Chapter 024. Gait and Balance Disorders (Part 6)

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Toppling Falls Some patients maintain tone in antigravity muscles but fall over like a tree trunk, as if postural defenses had disengaged. There may be a consistent direction to such falls. The patient with cerebellar pathology may lean and topple over toward the side of the lesion. Patients with lesions of the vestibular system or its central pathways may experience lateral pulsion and toppling falls. Patients with progressive supranuclear palsy often fall over backwards. Falls of this nature occur in patients with advanced Parkinson's disease once postural instability has developed. Gait Freezing Another fall pattern in Parkinson's disease and related disorders...

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Chapter 024. Gait and Balance Disorders (Part 6) Toppling Falls Some patients maintain tone in antigravity muscles but fall over like a tree trunk, as if postural defenses had disengaged. There may be a consistent direction to such falls. The patient with cerebellar pathology may lean and topple over toward the side of the lesion. Patients with lesions of the vestibular system or its central pathways may experience lateral pulsion and toppling falls. Patients with progressive supranuclear palsy often fall over backwards. Falls of this nature occur in patients with advanced Parkinson's disease once postural instability has developed. Gait Freezing Another fall pattern in Parkinson's disease and related disorders is the fall due to freezing of gait. The feet stick to the floor and the center of mass keeps moving, resulting in a disequilibrium from which the patient cannot recover. This
can result in a forward fall. Gait freezing can also occur as the patient attempts to turn and change direction. Similarly, the patient with Parkinson's disease and festinating gait may find his feet unable to keep up, resulting in a forward fall. Falls Related to Sensory Deficit Patients with somatosensory, visual, or vestibular deficits are prone to falls. These patients have particular difficulty dealing with poor illumination or walking on uneven ground. These patients often express subjective imbalance, apprehension, and fear of falling. Deficits in joint position and vibration sense are apparent on physical examination. Interventions to Reduce the Risk of Falls and Injury: Treatment Efforts should be made to define the etiology of the gait disorder and mechanism of the falls. Standing blood pressure should be recorded. Specific treatment may be possible, once a diagnosis is established. Therapeutic intervention is often recommended for older patients at substantial risk for falls, even if no neurologic disease is identified. A home visit to look for environmental hazards can be helpful. A variety of modifications may be recommended to improve safety, including improved lighting and the installation of grab bars and nonslip surfaces.
Rehabilitation interventions attempt to improve muscle strength and balance stability and to make the patient more resistant to injury. High-intensity resistance strength training with weights and machines is useful to improve muscle mass, even in frail older patients. Improvements are realized in posture and gait, which should translate to reduced risk of falls and injury. The goal of sensory balance training is to improve balance stability. Measurable gains can be achieved in a few weeks of training, and benefits can be maintained over 6 months by a 10- to 20-min home exercise program. This strategy is particularly successful in patients with vestibular and somatosensory balance disorders. The Yale Health and Aging study used a strategy of targeted, multiple risk factor abatement to reduce falls in the elderly. Prescription medications were adjusted, and home- based exercise programs were tailored to the patient's need, based on an initial geriatric assessment. The program realized a 44% reduction in falls, compared with a control group of patients who had periodic social visits. Further Readings Bronstein A et al: Clinical Disorders of Balance, Posture and Gait. London, Arnold Press, 2003 Ganz DA et al: Will my patient fall? JAMA 297:77, 2007 [PMID:
17200478] Masdeu J et al: Gait Disorders of Aging: With Special Reference to Falls. Boston, Little Brown, 1995 Snijders AHet al: Neurological gait disorders in elderly people: Clinical approach and classification. Lancet Neurol 6:63, 2007 [PMID: 17166803] Springer S et al: Dual-tasking effects on gait variability: The role of aging, falls, and executive function. Mov Disord 21:950, 2006 [PMID: 16541455] Sudarsky L: Gait disorders in the elderly. N Engl J Med 322:1441, 1990 [PMID: 2184358] Tinetti ME: Preventing falls in elderly persons. N Engl J Med 348:42, 2003 [PMID: 12510042]