Management of Medically Unexplained Fatigue States PDF
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Matt Jones, AEP
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This document discusses the management of medically unexplained fatigue states, including chronic fatigue syndrome (CFS) and post-cancer fatigue (PCF). It details strategies like activity pacing and graded activity, and explores the use of technology for neuromusculatory rehabilitation, including electrical stimulation, virtual reality, exergames, and telerehabilitation. This document will be helpful in learning about the different technologies and approaches for treating different neurological issues.
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Management of medicallyunexplained fatigue states Matt Jones, AEP What is fatigue? Fatigue as a ‘sign’ • failure of force generation in the muscle • peripheral and central components Fatigue as a ‘symptom’ • everyday phenomenon • may be disease associated (infective, inflammatory, neurological, m...
Management of medicallyunexplained fatigue states Matt Jones, AEP What is fatigue? Fatigue as a ‘sign’ • failure of force generation in the muscle • peripheral and central components Fatigue as a ‘symptom’ • everyday phenomenon • may be disease associated (infective, inflammatory, neurological, mood disorder) • Multidimensional - physical and mental components Medically-unexplained fatigue states Ensure there is no medical explanation for fatigue after careful history examination and laboratory investigation * cancer recurrence * thyroid issues * primary sleep disorder * mood disturbance How common is chronic fatigue? Prevalence estimates Working Group Royal Australasian College of Physicians, including Lloyd A. Chronic fatigue syndrome - Clinical practice guidelines 2002. Medical Journal of Australia 2002;176:S17-55. ME/CFS diagnostic criteria Post-cancer fatigue Definition • Significant fatigue, diminished energy, or increased need to rest, disproportionate to any recent change in activity level • Five or more of: – Complaints of generalised weakness or limb heaviness – Diminished concentration or attention – Decreased motivation or interest in engaging in usual activities – Insomnia or hypersomnia – Experience of sleep as unrefreshing or nonrestorative AND – Perceived need to struggle to overcome inactivity – Marked emotional reactivity (eg sadness, frustration or irritability) to feeling fatigued – Difficulty completing daily tasks attributed to feeling fatigued – Perceived problems with short-term memory – Post-exertional malaise lasting several hours ICD-10 revised Post-exertional exacerbation Post-exertional exacerbation PACE trial Activity pacing and graded activity Management of CFS Initial assessment/interview • Onset of symptoms & time to diagnosis • Sleep-wake cycle • Physical activity vs cognitive activity • Work/Study status • Home status • Support resources • Leisure / recreation: pre- & post- diagnosis • Walking tolerance • (Symptom-limited) functional capacity Activity pacing • Integrated approach; cognitive & physical • Overall aim to stabilise activity patterns • Involves limiting activity to symptom threshold limits • ‘True rests' and detailed scheduling • Micro- and macro-pacing Activity diary Activity monitoring Graded activity Graded Activity / Exercise ≠ Conventional Exercise. Symptom limited à post-exertional exacerbation in symptoms Continuous aerobic activity Stage 1: Walk x min every 2nd day (self-paced) Increase by 10-20% margin every 2 weeks (minimum period) maximum of 30min un-interrupted Stage 2: Walk x min every other day (self-paced) Increase by 10-20% margin every 2 weeks (minimum period) maximum of 30min un-interrupted Stage 3: Interval training e.g: 9 min walk, 1 min jog = 10mins x 3 = 30mins * Compensate activity during symptom aggravation Evidence for this approach - CFS ITT (n=264) CD (n=168) Evidence for this approach - PCF Inclusion criteria: clinically significant fatigue; completed adjuvant therapy for breast or colon cancer 3-12 months prior; free of comorbid medical or psychiatric conditions that explained ongoing fatigue N = 46 (43 women): Results: • Fatigue improved in both groups from baseline to 12 weeks • Clinically significant improvement in 7/22 in intervention arm versus 2/24 in education arm Summary • Medically unexplained fatigue states, including CFS and PCF, are relatively rare but can be debilitating • There are currently no effective pharmacological treatments, so management focuses on self-management strategies • • • Activity pacing Graded activity CBT/psychologically-informed therapy Technology in neurorehabilitation HESC3592 Neuromuscular Rehabilitation Dr Paulo Henrique Silva Pelicioni PhD, MSC, PostGrad Cert, BPT Lecturer School of Health Sciences Context Think about it Context • Difficult (e.g., chronic, neurodegeneration) • Adherence • Lack of enjoyment • Up-to-date (contextual) • Motivation • Engagement Context • Interventions • Assessments Interventions • • • • • • Electrical stimulation Transcranial Magnetic Stimulation (TMS) Virtual reality Exergames Robot-assisted training (RAT) Telerehabilitation (Telehealth/ e-health) Electrical stimulation It is a technique that uses low electrical impulses stimulating muscles to make their usual movement It is designed as an alternative tool for rehabilitating damaged, paralysed and weakened muscles Electrical stimulation Electrical impulses provoke an action potential, therefore eliciting muscle contraction. Effects: - peripheral effect: increased muscle trophy and blood flow circulation. - central effect (direct): increased excitability of the primary sensorimotor cortex; - central effect (indirect): increased motor recovery and muscle tone. Electrical stimulation Cerebral Palsy (CP) • It is safe and improves mobility in children with spastic CP - Sitting - Standing - Running - Jumping Salazar et al., 2019; Chen et al., 2023 Electrical stimulation Stroke • When applied two months post-stroke, it improves activities of daily living (ADL) • In the subacute stage, it is efficacious for ADL rehabilitation • It improves functional motor abilities in people with severe paresis (muscle weakness) Eraifej et al., 2017; Kristensen et al., 2022 Electrical stimulation Spinal Cord Injury (SCI) • When integrated with cycling exercises in adults, it improves - Muscle health and strength - Muscle power - Aerobic fitness - Spasticity - Voluntary movement - Functionality Garcia et al., 2020; van der Scheer et al. 2021, Massey et al., 2022 Transcranial Magnetic Stimulation TMS is a non-invasive stimulation using magnetic fields to stimulate nerve cells in different cortical areas (most commonly primary motor cortex and prefrontal cortex) It is believed that TMS increases activity in cortical regions, translating to better performance related to those areas (e.g., prefrontal cortex, improved cognition) Transcranial Magnetic Stimulation Parkinson’s disease (PD) • It promotes positive effects on - Walking - Muscle strength - Lower-limb function - Motor symptoms Krogh S et al., 2022; Zhang et al., 2022; Li et al., 2022; Deng et al., 2022 Transcranial Magnetic stimulation Stroke • It promotes