Prevention of falls in Parkinson Disease

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					Prevention of falls in Parkinson Disease

Zapobieganie upadkom w chorobie Parkinsona

Józef Opara #*, Janusz Błaszczyk*, Andrzej Dyszkiewicz*‡

Key words
Parkinson Disease, falls, posturometry
Some people suffering from Parkinson Disease experience problems with gait and keeping stable posture. Sometimes they fall down,
which can be dangerous. Statistics show that more than 50% of PD patients happen to fall. The rehabilitation of those patients is dif-
ficult and complicated and its most important elements are coordination and balance exercises. The factors predicting falls are the fol-
lowing: age, cognitive disturbances, troubles with eyesight, bowel and bladder incontinence, intake of drugs. According to Hoehn and
Yahr, in stages III, IV and V a loss of balance or/and a loss of body stability control can be observed. In this review the common rules
of comprehensive rehabilitation of the patients suffering from Parkinson Disease and the prevention of falls have been described. The
paper also presents the use of stabilometry, posturometry and gait analysis for early diagnosis, rehabilitation and prevention of falls.

Słowa kluczowe
choroba Parkinsona, upadki, posturometria
Co najmniej połowa pacjentów z chorobą Parkinsona ma doświadczenie związane z upadkiem, zaś w późniejszych stadiach choro-
by dotyka to dwóch spośród trzech chorych. Rehabilitacja chorych z chorobą Parkinsona, zwłaszcza w rozwiniętej postaci choro-
by, jest trudna i skomplikowana. Ważnym jej elementem są ćwiczenia koordynacyjno-równoważne i zapobieganie upadkom. W pra-
cy poglądowej przedstawiono zasady kompleksowej rehabilitacji osób z chorobą Parkinsona, omówiono zasady profilaktyki upad-
ków, zaprezentowano wykorzystanie stabilometrii, posturometrii i analizy chodu dla wczesnej diagnostyki, rehabilitacji i profilakty-
ki upadków.

Introduction                                        tracting patient’s attention from walk-             one year following the first fall. Bloem
                                                    ing by ordering to perform another                  et al.5 reported falls in over half of the
Postural and gait disturbances are
                                                    task enhances gait disturbances and                 patients with PD.
among the first symptoms of Parkin-
                                                    increases the risk of a fall.
son disease (PD). Gait hypokinesia
                                                      Results of studies by Stolze et al.2              Evaluation of the risk of falls in PD
in PD is characterised by a slow rate,
                                                    indicate that falls, among disorders of
shortening of the steps („decrement-
                                                    the nervous system, most frequently                 The following features are considered
ing”), narrowing of the posture, re-
                                                    occur in the following diseases, list-              to be risk factors for falls: age, cogni-
duction of distance between the foot
                                                    ed as per decreasing frequency: Par-                tive function disturbances, vision dis-
and the base („shuffling” the feet),
lack of arm and trunk swing, tripping               kinson disease (62% of patients), syn-              turbances, urinary and faecal incon-
steps during walking through an en-                 cope, polyneuropathies, past cerebral               tinence, intake of hypnotic and sed-
trance („tunnel sign”), signs of „pul-              stroke. In a population evaluated by                ative agents, incorrect posture, con-
sion” (propulsion, retropulsion, lat-               Gray and Hildebrand3, a total of 237                comitant diseases (particularly diseas-
eropulsion) resulting in a tendency to              falls were reported in 118 patients                 es of the motor system, e.g., coxar-
falls, abrupt motor block (freezing).               with PD, which indicates that 59%                   throsis, lower limb shortening etc.),
   Many patients had experienced                    of patients experienced at least one                previous falls. Undesirable effects of
a fall; every second fall results in                fall. Żak et al.4 observed, in the gen-             levodopa preparations and patients’
a limb fracture1. Frequency of falls in-            eral elderly population, a five-fold in-            poor general condition (anaemia, de-
creases with disease progression. Dis-              crease in the number of falls within                hydration, hypoproteinaemia, etc.)

