PADRECC NATIONAL VANTS AUDIO CONFERENCE Falls in PD Jeff Kraakevik, M.D. January 8, 2009 Kraakevik: We are going to get going, Ryan Rieger is going to start off the conference here. Rieger: We are going to go ahead and get started. My name is Ryan Rieger, I am the Administrative Officer with the Northwest PADRECC and welcome to PADRECC EES Audio Conference. Today’s presentation is entitled “Update on Impact and Treatment of Falls in Parkinson’s Disease by Dr. Jeff Kraakevik”. Before we get started, I would just like to take a minute to remind everyone out there to please put your phones on mute or turn your microphones off during the presentation, so we can minimize any background noise and also, please refrain from putting the call on hold. There will be an opportunity at the end of the presentation for questions and answers. I also would like to remind everybody that the handouts for this talk can be found at the VA EES website. It was distributed, the link, on the marketing materials for this presentation. So, in order to receive your continuing medical education certificate, what we need you to do is open the document found on that link entitled, “Brochure” and if you scroll down to the section called, “Registration, Evaluation, Obtaining the Certificate”, you will find the link for the evaluation form. Just complete the evaluation form and send or fax it back to EES and they will send you your Certificate of Completion. With that, I would like to provide just a brief introduction of Dr. Kraakevik. Dr. Kraakevik received his medical degree from Carver College of Medicine at the University of Iowa and completed his neurology residency at the University of Iowa Hospitals and Clinic. In 2004, he came to the Portland VA Medical Center for a fellowship and movement disorders and now serves as the Associate Director of Education for the Northwest PADRECC and with that, I will turn it over to Dr. Kraakevik. Kraakevik: Again, my name is Jeff Kraakevik and I want to thank you all for taking the time to learn a little bit about falls. Just a little more introduction about myself and about the PADRECC system. So, I did indeed go to the University of Iowa. I have been out here in Portland for four years now, completed my fellowship out here and in addition to my duties as Associate Director of Education, through fellowship and into the going on faculty here, I have worked on several research studies looking at various aspects of gait and balance of Parkinson’s Disease. In way of introduction to the PADRECC, if you are not familiar with the PADRECC, the icon is down at the, the mobile is down at the right, lower side of the opening slide. We are a Parkinson’s Disease Research Education and Clinical Centers. There are currently six sites, which the VA has identified as places that give excellent care for Parkinson’s Disease and the goal of the PADRECC is to not only provide cutting edge care for the veteran’s or taking care of each of these sites, but to also, as the name applies, work on research into finding new therapies and cures for Parkinson’s, protective care for Parkinson’s Disease and another main idea that we have is that we would like to be able to educate providers and patients about Parkinson’s Disease and so part of that goal or part of that mission is why we are doing this series of audio conferences and we had one in November on cognitive disorders. This one is going to be on falls and then we have several more coming up the rest of this year. So, keep your eyes open to the email system or however you found out about this conference for future conferences because, again, this is something we would like to continue doing. So, again, today we are going to be focusing on falls in Parkinson’s Disease. If you will go to the next slide after the initial slide, which says, “Topics for Today”, we are going to be looking at how falls impact our patient’s lives. We are going to spend some time learning about the evaluation of falls, both in history and in physical examination. Looking a little bit at normal walking and then using the knowledge of normal walking to be able to identify one of their abnormalities and then we are also going to look through some common causes of falls and common risk factors of falls for people with Parkinson’s Disease in particular and we are going end up by talking about some therapeutic approaches as to how we can address a patient of ours if they have had a fall to try and prevent future falls. A lot of the information that comes from this talk comes from literature that does not only specifically apply to Parkinson’s patients. Many of these ideas have come from the general elderly population. Looking at falls and then applying that to the subset of population that we take care of, which is in Parkinson’s Disease. So, if you are a person that doesn’t spend most of your day taking care of Parkinson’s patients, which I am assuming, probably most of you are in that boat. You can take the ideas and thoughts that we are talking about for Parkinson’s Disease and apply it to most of your patients. So, if you go to the next slide here that says, “Why do Falls in PD Matter?” The reason that falls matter, aside from the fact that it is obvious that people with Parkinson’s would be more likely to fall, is that research does bare that out. Meta-analysis of 473 patients that put together a total of 473 patients found that 46% had one fall in a three month period, which is a little surprising, in that somewhere around, of those who had a fall, somewhere around a ¼ of them are people who had not previously had a fall and as we will see, one of the greatest risk factors for having a fall is to have a history of a prior fall. Now, one thing we have to realize when we are looking at research for falls, is that even though it seems like it would be easy to define what a fall looks like, it actually, when you get a group of people who think about this a lot together, it is much harder than you think to come up with a definition of falls. So, sometimes these meta-analyses can have problems because falls may be defined differently among the different studies. You know, when you first think about it, you think well, what would be the problem with defining a fall, that doesn’t seem like such a big deal, but again, from a research standpoint, you start to hit these gray areas. If a person trips over a cord, is that a fall? Or should