positive effects in - upper limb function (chronic phase and 1-month post-stroke) - Hand function (chronic phase) - Muscle tone (chronic phase) - Balance (chronic phase) - Walking (chronic phase) - Functional ADL (chronic phase) van Lieshout et al., 2019; Krogh S et al., 2022; Chen et al., 2022 Virtual reality It is a computer-based technology that exposes consumers to a multisensory simulated environment and receives real-time feedback on performance Interactive exergames provide consumers with activities relevant to ADL and real-life scenarios Virtual reality Head-mounted VR Immersion VR Virtual reality CP • VR is effective to improve - Arm function - Postural control - Balance - Ambulation - Gross motor function Chen et al., 2018; Liu et al., 2022; Liu et al., 2022 Virtual reality Traumatic Brain Injury (TBI) • VR promotes a positive impact on balance and flexibility in children • VR is effective in enhancing motor skills in adults • VR is as effective in comparison to other modalities in improving balance and mobility Shen et al., 2018; Aulisio et al., 2020; Alashram et al., 2022 Virtual reality Multiple sclerosis (MS) • When examining traditional therapies, VR improves balance • VR has a short-term benefit in improving balance and fear of falling • In comparison to conventional therapy, VR improves fatigue, physical and cognitive function Nascimento et al., 2021; Calafiore et al., 2021; Cortes-Perez et al., 2023; Moeinzadeh et al., 2023 Virtual reality PD • VR has a short-term effect on gait (step/ stride length) • Compared to passive control, VR improves gait speed, step/stride length, balance, ADL and postural control • As effective as other treatments on motor function, step/stride length, balance and quality of life (QoL) Dickx et al., 2017; Lu et al., 2022; Kashif et al., 2022; Rodriguez-Mansilla et al., 2023 Virtual reality Stroke • In comparison to conventional therapy, VR improves - Upper limb function - Physical performance - Muscle strength - Gait - Balance Laver et al., 2017; Patsaki et al., 2022; Demeco et al., 2023; Bargeri et al., 2023 Virtual reality Alzheimer’s disease • VR improves: - Balance - Cognition - Memory - Executive function Yi et al., 2022 Virtual reality SCI • Positive effects on aerobic function, balance (sitting and standing), pain and motor function • In combination with RAT, VR improves upper limb function and muscle strength Araujo et al., 2019; Abou et al., 2020; Miguel-Rubio et al., 2022 Exergames • Technology-driven exercises requiring consumers to be physically active to play the game • It contains principles of video gaming (e.g., motivation, reward, progression) Exergames Not enough high-level evidence (YET!) Check it out our week 7 labs at NeuRA Schoene et al., 2013; Hoang et al., 2016; Schoene et al., 2015; Song et al., 2018; Sturnieks et al., 2019; Pelicioni et al., 2023 Robot-assisted training (RAT) • It is a modality in which a consumer uses the RAT to support their body weight (for gait training). • RAT helps consumers with functional movements to support their functionality. • Resistance and % of body weight can be manipulated as progression. Robot-assisted training (RAT) CP • In comparison to conventional therapy, RAT improves - Lower limb function - Balance - Walking endurance - Gait speed - Walking, running and jumping ability Cortes-Perez et al., 2022; Wang et al., 2023 Robot-assisted training (RAT) Stroke • The combination of conventional therapy with RAT leads to gait improvement • When electrical stimulation is combined with RAT, it leads to more gait improvements in comparison to RAT alone • RAT is better than no treatment for upper limb function and ADL ability Bruni et al., 2018; Yang et al., 2023 Robot-assisted training (RAT) SCI • RAT results in the improvement of - Spasticity - Pain perception - Proprioception - Gait - Sitting posture - Overall mobility Holanda et al., 2017; Bin et al., 2023 Telerehabilitation Telerehabilitation is the use of medical/health information to provide rehabilitation to people in different locations Telehealth E-health Check it out our week 7 labs at NeuRA Telerehabilitation MS • Telerehabilitation is effective in - Reducing motor disability - Improving gait - Improving balance Di Tella et al., 2020 Telerehabilitation SCI • Telerehabilitation improves - QoL - Functional ability - Motor impairment Solomon et al., 2022; Nayak et al., 2023 Telerehabilitation TBI • Telerehabilitation improves - Global functioning - Depression - Symptom management Ownsworth et al., 2018; Suarilah et al., 2022 Telerehabilitation PD • In comparison to standard treatments, telerehabilitation improves the QoL and adherence to treatment • Telerehabilitation maintains/ improves - Gait - Balance - QoL Vellata et al., 2021; Ozden 2023 Telerehabilitation Stroke • In comparison to standard treatments, telerehabilitation improves - Motor function - ADL - Independence • Telerehabilitation improves balance and functional mobility Appleby et al., 2019; Allayat et al., 2022 Assessments • Motion capture systems • Gait mat systems • Wearable devices • Exergames • Telerehabilitation Motion capture systems Kinematic analysis of movement 2D and 3D Remember week 4 and HESC2452 Gait mat systems It has some pressure sensors embedded into it and it easily measures gait parameters Wearable devices It has sensors measuring the acceleration of a person Remember week 4 and some activities that were completed for HESC2452 Exergames Technology-driven assessments requiring consumers to be physically active to play the game Check it out our week 7 labs at NeuRA Schoene et al., 2013; Hoang et al., 2016; Schoene et al., 2015; Song et al., 2018; Sturnieks et al., 2019; Pelicioni et al., 2023 Telerehabilitation “Telehealth is the use of medical information that is exchanged from one site to another through electronic communication to improve a consumer’s health” Check it out our week 7 labs at NeuRA Considerations • Consider the FITT (Frequency, Intensity, Time and Type) principle • Different stages of diseases and conditions • Reliability and validity of outcomes • For outcomes there is still a lack of information. MORE STUDIES ARE NEEDED! References Overall • Lazaro RT, Umphred DA. Umphred’s neurorehabilitation for the Physical Therapist Assistant. 3rd edition, SLACK Incorporated, 2020. Electrical stimulation • Salazar AP et al. Neuromuscular electrical stimulation to improve gross motor function in children with cerebral palsy: a meta-analysis. Braz J Phys Ther. 2019 Sep-Oct;23(5):378-386. • Chen Y et al. Effectiveness of neuromuscular electrical stimulation in improving mobility in children with cerebral palsy: A systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2023 Jan;37(1):3-16. • Eraifej J et al. Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis. Syst Rev. 2017 Feb 28;6(1):40. • Kistensen MGH et al. Neuromuscular Electrical Stimulation Improves Activities of Daily Living Post Stroke: A Systematic Review and Meta-analysis. Arch Rehabil Res Clin Transl. 2021 Nov 12;4(1):100167. • Garcia AM et al. Transcutaneous Spinal Cord Stimulation and Motor Rehabilitation in Spinal Cord Injury: A Systematic Review. Neurorehabil Neural Repair. 