UNSTEADY GAIT

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Treatment

Medical and surgical management of pathologies underlying balance and gait disturbances includes, but is not limited to, the following:

• levo-dihydroxy-phenylalanine (L-dopa) and/or amantadine for Parkinson's disease
• surgery to alter connectivity in the basal ganglia in Parkinson's
• dopamine antagonists in Huntington's choreaanti-spasticity medication (diazepam, baclofen, dantrolene) for patients who have had a stroke, head injury or other neurological insult
• particle repositioning maneuvers for benign paroxysmal positional vertigo (dizziness)
• surgery for Ménière's disease or acoustic neuroma (a tumor in the auditory canal)

These interventions can help to decrease the contributors to balance and gait disorders such as dyskinesia (impaired ability to move voluntarily), rigidity, hypertonicity (diminished muscle tone), or vertigo. Balance and gait, however, often must be retrained using physical therapy. Successful treatment intervention based on theories of motor learning addresses the interactions of the individual, task and environment. In the individual, it is important to recognize what impairments contribute to difficulties, and whether or not they can be realistically corrected or if compensation will be necessary. The patient must be evaluated for cognitive ability to relearn balance skills, and for the level he or she is at in learning a skill (acquisition, refinement, or retention/transfer). In evaluating a task, the clinician must determine what is predominantly required—mobility, stability or both— and the timing, force and duration needed. The environment also must be analyzed and manipulated to best aid the patient in preparing for function in the real world.

Treatments may involve the manipulation of sensory input while performing a task. This may be done for any of the three systems responsible for providing sensory feedback. For example, to encourage use of vestibular input, visual and somatosensory information may be challenged. Visual input is challenged by taking it away(e.g., eyes closed) or by destabilization (e.g., involving head and eye movements in the task). Unstable surfaces(e.g., rocker board or rough terrain) or compliant surfaces(e.g., foam) help to challenge somatosensory input. Vestibular input may be manipulated by changing the position of the vestibular organ (e.g., neck extension or repeated head movements).

Other physical therapy treatment for balance and gait focuses on the patient's ability to control his or her COG over the BOS. Exercises related to functional activities are performed and progressed according to patient ability. Initially, treatment may begin with practicing the ability to establish static balance in a position with a wide BOS, such as sitting and using hands for support. Eventually, the BOS is narrowed and/or destabilized to train automatic, anticipatory and voluntary postural responses. This type of progression can take place in sitting, standing, walking, etc., with or without the addition of such concurrent tasks as putting on a shoe while sitting or reading signs on a wall while walking. Specific balance

Author Info: Peggy Campbell Torpey, MPT, The Gale Group Inc., Gale, Detroit, 2002