“Let’s Keep Moving With APDA: Evidence-based Treatment to Improve Balance” – Webinar Notes

“Let’s Keep Moving With APDA: Evidence-based Treatment to Improve Balance” – Webinar Notes

The American Parkinson Disease Association (APDA) presented a three-part webinar series “Let’s Keep Moving with APDA” last summer 2020 on different aspects of balance.  The third in the series, “Evidence-based Treatment to Improve Balance,” featured Tamara DeAngelis, DPT, a physical therapist at Boston University’s Center for Neurorehabilitation. She spoke about different balance treatments, and how they impact the different balance symptoms.  We at Stanford Parkinson’s Community Outreach listened to the webinar and are sharing our notes. 

The speaker notes that there are six different aspects of balance: walking stability, expected reactions, unexpected reactions, strength and flexibility, standing stability and posture, sensory system.

Dr. DeAngelis spoke about different balance training programs such as:

  • Strength training which can improves the efficiency and speed of your muscles when you need them, such as for unexpected reactions
  • Tai Chi which involves complex movements, moving around base of support, and has a mind-body connection that can help with balance problems
  • Agility training which helps work the speed of your response of the movement
  • Dual task training which helps a patient concentrate on walking as well as a mental activity
  • Training sensory systems
  • Gait (walking) training which focuses on standing upright or taking larger and faster steps that can improve balance. 

According to Dr. DeAngelis, the best way to start to help balance is a strength training and walking program. Starting balance training before balance problems occur is ideal but starting anytime will benefit you. 

As noted, this webinar is a part of a three-part APDA series on balance that was hosted in Summer 2020.  You can find all the recordings here along with our blog posts with notes from each webinar:

  • “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
    Recording Link.
  • “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
    Recording Link.
    Blog Post.
  • “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
    Recording Link.

To get in contact with APDA’s exercise helpline contact:

View the APDA’s exercise guide.

Center for Neurorehabilitation, Boston University:

Website.

For resources on fall prevention, see the Stanford Parkinson’s Community Outreach website.

See extensive notes on the September 16th webinar below.

Regards,

– Joëlle Kuehn


“Let’s Keep Moving With APDA: Evidence-based treatment to improve balance”

Speaker: Tamara DeAngelis, DPT, physical therapist, Center for Neurorehabilitation, Boston University 

Webinar Host:  American Parkinson Disease Association (APDA)

Webinar Date:  September 16, 2020 

Summary by Joëlle Kuehn, Stanford Parkinson’s Community Outreach

Why treating balance is important:

  • People with decreased balance are more likely to fall
  • People with PD have a higher fall rate than other older adults
  • Falls are a contributor to disability, injury and decreased quality of life

Interesting fact: 68% of people with PD reported at least one fall per year.

What is balance?:

  • Control of the body’s center of mass over it’s base of support in order to achieve equilibrium and orientation
  • Being able to be steady and stay upright
  • Brain gets input from our nervous system, visual input, touch sensation from our feet, our inner ear and our muscular-skeletal system (muscles, joints).
  • It involves both standing and moving activities. 

Balance Framework to discuss all different systems:

  • Walking stability – how steady and stable when walking?
  • Expected Reactions – reaction to an expected behavior such as reaching for something in a cabinet?
  • Unexpected reactions – when unexpected actions such as a leashed dog chasing a squirrel require our body to adjust balance.
  • Strength and flexibility 
  • Standing stability and posture – standing in place
  • Sensory system – vision, inner ear, sense of where we are in space

Some systems are more impacted by Parkinson’s than others. We can target different systems based on their ability to change, and what specifically the person has difficulty with. 

Balance Treatment Programs:

  1. Strength Training
    1. Helps: Unexpected reactions, Strength and flexibility, Standing stability and posture.
    2. Important for any balance program
    3. It adds to easier day-to-day mobility such as standing up from chairs, getting out of a car and walking 
    4. Improves the efficiency and speed of your muscles when you need them, such as for unexpected reactions.
    5. Note: it can also help other Parkinson’s symptoms such as bradykinesia and rigidity even before a person exhibits balance problems, and you can get ahead of balance problems (can be preventative for balance problems)
  2. Tai Chi and Dance (specifically Tango)
    1. Helps: expected reactions, unexpected reactions, strength and flexibility, standing stability and posture
    2. Involve complex movements, moving around base of support, has a mind-body connection that can help with balance problems
    3. Can be fun and more engaging than other forms of exercise
    4. Tai Chi has lead to decreased falls and improved balance
  3. Agility training:
    1. Helps: walking stability, expected reactions, unexpected reactions, strength and flexibility, standing stability and posture, sensory system
    2. Complex movements, weight shifting, quick movements, quick directional changes
    3. Ex. standing on one leg and throwing a ball
    4. Require a lot of focus and maintain balance while focusing on something else
    5. Helps work the speed of your response of the movement
    6. Best done in a physical therapy clinic or supervised from an exercise professional, a bit more difficult at home because of safety
    7. Should be challenging, and when improve, need to be challenged at the next level
  4. Dual-task training
    1. Helps: walking stability, expected reactions, unexpected reactions, strength and flexibility, standing stability and posture, sensory system
    2. Difficulty with dual tasks can be one of the earliest things that people will notice a change in balance with Parkinson’s because as motor tasks become more complex or require more attention, you might notice it is more difficult to focus on the motor task and the physical task
    3. Ex – walking through the mall and the cellphone rings – has difficulty focusing on walking 
    4. Issues with Parkinson’s: issue of prioritization, prioritize cell phone instead of walking
    5. We can train dual-tasks to go better. 
    6. Ex. doing subtractions in your head or verbal fluency tasks while practicing high-quality walking (larger steps and better speed)
    7. Can reduce fall risk
  5. Sensory systems:
    1. Helps: walking stability, expected reactions, unexpected reactions, strength and flexibility, standing stability and posture, sensory system
    2. Can be incorporated into some of other treatments
    3. Ex. do squats on a piece of foam rather than on the floor, or practice with eyes closed to enhance other symptoms, walk on different or uneven surfaces (grass or sand)
    4. Important to address because with Parkinson’s people rely heavily on their visual system
  6. Gait (walking) training
    1. Helps: walking stability, expected reactions, strength and flexibility, and sensory systems
    2. The practice of walking is critical to improving balance
    3. Parkinson’s can impact walking with slower or smaller steps, or change a posture to leaning forward
    4. Walking while focusing on standing upright or taking larger and faster steps can improve balance
    5. It also increases muscle strength in your legs

How much is enough?:

  • 30 minutes, 2-3 times a week
  • The intensity matters – you don’t have to do it for a long time but you want to make it challenging while you are doing it, you want to push stability limits
  • Safety is important, so it is good to do it in a physical therapist’s office or with an exercise professional
  • Help with a professional allows you to have progressive challenge because they can create an individualized program

When should we treat balance?

  • There are early changes to how the muscles respond due to the bradykinesia and the rigidity
  • That can happen early on
  • We should always be treating and assessing balance throughout the disease and intervening in those different domains depending on what areas need help

Questions and Answers:

Question: What are the pros/cons of going barefoot for Parkinson’s disease?

Answer: There are some programs that encourage barefoot walking or running but the one concern I would have with barefoot is not protecting the skin on your feet. Some older adults might have challenges with neuropathy which changes to the sensation of their feet, and they could get cut. However, in a controlled environment (such as agility training), it could be helpful. 

Question: Is sitting on a stability ball a good way to help develop your balance?

Answer: It targets a different type of balance (your core strength and balance), but it is a great way to target that. A lot of exercise professionals will use it to add a bit of balance challenge while doing other activities such as an arm exercise.

Question: What are the best ways to work on your balance if you have mid to later stages of Parkinson’s disease?

Answer: Walking and gait or walking parameters and strengthening your legs are a great start but it is important to have an assessment from a physical therapist to see where your time is best spent in terms of balance, because they will identify which of those systems need the most work. 

Question: If someone is 10 years into a Parkinson’s diagnosis but has no issues with balance, is it an indication of no balance issues in the future? 

Answer: As we get older we all have changes that affect balance, so I think it’s important early on to start addressing things that are possibly changing (muscle strength). It’s also important to consider if you’ve changed your lifestyle or activity level to not be put in situations where your balance is challenged or have you kept up with what you’re doing with no balance problems?

Question: For a person with moderate/severe lower back pain that makes it difficult to stand for an appreciable amount of time, are there any specific exercises?

Answer: I recommend asking a physical therapist about this, because there are a lot of conditions that could be going on. It can cause issues with activity level and balance so it is important to address. 

Question: Could you elaborate on the optimal medication and exercise balance. 

Answer: When I say optimal I mean that your symptoms are well treated and managed, which can be challenging. Before entering into a balance program with a physical therapist I recommend checking with your neurologist that your symptoms are as well managed as possible, particularly regarding bradykinesia and rigidity because those are the two symptoms that impact balance and respond well to medication.