2020 Jan;34(1):3-12. • Massey S et al. Neurophysiological and clinical outcome measures of the impact of electrical stimulation on spasticity in spinal cord injury: Systematic review and meta-analysis. Front Rehabil Sci. 2022 Dec 16:3:1058663. • Van der Scheer AW et al. Functional electrical stimulation cycling exercise after spinal cord injury: a systematic review of health and fitness-related outcomes. J Neuroeng Rehabil. 2021 Jun 12;18(1):99. Transcranial Magnetic Stimulation • Krogh S et al. Efficacy of repetitive transcranial magnetic stimulation for improving lower limb function in individuals with neurological disorders: A systematic review and meta-analysis of randomized sham-controlled trials. J Rehabil Med. 2022 Feb 3:54:jrm00256. • Zhang W et al. Efficacy of repetitive transcranial magnetic stimulation in Parkinson's disease: A systematic review and meta-analysis of randomised controlled trials. EClinicalMedicine. 2022 Jul 29:52:101589. References Transcranial Magnetic Stimulation • Li R et al. Effects of Repetitive Transcranial Magnetic Stimulation on Motor Symptoms in Parkinson's Disease: A Meta-Analysis. Neurorehabil Neural Repair. 2022 Jul;36(7):395-404. • Deng S et al. Effects of repetitive transcranial magnetic stimulation on gait disorders and cognitive dysfunction in Parkinson's disease: A systematic review with meta-analysis. Brain Behav. 2022 Aug;12(8):e2697. • van Lieshout et al. Timing of Repetitive Transcranial Magnetic Stimulation Onset for Upper Limb Function After Stroke: A Systematic Review and Meta-Analysis. Front Neurol. 2019 Dec 3:10:1269. • Chen G et al. Effects of repetitive transcranial magnetic stimulation on sequelae in patients with chronic stroke: A systematic review and meta-analysis of randomized controlled trials. Front Neurosci. 2022 Oct 20:16:998820. Virtual reality • Dockx K et al. Virtual reality for rehabilitation in Parkinson's disease. Cochrane Database Syst Rev. 2016 Dec 21;12(12):CD010760. • Lu Y et al. The effectiveness of virtual reality for rehabilitation of Parkinson disease: an overview of systematic reviews with metaanalyses. Syst Rev. 2022 Mar 19;11(1):50. • Kashif M et al. Systematic review of the application of virtual reality to improve balance, gait and motor function in patients with Parkinson's disease. Medicine (Baltimore). 2022 Aug 5;101(31):e29212. • Rodriguez-Mansilla J et al. Effects of Virtual Reality in the Rehabilitation of Parkinson's Disease: A Systematic Review. J Clin Med. 2023 Jul 26;12(15):4896. • Laver KE et al. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev. 2017 Nov 20;11(11):CD008349. • Patsaki I et al. The effectiveness of immersive virtual reality in physical recovery of stroke patients: A systematic review. Front Syst Neurosci. 2022 Sep 22:16:880447. • Demeco A et al. Immersive Virtual Reality in Post-Stroke Rehabilitation: A Systematic Review. Sensors (Basel). 2023 Feb 3;23(3):1712. • Bargeri S et al. Effectiveness and safety of virtual reality rehabilitation after stroke: an overview of systematic reviews. EClinicalMedicine. 2023 Sep 14:64:102220. • Chen Y et al. Effectiveness of Virtual Reality in Children With Cerebral Palsy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Phys Ther. 2018 Jan 1;98(1):63-77. References Virtual reality • Shen J et al. Virtual Reality for Pediatric Traumatic Brain Injury Rehabilitation: A Systematic Review. Am J Lifestyle Med. 2018 Feb 6;14(1):6-15. • Aulisio MC et al. Virtual reality gaming as a neurorehabilitation tool for brain injuries in adults: A systematic review. Brain Inj. 2020 Aug 23;34(10):1322-1330. • Alashram AR et al. Virtual reality for balance and mobility rehabilitation following traumatic brain injury: A systematic review of randomized controlled trials. J Clin Neurosci. 2022 Nov:105:115-121. • Araujo AVL et al. Efficacy of Virtual Reality Rehabilitation after Spinal Cord Injury: A Systematic Review. Biomed Res Int. 2019 Nov 13:2019:7106951. • Abou L et al. Effects of Virtual Reality Therapy on Gait and Balance Among Individuals With Spinal Cord Injury: A Systematic Review and Metaanalysis. Neurorehabil Neural Repair. 2020 May;34(5):375-388. • Miguel-Rubio A et al. A Therapeutic Approach Using the Combined Application of Virtual Reality with Robotics for the Treatment of Patients with Spinal Cord Injury: A Systematic Review. Int J Environ Res Public Health. 2022 Jul 19;19(14):8772. • Nascimento AS et al. Effectiveness of Virtual Reality Rehabilitation in Persons with Multiple Sclerosis: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Mult Scler Relat Disord. 2021 Sep:54:103128. • Calafiore D et al. Efficacy of Virtual Reality and Exergaming in Improving Balance in Patients With Multiple Sclerosis: A Systematic Review and Meta-Analysis. Front Neurol. 2021 Dec 10:12:773459. • Cortes-Perez I et al. Virtual reality-based therapy improves balance and reduces fear of falling in patients with multiple sclerosis. a systematic review and meta-analysis of randomized controlled trials. J Neuroeng Rehabil. 2023 Apr 11;20(1):42. • Moeinzadeh AM et al. Comparing virtual reality exergaming with conventional exercise in rehabilitation of people with multiple sclerosis: A systematic review. Neuropsychol Rehabil. 2023 Sep;33(8):1430-1455. • Yi Y et al. Effect of virtual reality exercise on interventions for patients with Alzheimer's disease: A systematic review. Front Psychiatry. 2022 Nov 9:13:1062162. • Liu W et al. Effect of Virtual Reality on Balance Function in Children With Cerebral Palsy: A Systematic Review and Meta-analysis. Front Public Health. 2022 Apr 25:10:865474. • Liu C et al. The Effects of Virtual Reality Training on Balance, Gross Motor Function, and Daily Living Ability in Children With Cerebral Palsy: Systematic Review and Meta-analysis. JMIR Serious Games. 2022 Nov 9;10(4):e38972. References Robot-assisted training • Wang Y et al. Systematic review and network meta-analysis of robot-assisted gait training on lower limb function in patients with cerebral palsy. Neurol Sci. 2023 Nov;44(11):3863-3875. • Cortes-Perez I et al. Efficacy of Robot-Assisted Gait Therapy Compared to Conventional Therapy or Treadmill Training in Children with Cerebral Palsy: A Systematic Review with Meta-Analysis. Sensors (Basel). 2022 Dec 16;22(24):9910. • Bruni MF et al. What does best evidence tell us about robotic gait rehabilitation in stroke patients: A systematic review and metaanalysis. J Clin Neurosci. 2018 Feb:48:11-17. • Yang X et al. Efficacy of Robot-Assisted Training on Rehabilitation of Upper Limb Function in Patients With Stroke: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil. 2023 Sep;104(9):1498-1513. • Holanda LJ et al. Robotic assisted gait as a tool for rehabilitation of individuals with spinal cord injury: a systematic review. J Neuroeng Rehabil. 2017 Dec 4;14(1):126. • Bin L et al. The effect of robot-assisted gait training for patients with spinal cord injury: a systematic review and meta-analysis. Front Neurosci. 2023 Aug 22:17:1252651. Telerehabilitation • Vellata C et al. Effectiveness of Telerehabilitation on Motor Impairments, Non-motor Symptoms and Compliance in Patients With Parkinson's Disease: A Systematic Review. Front Neurol. 