Parkinson's Disease and walking aids

[AnnaMonk]

I would like to hear from people precsribing walking aids to patients with parkinson's disease who have impaired balance. I am working in the community and am wondering what are the most appropriate walking aids for this group and also the best means of access into their homes i.e. ramp versus lift
Any ideas/comments gratefully received.

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[Andyzo]

As you probably know this group of patients really likes to keep going once they are.(so I avoid stop-start) Do they need a lot of support or is it just to back them up in case they do loose balance? In the Parkinson clinic of a hospital I used to work they used a lot of " A-frames" (aka delta frame I think). 4 wheels, Handbrakes (!) and a seat. Ofcourse they need sufficient strength to control the brakes. But it is safer then the push-down brake option. They often can not apply them in time and may fall forward. The other thing they did was having the handelbars pretty high so that they actually don't lean on it much (again just some balance support). Bey Bey

[perfphysio]

I am trying some initial pilot work in the use of unweighting over a treadmill with Parkinsons patients. The idea being the support will provide a better posture while the treadmill stimulates continued gait patterning as promotes all the generalised benefits of "fitness" training, an option that is rarely available to this population. You can see an add for the unweighting machine we use in the clinic on your mailpage or on the physiowork page. Actually the company does a home model but this would be for the wealthy amongst us, not the average Parkinsons patient.

[doability]

I know I am a little biased but I think the Volaris walking aids are great for helping people get around the home as well as outside safely. Particularly for people with Parkinson's disease.

You can fully customise them to suit individual needs.

The slow down brake is something that OTs and Physios look for particularly with Parkinson's because the shaking (tremor), and slowness of movement can sometimes make it difficult for the users to slow walking aids down by themselves. The slowdown brake acts like a resistance wheel on an exercise bike where you can screw down a small wheel onto the larger wheel and increases the resistance of the walkers’ movement so it does not roll away too fast. It allows you to slow the walker down depending on the needs of the user.

There are many other accessories available which will enable you do adapt the walker to individual needs depending on the severity of the case.

[gcoe]

Hi

Doability that Volaris walker looks a really mean beast! - looks like an excellent piece of design - I hadn't heard of it before.

I thought I would add to the conversation a fairly obvious thing to consider which you touched on, Doability; that is the difficulty our PD patients have with dual or multitasking and that adding a walking aid can complicate things for our paitients. The least they have to control the aid the better - so having to operate brakes, controlling and coordinating a stick etc - all make things harder for this group.

As far as things like ramps and lifts etc - depends where they up to in the progression of the disease but anything we can do to keep these patients as physically active as possible is a bonus. so we should think carefully about providing aids that encourage our patients to be more sedentary. On the other hand at the right time such things may be needed.

[TaraMa]

I have found the U-Step walker very helpful. The laser cueing device and the on the spot turning are particularly useful. Bit bulky though and not really a suitable outdoor device.

[avinash8891]

Did you use, automated gait trainer for improving walking conditions?

[aprilandy]

i post some assisted device, hope this will help you...........

Standard walkers-A standard or pick-up walker is a metal, four-legged frame with rubber tips, which must be lifted and moved forward with each step or two.
Front-wheeled walkers For people who have weak arms or a tendency to fall backward, a walker with wheels on the front two posts can be used.

Four-wheeled walkers- For people who have weak arms or a tendency to fall backward, a walker with wheels on the front two posts can be used.

[oldbiddie]

I have a fair ´hands on´ knowledge of PD since I have been a caregiver for 20 years of a PWP (person with Parkinson). So far, the Ustep is definitely the best walker for them. It is a little bulky but very stable and will revolve on itself in narrow areas. For outdoors, we used a light 3wheel delta, with supervision.

[gcoe]

Hi old Biddie

Always good to hear from the "end users" - carergivers and PWPs as you have the ground knowledge. THe Ustep is a very nicely designed pieces of equipment although I have limited experience of prescribing it - so good to know you find it valuable.

