How to manage falls and declining physical independence in patients with progressive corticobasal degeneration?

Managing Falls and Physical Independence in Corticobasal Degeneration

A multifactorial approach combining physical therapy, environmental modifications, and assistive devices is essential for managing falls and maintaining physical independence in patients with progressive corticobasal degeneration (CBD). 1, 2

Fall Risk Assessment

• Perform standardized fall risk assessments:

  • Timed Up and Go (TUG) Test (>12 seconds indicates increased fall risk) 1
  • 4-Stage Balance Test (inability to hold tandem stand for 10 seconds indicates increased risk) 1
  • Ask key screening questions: falls in past year, feelings of unsteadiness, fear of falling 1

• Evaluate specific CBD-related factors contributing to falls:

  • Asymmetric limb apraxia and rigidity (present in 92% of patients) 3, 4
  • Gait disturbance (occurs early, median 0.0 years from symptom onset) 4
  • Freezing of gait (common early symptom in CBD) 4
  • Myoclonus (present in 55% of patients) 3
  • Visual-spatial dysfunction 5

Physical Therapy Interventions

• Implement targeted exercise programs:

  • Balance training: minimum 3 days/week 1
  • Strength training: 2 days/week focusing on major muscle groups 1
  • Gradual aerobic activity: start with 10 minutes, progress to 30 minutes 1

• Consider locomotor training:

  • Treadmill training (with or without body-weight support) has shown benefits in slowing gait decline and reducing falls in CBD 6
  • Stretching and strengthening exercises can help maintain mobility 6

Environmental Modifications

• Conduct home hazard assessment and implement modifications 2, 1:

  • Install grab rails in bathrooms and along stairs
  • Remove loose rugs and clutter
  • Improve lighting, especially in hallways and stairwells
  • Install sensor night lights 2

• Safety items that reduce fall risk:

  • Grab rails (RR = 0.50,95% CI: 0.32 to 0.78) 2
  • Sensor night lights 2
  • Electronic bracelets with tele-assistance support 2

Assistive Devices

• Introduce appropriate mobility aids early:

  • 4-wheeled walkers have shown benefits for maintaining community ambulation 6
  • Evaluate for appropriate cane or walker based on degree of impairment 1
  • Consider orientation and mobility training for safe ambulation 2

• Early acceptance of assistive devices is crucial to prevent progression to wheelchair dependence 6

Medication Management

• Review and minimize medications that may impair balance:

  • Benzodiazepines (used for dystonia/myoclonus in CBD) may cause sedation 3
  • Levodopa response is typically poor in CBD but may provide minimal benefit for bradykinesia and rigidity 7, 3
  • Clonazepam may help manage myoclonus (improvement in 23%) and dystonia (improvement in 9%) 3

• Be cautious with medications that commonly cause adverse effects in CBD patients:

  • Somnolence, gastrointestinal complaints, confusion, dizziness 3

Multidisciplinary Approach

• Coordinate care through a multidisciplinary team:
  • Neurologist: disease management and medication adjustments
  • Physical therapist: gait training and fall prevention
  • Occupational therapist: ADL adaptations and home modifications
  • Speech therapist: communication strategies
  • Ophthalmologist: manage visual issues affecting balance 7

Disease Progression Considerations

• Anticipate and prepare for key milestones in CBD progression:
  • Falls (median 2.0 years from symptom onset) 4
  • Cognitive impairment (median 2.0 years) 4
  • Supranuclear gaze palsy (median 3.0 years) 4
  • Urinary incontinence (median 3.0 years) 4
  • Dysphagia (median 5.0 years) 4

Common Pitfalls to Avoid

• Focusing on single interventions rather than addressing multiple risk factors 1
• Overlooking medication effects on balance and gait 1
• Delaying introduction of assistive devices due to stigma or denial 6
• Failing to identify and address festination (progressive acceleration of steps with shortened stride length) 1

By implementing these evidence-based strategies early and consistently, it is possible to reduce falls, maintain physical independence longer, and improve quality of life in patients with progressive corticobasal degeneration.