2021 Aug 26:12:627999. • Ozden F. The effect of mobile application-based rehabilitation in patients with Parkinson's disease: A systematic review and metaanalysis. Clin Neurol Neurosurg. 2023 Feb:225:107579. • Appleby E et al. Effectiveness of telerehabilitation in the management of adults with stroke: A systematic review. PLoS One. 2019 Nov 12;14(11):e0225150. • Alayat MS et al. The Effectiveness of Telerehabilitation on Balance and Functional Mobility in Patients with Stroke: A Systematic Review and Meta-Analysis. International Journal of Telerehabilitation 2022;14(2). • Solomon RM et al. Telerehabilitation for individuals with spinal cord injury in low-and middle-income countries: a systematic review of the literature. Spinal Cord. 2022 May;60(5):395-403. References Telerehabilitation • Nayak P et al. Effect of telerehabilitation on motor and functional outcomes in people with spinal cord injuries – a systematic review. European Journal of Physiotherapy, DOI: 10.1080/21679169.2023.2195439 • Ownsworth T et al. Efficacy of Telerehabilitation for Adults With Traumatic Brain Injury: A Systematic Review. J Head Trauma Rehabil. 2018 Jul/Aug;33(4):E33-E46. • Suarilah I et al. Effectiveness of telehealth interventions among traumatic brain injury survivors: A systematic review and meta-analysis. J Telemed Telecare. 2022 Jun 3:1357633X221102264. doi: 10.1177/1357633X221102264. • Di Tella S et al. Integrated telerehabilitation approach in multiple sclerosis: A systematic review and meta-analysis. J Telemed Telecare. 2020 Aug-Sep;26(7-8):385-399. Exergames • Sturnieks DL, Menant J, Valenzuela M, et al. Effect of cognitive-only and cognitive-motor training on preventing falls in communitydwelling older people: protocol for the smart±step randomised controlled trial. BMJ Open. 2019 Aug 2;9(8):e029409. doi: 10.1136/bmjopen-2019-029409. • Song J, Paul SS, Caetano MJD, et al. Home-based step training using videogame technology in people with Parkinson's disease: a single-blinded randomised controlled trial. Clin Rehabil. 2018 Mar;32(3):299-311. doi: 10.1177/0269215517721593. • Schoene D, Valenzuela T, Toson B, et al. Interactive Cognitive-Motor Step Training Improves Cognitive Risk Factors of Falling in Older Adults - A Randomized Controlled Trial. PLoS One. 2015 Dec 16;10(12):e0145161. doi: 10.1371/journal.pone.0145161. • Hoang P, Schoene D, Gandevia S, et al. Effects of a home-based step training programme on balance, stepping, cognition and functional performance in people with multiple sclerosis--a randomized controlled trial. Mult Scler. 2016 Jan;22(1):94-103. doi: 10.1177/1352458515579442. • Schoene D, Lord SR, Delbaere K, et al. A randomized controlled pilot study of home-based step training in older people using videogame technology. PLoS One. 2013;8(3):e57734. doi: 10.1371/journal.pone.0057734. • Pelicioni PHS, Lord SR, Menant JC, et al. Combined Reactive and Volitional Step Training Improves Balance Recovery and Stepping Reaction Time in People With Parkinson's Disease: A Randomised Controlled Trial. Neurorehabil Neural Repair. 2023 Oct 21:15459683231206743. doi: 10.1177/15459683231206743. [email protected] FALLS & BALANCE: OVERVIEW & ASSESSMENTS HESC3592 NEUROMUSCULAR REHABILITATION Dr Jasmine Menant Research Fellow, Falls, Balance and Injury Research Centre , NeuRA Conjoint Senior Lecturer, UNSW Medicine Acknowledgements • Professor Stephen Lord, NeuRA • Dr Daina Sturnieks, NeuRA / UNSW 2 KEY LEARNING OUTCOMES At the end of this lecture you should Demonstrate knowledge of the neurological changes that occur with aging and their implications for physical function/activity. Sensorimotor and cognitive changes Develop an awareness of ‘falls’ as a major indicator and consideration for exercise interventions Understand the prevalence, risk factors for, and implications of falls in elderly populations. Multifactorial – exercise interventions form one part of a bigger clinical picture Effectively differentiate between a ‘screening’ and ‘assessment’ in the context of falls. Demonstrate knowledge/skills to determine the most relevant/applicable test for particular contexts (i.e. instrument selection, validity, reliability, floor and ceiling effects) Have a resource for future use to help in the selection of falls related tests. PRIOR KNOWLEDGE In HESC3504 you have learned about aging with regard to ▫ Aerobic fitness testing and exercise ▫ VO2, VT, Cardiac, pulmonary and vascular changes ▫ Muscular function testing and exercise ▫ Sarcopenia - Skeletal muscle changes in structure and function ▫ Resistance training You haven’t yet learned about the neurological changes that occur with aging. NEUROLOGICAL CHANGES WITH AGING Sensorimotor changes Loss of motor units as source of muscle loss Loss of peripheral sensation Cognitive changes Decline in executive function, reaction time, attention Importance of balance Balance is the ability to maintain the position of the body (its centre of mass) within specific boundaries of space (stability limits) Poor balance is a significant contributor to falls in people aged 65 years and older Balance requires the integration of different sensory information (visual, vestibular, proprioceptive) and the ability to generate appropriate motor responses istockphoto.com/ Physiological systems for balance oaktreemobility.co.uk Vision • An important source of information for the control of balance – information about the external environment – feedback about the position and movements of the body • Postural sway increases ~ 30% with eyes closed Age affects • Visual acuity • Contrast sensitivity • Depth perception • Visual field (peripheral vision) • Increased use of spectacles visiontherapy.co.uk Cataracts Macular degeneration 16% of people over the age of 65 9% of older people over 65 Opacity of the lens of the eye, causing clouded vision Thinning of the macula area (centre) of the retina Usually a result of denaturation of lens proteins Causes a loss of central vision and inability to see fine details Due to advanced age and diseases such as diabetes Sensation / proprioception Balance relies upon combination of cues from the proprioceptive system Tactile information from hands and feet Input from muscles and joints Vestibular sensation Inner ear structures that detect position and motion of the head Important for posture and coordination of head, eye and body movements Reduced sensation with age Some evidence suggests that impaired vestibular function may contribute to falls in older people Age-related neurological changes The human brain loses 10% of its weight by the age of 90 years (loss of neurons) Reduced brain blood flow and metabolism Declining production of neurotransmitters Functional problems depend on region of loss/damage Degeneration of myelin sheaths, axonal degeneration Reduced nerve conduction velocity: slower responses Compensatory mechanisms reorganisation and redistribution of functional networks 87 year old 27 year old Reaction time 25% increase in simple reaction time from age 20-60 Increased simple reaction time is a strong risk factor for falls in older people Fallers have particularly slower reaction times in more complicated tasks, such as stepping 1. J L. Fozard et alJ Gerontol. 