[oldbiddie]

As a physio with fairly limited knowledge about PD, I learned more than I wanted to about the disease. If I can be of any help. all the better.
It is possible to fall with the Ustep but it is more difficult than with other walkers. A lot of PWP falls ( not all) are more due to sudden drop of BP than other manoeuvres and there is not much anyone can do about that. They all have balance problems and most of them have spatial difficulties too which makes walking really hazardous.

[Dr Damien]

I dont think grouping all parkinsons patients as similar is the answer to walking aid prescription. In my experience, the following will determine what kind of walking aid the client needs.

1) severity of the condition
2) main movement issues with the client
3) the environment the client is expected to use the walking aid in

I had a PD patient once who was referred because the nurses at the home felt he was unsafe with a static zimmerframe, he functioned well with a wheeled zimmerframe. his problem was he couldnt coordinate the movement of lift zimmer forward, step to zimmer, lift zimmer, step to zimmer...with the wheelie he had no problems

I had another one who was an absolute nightmare with any walking aid, in the end we had to leave him to mobilize without any aid which was safest for him.

PD patients who festinate badly will probly not be able to manage anything with too many wheels, PD patients who freeze badly will probly not be able to work the brakes effectively when its most crucial. i.e up and down slopes, etc

See why you cannot group all PD patients as the same and have a preset for issuing a walking aid?

You just have to assess the individual and use ur clinical judgement to what method of mobilizing is safest for the patient.

[oldbiddie]

I cannot think how any PWP could really walk with a static zimmer frame.
I think the original question was what the best walking aid was for PD. I am not the only one to think the Ustep is so far the best one. Which doesn´t mean others cannot be useful too.
There are 2 types of PWPs, the akinetic and the trembling one. Of course they are different. Festination is a stage, so is retropulsion. Freezing is not due to PD but more to the dopatherapy and it is true you cannot put all PWPs in the same bag and through the various stages, most walkers will help. Ultimately, most PWPs and caregivers will agree, the Ustep is the safest.Brakes are on unless to undo them so if you freeze, the break is on. The 6 wheels make it easier to manoeuvre than other 3 or 4 wheelers and it is more stable. It is expensive, some countries health schemes will pay for it.

[Dr Damien]

Dear Oldbiddie

Thanks for the input and I really value your comments as they show your expertise and experience. If there was a study that showed that the majority of parkinsons clients manage well with the U step walker, then I would probably advise most of my clients to get one if I thought they were safe with it. As I have no experience with the U step walker I reserve my comments on its safety for "all" PWPs.

However, Im slightly confused with your explanation for the symptoms of Pakinsons, You say Festination is a phase? so is "retropulsion"? that freezing is not caused by PD but by the medication given? I may be wrong but in my experience medication is given to alleviate these symptoms, of course it can make it worse if the dosage is too high however in no way does the medication cause the symptoms that are classic to true PD.

Please these symptoms are classic to parkinsons, they do not occur in all but clinically thats how parkinsons is diagnosed without having to do a brain scan(at least three of the symptoms present suggests PD). I dont want anyone misinformed. Of course there are other Parkinsonian type diseases, that medication appears to not have any effect on i.e PSP etc.

With regards how a parkinsons patient can use a static frame, the gentleman in question had been using that frame for years until his symptoms progressed. Similarly, some professionals might wonder how a PD can use a walking stick but some can others wont be able to...all depends on the severity and presence of the symptoms.

Ultimately what would also impede the use of a walking aid effectively and safely would be the state of cognitive impairment associated with the condition. Ultimately my standpoint is an assessment is always necessary.

If you have any materials on the Ustep walker (research paper wise), pls send me some, id be more than happy to educate myself

Cheers

[oldbiddie]

Dear dr Damien,
Freezing and dyskinesias are well known side effects of dopatherapy. (see: L-DOPA - Wikipedia, the free encyclopedia for a start). I am not referring to PSP or other so called PD+ diseases which do not respond to Ldopa.
I doubt if any study was done on the use of the Ustep but I suggest you join some PD or PD caregivers lists. One learns a lot more form the patients or their caregivers troubles than by reading the results of studies.
I don´t say all PWP must use the Ustep, I say it is at the moment the best available for the condition.