Article from Górnośląskie Rehabilitation Centre “Repty” in Tarnowskie Góry#, Faculty of Physiotherapy at Academy of Physical Education in Katowice*, and
Faculty of Computer Science and Materials Science in Sosnowiec at University of Silesia in Katowice ‡, Poland
Received 05.01.2005; accepted 22.03.2005

Medical Rehabilitation 2005, Vol. 9, Nr 1                                                                                                                  25
     should also be listed as factors con-        termined by the size and separation          started earlier. Posturograph can also
     tributing to an increased risk of falls.     of the feet. It should be mentioned          be used for balance exercises.
     Distracting patient’s attention and di-      that the active role of the nervous
     viding it to two or more simultane-          system in stability control introduc-        Rehabilitation
     ous activities also contributes to falls.    es additional factors determining the
     Preventing falls in PD involves reha-        effectiveness of posture maintenance.        PD patients’ needs and rehabilitation
     bilitation and prophylaxis – the lat-        Therefore, postural stability depends        programme are determined individ-
     ter comprising primary and secondary         on how rapidly the nervous system            ually. Risk factors, especially those
     prevention. Many dangers lie in wait         can detect and correct a disturbance         for falls, should be considered here1.
     for the patient at home – this will be       of stability and perform a motor pro-        Kinesitherapy constitutes the ba-
     described in the next section.               gramme counteracting loss of balance.        sis of comprehensive rehabilitation.
        Stabilometry, posturometry and gait       These features are dependent on the          The exercises are adjusted to disease
     analysis constitute an important part        rapidity of processing the information       stage13,14. The methods used in PD pa-
     of prevention of falls in PD6–-12. In Par-   within the nervous system and on the         tients include those known from oth-
     kinson disease, staggering or loss of        motor performance. All pathological          er diseases of the central nervous sys-
     postural stability control can occur.        or functional changes compromising           tem such as the NDT Bobath meth-
     Correct posture is inevitable for all        the control or executive system are re-      od (neurodevelopmental treatment),
     sensory and motor activities, hence          flected in postural stability alterations.   the PNF Kabat method (Propriocep-
     postural stability control is essential      This is also present in PD.                  tive Neuromuscular Facilitation), ap-
     for the organism. A vertical position           The area of the erect posture sta-        plication of bio-feedback elements,
     of the human body in relation to the         bility can be divided, with regard to        e.g. with the reach test performance,
     support surface is a characteristic fea-     balance control, into several domains:       strategies associated with concentra-
     ture of the human profile. Such orien-       stability margin (SM – projection of         tion (compensation), sensory stimu-
     tation of the body in the gravitation        the centre of gravity is located in the      lation methods (Sensory Integration),
     field implies constant threat of loss of     middle of SM; even when standing             stretching methods, and – in an early
     balance. Only owing to the process-          still, the body performs unconscious-        stage of PD, when the signs are unilat-
     es associated with active balance con-       ly slight oscillatory movements that         eral – the forced use movement ther-
     trol, are the consequences of instabil-      can be captured using a posturograph         apy (Constraint-Induce Movement
     ity compensated for. This indicates          – this phenomenon is referred to as          Therapy – CIT)15–-21. Many specialists
     that such control ensures optimal bor-       postural sway, PS), safety margin (SfM       stress out that the exercises should be
     ders of stability enabling an effective      – significant balance disturbance and        simple and uncomplicated, especially
     performance of any motor activity, in-       the associated shift of the centre of        at later stages of the disease22.
     cluding locomotion. Steering the mo-         gravity outside the stability margin            First rehabilitation efforts should be
     tion and posture occurs via the same         requires termination of a motor pro-         directed towards improving the gait
     effectors. Controlling the posture re-       gramme being actually performed              and the awareness of posture. For the
     solves itself to giving the body its spe-    and performance of an appropriate            assessment of patients’ abilities and
     cific profile, whereas postural stabil-      correction programme). If, as a result       needs in this domain, the Podsiadło
     ity control refers to dynamic proper-        of a disturbance, the centre of gravi-       and Richardson’s Timed Up and Go
     ties associated with balance mainte-         ty projects beyond the safety margin,        Test is useful: the time needed for the
     nance or recovery in cases of balance        regaining balance becomes impossible         patient to stand up from a chair, walk
     loss. A disturbance of postural stabili-     and the individual falls. Stability bor-     a distance of 10 metres, turn around
     ty may be induced both by organism’s         der (SB) can project outside the area        and assume again the sitting position
     own motor activity and result from           demarcated by feet envelope.                 is measured with a stopwatch 23–-25.
     the interaction with the surround-              There are three strategies of regain-     Learning to concentrate is very im-
     ings. According to the most general          ing balance: the distal-proximal strate-     portant in these patients.
     definition, postural stability can be de-    gy called ankle joint strategy, the prox-       Gait learning exercises may be con-
     fined as ability of the organism to re-      imal-distal strategy called hip joint        ducted individually or in groups, de-
     gain particular position in space after      strategy, and the balance maintenance        pending on patient’s clinical state.
     a destabilising stimulation has ceased.      strategy called step strategy. Posturog-     The exercises should be planned for
     Considering the body as a purely ge-         raphy has a prognostic value for the         the time of levodopa peak dose. The
     ometric object, it can be stated that        anticipation of falls and the progno-        training takes place both in gymnas-
     the erect posture is stable as long as       sis of early rehabilitation outcomes.        tic halls and on the grounds; various
     the projection of the centre of gravi-       Based on the results obtained from           types of surfaces may be taken advan-
     ty of the body remains within its area       this evaluation, some elements can be        tage of. Coordination-balance exercis-
     of the base. Within this context, pos-       introduced to the rehabilitation ear-        es according to H.S. Frenkel are par-
     tural stability would primarily depend       lier than it could be presumed based         ticularly useful in PD. In this method,
     on physical characteristics of an indi-      on Hoehn & Yahr disease staging (see         use of footprints painted on the pave-
     vidual, especially on his body weight,       the section “Rehabilitation”), and co-       ment is one of the gait learning tasks.
     height and on the area of the base de-       ordination-balance exercises could be        The rehabilitee is to take steps on the

