Power and Vestibular Training to Minimize Risk of Falls for a Patient with Peripheral Neuropathy: A Case Report

Authors: Zachary Urbanski, DPT1, Jessica Abraskin PT, DPT, CBIS, OMPT, OCS1, Linda Horn PT, DScPT, MHS, FNAP2

Affiliations:
1 Sparks Physical Therapy, Sparks Glencoe, Maryland, USA; 2 University of Maryland School of Medicine, Department of Physical Therapy and Rehabilitation Science

Introduction

Falls are the second leading cause of injury-related death in older adults and are expected to double by 2030.³ The specific causes of a fall depends on the individual, but many can be related to Presbystasis, which refers to the multifactorial and progressive impairment of balance in older adults.¹ The purpose of this case report is to determine the effectiveness of vestibular and power training in a patient with peripheral neuropathy on decreasing risk for future falls.

Patient Presentation

Patient is a 70 year old male with difficulty maintaining his balance on grass and experiencing frequent falls over the past four years.

• History of Present Illness: Patient reports he has had 10-12 falls in the past 4 years. His last fall was 2 months ago in a restaurant. He does not remember if he tripped, or his legs gave out. Patient reports he avoids activities due to fear of falling.
• Past Medical History: Cardiovascular disease, High Blood Pressure, skin cancer (active), Aortic Valve Replacement, Shortness of Breath, Chronic Back and Knee Pain, Peripheral Neuropathy, non repaired left Achilles tendon tear.

Interventions

Block 1: 2 weeks in duration

• Power
  • Weighted Sit-to-stand 3 x 6 → Concentric “as fast as possible,” eccentric 2-3 s
  • Single Arm Dumbbell Snatch 2 x 6 (B) → Concentric “as fast as possible,” eccentric 2-3 s.
• Vestibular
  • VOR (Vestibular Ocular Reflex) x 1 viewing exercise (adaptation exercise) – 3 x 1 min. vertical and horizontal attempted at ~120 bpm with metronome
  • COR (Cervical Ocular Reflex): Imaginary Targets 3 x 1 min Vertical and horizontal

Block 2: 3 weeks in duration

• Power
  • Hip Hinging Deadlift 3 x 6 → Concentric “as fast as possible,” eccentric 2-3 s
  • Standing Row with Cable Machine 3 x 8 → Concentric “as fast as possible,” eccentric 2-3 s
  • Alternating Step Ups with 4’’ box 3 x 1 min.
• Vestibular
  • Ambulation with single point cane with horizontal head turns, Wide and narrow base of support on foam – eyes closed 3 x 30 s
  • COR Active eye/head movements → vertical and horizontal 2 x 1 min.

Results

Discussion

The combination of vestibular and power based interventions appear to be effective in decreasing fall risk based on the results of the functional outcome measures. Both traditional strength training with heavy loads and power training increase rate of force development.3 However, in untrained older individuals, utilizing a lower percentage of one-rep max allows for a decreased barrier of entry for those attempting to increase Type II muscle fibers, which are crucial in fall prevention. Due to the patient’s peripheral neuropathy and impaired somatosensory integration, he also required increased use of visual and vestibular sensory input to reduce his risk for falls. This can be accomplished with vestibular ocular reflex adaptation and cervical ocular reflex substitution exercises in vestibular rehabilitation.

References

1. Teggi R, Familiari M, Battista RA, Gatti O, Cangiano I, Bussi M, Bubbico L. The social problem of presbystasis and the role of vestibular rehabilitation in elderly patients: a review. Acta Otorhinolaryngol Ital. 2023 Aug;43(4):227-234.
2. Morrison RT, Taylor S, Buckley J, Twist C, Kite C. High-velocity power training has similar effects to traditional resistance training for functional performance in older adults: a systematic review. J Physiother. 2023 Jul;69(3):148-159.
3. Jiménez-Lupión D, Chirosa-Ríos L, Martínez-García D, Rodríguez-Pérez M, Jerez-Mayorga D. Effects of Power Training on Functional Capacity Related to Fall Risk in Older Adults: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil. 2023 Sep;104(9):1514-1525.
4. Hall CD, Heusel-Gillig L, Tusa RJ, Herdman SJ. Efficacy of gaze stability exercises in older adults with dizziness. J Neurol Phys Ther. 2010 Jun;34(2):64-9.