Transcript A National Survey of Written Protocol Utilization and

Clinical Measures for Therapeutic Intervention in
Huntington’s Disease
Muratori,
Marder,
2
K,
Louis,
2
ED ,
Moskowitz
of Physical Therapy, Stony Brook University, Stony Brook, NY
Thirty individuals with clinically confirmed HD were
tested.
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Age Range:Stage 1 range 30-60years, median 52yo
Stage 2 range 30-71years, median 55yo
Stage 3 range 34-69years, median 46yo
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3. Self-assessments of function and well-being
(SF-36) are in line with clinical evaluation.
4. Tests of isometric strength are NOT well
correlated with functional capacity or risk of
falls in patients with HD.
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Analysis of gait velocity
showed that as subjects’
ambulation speed decreased
there was a greater risk for
balance problems and falls.
r =-0.60
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Velocity
Total functional capacity (TFC) correlated
with clinical measures
Functional Reach Test – A measure of balance that
uses the difference, in inches, between arm’s length
and maximum forward reach, using a fixed base of
support. A reach of 6 inches or less is considered a
predictor of falls.
Functional Reach vs. TFC
Berg Balance Scale vs. TFC
Timed Up and Go (TUG) – A screening tool
developed to identify individuals with balance deficits,
this test measures the time taken to complete the
following series of tasks: standing up from a seated
position, walking 3 meters, turning, stopping, and
sitting down.
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r = 0.61
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TFC
Individuals with HD show a
strong relationship between
functional capacity and
measures of balance,
cognition, and visual-motor
ability.
r = 0.62
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TFC
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1. Standardized clinical tests already familiar to
clinicians working with patients with
movement disorders can be used for clinical
decision making in HD.
2. Areas of deficit correlated to disease
progression, particularly reaching out of ones
base of support, unilateral stance, and
turning, may be useful to target during
therapeutic intervention.
3. Strengthening should take place within a
functional context to maximize benefits.
r = 0.58
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Clinical Implications
References
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SDMT vs TFC
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Total Functional Capacity (TFC) - A standardized
scale used in HD to assess capacity to work, handle
finances, perform domestic chores and self-care tasks,
and live independently. The TFC scale ranges from 13
(normal) to 0 (severe disability).
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Velocity
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Symbol Digit Modality Test – a test of visual-motor
speed and cognitive function requiring the decoding of
visual symbols using a paired template.
r = 0.68
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5
Berg Balance Scale – A falls risk assessment that
measures fourteen tasks, including transfers (e.g., sit
to stand), retrieving objects from the floor, turning
360°, tandem stance, reaching forward while standing,
and standing on one foot.
2. Scales which are validated for use to assess
falls risk and balance are particularly useful to
evaluate functional status in patients with HD.
Velocity
Timed Up and Go vs Velocity
Berg
This study was approved by the Institutional
Review Board of NYS Psychiatric Institute and
Columbia University Medical Center. All
subjects provided informed consent prior to
participation.
Procedure: Subjects were given an evaluation
that included fall history, gait assessment,
balance, functional mobility, and selfassessments of function and well-being. In
addition, dynamometry was used to assess
isometric strength of the upper and lower
extremities.
Data Analysis: Pearson correlations were
calculated for each of the clinical tests with
measures of gait (recorded using the GaitRite©)
and the Total Functional Capacity (TFC).
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Clinical Measures
1. Objective measures of gait are sensitive to
disease progression in HD and are wellcorrelated with standardized clinical tests.
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Years since symptom onset: stage I – 5 years
stage 2 – 7 years
stage 3 – 10 years
Conclusions
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SDMT
Methods
r = 0.62
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Functional Reach
Gender: 16 males and 14 females
2
AK
University Medical Center, NY, NY
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Stage of disease: 10 stage I, 10 stage II, 10 stage III
and Rao,
Functional Reach vs Velocity
Berg Balance Scale vs Velocity
Purpose
Quantitative gait measurements have been
correlated with disease progression5. However,
instrumented gait analysis systems like the
GaitRite© are not readily available in clinics.
Therefore, we tested widely used standardized
clinical tests with findings from the GaitRite© to
determine the utility of these tests for evaluation
in HD.
2Columbia
Functional Reach
Longitudinal analysis of brain morphology in
Huntington’s disease (HD) shows unremitting
deterioration of tissue in important motor areas.1
Motor impairment in HD is associated with loss
of postural control2 and decreased
independence in ambulation is a significant
predictor of nursing home placement.3 Thus,
clinicians are challenged to identify and
implement therapies aimed at retarding this
degeneration. Pilot work has shown that
physical therapy for individuals with HD can
decrease the effects of motor impairments and
improve quality of life.4 While several authors
have addressed possible causes of impairments
in gait and balance in HD e.g., 5,6, less is known
about which assessment tools might be useful in
clinical decision making for therapeutic
intervention.
Subjects
Berg
Introduction
2
CM
Gait velocity correlated with clinical
measures of balance
TUG
1Department
1
LM ,
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1
Aylward EH, Li Q, Stine OC, Ranen N, Sherr M, et al (1997)
Longitudinal change in basal ganglia volume in patients with
Huntington's disease. Neurology 48:394-9.
2
Tian J, Herdman, SJ, Zee DS, Folstein SE. (1992) Postural stability
in patients with Huntington’s disease. Neurology 42:1232-8.
3
Wheelock VL, Tempkin T, Marder K, et al. (2003) Predictors of
nursing home placement in Huntington’s disease. Neurology
60:998-1001.
4
Quinn L, Rao AK (2002) Physical therapy and Huntington’s disease:
current perspectives and case report. Neurology Report 26:145-53.
5
Churchyard AJ, Morris ME, Georgiou N et al. (2001) Gait
dysfunction in Huntington’s disease: parkinsonism and a disorder of
timing. Implications for movement rehabilitation. Adv Neurol 87:37585.
6
Louis ED, Lee P, Quinn L, Marder K (1999) Dystonia in
Huntington’s disease: prevalence and clinical characteristics. Mov
Disord 14:95-101.