[Dr Damien]

Dear Old biddie

Thanx for that piece of information and I have taken it on board as i find it very useful? however you are not telling me anything i do not know already. what i was confused about was the definite statement you made that medication is the cause of the freezing and not the pathology of PD. This I partially agreed with you when I said these symptoms can be worse when taken in high doses or perhaps in longterm use however, some patients that do not get this treatment still freeze. It is this misinformation i was correcting, perhaps what you meant to say was that freezing can be caused by extreme use of ldopa therapy.

Your advise on joining a PD caregivers list is a good one and I will look into that however, working in the community and seeing PD patients almost daily counts for something. The studies that are carried out are carried out on patients by the way, either way our whole practice should be based on evidence.

I still respect your views as they come from your experience and expertise for that i can not but learn from you nonetheless what is fact is fact. Evidence based practice should be what we all gear for, freezing is a symptom of PD but high doses of medication can be a cause too

Hope your weekend is going good...lol

[oldbiddie]

Hi Dr Damien,
I think (or hope) that anyone who deals with PD patients knows that after a few years of dopatherapy, the patients fight at least as many side efftects of the treatment as symptoms of the disease. You mention patients not on dopatherapy, there are very few. So far, it is the only treatment and I do hope they finally find another path.
AS far as walking is concerned, drop of BP due to treatment mainly can be an obstacle. Loss of balance ( also aggravated by treatment) is another. Dyskinesia, which is definitely a consequence of dopa can prevent someone from walking. And the patient does not need to take a high dose. There are many fluctuations of state during the day, due again to the therapy and what can be possible in the morning may not be possible in the afternoon, etc. A good steady walking aid is a great help even though the patient is capable of walking just with a cane during good spells.

[Dr Damien]

this is very true old biddie, this why they need to be evaluatedby their specialist ever so often as the disease progresses. i tried to explain this once to a family of a patient who were worried bout their moms funny turns during the day. i said it was the sideeffect of the sinemet, of course the GP wasnt too happy i said that but it was true.
Over here we group them under longterm neurological cases, we keep an eye on them every couple of months and give them the opportunity to call our service if they feel their symptoms are not makig them cope well at home anymore, we also try to keep them in touch with a specialist I.e nurse and/or neurologist.
medication induced symptoms are really the hardest cos its a catch twenty for everyone. Im just seeing a newly diagnosd parkinsons client whose symptoms increased because the doctor increased his meds dose, however that has been sorted now.
Im very much interested in trialing out the U step walker, as it is not commonly used in the NHS (perhaps for its costs) but if it is infact as helpful as its suggested maybe it should really be recommended.

[oldbiddie]

Agonists have the same effect on BP + quite a few non motor side effects which do not help with cooperation nor cognition

[oldbiddie]

Some PD caregiver has just mentioned trying a new walkwer, the Dashaway (Dashaway » Home). She says her husband found it stable and he had to remain straight while walking.

[AlterG]

Hi
There are some great work going on with the AlterG and Parkinson's check it out at alter-g.com

“I love this machine, and I tell all of my prescribing physicians about it. Patients definitely feel great when they exercise using the Alter-GTM anti-gravity treadmill. People with chronic pain are running without discomfort, elderly patients are able to maintain their aerobic capacity and it is a great way to maximize brain plasticity. My patients with Parkinson’s Disease can’t say enough about how good it feels to run again.”
Nancy Byl, PhD, PT University of California, San Francisco

[oldbiddie]

Looking at your name ,AlterG, I expect you work for the firm?

[gcoe]

Yes looks like some pretty blatant free advertising

[alysacamron]

Wheelchairs with ramps are beneficial for people with impaired balance.

[Mohammad Raza PT]

i would like you to send me the complete detail of the case with video clips and muscles power of all four limbs i will be able to advice you about walking aids

thanks
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