we call that not a Parkinson’s related fall? How do you put something that isn’t kind of a spontaneous fall? You also need to worry about if the person starts to fall but then someone assists them to the ground. Do you call that a fall or is that not a fall? If the person almost falls but catches themselves on a chair or if they are getting up from the chair and fall back into the chair, do you call that a fall? So, all of these things make it difficult to be able to do research into falls in Parkinson’s Disease and it’s part of the reason that it’s taken up till now before researching the falls has kind of started to gain some momentum. I think most people would now agree that a reasonable definition of a fall is any unintended movement, which ends with contact with the floor. That’s kind of baseline definition that we can kind of move forward with. Again, once you have a definition that everybody sort of accepts, then you can start to move forward in, not only track how frequent falls are happening in Parkinson’s Disease, but also, as we are starting to get more therapies for it, to be able to see if those therapeutic interventions are working or not. We also, we will see falls and balance were highly correlated with poor quality of life. The study is looking at for everyone with Parkinson’s Disease, what did the patients think have the most impact with their quality of life. Falls and balance was among, I think it was the top two things that affect people’s lives. Also, looking at the total cost of falls, this is for the general, elderly population and this was from the CDC website and this figure came from a few years ago, so it might even be more now, but somewhere around 27.3 billion dollars spent on falls in the United States. So, all of these things tell us that it’s a problem that is, even though it is intuitively obvious that people with Parkinson’s would probably fall more, the evidence does indeed show us that it is a problem. So, if we go to the next slide called, “Impact of Falls”. So, we know there are a lot of falls. What do those falls, how do they affect people’s lives? Well, you would obviously think about fractures, broken bones. 33% of people in one study with Parkinson’s Disease, we found out falls or fractures after a fall, of those fractures, probably about the most costly kind of fracture is the hip fracture and if you dealt with hip fractures at all, you realize that these people, if a person has a hip fracture, they are immobilized for a good amount of time. They are going to need to be in the hospital and be at risk for a whole bunch of problems from being immobile and being in the hospital and then most of them require extended rehabilitation stays. So, even though hip fractures are of the minority of the fractures that occur from falls, hip fractures account for most of those medical costs. Other things, including bruising, brain hemorrhages, which are less likely, but sub hematoma and things like that do occur. This idea of immobility if you are unable to arise after a fall, you know, this can be as simple as having a caregiver, who perhaps for some reason or another because it’s a large man and the caregiver is a little lady that, if the person is not able to get up on their own, the caregiver may not be able to get them back up. I have certainly heard of people who have had difficulties with needing to call the ambulance for things like that. I have also, anyone who has been in emergency rooms or on internal medicine services for any amount of time, have taken care of someone who fell down at some point and if the person is living alone, they may be on the ground or an extended amount of time and there’s just a lot of medical problems which can arise from that. So, in addition to those sort of things, the one that I think has kind have been shown to affect people’s quality of life more is this fear of falling. Even though it is something that we don’t consider to be as big of a deal, in some sense as these other problems, if you ask patient’s about it, this fear of falling is actually a very big deal. Studies looking at this, looking at the fact that once a person has had a fall, they are much less likely to go out, much less likely to go out to eat with relatives, much less likely to participate in other social activities. Going to various clubs, going to church or other religious activities, going out shopping. All of these things curtail that the person has had a fall, simply because they are afraid of just walking is a risky activity and they may have a fall just from not doing any activity. So, these people can become very socially isolated and again, if you ask, when I ask patients about it, this fear of falling is probably actually a bigger deal than a lot of us think it should be or would think it would be. So, if we go to the next, and again, there’s lots of other impacts of falls I didn’t put on here, we just don’t have time to go into all of them. If you go to the next slide, we are going to move from, how falls impact people’s lives into how exactly do we look at this in the clinic and what sort of things go into a fall. So, physiologists will often refer to walking as controlled falling. To explain this, essentially, you need to remember back to high school physics or college physics, if you took college physics, where any object has a basis support. In a human that would be a box that is drawn around the outside of the heels or around the feet and then every object also has, what we call a center of mass. The center of mass is simply where, if you draw a line straight down from that, that’s where basically all of the mass is centered around and it’s sort of a tipping point, if you will. So, if your center of mass, which is usually somewhere around the belly button and about mid-line through the belly button, if that center of mass moves outside of your base of support, that is when the object will fall over. So, in the case of walking if you think about what you have to do, you have to un-weight one leg and then you move your trunk forward until your trunk is in front of where your foot is. So, you are starting to fall forward and the next foot stops that motion by bringing the foot out and hitting the ground. Then, you repeat that motion over and over again. So, again, indeed it is a controlled fall each time we take a step. As you can imagine, this idea that we are having a controlled