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A Matter of Balance

Gait and balance issues associated with movement disorders can often be a sensitive subject for physical therapists to broach with their patients. Discussing concerns about falling and the emotional impact of appearing impaired in public often causes discomfort for patients.

Often seen in patients with multiple sclerosis, Parkinson’s disease, and stroke, difficulty with walking is caused by a variety of factors: fatigue, damage to nerve pathways that hamper coordination and/or cause weakness, poor balance, numbness, or spasticity.

Finding the cause of a gait or balance issue is a difficult problem to address. “Difficult, but not impossible,” says Diane Huss, PT, MS ED, NCS, who works with the University of Virginia’s Movement Disorder Clinic.*

“The big issue is getting the patient assessed regularly,” she says. Many patients assume that each of these disorders will progressively get worse, but they may be unaware of the treatments that can improve and even reverse gait and balance issues.

If a patient is having difficulty walking or keeping their balance, if fatigue turns their legs to cement, encourage them to speak up. Many gait problems can be significantly improved with physical therapy, exercise, medication, or the right assistive device. Untreated gait problems can lead to emotional distress, injuries, added fatigue, and unwarranted suspicion by other people that their gait problems stem from use of alcohol or drugs.

A comprehensive assessment will identify what is causing the problem, and only then can a proactive program be created for the individual patient. Treatments may include strength training, gait training, and a focus on technique and balance retraining.

Physical therapists analyze the biomechanics of a patient’s gait by asking them to walk across a room or down a hallway in order to observe coordination, positioning of feet, posture, and momentum. Additional tests measure muscle strength, fatigue levels, range of motion, and spasticity. Some PTs use video cameras to record their observations. (Research laboratories specializing in gait analysis have a wide range of high-tech machines to calibrate body movement.)

Evaluation may be embarrassing for patients, but it is not painful. Once the factors involved in a patient’s particular gait problems are identified, the patient, the PT, and the physician will work together on a plan of action.

PROGRESSIVE NEUROLOGICAL DISORDER

Movement disorder expert Huss works primarily with Parkinson’s patients. It is the most common of the major movement disorders. Parkinson’s disease is a chronic, progressive neurological disorder. The symptoms include tremor, stiffness, difficulty moving, and problems with walking and balance. According to the Parkinson’s Disease Foundation, an estimated 1.2 million people are affected. Some 50,000 new cases are diagnosed each year, a number that is expected to rise as the population ages. Most cases begin between the ages of 50 and 65, with the average age of onset about 60—though younger people are affected, too.

There is not a cure for Parkinson’s, but treatments exist to help control symptoms. People with the condition can live a normal life span, although they are at a heightened risk of falling or choking. “Some patients fall as many as 15 times per day,” Huss says.

Four basic gait issues are associated with movement disorders, such as Parkinson’s:

Posture instability—In approximately 75% of Parkinson’s patients, the upper torso leans forward, which often leads to a fall.

Freezing of gait—”Freezing” occurs when the natural flow of movement is hampered. It refers to sudden, temporary difficulty initiating or continuing a movement, such as a step. Patients literally stop in their tracks and cannot move. Interestingly, it occurs often when walking toward an “exit” door or in hallways and rest rooms.

Start hesitancy—When the patient gets ready to “get going,” turn, or get up, their feet won’t move.

Festinating gait—A patient takes short steps, with their weight on the ball of the forefoot. The heal should hit the ground first; if the ball of the forefoot hits first, the center of balance is off and the patient can pitch forward.

Medications can improve or eliminate these symptoms for some. Unfortunately, medication may wear off unexpectedly, making alternative therapies crucial for a patient with gait and balance issues. Suggested therapies include: sensory; metronomes; light tapping of a cane or stick; use of a walking cane or stick; developing cognitive cues to maintain gait continuity; marching; counting, and “stepping to.” Only a physician or therapist can assess and prescribe the correct treatment for gait and balance issues. The right assistive device is often the most effective strategy.