painted trace. In this task, quarter-      ercises. In the leading rehabilitation      es problems with standing and walk-
steps, half-steps, three-fourths steps     centres, tensometric platform or pho-       ing, a help of a care-giver is needed.
and full steps are taken. All Frenkel      tometric podoscopy is used for train-       Apart from the instructions as of the
method exercises are performed with        ing the balance and the awareness of        stage III – but with assistance of and
three beats. Learning the turns is also    posture. Accelerometric sensors of bal-     cooperation with the care-giver – the
a part of this method –with three          ance during standing and acceleromet-       following tasks are emphasised: con-
beats, the patient is to turn around and   ric sensors assessing indices of dynam-     centration exercises, limiting the ac-
come back. Difficulties with turns are     ic gait phases play a significant role in   tivity to a performance of only one
characteristic for PD. While an elderly    quantitative and qualitative evaluation     task at a time, learning the standing-
without PD turns 360º taking 6 steps,      of balance disturbances29,30.               up from a chair, turning in bed, reach-
a patient with advanced PD needs up           Many exercises can be performed          ing exercises, manipulation exercises,
to 20 small, ever-shortening steps.        by patients at home. At Hoehn & Yahr        writing, stretching exercises. At stage
   Gait training in PD patients involves   stage I, the following activities are       V, where the patient remains in bed
both walking with step forward with        emphasised: maintenance of regular          or wheelchair, passive tilting and ac-
one foot and bringing the other beside     physical activity, long walks (at least 3   tive standing with assistance or help
the supporting foot and walking with       times a week, 40-minute long) on var-       from the care-giver are recommend-
an alternating step. With three beats      ious surfaces, with paying attention on     ed, while balconies or push-carts for
(1. a step forward with one foot, 2.       taking long steps, with high elevation      gait learning (type of the provided re-
loading this foot, 3. bringing the oth-    of the feet, recreation, leisure activi-    habilitation aid should be determined
er foot), walking sidewards, forwards,     ties involving active behaviour1.           by the physician – a medical rehabili-
backwards, and on a stairway is prac-         At stage II of the disease, where        tation specialist) should be used when
ticed. This method also comprises          balance disturbances are still not ob-      walking. It is advised to assume a neu-
learning the upper limbs swing and                                                     tral position in the joints of the low-
                                           served, the following exercises, apart
walking with simultaneous use of the                                                   er limbs when supine, twice a day for
                                           from the instructions as of the previ-
upper extremities by carrying objects,                                                 15 minutes (prevention of flexion
                                           ous stage, are recommended: the erect
removing obstacles in the way etc.                                                     contractures). Education of patients,
                                           posture, exercises in writing with large
   Standing-up and sitting-down learn-                                                 care-givers and nurse staff about the
                                           letters (avoiding micrography), rising
ing is an important part of the Fren-                                                  optimal body position, frequent posi-
                                           from a chair, squatting, walking on
kel method. These exercises are also                                                   tion changes and decubitus prophy-
                                           a stairway, exercises in turning over
performed with three beats – with the                                                  laxis should be conducted18.
                                           and sitting-up in bed, stretching exer-