movement like this is going to require a lot of different integration of various things within the nervous system. So, the next part of this slide walks our way through a lot of these things, a lot of these areas of the brain, which are required to do this. So, we need sensory perception that largely comes from the vestibular, visual and proprioceptive information, telling you where your muscles are in space, so that you can react to walking and balance or to keep the walking motion going forward. All that information is filtered through a higher processing center and as you can see, there’s not any one single center in the brain that takes care of balance or walking, as you may think of like language or things like that. All of these things are a combination of a whole bunch of centers working together. So, it includes the basic Basal ganglia, premotor cortex, SMA, PPN or the Pedunucolopontine Nucleus, cerebellum . In terms of walking, there may actually be some lower brain stems and spinal centers, which are involved with walking as well. The PPN in particular is something we are going to talk about, which is kind of emerging in the area of balance and gait, because we are beginning to, we are wondering if using this as a target for therapy for this deep brain stimulation may help with balance and we are going to get to that later in the talk here. Once that information is processed and we have a plan that is going to be sent out, the signals have to be sent out to the muscles, so primarily three of the cortical spinal tract, but it can have some input from lower brain stem centers going out to multiple muscle groups. Again, if you think about when you are walking, you are moving almost everything. You have to move your arms and your legs. You have to have your trunk and your hips all going in a coordinated fashion. So, really any perturbation anywhere along this whole line is going to cause a problem with gait and balance. In Parkinson’s, in particular, we worry about basil ganglia and the affects of basil ganglia, there may be some problems with other areas as well, which cause some balance and gait problems. In general, when we have a patient in front of us with falls, we need to work our way through all of these systems in order to be able to tell exactly what’s causing the falls, so we can treat it appropriately. If you go to the next slide, which is called “Gait and Balance Problems in Parkinson’s Disease”, when we are talking about gait and balance in Parkinson’s Disease, usually we see these gait and balance problems later in the disease. Everyone with Parkinson’s is a little bit different, but in general, about five to ten years is where balance and gait problems begin to become something that people start to complain about. In kind of dividing the two out for the gait problems, there are these small, shuffling steps. The posture becomes sort of hunched over. There’s this festination, which is the entity where the steps keep getting shorter and shorter and shorter until it is kind of like the feet are just sort of moving in place, but going up and down and up and down. Or, freezing, which is closely related to festination, where the person feels like they just can’t even move their feet off of the floor. You can imagine with the festination, your feet are moving forward and forward and smaller and smaller steps and you haven’t slowed down your momentum from your trunk, you can imagine that makes it fairly easy to fall forward with that sort of problem. Looking more specifically at balance, balance usually early in the disease, we can tell difference when the person complains about it mainly when turning or on uneven surfaces. People may have troubling falling backwards and as the disease becomes more severe, that balance does get more affected and then they have trouble specifically walking or if the balance is severely affected, they may have problems even just standing still on a flat surface. As you can see, the balance issues, in particular, did not likely respond to our dopaminergic medications, as well as the gait problems do. I like to tell my patients about that because a lot of times when people are trying to decide if their medications are working or not, they sometimes have expectations and it is going to take care of all of the symptoms in Parkinson’s Disease and I make sure they know that balance is one of those things is not as likely to respond to these dopaminergic medications. So, let’s move to the next slide then, “What Makes the Assessment of Falls So Difficult?” Well, you know, when a person comes in with falls, it can be sort of like complaints of dizziness or weight loss or things like that where, as a clinician, if you see someone with that problem, you realize that this visit is now going to take place as long as you thought it was going to take because the list of possible causes for it is very, very large. Once you do find the problem, there’s usually not just one problem that’s going on, but it is usually two or three things that are contributing to the falls. So, for example, in a Parkinson’s patient, that Parkinson’s patient may have arthritis in the knees, they may have a little bit of positional vertigo. They may have a whole bunch of other problems in addition to the basal ganglia balance problems or gait problems. So, you have to address each of these things in turn. There is also this belief out there that you go through all this work and then there’s really not that much that we can do for falls. Hopefully, by the end of this talk, after we go through the therapies that are available, you will understand that there are actually a number of things you can do for falls and that even though the list of possible causes is huge, we can work our way through it and come up with a rational plan that does actually address what needs to be addresses and we can decrease the person’s risk of having another fall. So, if you go to the next slide, we are going to go over some of the risk factors then for people with Parkinson’s to have falls. The one that’s on the top there is the one that’s been borne out with the most studies. The one that’s kind of the number one risk factor for falls and that is previous falls. So, if the person has had more than two falls in the last two years, they are much, much more likely to have another fall. So, that leaves some people to say well, we need to work hard to prevent