Gait, freezing, postural instability and FALLS · Microsoft PowerPoint - Gait and balance_MDS...
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5-10-2014 1 Professor Bastiaan R. Bloem Parkinson Center Nijmegen (ParC) Radboud University Nijmegen Medical Center @BasBloem Gait, freezing, postural instability and FALLS Falls typically have a single cause Most falls are environmental Falls are mainly motor disorders Falls cannot be prevented Falls have relatively little importance for patients The windmills
Transcript of Gait, freezing, postural instability and FALLS · Microsoft PowerPoint - Gait and balance_MDS...
5-10-2014
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Professor Bastiaan R. BloemParkinson Center Nijmegen (ParC)
Radboud University Nijmegen Medical Center
@BasBloem
Gait, freezing, postural instability and FALLS
Falls typically have a single cause
Most falls are environmental
Falls are mainly motor disorders
Falls cannot be prevented
Falls have relatively little importance for patients
The windmills
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Why are falls so
important?
Importance of falls
… and immediately decides to retire!
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The best predictor offalls is a prior fall
(but falls predict much more …)
“Take home” message!
1967
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Scientific confirmation
1999
Bloem et al., Mov Disord 2004;19:871‐884
Is falling an issue in Parkinson disease?
Falls are a “late” feature in Parkinson’s
UPDRS score80
Risk of falls (in subjects with no prior falls)
0.6
0.4
0.2
0.0
6040200
Pickering et al., Mov Disord 2007;22:1892‐1900
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But when falls do occur ...
Fear of falling
Fewer falls is not necessarily better!
“Take home” message!
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I will never fall again!
Fear also leads to inactivity
Van Nimwegen, Speelman, Bloem & Munneke (submitted)
Physical inactivity in Parkinson disease
‐13%
‐21%
‐84%
IVIIIIII
Hoehn & Yahr stages
Physical Activity (LAPAQ questionnaire)
The ParkFit trial
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Signing up is not enough!
Prevention of physical inactivity
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Falls (Cumulative)
1 3 6 9 12 15 18 21 24 (months)
Controls
ParkFit
Safety?
Difference is not significant
(Clinical)
assessment of falls
STEP 1: classification of falls
WITH preceding loss of consciousness
WITHOUT preceding loss of consciousness
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Useful tips & tricks
! Contact moment with the floor !
! Nature of the injuries !
Further classification of falls
Intrinsic falls Extrinsic falls
Analysis of security videos
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Fall type 2: narrowed base of support
Fall type 4: trip over obstacle
Commonest environmental hazard??
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Most falls in Parkinson’s disease are intrinsic
Treat the patient, not the environment
“Take home” message!
STEP 2: prior falls yes or no?
The falls telephone
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Automated falls detection
• 3 linear accelerometers• 1 altitude sensor• Validated algorithms
Is my patient likely
to fall (again)?
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Intoxications
Avoid benzodiazepines!
Benzodiazepines
With benzodiazepines
No benzodiazepines
RR 5.0 (P < 0.01)
Bloem et al., J Neurol 2001;248:950‐958
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Also common in COGNITIVE disorders
Falls are common in dementias
Particularly often in MIXED disorders
Normal pressure hydrocephalusParkinson disease
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‘Spot’ diagnosis
Perhaps even particularly cognitive?
Severity (in Parkinson’s disease)
Time
Gait impairment & postural instability
Compensatory mechanisms
Falls and injuries
Cognitive impairment
Hypothesis
Beware of EPISODIC gait disorders
Continuous gait disorder
Episodic gait disorder
??
Normal
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Hypokinetic walking & turning
EPISODIC: freezing of gait
This is NOT freezing of gait
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Freezing = most often trembling
Nieuwboer et al., Gait & Posture 2009;30:459‐463
Freezing of gait questionnaire, version 2.0
Courtesy of Alice Nieuwboer
Important cause of falling
Important cause of falls
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Falls in Parkinson’s disease = freezing!
“Take home” message!
Absent when being examined
A good illustration
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Rapid turning “on the spot”
Recommendations for clinical practice
Forced rapid, small steps
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Forced rapid, small steps
Analysis of security videos
Fall type 1: turning (& freezing?)