1994 2. Lord SR et al. J Am Geriatr Soc. 1994 Cognitive changes The basic cognitive functions most affected by age are processing speed, attention and memory. Balance control requires attentional resources balance is affected by one’s information-processing ability when performing two or more tasks simultaneously (distracted) A greater cost of dual tasks in older persons than young, suggests that there is an increase in the cognitive resources required for postural control with age Definition of a fall “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level” (World Health Organisation, 2007) “an unexpected event in which the participant comes to rest on the ground, floor or lower level” (Prevention of Falls Network Europe (ProFaNE) collaborators, 2007) • “unintentionally coming to the ground or some lower level and other than as a consequence of sustaining a violent blow, loss of consciousness, sudden onset of paralysis as in stroke or an epileptic seizure” (Kellogg International Working Group on the Prevention of Falls in the Elderly, 1987) Causes of falls N= 529 older people aged 70+ y living in the community 46% fallers , 20% multiple fallers 85% balance-related falls, 15% of unexplained falls (blackout, dizziness, faint as cause of fall) Falls incidence rate 1 in 3 community dwelling >65years, per annum 10-20% multiple fallers 1 in 2 people living in residential aged care facilities, per annum “Greying of the population”: 1 in 4 Australians will be over 65 by 2051 Falls in clinical groups Incidence rate of falls increases to double that of healthy older people Cognitive impairment Parkinson’s disease Multiple sclerosis Stroke Other groups at risk of falls Visual impairment Peripheral neuropathy: diabetic, chemotherapyinduced Adapted from Taylor et al., International Psychogeriatrics; 2013 Personal costs Morbidity & mortality Leading cause of hospitalisation (4%) in older people Leading cause of injury-related death in older adults Loss of independence Institutionalisation Loss of functional mobility, reduced physical activity Loss of confidence NSW Health projected costs to 2050 700.0 600.0 falls Cost $millions 500.0 400.0 300.0 road trauma 200.0 100.0 violence self harm 0.0 1994 1996 1997 2001 2006 2011 2021 2031 2051 Moller J: Changing resource demands related to fall injury in an ageing population – unpublished paper (NSW Health, Injury Prevention Policy Unit), 2000. Falls are multifactorial Medical conditions Psychosocial and demographics Medications Falls Environment Sensorimotor function and balance Screening vs. assessment Screening Identification of people at risk Increased surveillance Referral for further assessment and intervention Assessment Identification of risk factors amenable to treatments/correction Tailoring of intervention strategies Considerations for instrument selection Reliability – measures consistently each time Validity – measures what it is supposed to measure Feasibility – appropriate for population and setting Diagnostic accuracy Sensitivity - how well a test correctly identifies the cases in a population with the condition Specificity - how well a test correctly identifies the cases without the condition Comparison of 8 mobility tests 362 community-dwellers aged 74–98 years; 22% (n=80) had ≥2 falls in one-year follow-up (Tiedemann A. et al. Age Ageing. 2008) Test Validity Reliability Feasibility Total Sit -to-stand 5 ** 10 5 5 20 Alternate step** 10 4 4 18 6m walk** 10 4 3 17 Stair descent** 10 5 0 15 Stair ascent 5 5 0 10 Turn 0 4 5 9 Sit-to-stand 1 0 2 5 7 Pick-up weight 0 1 4 5 ** significantly worse in multiple fallers Different settings Community Residential Hostel Nursing home Hospital ward Emergency department (ED) Screening tools 2 or more falls in past year Mobility /functional tests Standing balance Tandem stand Check for excessive swaying or falling One-leg stand Maintained for 10 secs Sit to stand Time to stand up and sit down five times from a seated position Complete the task in less than 12 seconds Step tests strength, balance and co-ordination Hill step test – Alternate step test – test one leg at a time alternate left and right step ups 7.5cm or 15cm Average 16 steps in 15 seconds 18cm Complete the task in less than 10 seconds Walking tests 6 min walk 6 metre walk 6 metres • Associated with survival in older people (Studenski et al., JAMA 2011) • When performed with concurrent cognitive task, no better than single task to predict falls (Menant et al., Ageing Res Rev, 2014) • Frail / mobility impaired: 2-min walk Timed up and go • stand up • walk 3m • turn • walk back • sit down Useful to assess functional mobility; for falls risk prediction, better in frail, low functioning older people (Schoene et al., J Am Geriatr Soc, 2013) Berg balance scale 41-56 = low fall risk 21-40 = medium fall risk 0 –20 = high fall risk Berg K, et al. Can. J. Pub. Health, 1992. Berg balance scale • 14-items (0: worst - 4: best) (total score /56) • Designed for frail older people – has ceiling effect in healthy elderly • Has reasonable validity as a screen for falls • Most useful in identifying functional limitations for informing exercise intervention strategies 41-56 = low fall risk 21-40 = medium fall risk 0 –20 = high fall risk Berg K, et al. Can. J. Pub. Health, 1992. Other balance screening tests FROP – Com https://www.nari.net.au/resources/health-professionals/falls-and-balance Tinetti Performance Oriented Mobility Assessment (Tinetti ME et al., JAGS. 1986) Short Physical Performance battery (Guralnik et al., J Gerontol. 1994) 5 sit-to-stand time Standing with feet together, in semi-tandem and in full tandem for 10s 4-m walk time QuickScreen© Clinical Falls Risk Assessment • A validated and reliable set of measures used to predict the probability of future multiple falls and identify risk factors Tiedemann A et al., J Gerontol; 2010 QuickScreen© Clinical Falls Risk Assessment Sit to stand test 5 repetitions with arms folded, must complete within 12 secs Alternate step test 8 foot taps, must complete within 10 secs Low contrast visual acuity test Read all of the letters on the 3rd line Near tandem stand test 2.5cm 2.5cm Stand for 10 secs with eyes closed Tactile sensitivity test Must feel at least 2 of the 3 trials Clinical Falls Risk Assessment Form Client Name:___________________________ MEASURE Date:_____________ RISK FACTOR PRESENT? (please circle) ACTION Previous Falls One/more in previous year Yes/No Medications Four or more (excluding vitamins) Yes/No Any psychotropic Yes/No Recommendation: Review current medications Vision Visual acuity test Unable to see all of line 16 Yes/No Recommendation: Give vision information sheet. Examine for glaucoma, cataracts and suitability of spectacles. Refer if necessary. Peripheral Sensation Tactile sensitivity test Unable to feel 2 out of 3 trials Yes/No Recommendation: Give sensation loss information sheet. Check for diabetes. Strength/ Reaction Time/ Balance Near tandem stand test Unable to stand for 10 secs Alternate step test Unable to complete in 10 secs Sit to stand test Unable to complete in 12 secs Yes/No Yes/No Yes/No Recommendation: Give strength/balance information sheet. Refer to community exercise class or home