that first fall. You know, I think is a good goal. We also want to look at the person’s medication list, because not only in Parkinson ’s disease, but in the elderly population, polypharmacy, again, has been proven over and over again, especially with psychotropic medication to really increase risk of falls. In the next slide here, we are going to go over some of those specific medications that are troubles. Increased disease severity, obviously, you are going to have more balance and gait impairment the more severe the disease is. Orthostatic hypotension, we don’t have a lot of time in this talk to talk about all of the various things we can do to try and address orthostatic hypotension, but you know, it is something that is very common in Parkinson’s Disease, both from the disease and from the medications we get for it and it is something we need to address, we need to look for to see if they are having black-out spells or those sort of things around the falls or if they are feeling light-headed. Other orthopaedic and neurologic problems, as I said, a lot of people with Parkinson’s Disease, may have other problems, which may contribute to balance and gait problems. Cognitive dysfunction is one that is a little bit, it does increase the risk factors in falls, but it may also have the added difficulties if they are cognitive dysfunction or there is insight problems, these people, if you have a balance problem and you link that with a person who doesn’t understand that they are doing a risky behavior, that can lead to a lot of falls because the person keeps doing a risky activity, such as getting up without support or not using assistance devices. Other things to think about, we talked about fear of falling before. Visual difficulties, in studies it has been a little more of a mixed bag as far as how much of a risk factor a visual difficulty is, but obviously, if someone has a cataract or has a prescription that is old or out of date, that may cause troubles with falling. They also talk about environmental problems with lighting, which can also be somewhat of a visual difficulty. If a person gets up and they are having difficulties with balance, their visual system kind of helps to compensate for that. You take away that lighting, that can be the cause for middle of the night falls, when people are trying to go the bathroom and things. Also, in the elderly population, there’s a lot of work being done on substance abuse. The Parkinson’s population, for whatever reason, these substance abuse situations don’t arise as frequently, but I certainly have had some people with Parkinson’s who have had alcohol problems and you just have to keep reminding them that if you have a balance problem to begin with and you add alcohol to that, that’s just a recipe for a lot of problems and potential falls. So, let’s move to the next slide, which is going to focus more on this polypharmacy. You will see the list of medications there and if you have spent time thinking about medications, you will understand that all of these are medications, or most of these are medications that can affect or can penetrate into the central nervous system. Antihypertensives obviously are medications which can cause some of this light-headedness we have been talking about and cause trouble with those static hypertension leading to falls. The last one on the list there, Coumadin, is a little different because it’s a blood thinner, so it doesn’t directly cause balance problems, however, if a person does fall and they are on Coumadin, they are going to be much more likely to have a bleeding complication. So, again, you need to take that into consideration in a person with Parkinson’s Disease who is having balance problems as to whether or not the risks and benefits of Coumadin make sense or not. Can you see at the bottom there, this study, which was done in 1999? It essentially looked at people with falls and over 13 weeks, tapered off all medications active in the brain and found a 39% reduction in falls, which everybody would say that’s a very significant reduction in repeat falls. Now, again, what you need to do, as with anything in medicine, is weigh risks and benefits. You know, sometimes you go through the list and you look at all these psychotropic medications and some of them are actually going to be necessary. For example, a person with REM sleep behavior disorder, which is very common in Parkinson’s Disease, may need a little bit of Clorazapan to prevent them from jumping out of their bed in the middle of the night and injuring themselves or their bed partner. Again, the example of the Coumadin, if the person has atrial fibrilllation, if you take them off of the Coumadin, there is going to be increased risk for strokes or other blood-clot related and thrombotic complications. So, you always need to keep that in mind when you are trying to decide what is going on. We have someone without their mute button on. So, if we go to the next slide then, “Assessment of Falls”, again when a patient comes into us with a complaint of a fall, “A”, we need to ask about it and “B”, we need to try and determine the cause of the falls from that long list of potential areas of the brain that could be affected. So, one way that I found that helps out, that helps me out with that is to pick out a few specific, recent falls and go through the circumstances of that fall. So, find out where they were, who was with them, what shoe wear they were wearing, if they were in their bare feet or if they were in high heels. If they were on a bumpy, gravel road, if they were on an icy sidewalk. All these things go into consideration for being able to figure out what’s going on and a lot of times, people will not remember in generalities exactly what causes them to fall, but if you go back over two or three specific falls, you may find some patterns start to come out. The other thing is with a lot of things with Parkinson’s Disease, especially if the person has some cognitive problems, I always want to try and involve the caregiver, spouse or partner in this discussion. This is the type of thing where people will often underestimate their balance problems and it’s not uncommon to have this situation where you ask how the balance is, the person says, oh it’s fine, and then they get the big old elbow from their spouse saying, what are you talking about, you are grabbing at the sofa every time you walk