factors (weather, foot wear, drugs) Sensory Orientation Sensory weighing Visual dependence Poor Kinesthesia Comorbidities

37 TAI CHI Improves balannce by maintaining COM within BOS Slow control of movements, strength, multidirectional movement, complex sequential action cognitive tasks Reduces falls

38 2. DANCE Advantage Cueing, Spatial awareness Balance Strength Flexibility Social activity Enjoyable Peer support Waltz, Tango Fox trot Benefit Balance Dual tasking

39 EXERCISE PROS AND CONS RISK Higher injury rates- falls and fractures CVS risks Greater risk in advance PD stage. BEHAVIORAL CHANGE Adhering to exercise can be a challenge. Risk factors for poor adherence are Older age Low self-efficacy Poor health /mental issues Lack of motivation

40 CONCLUSION Falls are very common in PD Falls in PD are associated with high incidence of injury. Falls occur as a complex neurological system failure Assessment should involve General and PD specific assessment Falls prevention requires a multidisciplinary approach.