exercise program if appropriate to individual level of functioning. Number of risk factors Probability score 0-1 2-3 4-5 6+ 7% 13% 27% 49% Probability score: The patient has a _______% probability of falling in the next 12 months. QuickScreen© Clinical Falls Risk Assessment • A validated and reliable set of measures used to predict the probability of future multiple falls and identify risk factors • 72% accuracy in predicting risk • Proven feasibility for use with older community dwellers by a variety of health professionals • Results guide interventions • Quick and easy to use, minimal equipment, low cost Tiedemann A et al., J Gerontol; 2010 Physiological assessment of fall risk Physiological Profile Assessment (PPA) (Lord SR et al, Physical Therapy 2003) Physiological, rather than disease-oriented Involves direct assessment of sensorimotor abilities Assumes that disease processes will be manifest in impaired performances in one or more tests Cataracts – poor vision Neuropathy – poor sensation Prior-polio – weakness Stroke – weakness, poor coordination, instability Vision Reaction time Lower limb strength Peripheral sensation Balance Use of a physiological profile to document motor impairment in ageing and in clinical groups The Journal of Physiology, Volume: 594, Issue: 16, Pages: 4513-4523, First published: 25 September 2015, DOI: (10.1113/JP271108) PPA – Composite fall risk score use Predicting outcomes Falls Fall-related injuries, fractures Disability, need for institutional care Evaluating interventions Exercise interventions Balance and mobility training Multifaceted interventions Stepping tests A. Choice-stepping reaction time test B. Inhibitory stepping test Composite measure of balance, strength and processing speed + inhibition B. Stroop stepping test Predictive of falls in older people Used as outcome measure of exercise interventions Lord & Fitzpatrick, J Gerontol, 2001; Schoene et al., J Am Dir Assoc, 2017. Gait assessments Walking speed Step length Cadence (step rate) Step time variability Rhythm or smoothness Symmetry Stability indices Kinematics Kinetics Complementary assessments I 8 Cognitive function – executive function and attention 9 4 H 3 Trail making test – executive function Fear of falling 7 12 1 C G Environmental conditions HOME FAST (Mackenzie et al., 2000) 5 J 2 L Medications Medical conditions D B Montreal Cognitive Assessment (Nasreddine et al., 2005) Falls Efficacy Scale-International (FES-I) (Yardley et al., 2005) 10 A 6 F K E 11 Conclusions Balance relies on contributions from sensorimotor systems which are progressively affected by age, contributing to the increased risk of falls. Epidemiological studies have identified demographic, physiological and medical risk factors for falls The screen or assessment used depends on the resources available and the extent to which the understanding of the causes of falls is required Tests of vision, sensation, strength, speed and balance can accurately predict older people at risk of falls Assessments in complementary domains may help refine the approach Physiological profiles provide information about the causes of falls on an individual basis and provide information about potential intervention strategies Importance of using right assessment for the participant and setting Resources • NSW Falls Prevention & Healthy Aging Network https://fallsnetwork.neura.edu.au/ • Active & Healthy https://www.activeandhealthy.nsw.gov.au/ References General knowledge in ageing and clinical groups at risk of falls Series of articles: Day BL and Lord SR. Balance, Gait, and Falls. Handbook of Clinical Neurology, 2018: 159, pages 2-432. Fasano A, Canning CG, Hausdorff JM, Lord S, Rochester L. Falls in Parkinson's disease: A complex and evolving picture. Mov Disord. 2017 Nov;32(11):1524-1536. doi: 10.1002/mds.27195. Gunn HJ, Newell P, Haas B, Marsden JF, Freeman JA. Identification of risk factors for falls in multiple sclerosis: a systematic review and meta-analysis. Phys Ther. 2013 Apr;93(4):504-13. doi: 10.2522/ptj.20120231. Epub 2012 Dec 13. PMID: 23237970. Assessment tools Tiedemann A et al. The comparative ability of eight functional mobility tests for predicting falls in community-dwelling older people. Age Ageing. 2008 Jul;37(4):430-5. doi: 10.1093/ageing/afn100. Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc. 2006 May;54(5):743-9. doi: 10.1111/j.1532-5415.2006.00701.x. PMID: 16696738. Freiberger E, de Vreede P, Schoene D, Rydwik E, Mueller V, Frändin K, Hopman-Rock M. Performance-based physical function in older community-dwelling persons: a systematic review of instruments. Age Ageing. 2012 Nov;41(6):712-21. doi: 10.1093/ageing/afs099. Physiological profile assessment Lord SR, Menz HB, Tiedemann A. A physiological profile approach to falls risk assessment and prevention. Phys Ther. 2003 Mar;83(3):237-52. PMID: 12620088. Lord SR, Ward JA, Williams P, Anstey KJ. Physiological factors associated with falls in older community-dwelling women. J Am Geriatr Soc. 1994 Oct;42(10):1110-7. doi: 10.1111/j.15325415.1994.tb06218.x. PMID: 7930338. Lord SR, Delbaere K, Gandevia SC. Use of a physiological profile to document motor impairment in ageing and in clinical groups. J Physiol. 2016 Aug 15;594(16):4513-23. doi: 10.1113/JP271108. Quickscreen Tiedemann A, Lord SR, Sherrington C. The development and validation of a brief performance-based fall risk assessment tool for use in primary care. J Gerontol A Biol Sci Med Sci. 2010 Aug;65(8):896-903. doi: 10.1093/gerona/glq067. Berg Balance scale Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Measuring balance in the elderly: validation of an instrument. Can J Public Health. 1992 Jul-Aug;83 Suppl 2:S7-11. PMID: 1468055. Performance Oriented Mobility Assessment (POMA) Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc. 1986 Feb;34(2):119-26. doi: 10.1111/j.1532-5415.1986.tb05480.x. PMID: 3944402. Timed up and go Schoene, D., et al., Discriminative ability and predictive validity of the timed up and go test in identifying older people who fall: systematic review and meta-analysis. Journal of the American Geriatrics Society, 2013. 61(2): p. 202-208. Short Physical Performance Battery (SPPB) Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, Scherr PA, Wallace RB. A short physical performance battery assessing lower extremity function: association with selfreported disability and prediction of mortality and nursing home admission. J Gerontol. 1994 Mar;49(2):M85-94. doi: 10.1093/geronj/49.2.m85. PMID: 8126356. FROP-COM Russell, M.A., et al., Development of the Falls Risk for Older People in the Community (FROP-Com) screening tool. Age and Ageing, 2008. 38(1): p. 40-46. https://www.nari.net.au/frop-com References Stepping tests Lord SR, Fitzpatrick RC. Choice stepping reaction time: a composite measure of falls risk in older people. J Gerontol A Biol Sci Med Sci. 2001 Oct;56(10):M627-32. doi: 10.1093/gerona/56.10.m627. PMID: 11584035. Okubo Y, Schoene D, Caetano MJ, Pliner EM, Osuka Y, Toson B, Lord SR. Stepping impairment and falls in older adults: A systematic review and meta-analysis of volitional and reactive step tests. Ageing Res Rev. 2021 Mar;66:101238. doi: 10.1016/j.arr.2020.101238. Gait speed Hardy SE, Perera S, Roumani YF, Chandler JM, Studenski SA. Improvement in usual gait speed predicts better survival in older adults. J Am Geriatr Soc. 2007 Nov;55(11):1727-34. doi: 10.1111/j.1532-5415.2007.01413.x. Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA. 2011 Jan 5;305(1):50-8. doi: 10.1001/jama.2010.1923. PMID: 21205966; PMCID: PMC3080184. Menant JC, Schoene D, Sarofim M, Lord SR. Single and dual task tests of gait speed are equivalent in the prediction of falls in older people: a systematic review and meta-analysis. Ageing Res Rev. 2014 Jul;16:83-104. doi: 10.1016/j.arr.2014.06.001. Inertial sensors Baker N, Gough C, Gordon SJ. Inertial Sensor Reliability and Validity for Static and Dynamic Balance in Healthy Adults: A Systematic Review. Sensors (Basel). 2021 Jul 30;21(15):5167. doi: 10.3390/s21155167. PMID: 34372404; PMCID: PMC8348903. Kobsar D, Charlton JM, Tse CTF, Esculier JF, Graffos A, Krowchuk NM, Thatcher D, Hunt MA. Validity and reliability of wearable inertial sensors in healthy adult walking: a systematic review and meta-analysis. J Neuroeng Rehabil. 2020 May 11;17(1):62. doi: 10.1186/s12984-020-00685-3. PMID: 32393301; PMCID: PMC7216606. Cognitive function Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005 Apr;53(4):695-9. doi: 10.1111/j.1532-5415.2005.53221.x. Erratum in: J Am Geriatr Soc. 2019 Sep;67(9):1991. PMID: 15817019. Muir, S.W., K. Gopaul, and M.M. Montero Odasso, The role of cognitive impairment in fall risk among older adults: A systematic review and meta-analysis. Age and Ageing, 2012. 41(3): p. 299308. Brodaty, H., et al., The GPCOG: a new screening test for dementia designed for general practice. Journal of the American College of Cardiology, 2002. 50(3): p. 530-4. McFadyen BJ, Gagné MÈ, Cossette I, Ouellet MC. Using dual task walking as an aid to assess executive dysfunction ecologically in neurological populations: A narrative review. Neuropsychol Rehabil. 2017 Jul;27(5):722-743. doi: 10.1080/09602011.2015.1100125. Morris R, Lord S, Bunce J, Burn D, Rochester L. Gait and cognition: Mapping the global and discrete relationships in ageing and neurodegenerative disease. Neurosci Biobehav Rev. 2016 May;64:326-45. doi: 10.1016/j.neubiorev.2016.02.012. Fear of falling Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C, Todd C. Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age Ageing. 2005 Nov;34(6):614-9. doi: 10.1093/ageing/afi196. PMID: 16267188. Delbaere K, Close JC, Mikolaizak AS, Sachdev PS, Brodaty H, Lord SR. The Falls Efficacy Scale International (FES-I). A comprehensive longitudinal validation study. Age Ageing. 2010 Mar;39(2):210-6. doi: 10.1093/ageing/afp225. Epub 2010 Jan 8. PMID: 20061508. Delbaere, K., S.T. Smith, and S.R. Lord, Development and initial validation of the Iconographical Falls Efficacy Scale. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 2011. 66(6): p. 674-680. Home hazards assessment tool Mackenzie, L., Byles, J., & Higginbotham, (2000). Designing the Home Falls and Accidents Screening Tool (HOME FAST): Selecting the items. British Journal of Occupational Therapy, 63, (6), 260-269 Parkinson’s disease HESC3592 Neuromuscular Rehabilitation Dr Paulo Henrique Silva Pelicioni PhD, MSC, PostGrad Cert, BPT Lecturer School of Health Sciences Epidemiology • 2nd Most prevalent neurodegenerative disease worldwide (and in Australia) • Over 200,000 of the Australian population • 2/3 of people diagnosed with PD are men • 18% of people with PD are 65 years older and younger (early-onset PD), and 10% are diagnosed younger than 45 years old • Globally, the number of people with PD will duplicate by 2040, reaching 17.5M of the World population - increased longevity - industrial by-products - reduction in smoking Epidemiology Parkinson’s disease What is Parkinson’s disease? • Neurodegenerative and progressive disorder • Death and depletion of dopaminergic neurons in substantia nigra pars compacta Parkinson’s disease Parkinson’s disease “Healthy” person Parkinson’s person Parkinson’s disease Signs and symptoms Parkinson’s disease • Heterogenous • Progressive • Motor symptoms • Non-motor symptoms • Motor complications Signs and symptoms Motor symptoms Non-motor symptoms • Bradykinesia • Resting tremor • Rigidity • Postural instability • Gait disorders • Anxiety • Depression • Cognitive impairment • Sleep disorders • Apathy • Autonomic dysfunction Signs and symptoms Signs and symptoms Hoehn and Yahr stages 1. 2. 3. 4. Unilateral motor impairment Bilateral motor and axial impairment Bilateral disease with impaired postural control Moderate/ severe disease. Might still walk or stand unassisted 5. Wheelchair bound or bedridden Signs and symptoms Presence of impairments with PD progression • More common presence of cognitive impairment • Freezing of gait • Falls • Physical dependence • Weakness • Issues associated with ageing become exacerbated Main medications for Parkinson’s Symptomatic treatment – not disease-modifying • Dopamine replacement • Dopamine agonists • COMT inhibitors • Anticholinergics – for tremors, mostly • MAO type B inhibitors – prolong dopamine effect Too much PD medication causes dyskinesia • Amantadine – helps with severe dyskinesias Main medications for Parkinson’s Main medications for Parkinson’s Main medications for Parkinson’s Main medications for Parkinson’s The role of an exercise physiologist • To examine a client with PD • To plan and deliver an exercise programme to attenuate PD symptoms • To plan and deliver an exercise program to tackle co-morbidities • To be part of a multi-disciplinary team Parkinson’s assessments Parkinson’s assessments Parkinson’s assessments Parkinson’s assessments Parkinson’s assessments • Part I – non-motor experiences of daily living • Part II – motor experiences of daily living • Part III – motor examination • Part IV – motor complications Exercise for Parkinson’s disease Primary outcomes • MDS-UPDRS part III (motor examination) • PDQ-39 (quality of life) Exercise on motor examination Exercise on quality of life Exercise for Parkinson’s disease Secondary outcomes • TUG (functional mobility) • Freezing of gait (FOG-Q and NFOG-Q) Exercise for Parkinson’s disease Exercise for Parkinson’s disease Exercise on quality of life Exercise on quality of life Only on TUG Exercise for Parkinson’s disease Adverse events (considerations) • Falls • Pain Virtual reality for Parkinson’s disease Outcomes • Gait • Balance • Quality of life • Adverse events Virtual reality for Parkinson’s disease Virtual reality for Parkinson’s disease Virtual reality for Parkinson’s disease Virtual reality for Parkinson’s disease Freezing of gait (FoG) • One of the most disabling PD symptoms • Its occurrence increases with disease progression (usually Hoehn and Yahr 3 and above) • FoG usually occurs during turning, gait initiation and narrow pathways • Severe FoG can happen during normal walking • Increased the risk of falling substantially Freezing of gait (FoG) Freezing of gait (FoG) Freezing of gait (FoG) Freezing of gait (FoG) Freezing of gait (FoG) Freezing of gait (FoG) Freezing of gait (FoG) Freezing of gait (FoG) Types of visual cueing • Stripes taped on the floor/ cones • Laser shoes/ belt • Holographic