by. So, it’s always good to involve the caregiver or spouse in these sort of discussions. And then once we have done that, we want to go through a full physical examination and we are going to talk about some of the things that we are going to do. We’ll hone in on a physical examination. So, going through these circumstances, go to the next slide called, “Clinical Circumstance”. So, what we want to do is look at again, what precipitated the fall and specifically sort of look for, you want to see if there is some light-headedness or fainting. Are they complaining of leg weakness, is there a strength problem that they are thinking about? Was there joint instability or their knee kind of locked up on them, suggesting some kind of orthopaedic problem. Did they just lose their balance with no other warning at all? And if they do lose their balance, it’s also kind of helpful to be able to tell whether they are consistently losing their balance in the same direction or if it’s any which way. Whether they are standing, if they did lose their balance, again, look at where they were. Were they on an uneven surface or is this just on a kitchen floor? All these things, again, help us to figure out from that list of areas in the brain and in the nervous system, which can cause falls, where the problem might be. Looking for signs of vertigo or dizziness and then also asking about tripping. If they do talk about tripping, what precipitated the tripping? Are their feet not getting up high enough or was it just something that just came up out of the middle of nowhere, did they not see what they were tripping over? All these things, again, help us figure out what was going on with the fall and then also looking at this freezing or festination and asking about that. Asking how they do when they first start walking. Asking if they ever have troubles with the feet sort of sticking to the floor. Those are going to be able to help us again, to be able to try and come up with a therapy plan. So, if you look at the next slide, this kind of shows a little bit through Calvin and Hobbes how clinical circumstances can make you think differently about a fall. So, if you have a seven year old boy who comes into the ER with a broken wrist, you are going to treat that a little bit differently than if you have the story from the mother that he was trying to jump off of a ladder. Obviously, there’s some very different sort of things you are going to need to do in terms of counseling based on what the clinical circumstance is. You can think about this with the Parkinson’s patient as well. It’s what the circumstance around the fall is that is going to help us to be able to tell what to do. If you go to the next slide called, “Environment”, so when we are talking about clinical circumstances, if there was tripping and if there were things like that, we want to be able to tell if there are some hazards around them that precipitated the fall. Were there uneven surfaces, were there tripping hazards around? Was it on stairs, was it slippery out? We had out here in Portland, I don’t know if you heard about it, but we had our 10-year one-foot snow fall that shut down the town, so I am sure there are numerous falls that came into the ER here with ice and slippery surfaces for Portlanders who aren’t used to that sort of situation. I am from Colorado, so we sort of laughed at the Portanders, but that’s another story. So, there are also troubles with insufficient lighting, as we were talking about. When a person has some problems with balance, especially if they have some basil ganglia or some proprioceptive problems for example from a peripheral neuropathy, they start to rely on these other systems, which we don’t use quite as frequently, so usually vision is one of the lower things we use for balance, but if we have problems, then you compensate by adding that information you are getting from vision. So, then if the person has to get up in the middle of the night and it is not well lit, they are going to be more likely to have a fall and we are going to talk about that when we talk about some of the things that occupational therapy can do for falls. We can also look for improperly used assistance devices. A lot of times people start to feel unbalanced and they will go to the local drug store and buy themselves a cane. If that cane is not the proper height, if is not put in the proper place of if you buy a walker that is not the proper height, it can actually become a tripping hazard in and of itself. So, in my patients, when I am thinking about adding an assistance device, I will have them either be seen by physical therapy or prosthetics or a medical supply company or somebody like that. I just want to make sure that the device is properly adjusted and also that the patient knows how to properly use that device. Again, when we come to treatment, a lot of these things are going to be taken care of in terms of environmental hazards through occupational therapy and physical therapy visits. If we go to the next slide, which is a continuation of our assessment, so once we have gone through the history, we are going to want to do a thorough physical examination. Orthostatic blood pressures in a person who falls is very important. In our clinic here, we have everybody who comes through the clinic with Parkinson’s Disease have orthostatic blood pressures drawn, especially, if that is not possible in you clinic, especially in a person with a fall, you are going to want to take their orthostatic blood pressures. Again, because the medications we use for Parkinson’s can cause orthostasis, as can Parkinson’s in and of itself. So, it is something that we need to look at and it’s also something that we have lots of good treatments for. So, it’s going to be a very important part of the evaluation. Mental status examination, we are looking for cognitive deficits and looking for insights. Again, because of that problem we talked about where people might have balance problems and not have insight into the fact that they had balance problems. Strength and sensation testing, obviously, we need to be able to move our feet and sense where are feet are in space in order to be able to maintain balance and be able to walk, so we want to look at that and see how much that’s contributing. Coordination testing, looking at disease severity in Parkinson’s, looking at rapid ulterior movements and all those