In August 2020, the American Parkinson Disease Association (APDA) hosted Teresa Baker, PT, DPT for a webinar called “Let’s Keep Moving with APDA: Assessing Balance with a Physical Therapist.” Teresa is a physical therapist from Boston University’s Center for Neurorehabilitation. (This is the APDA’s National Rehab Resource Center.) We at Stanford Parkinson’s Community Outreach listened to the webinar and are sharing our notes.
Balance is important for people with Parkinson’s because many of their motor symptoms (postural instability, bradykinesia, and rigidity) can contribute to balance problems. Balance assessments can identify people who may be at risk of falling. Up to 68% of people with Parkinson’s Disease (PD) reporting at least one fall per year. This is a higher rate than equivalent older adults, and can lead to disability, injuries and a lower quality of life. A balance assessment can also find a pattern of difficulty which could identify the reason for the balance issue and can help the development of individualized balance training programs.
The balance assessment consists of multiple parts. First a physical therapist gathers information such as history of falls, near falls or close calls, how balance presents a concern, conducts questionnaires regarding self-confidence with balance that can be tracked over time, as well as asking about other health factors such as sleep, cognition, blood pressure and depression.
Next there is a physical component. It measures 6 things. Firstly, strength and flexibility of different muscle groups and joints. Next, they measure standing stability and posture to find where the center of the body is in relation to the support base. Then they measure expected balance reactions which are intentional tasks such as reaching into a cabinet or getting dressed where the body can anticipate what changes need to be made to maintain balance. Next is measuring unexpected balance reaction, which are reactions to movements that are unexpected but the body has to react to keep your balance, such as being bumped into. Next is testing sensory systems such as vision, inner ear and touch sensation to measure the body’s reactiveness to walking on unsteady surfaces, or with impaired vision such as in the dark or with closed eyes. Finally, they measure walking stability which measures people’s ability to walk steadily while being distracted with a counter task and disrupting the concentration on walking such as walking and talking, or stepping over an obstacle. After these assessments are completed an individualized balance training program is created to help the person manage and improve their balance.
For resources on fall prevention, see the Stanford website.
For further questions about the content of this webinar, please contact the APDA’s National Rehab Resource Center, which is based at Boston University’s Center for Neurorehabilitation:
This webinar is a part of a three-part APDA series on balance that was hosted in Summer 2020. You can find the recordings here:
- “Let’s Keep Moving with the APDA: The Impact of PD on Balance”
July 22, 2020
Speaker: Tim Nordahl, PT, MPT, PhD, with the APDA Rehab Resource Center at Boston University
- “Let’s Keep Moving with the APDA: Assessing Balance with a Physical Therapist”
August 12, 2020
Speaker: Teresa Baker, PT, DPT, with the APDA Rehab Resource Center at Boston University
- “Let’s Keep Moving with the APDA: Evidence-based Treatment to Improve Balance”
September 16, 2020
Speaker: Tamara DeAngelis, PT, DPT, with the APDA Rehab Resource Center at Boston University
See extensive notes on the August 12, 2020 webinar on balance assessment below.
– Joëlle Kuehn
“Let’s Keep Moving with APDA: Assessing Balance with a Physical Therapist”
Speaker: Teresa Baker, PT, DPT, APDA’s National Rehab Resource Center, based at Boston University’s Center for Neurorehabilitation:
Webinar Host: American Parkinson Disease Association (APDA)
Webinar Date: August 12, 2020
Summary by Joëlle Kuehn, Stanford Parkinson’s Community Outreach
Why is it important for people with Parkinson’s to assess balance:
Main motor and movement symptoms of People with Parkinson’s are:
- Postural Instability:
- Definition: imbalance and difficulty with balance
- It is one of the major motor symptoms of people with Parkinson’s
- Definition: slowness of movement
- Also a major motor symptom
- Definition: Stiffness of movement
Postural Instability, Bradykinesia and Rigidity can contribute to balance problems.
Interesting fact: Of the four major movement symptoms, Bradykinesia, Rigidity and Tremors are more responsive to medication than Postural Instability.
People with balance difficulties who have Parkinson’s disease are at a higher risk of falling, with up to 68% of people with Parkinson’s Disease (PD) reporting at least one fall per year. This is a higher rate than equivalent older adults, and can lead to disability, injuries and a lower quality of life.
Fall Risk Assessment Measure (3 Questions):
- Have you had a fall in the past year?
- Have you experienced freezing of gait symptoms in the past month?
- A quick walking speed measure: Given 4 meters (~13 feet), can a person walk that in under 3.5 seconds or does it take longer?
With these answers, there is a prediction of their likelihood (low, medium, high) of falling in the next 6 months.
Purpose of balance assessment: Considering different components of balance, she is trying to investigate for the particular person, what is the pattern of difficulty, and does one tend to stand out, to decipher what the reason for the balance issue could be. This helps with creating a tailored balance training program.
What does a Physical Therapist examine:
- Gathering information: listening, questions and discussion
- Examples: History of past falls, near falls or close calls: What happened and environmental factors?
- How does balance present a concern for the individual in their daily lives? Does it prevent them from vacuuming, walking alone outside, etc.
- Questionnaires regarding a person’s self-confidence with balance under different conditions to give a number that can be tracked over time.
- Ask about other health factors: sleep pattern, cognition, blood pressure, depression.
- Physical Balance Examination:
- Strength and Flexibility:
- Physical therapist looks at flexibility in different joints of the body
- Strength of different muscle groups
- What is tight or painful?
- Standing Stability and Posture
- Forward-leaning posture?
- Where is center of body in relation to support base?