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Consider freezing of gait when patients
• Fall forward
• Claim “spontaneous” falls
• Fall while turning around
Some rules of thumb
Freezing in other species
Treatment of freezing
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Dopaminergic abnormalities
Dopa‐induced abnormalities
Non‐dopaminergic abnormalities
Clinical state while freezing
Increaselevodopa
“OFF” period freezing
Courtesy of Alberto Albanese Albanese et al., Neurology 2005;64:1958‐1960
Dopa‐responsive freezing
Threshold to treat freezing of gait
Pseudo ON state freezing
Freezing of gait
Dose of antiparkinson med
ication
Threshold for treatment response
Appendicular symptoms & signs
Dose of antiparkinson med
ication
OFF state
ON state
Threshold for treatment response
OFF state freezing
ON state freezing
My private hypothesis
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Dopaminergic abnormalities
Dopa‐induced abnormalities
Non‐dopaminergic abnormalities
Clinical state while freezing
“OFF” period freezing
Decreaselevodopa
Decreaseagonist
ON state freezing of gait
Espay et al., Neurology 2012;78:454‐457
What is this?
Růžička, Nutt and Bloem, Mov Disord, in press
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Looks just like …
Dopaminergic abnormalities
Dopa‐induced abnormalities
Non‐dopaminergic abnormalities
Clinical state while freezing
Idazoxan?“Non‐dopaminergic”
freezing?L‐threo‐DOPS?
Duloxetine?
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STN stimulators ON STN stimulators OFF
Effects on gait
Krack et al., N Eng J Med 2003;349:1925‐1934
0
0.5
1
1.5
2
2.5
Baseline 1 year 3 years 5 years
Postural stability
Postoperative
‐1
0
1
2
3
Baseline 1 year 3 years 5 years
Freezing of gait
Postoperative
0
5
10
15
20
25
30
35
Baseline 1 year 3 years 5 years
UPDRS total score
Postoperative
Effects on gait
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Targeting the PPN
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PPN stimulation (OFF)
Courtesy of Peter Silburn
PPN stimulation (ON)
Courtesy of Peter Silburn
Specific tests
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Traditional testing
Real life example
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Real life example
0
10
20
30
40
50
60
70
80
Patients
PercentageP = 0.001
Bloem et al, J Neurol 2001;87:950‐958
Controls
Multiple tasking and falls in PD
Parkinson MSA
Tandem gait testing
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Parkinson’s disease
(n = 36)
Atypical parkinsonism
(n = 49)
Able
Unable
33 (92%)
3 ( 8%)
9 (18%)
40 (82%)
• Sensitivity 82%, specificity 92%
• Positive likelihood ratio 9.8
• Post‐test probability 87%
Abdo et al, JNNP 2006;77:1367‐1369
“Bloem’s test”
The bicycle sign
Aerts et al., Lancet 2011;377:125‐126
Stopped cycling since diagnosis
P < 0.001
Aerts et al, Lancet 2011;377:125‐126
Main findings
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Even in Japanese Alps (and Korean mountains?!)
Miwa and Kondo, J Parkinson’s Disease 2012;1:167‐168
Tandem gait and cycling are easy ways to differentiate Parkinson disease
from atypical parkinsonism
“Take home” message!
Freezing in vascular parkinsonism
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Under recognized?!
Under recognized?!
Main results
305 consecutive Parkinson patients
• Dizziness Handicap Inventory• Dix‐Hallpike manoeuvre• Test for orthostatic hypotension
Not dizzy (n=154, 51%)Dizzy (n=151, 49%)
Orthostatic hypotension(n=57, 38%)
Classical BPPD(n=12, 8%)
Atypical BPPD(n=4, 3%)
• Symptom free (n=10, 63%)• Improved (n=3)• No improvement (n=3)
• Canalith‐reposition manoeuvre• 3‐month follow‐up
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Benign paroxysmal positional vertigo is
common, under recognized but treatable
“Take home” message!
Falls are NOT untreatable
Some rules of thumb
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Thank you