rigidity, all those things we do when we are looking at a person with Parkinson’s and then also, looking at perhaps whether there’s some cerebella dysfunction as well. That can come out of the coordination also. Then, the station and gait testing, we are going to talk a little bit more about specifically what to look for in the gait testing, but aside from just looking at the person walking, we are also going to watch then arise from the chair and typically in my clinical, I will have them arise from the chair first without using their arms if they can and if they can’t, then allow them to use the arm rests and as a next step, see if someone has to assist them to get out of the chair. We also want to look at Romberg testing and then posterior pull and the push and release test, which we will talk a little bit more in the subsequent slides here. So, if you go to the next slide, which is a picture of a person walking, as I went through medical school, we didn’t have much formal training in how to look at gait. I know the physical therapists spend much more time trying to sort out the various parts of the gait examination. A lot of times the orthopaedic and physical medicine and rehab physicians will have more formal training in gait, but when I am looking at gait, these are the things that I look for. So, as you can see, gait is sort of a cycle. So, if we start up with the little guy on the left, on the top, so, first you have a heel contact and the left toe comes up, the left foot, which is the foot in the background is going into the swing phase, where it is swinging along and the front foot there, the black foot is unilateral support at that time. The right foot there is supporting all of the person’s weight at that point. Then, you have to go swing the foot forward and you have a heel contact and then you repeat the cycle on the other side. So, there are several important things there: you have to be able to push off, which requires gastrocnemius, you have to be able to swing the leg, which requires the hip flexors. It also involves the dorsi flexors for the ankle to be able to make sure you don’t trip over your ankle or over your foot as you are swinging you leg. Then, on the other leg, you have to be able to hold that leg relatively rigid in order to be able to allow yourself to swing over and get to the next step. So, again, there are a lot of different things that are involved in gait and to look at when you are examining a person with gait. So, if you go to the next slide then, it gives you some of those specific things to look for. Step initiation, you want to look for swing phase on both sides, heel strike on both sides to look for when the person is in double support and look for when the toe is able to push off. We also want to pay attention to arm swing in Parkinson’s disease, typically, arm swing will be reduced on one side first and then may eventually be reduced on both sides. You want to look at where their base of support is as they walk. A lot of times in Parkinson’s Disease that is going to be more narrow than the normal population. Also, you are going to want to spend some time, if you can observe a freezing episode, you would like to be able, it is good if you can see that. We can’t always elicit it on demand. Sometimes, if a person is complaining about freezing episodes, having them walk through a doorway or even having a narrow part in the hallway. So, putting a cart or something on one side of the hallway and having them walk through that narrow space can often be enough to bring on one of these freezing episodes. So, again, there’s a lot more to watching gait than just sort of watching a person walk up and down the hall. You have all these individual aspects of the gait to look at. The other thing is that a lot of times, in order to see difficulties with gait, you need the person to take at least five or ten strides. So, in our clinic, we always bring people out into the hallway and have them walk up and down because there just is not enough room in our clinic rooms to be able to adequately tell what the gait looks like. Another thing is if you are interested in finding out about gait more, the best place I tell our medical students to go find, to be able to get good at evaluating gait is to go to a place where there are a lot of gaits to look at. So, go to the mall, next time you are stuck in the airport, watch people walking by and as you watch them, you are going to see the variation of normal, but you are also going to see a lot of abnormal gaits if you start to pay attention. So, the next time you are stuck in Chicago, you can spend some time watching gaits. If we go to the next slide, we have in addition to that kind of clinical examination of gait, there are some finer tests of gait and balance and most of these, where I could, I included some links where you can download the PDF’s for these scales. All these do require a little more time than just having the person walk up and down, but all of these have been validated. All of them you can use in a patient over time to be able to tell if the therapy is working or how severe or if their gait is affected over time. So, this includes the get up and go test, which has been around for a long time, there’s variations on this. You actually have the person sitting on the floor and you have them stand up and walk 15 feet, turn around and walk back and sit down. You have a timer going from the time they get up until the time they sit back down. There’s also what’s called the Berg Balance Scale. This is a little more complex and includes various tasks that the person does and the person gets scored on how they do on the tasks. So, the more severely they are affected, they lower their score is going to be. There’s also the activities of specific balance confidence (ABC) scale, which is more of a patient questionnaire, where the patient is supposed to say how confident are you that you won’t fall on a 0 – 100 scale on these various sort of activities. So, it includes standing in your kitchen, walking on a slippery surface, all of these sort of situations, standing on an escalator. These sort of things where people, everyday situations, asking the person how confident do they feel that they won’t fall. And on that one, a higher score is better as well. Posterior pull test versus the posterior release test, push and release test. Posterior pull test, you stand behind