cueing • Floor pattern Falls prevention • 45% - 68% of people with PD fall in each year • 50% - 86% of people with PD fall (2+) in each year • Its occurrence increases with disease progression (Hoehn and Yahr 3 and above) • People with PD PIGD are more likely to fall due to - FoG - Balance-related circumstances (e.g., trips/ slips) - At home Falls prevention Primary outcome • Rate of falls (falls/month) Falls prevention Falls prevention Falls prevention Falls prevention Falls prevention Falls prevention Primary outcome • Number of people who fell at least once Falls prevention Falls prevention Cognitive impairment in Parkinson’s Cognitive impairment in Parkinson’s • Impaired visual-spatial processing • Poor attentional processing • Poor short-term memory • Executive dysfunction • Deficient information processing • Difficulties with dual-tasking Altogether, they can increase the risk of falling Cognitive impairment in Parkinson’s Tests A. CSRT B. iCSRT C. SST Cognitive impairment in Parkinson’s DLPFC Broca’s Cognitive impairment in Parkinson’s DLPFC PMC SMA Broca’s Cognitive impairment in Parkinson’s Reduced cortical activity during inhibitory complex stepping tasks may reflect a “slow-down” phenomenon in people with PD. Fronto-striatal circuit damage Cognitive impairment in Parkinson’s Cognitive impairment in Parkinson’s Cognitive impairment in Parkinson’s Outcomes • Global cognition • Executive functioning • Attention • Verbal memory • Visual processing • ADLs and QoL Cognitive impairment in Parkinson’s Outcome • Attention Cognitive impairment in Parkinson’s Outcome • Verbal Memory Cognitive impairment in Parkinson’s Cognitive impairment in Parkinson’s Training groups • Locomotor • Multimodal • Cognitive maintenance in cognitive levels reduced physical stress maintenance in cognitive levels Locomotor & multimodal groups Delay in the progressive course of PD on non-motor symptoms Patients trained what really matters? Exercise considerations • Higher disease severity (e.g., increase falls risk) • Dyskinesia (e.g., too uncontrolled can hurt themselves) • Tremor (e.g., affecting gripping) • Not in “off” stage • Cognitive impairment (e.g., levels of understanding) • Freezing of gait • Orthostatic hypotension • Co-morbidities • Pain during execution [email protected] Traumatic Brain Injury Callum Baker PhD AEP Case Jeremy from Utah • • • • • • • Think about how the TBI changed Jeremy’s life and how he has changed since the TBI. Think about how the life of Jeremy’s family members have changes What impairments do you see? What were Jeremy’s goals following his injury? What do the family think helped with Jeremy’s recovery? What complication could arise from having the family so involved? How do you see an AEP helping Jeremy? Demographics of Persons with a TBI • • • The incidence of TBI peaks in the 15-35 years age group TBI by gender: 3.4 males to 1 female (largely thought to be related to risk-taking behaviour among young males) 2/3 mod-severe TBI caused by MVA • • • About 50% of the adult and paediatric NSW BIRP populations have 1 or more challenging behaviours following TBI Mental Health, Drug and ETOH are common comorbidities both pre and post TBI Employment rates post TBI average 29% and there is a marked and consistent post injury shift from full-time to part-time employment. TBI - Pathophysiology Primary injury • Initial application of force to the skull that disrupts white/grey matter and blood vessels in the brain. (Osmosis.org) Pathophysiology Secondary Injury Events occurring following the primary injury that cause further injury: edema, build-up of neurotoxins • Intracranial haemorrhage (bleeding inside the skull) • Brain swelling • Increased intracranial pressure (pressure inside the skull) • Brain damage associated with lack of oxygen • Infection inside the skull, common with penetrating trauma • Chemical changes leading to cell death • Increased fluid inside the skull (hydrocephalus) McKee CA, Lukens JR. Emerging Roles for the Immune System in Traumatic Brain Injury. Front Immunol. 2016;7:556. Pathophysiology Location and severity of injury dictates functional changes in TBI: Frontal lobe damage: • Speech problems • inattentiveness Parietal lobe damage • Sensory deficits Severity • • • • • Graded on degree of neurological deficit resulting from injury (not severity of injury per se) GCS <8 = severe 9-12 = moderate 13-15 = mild • Duration of post-traumatic amnesia Period of time the brain is unable to lay day-to-day memory. Best indicator of functional and cognitive deficits after TBI 10%–15% of mild TBI survivors have persisting symptoms and impairments Clinical Presentation Seizures (penetrating TBIs) • Early seizures (within the first few weeks of injury) • Later seizures (within 2 years) • Require medication (side effects) • Lifestyle implications Hypertonia and spasticity (brainstem/cerebellum or midbrain TBIs) • High muscle tone/muscle stretch reflex • Spasticity: • • • • “Velocity dependent increase in resistance when a joint is passively moved through ROM” Often prevents/interferes with ADLs Medications Measurement of spasticity • Poor muscle co-ordination/co-contraction • Spastic dystonia • Contractures Hypotonia Heterotopic ossification Balance disorders Case Sean from New Orleans • • • • What symptoms do you observe? What would you imagine is the impact of Sean’s disabilities on his day-to-day life? What medications are discussed and what are the short term and long-term effect? What exercises do you see and how are the related to his disabilities? Clinical Presentation Musculoskeletal injuries • Msk injuries associated with cause of TBI (MVA or fall) • Need to be treated alongside TBI Hypotonia (cerebellum) • Less common than spasticity • Low muscle tone Heterotopic ossification • ectopic growth of bony tissue in tissue planes around major joints • Surgery/pharmacological intervention Balance disorders • High prevalence • Diverse presentation and root cause Case Joey from New York • What symptoms do you observe? • What are Joey and the therapist working on? • What is the function of the strap on Joeys R leg? • How would the anti-gravity treddy/pool help? Clinical Presentation “The importance of these behavioral, psychiatric, speech, and sensory consequences cannot be underestimated because they may be the primary reason for failure of successful community reintegration after brain Injury” Anthony Lequerica, PhD Riggio S. Traumatic Brain Injury and Its Neurobehavioral Sequelae. Neurologic Clinics. 2011;29(1):35-47. Clinical Presentation Neurocognitive function, sensory function, speech, and communication • psychiatric disturbance (depression, anxiety, mood disorders) • Extremely common • Sensory changes (heightened sensitivity, difficulty filtering sensory input, sensory loss) • Other: Sleep disturbances, chronic pain, and headaches Clinical Presentation Neurocognitive function, sensory function, speech, and communication • Cognitive problems • Memory impairment, difficulty with new learning, attention and concentration; reduced speed and flexibility of thought processing; impaired problem-solving skills • Problems in planning, organizing, and making decisions • Language problems –