If left untreated, spasticity can lead to discouragement and the patient can develop contractures. PTs should focus on rehab as well as management. Treatments for spasticity may include botox injections, muscle and strengthening exercises, and muscle relaxers.

BALANCE AND COORDINATION

Impaired balance not only makes walking difficult, it can result in falls and injuries. A loss of balance and coordination can produce a swaying, uneven gait—called ataxia—that is often mistaken for drunkenness.

“Poor balance is not always an isolated symptom,” observes Brian Hutchinson, PT, a physical therapist at the Heuga Center, when discussing balance disorders of people with MS for the center’s Web site. “One leg may be weaker than the other or have spasticity, resulting in an uneven gait. Or the source might be MS lesions in the parts of the central nervous system that control balance. It is important to identify what’s causing the problem in order to find the best solution.”

Therapeutic strategies that may help balance deficits include inner ear (or vestibular) exercises. Aerobic activity, stretching, and strengthening specific muscles can address some of the “secondary” reasons for balance difficulties, he says.

Gait and balance issues can be alleviated or even reversed with the proper diagnosis and treatment. Patients should get a regular assessment that will ensure they are in the best physical (and mental) shape for all the challenges movement disorders create.**

*(As part of a US government effort to find the cause and a cure for Parkinson’s, the University of Virginia is one of only 12 medical centers to be designated a Morris K. Udall Parkinson’s Disease Center of Excellence by the National Institutes of Health.)

University of Virginia neurologist Joel Trugman, MD, says freezing occurs in approximately 30% of Parkinson’s patients. “Walking is an automatic, unconscious movement. However, it’s been known for 30 to 40 years that you can convert an automatic walk into an attention-driven step,” Trugman says.

Building on that idea, one of Trugman’s patients, Mike Tucker, a former police officer with Parkinson’s disease, invented a device to help people with the neurological disorder get around—and get “unstuck” when experiencing a freezing episode.

Tucker suffered daily from freezing episodes that led him to become a virtual prisoner in his home. After one freezing episode that lasted 2 hours while eating out with his family, he became determined to find a solution. He knew that sometimes he could break his freeze if someone placed an object in front of him to step over. After tinkering in his workshop for a year, Tucker created a device that is attached to the bottom of a walking cane or stick and can be activated if a freeze occurs.

“By the time Parkinsonians experience freezing, most usually are using a cane to assist in balance. This device not only offers balance support, but also can be used to break a freeze by setting the device’s visual cue, a rod, to project when the cane hits the floor. This visual cue allows the patient to ‘think’ about their next step, by having a solid object to step over,” Tucker says.

Tucker has been using the NextStep successfully for 2 years. Working with a team of experts, including neurologists and PTs, Tucker’s invention is available at www.icanstep.com. The device has worked as well for hundreds of Parkinson’s patients with freezing. “The letters we get from people who use our device have been so encouraging. One talks of finally feeling safe enough to attend an Orioles baseball game, another was able to take his wife out to dinner for the first time in 3 years. They all say the security of having this walking aid device with them when they go out in public provides a feeling of independence and freedom they were incapable of before the device was available,” Tucker says.

Huss relayed a story about one of her patients who was walking with rose bushes to plant in his yard, and suddenly experienced a freezing episode. The forward momentum of walking, along with an immediate freezing of his feet, made him pitch forward, breaking his nose. “This is not uncommon with Parkinson’s patients. They must understand that an assistive device is not a ‘crutch,’ it is a tool that will help improve quality of life.”

Gait and balance issues can be alleviated or even reversed with the proper diagnosis and treatment. Patients should get a regular assessment that will ensure they are in the best physical (and mental) shape for all the challenges movement disorders create.

For more information on therapies and treatments for gait and balance disorders, visit the links and resources page found at www.icanstep.com.

—RA

Rebecca Antonelli is a contributing writer for Rehab Management.