the person and pull them back at the shoulders. A normal posterior pull test, the person should take one step and may take a catch up step, but in Parkinson’s, we will often see that people will take two or three steps before they can stop themselves. A more severe example is have the person keep taking steps until you catch them or they fall down, which hopefully they won’t do because you will be there to catch them. Or you can do what’s called the push and release test, which has been studied here in Portland by Dr. Horak in her group, where the person, you hold the person up with a hand in the middle of the back and have them lean back so they are being fully supported by you and then you release your hands so the person has to take a step to catch themselves. I think the majority of people still are using the posterior pull test for balance. The studies here in Oregon and in other places, the push and release test feel that it is a little more accurate in terms of repeatability because obviously with the posterior pull test, the force that is used is going to be depend on how big the patient is and how big the examiner’s biceps are. Whereas push and release is always is going to be about the same force that the person is going to need to overcome. In our clinic, we primarily use the posterior pull test, or at least I primarily use the posterior pull test. The get up and go testing, Berg Balance Scale and the ABC scales are things that a physical therapist will use when I send someone down there. Diagnostic testing, again this is going to be the next slide now. “Diagnostic Testing”, is commonly dependent on findings. There is something called the Balance Master or a Gait Rite Testing. Here at the Portland VA, I understand that this kind of Balance Master that is going to be available in our physical therapy department. This is essentially is a platform the person stands on where the feet can be rotated up or down and it tests under various conditions with eyes open, eyes closed and essentially can give you a pretty good idea of whether the problem is more cerebellar or whether it is basil gangliar or proprioceptive problem, exactly where the problem is that is causing the balance disturbance. It can also be used as therapy as well because there are some therapeutic programs that people can do over time to learn how to respond to various perturbations to balance. Gait Rite testing is a map that is put on the floor that people walk on it and it traces where their feet go. That’s useful for kind of following people over time, seeing how they are changing in response to their therapies. Imaging obviously warranted if you are concerned about fractures or other things like that. Again, other diagnostic testing based on whatever came out of your assessment of the fall. So, then the next slide which is called, “Treatment”. Medically, when we are talking about treatment of falls, medication options are actually fairly limited. Especially if we are specifically targeting the balance side of things. There is emerging evidence about the use of what is called methylphenidate in gait and freezing, but again, that’s really just in the very first stages of that. Nobody really knows what’s going to pan out from that. The initial results have been promising, but nobody knows for sure. Dr. Chung, one of the doctors here at the Portland PADRECC has done a small study with Aricept, with its affects on balance, but again, nothing has really been proven yet. You can help with dopaminergic medication if there is off freezing. In other words, the freezing worse when the medication is not working. So, if you can get the person to be on their medication more of the day, that can help out with some of these falls and mobility problems. But, again, we want to be careful in the setting of cognitive impairment because we are not helping balance. We may be helping mobility, but not balance. So, again, in the setting of cognitive impairment, that can actually lead to a person having more falls. If they are more mobile, they don’t realize they are risky and they are taking more, doing more risky behaviors. Also, as we talked about tapering off of psychoactive medications if possible, however, the fact that we have limited medication options doesn’t mean that we can’t help. Here are a couple of ways that we can help. The first is the next slide, which is called, “Surgical Treatments”, so if we have things, which we think may respond to dopaminergic medications, we can use deep brain stimulation. There have been some things, which have come out recently about the use of various parameters we do to use to program these deep brain stimulators. Later in the course of the disease by decreasing the frequency may help out with gait and balance and the last part there, looking at this PPN, this is again, an experimental protocol at this point, they are using this in several centers to try and see if this does help out with gait and balance, but I think the jury is still out at this point, as to whether this actually is going to help out with balance and gait problems. If you go to the next slide, looking at “Other Medical Concerns”, obviously, orthostasis can be aggressively treated, but we don’t have time today to go into what might help out with that. Suffice it to say, there are lots of good treatments out there, both non-medical and medical to be able to help out with orthostasis. Osteoporosis, more common in Parkinson’s Disease and supplementing with Vitamin D actually may have direct affects on balance and gaits and this again, emerging picture, one of our fellows here, Amy Peterson at the PADRECC here in Portland, as part of her fellowship, looking into this very question as to how Vitamin D in and of itself may affect balance and gait. Next slide on “Physical Therapy”, we have physical therapy help us out with motor strategies the person may be using that may not be adequate. I have them help me out if a person needs to use an assistance device. It may help with various cueing, especially with freezing, there’s a lot of literature with using various cadences or things like that for cueing and there are exercise programs out there as well, which can help out with mobility and Parkinson’s Disease. Specific things looking at balance have been looked at in water therapy, Tai Chi, tread mill training. I tell people there’s nothing magical about something like Tai Chi, but