How can falls be prevented in a patient with CANVAS (cerebellar ataxia, neuropathy, and bilateral vestibular areflexia)?

Fall Prevention in CANVAS Syndrome

Patients with CANVAS require an aggressive, multidisciplinary fall prevention strategy that addresses their triple sensory deficit (vestibular, proprioceptive, and cerebellar), with physical therapy for balance training, comprehensive medication review to eliminate psychotropic and high-risk medications, home safety modifications, and assistive devices as core interventions. 1

Understanding the Unique Fall Risk in CANVAS

CANVAS patients face extraordinarily high fall risk due to the simultaneous loss of three critical balance systems 2, 3:

• Bilateral vestibular areflexia eliminates vestibular input for balance
• Sensory neuronopathy removes proprioceptive feedback from the limbs
• Cerebellar ataxia impairs motor coordination and balance integration

This triple deficit means patients cannot compensate when one system fails, making falls a major clinical priority in management 2.

Core Fall Prevention Interventions

Physical Therapy and Balance Training

Refer immediately to physical therapy specializing in vestibular and ataxia rehabilitation. 1 The program should include:

• Balance training at least 3 days per week, focusing on visual compensation strategies since vestibular and proprioceptive systems are compromised 1
• Strength training twice weekly to maintain proximal muscle strength 1
• Gait training with assistive devices (canes, walkers) as part of comprehensive intervention, not in isolation 4
• Training should emphasize visual reliance for balance since vestibular and somatosensory inputs are lost 2, 5

Medication Review and Reduction

Perform immediate comprehensive medication review with aggressive deprescribing. 4, 1

• Eliminate or reduce psychotropic medications (benzodiazepines, antipsychotics including quetiapine, antidepressants) which have an odds ratio of 1.7 for falls 6
• Target polypharmacy: reduce medications if taking 4 or more preparations 4
• Address orthostatic hypotension aggressively, as CANVAS patients may have concurrent autonomic dysfunction 2
• Monitor orthostatic vital signs: check blood pressure supine, immediately upon standing, and after 5 minutes 6

Home Environmental Modifications

Arrange occupational therapy home safety evaluation with direct intervention, not just advice. 1 Specific modifications include:

• Remove all loose rugs and floor clutter to create completely clear walking paths 4, 1
• Install adequate lighting throughout, including night lights for evening mobility 4, 1
• Eliminate slippery surfaces and ensure bathroom safety with grab bars 4
• Ensure proper footwear: well-fitting shoes with non-skid soles at all times 4, 1
• Environmental modification alone is insufficient; it must be part of comprehensive intervention 4

Assistive Devices

Prescribe appropriate assistive devices as part of the comprehensive program. 4, 1

• Canes or walkers should be fitted and training provided by physical therapy 4
• Consider bed alarms for high-risk patients, though evidence is limited 4
• Devices must be combined with other interventions; isolated use is ineffective 4

Behavioral and Safety Strategies

Educate patients and caregivers on specific movement strategies. 4, 1

• Slow down all movements during transfers and walking; quick movements cause falls in CANVAS due to inability to compensate rapidly 4
• Teach safe transfer techniques from sitting to standing and bed mobility 1
• Implement scheduled voiding to prevent rushing to bathroom 1
• Maximize visual input: ensure eyes are open during all movements, as vision becomes the primary balance system 5

Visual Optimization

Formally assess and optimize vision, as CANVAS patients are entirely dependent on visual input for balance. 4, 5

• Correct any refractive errors immediately 4
• Treat cataracts or other remediable visual problems urgently 4
• Ensure adequate contrast sensitivity, as this is critical for fall prevention 4

Additional Considerations Specific to CANVAS

Address dysphagia risk, as this is a major clinical priority alongside falls in CANVAS 2. Aspiration risk may limit certain exercise programs.

Monitor for chronic cough, which is common in CANVAS and may destabilize balance during coughing episodes 2, 3.

Recognize progressive nature: CANVAS is slowly progressive, requiring ongoing reassessment and intervention adjustment 2, 3, 7.

Implementation Strategy

1. Immediate: Medication review and reduction, safety assessment, assistive device prescription 4, 1
2. Within 1 week: Physical therapy initiation, occupational therapy home evaluation 1
3. Ongoing: Balance training 3+ days/week, strength training twice weekly, regular reassessment 1

Critical Pitfalls to Avoid

• Never rely on single interventions: isolated exercise, education, or environmental modification alone are ineffective 4
• Do not provide advice without implementation: facilitated home modifications with direct intervention are required, not just recommendations 4
• Avoid psychotropic medications: these dramatically increase fall risk and should be eliminated whenever possible 4, 6
• Do not underestimate visual dependence: CANVAS patients rely almost entirely on vision for balance; any visual impairment is catastrophic 5