beat “one” – withdrawal of the legs                                                       The second element, aside the reha-
                                           cises, concentration learning, avoiding
under the chair, with the beat “two”                                                   bilitation, of preventing falls is the pri-
– leaning the trunk forwards, and          falls by removal of obstacles at home
                                                                                       mary and secondary prevention. The
with the beat “three” – extension of       (removal of loose cables and carpets
                                                                                       most frequent causes of falls should
the lower limbs and assuming the up-       off the floor, of folded carpets, repair-   be recognised and their elimination
right posture. It is recommended to        ing the uneven surface of the pave-         attempted31,32. Care-givers of patients
use various types of chairs, of differ-    ment, removal of door-sills etc.) and       with previous falls are encouraged to
ent heights, for these exercises.          installation of auxiliary devices, es-      start a falls diary and to indicate there-
   Learning to turn over in bed, to sit    pecially in the bathroom (additional        in circumstances and causes of falls.
up in bed and to stand up also cor-        handrails, handles etc.). It is also rec-   Based on the analysis of a fall, actions
responds to the standing-up and sit-       ommended to change the bath tub for         aimed at reducing the risk of a subse-
ting-down training1. These exercises       a shower cabin built in without a sill      quent fall should be undertaken. The
are performed in the following order:      (special bath chairs are available for      most frequent causes of falls associat-
shifting the pelvis towards the centre     purchase). Special attention should be      ed with household are listed below:
of the bed, turning the head, lifting      paid to proper shoes – they should be       1. Room lighting:
the upper limb, lifting the lower ex-      Velcro-strapped, have a rubber sole,            – insufficient,
tremities over the edge of the bed, as-    and high, stiff tops.                           – no switches at the entrance.
suming the sitting position.                  At stage III, where signs of postural    2. Floors:
   Training the balance and the aware-     reflexes abnormalities appear, it is rec-       – slippery,
ness of posture in Parkinson disease       ommended to walk at least 100 me-               – carpets: loose, folded, ragged,
has recently remained in the centre        tres daily, taking long steps, with ele-        – unnecessary sills.
of interest of researchers studying re-    vating the feet over 1.5 cm above the       3. Stairs:
habilitation, gait disturbances, bal-      ground, walking on different surfac-            – uneven, damaged,
ance and correct posture awareness.        es with overcoming outside obstacles            – no handrails.
A beneficial influence of rehabilitation   (e.g. kerbs), walking on a stairway,        4. Furniture:
on the awareness of balance and cor-       keeping on recreational activities. Pa-         – making it difficult to walk (too
rect body posture in these patients has    tients may also practice at home on                compact arrangement of the fur-
been emphasised22,25–-28. This purpose     a cycloergometer or on a treadmill.                niture),
is reached primarily by the above gait        At stage IV, where the patient is al-        – too unstable to use them as
training and coordination-balance ex-      ready handicapped and experienc-                   a support,

         – chairs and armchairs: too unsta-                     comparison with Parkinson’s disease and            Address for correspondence
                                                                healthy controls. Arch. Neurol. 2000; 57(10):
           ble, too low, without handrails.                     1464–1469
                                                                                                                   Prof. Józef Opara, MD PhD
                                                                                                                   “Repty” GCR, ul. Śniadeckich 1
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