I think there is something magical about working on any therapy that is going to give you, get you in a position where you are almost out of balance and have to recover yourself and have to think about your balance. So, we encourage people to get involved in these types of therapies. If you go to the next slide about “OT Home Visits”, you can see there’s a whole bunch of things and that’s just a sampling of things that OT can do when they go into the home. Often times when I talk to OT, they say people haven’t even thought about a lot of these things as being potential trip hazards or as being things which make an increase risk of falls and a lot of times, they can get these rails or things like that, which the person might not have thought about putting in. So, people with falls I think that it has been well validated that this is a good thing to do, to have an occupational therapist go actually into the home and look through and see what’s going on. A lot of people, those throw rugs, people don’t often think about those being fall hazards. You go to the next slide, “Strategies to Reduce Falls”, I realize it’s a bit of a fuzzy slide, this came from a review by Tinetti in 2003 in the New England Journal. The main thing I want you to know here and to look at here is where it says healthcare based strategy. It gives various things that they have looked at using to try and reduce falls in terms of studies that are out there. If you look at that, multifactorial risk assessment with targeted management, that did much better than all the rest of them. So, the point here is that any one single intervention is probably not going to be as good as if you use the multifactorial approach. This is one of those areas the team is always better in Parkinson’s Disease. We like to have physical therapy, occupational therapy, pharmacology, the physician, the nurse, all working together to be able to come up with an overall plan for the person with falls in order to reduce the risk. The next slide here talks about “Nursing Home Recommendations”, as it says prevalence of falls increases sharply in nursing home residents. There’s some reasons or some ideas the facilities can use. I know the accrediting agencies are spending a lot of time looking at falls, not only in Parkinson’s, but in the general elderly population and in hospitals and nursing homes and things like that. One of the things about Parkinson’s Disease is that there are very specific problems that a person with Parkinson’s Disease can have that may not come up in other patient populations. So, there are things out there to allow if you have a patient with Parkinson’s who is in a nursing home that doesn’t seem to quite get what they are supposed to do for that patient, there are programs out there including the link I put at the bottom there, which is through the Struthers Parkinson’s Center. It is called Tulips. They have materials available, in terms of reading materials. They also have a video you can show at the nursing home to train people so they know the specific things not only for falls, but all aspects of Parkinson’s as far as how to take care of this specific patient population. So, if you go to the next slide, “Conclusions”, hopefully what we have done today has proven to you that falls do have significant immobility and do cause a lot of troubles in Parkinson’s Disease. Evaluation of falls requires us to look at a broad differential diagnosis. Pay attention to those circumstances of the falls and then assess the gait in sort of a systematic fashion to figure out exactly what the cause of the fall is. Then, we look at our therapeutic interventions and we try to again, use a team approach and try and come at the various aspects that may have caused the fall, realizing that more than one thing may have occurred, which may have caused that fall. So, I think if we put all of these things into place, we can really help reduce the risk of our patients from having a second fall. Honestly, the physical therapists here in Portland tell me even if a person hasn’t had a fall, we would rather see them early and give them ideas on how to prevent falls in the future. So, I think even sending people who haven’t had trouble and thinking about some of these interventions to try and prevent falls is another really good idea. All right, well we have a minute or so left, are there any questions? Rose: I have a questions, this is Rose from the Philadelphia VA Center. My question is one of my patients had a traumatic brain injury and I wondered if you have any statistics on the percentage of PD patients whose falls result in traumatic brain injury? Kraakevik: You know, off of the top of my head, I don’t know that number. It’s less common than the fractures. I would hazard a guess somewhere around maybe 1% - 3%, maybe less than that. I don’t know if anybody specifically looked at, I think people have more looked at subdurals and things like that, so I don’t know if anybody has looked at close head injury without contusion or things like that. I don’t know if anybody has looked specifically at that question or not. Thank you. Any other questions? [NO RESPONSE.] Okay, since we are close, we are a little bit over. Ryan is going to go over again, how to get CME credit for this and also, we would appreciate your input even if you are not getting the CME credit, by sending in the program evaluations. So, we are going to have Ryan close up here by explaining again how to get that done. Rieger: So, one more time just as a quick reminder in order to get credit for the continuing medical education for your participation in this conference, what you need to do is go onto the VA EDS catalog link that was provided to you on the distributed materials that marketed this event. You will scroll down and click on the document that is entitled, “Brochure” and from there, there’s a section that’s titled, “Registration, Evaluation of Obtaining the Certificate” and you will find a link there to the evaluation form. If you print out that evaluation form, complete it and then send it or fax it back into EDS, from there you will receive your Certificate for Completion. Again, we want to thank you for your participation today and we hope to see you on a future PADRECC conference. Thanks a lot. Kraakevik: Thank you. [END OF CONFERENCE]. PADRECC National Vants Audio Conference Falls in PD Jeff Kraakevik, M.D. January 8, 2009 Page 1