- Can their posture be changed or modified?
- Can they stand up straight?
- Expected Balance Reactions
- Intentional tasks in an everyday life that take a balance reaction that we know is coming
- Examples: Reach into a cabinet, vacuum, chores, getting dressed
- The body anticipates what is needed and adjusts muscles and joints so we have the balance that we need for the task we expect is going to happen
- Physical Therapists can test this by asking patients to perform tasks such as to stand up from a chair without using their hands, or coming up on their toes
- Unexpected Balance Reactions
- Situations or tasks that happen that you don’t expect are coming but your body has to react to keep your balance
- Examples: You are standing in a bus and the driver slams on the breaks; your dog is on a leash and pulls because it sees a squirrel; being bumped into.
- Physical therapists can test this by asking a standing patient to lean into a physical therapist and the physical therapist is holding the patient for support and then unexpectedly lets go. The test is seeing how the patient will react and are they able to take a step to catch their balance.
- Sensory Systems:
- Vision, Inner Ear (tells the brain where the head is in space), Touch Sensation (what joints feel, touch of the feet)
- Examples: If walking on an unsteady surface (grass, beach, leaves), body has to adjust to the surface that is not steady and the information is constantly sent from the joints to the brain and then back down with adjustments to keep you balanced; if don’t have full vision available to: in the dark and have to find a way to the restroom and your vision hasn’t adjusted.
- Physical therapists test by evaluating balance on steady surface, foam surface, when their feet are narrow, how balance responds when eyes are open and closed etc.
- Walking stability
- What elements of walking stability may be problematic for certain persons?
- People with Parkinsons need to focus and concentrate on walking, and when something disrupts that concentration, it can be a problematic challenge for balance.
- Examples: If walking and talking, or walking and checking phone, or another distraction, is there an impact on stability and balance?
- Physical therapists can test this by asking to walk faster, then slower, walk while actively turning their head, walk and do a quick turn and stop, walk and step over an obstacle, walking while doing a counting task in their head.
- They are purposely designed to distract someone to see how these challenges affect someone’s stability with walking.
Additional information on balance tests can be found in a separate webinar called “Let’s Keep Moving With APDA: The impact of PD on balance” by Tim Nordahl, PT, MPT, PhD, with the APDA Rehab Resource Center at Boston University in July 22, 2020. That separate webinar can be viewed here.
[Editor’s Note: Part 3 of the “Let’s Keep Moving with APDA: Evidence-based treatment to improve balance” was presented on September 16th by Tamara DeAngelis, PT, DPT, with the APDA Rehab Resource Center at Boston University, and can be viewed here.]
Question and Answer Section:
Question: My balance issues occur with no schedule — when I’m sitting for too long or I’m inactive. Once I get up I kind of feel frozen and the legs don’t want to move. Do you have any suggestions for helping with that?
Answer: If someone’s been sitting for a while, this stiffness is more prominent. If someone can’t take it slow while standing (i.e. if someone is rushing to go to the bathroom, remember that the first standing after sitting will be more difficult). Some recommendations are:
- Integrate a sitting stretching routine before they’re able to get up. (ex. tai chi style program when they first stand)
- Trying to stay in place
- Have a hand on something to support to avoid any blood pressure issues
- Try standing briefly and doing small gentle movements before walking off
- A balanced training portion of someone’s weekly exercise routine is critical.
Question: Do you recommend any particular footwear for people with balance, as well as any particular insoles. How about for people with neuropathy?
Answer: Comfortable well-fitting footwear that is secure on the foot is my first very general recommendation. No flip-flops, or slippers or sandals. Footwear that either ties or that’s secure and that has a heel support. Some footwear marketed for balance training is higher and sometimes cushier and sometimes that provides an element of instability, so be mindful of that when selecting a shoe.
When it comes to neuropathy, it indicates that the sensation is not as clear from what the feet feel to the brain. So in that situation they recommend people are not barefoot. That they have a well-fitting shoe that would protect their foot from stepping on something they don’t feel.
Question: What would you advise people do to improve their balance?
Answer: The first step is a balance assessment so that there could be specific recommendations made for you. There is a lot of information out there, and it is important to challenge balance in an appropriate way. Sometimes we’ll use the “just right challenge”, and that’s going to be for everyone. What that means is activities or movements where you are actively working your balance. One example is a movement style similar to tai chi where there’s shifting of weight from different parts of the body back and forth. It’s training the brain and the muscles and the joints how to accept a weight shift..There’s a lot of evidence that dance-related movements or dancing in general can have positive effects on balance. Having a balance exercise program 2-3 times a week is critical.
Question: How do you find a physical therapist who is either trained in this or is experienced in Parkinson’s, especially if you live in an area where there are less resources like that?
Answer: Physical therapists can have certain specialties. Try to find one with a neurologic or geriatric specialty. Another suggestion is there may be hospital-based groups or other physical therapy offices that indicate that they are familiar with treating people who have Parkinson’s disease that can do a balance assessment.
Question: Any advice for people falling several times per day? One person asking has a component of freezing of gait that is contributing to those falls.
Answer: Sometimes we can find a pattern with those falls. It’s possible if this is something happening in the house it can be typical for a more freezing episode to happen in a very narrow environment such as a doorway or you’re just turning to get to the bathroom. If someone’s freezing, we try to stop the freeze and not keep trying to progress through it. We train people to try to stop immediately and then use different style strategies or different style movements or visual cues. Some examples are imagining stepping over something, putting tape lines on floors so they have a visual cue of how to keep steps even and regular. Other options are music or something with a beat that provides a timing to help the stepping instead of very short small steps that are ineffective.
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