“Balance & Eye Movement Training”-WebinarNotes

Here are my notes from tonight’s CurePSP webinar with Dr. Cris Zampieri on “Balance and Eye Movement Training in PSP.”

Dr. Zampieri’s presentation was terrific. However, the Q&A afterwards was almost worthless. So many questions had absolutely nothing to do with the topic at hand. This has been a problem to varying degrees with all of the webinars. (As the next two webinars are entirely Q&A, I do hope the organizers can do a better job screening the questions.)

Dr. Zampieri co-authored two interesting articles on balance and eye movement training in PSP in late 2008 and early 2009. In addition to the webinar tonight, there’s a very nice layperson-oriented summary of the research in the March 30, 2009 issue of a publication called “Today in PT.” See:
http://news.todayinpt.com/article/20090 … 4/90327004

You can find the December 2008 article in the Physical Therapy journal for free online here:
http://ptjournal.apta.org/cgi/reprint/88/12/1460 (PDF version)

The February 2009 article in the Archives of Physical Medicine & Rehabilitation is NOT available for free online. A few of those excerpts and the abstract were posted here:

“Balance & Eye Movement Training in PSP”
Cris Zampieri, PhD, PT
CurePSP Webinar, 3/11/10

Background: She is currently doing research at the NIH on gait and balance in neurological disorders. She is a researcher, not a clinician. She has a PhD in Rehab Science from the University of Minnesota. Her thesis was on rehabilitation of gaze control to improve attention and mobility in PSP.

The study – published with Dr. Fabio – was on the interplay between eye movements, gait and balance in PSP.

Eye movements are important to balance:
* Saccades (quick eye movements) bring object of interest to focus
* VOR (vestibulo-ocular reflex) – stabilization of gaze; helps keep the visual image steady while the head moves

Vestibular: self to earth
Vision: object to object
Somatosensory: self to self (proprioceptors)

Eye movements are important to walking:
* Saccades helps when changing direction of walking, avoiding obstacles on the walking path, stepping up/down (stairs, curbs), judging distances
* VOR helps to keep the visual image steady as we move our head up and down while walking, turning
* Problems with eye movements have been associated to increased risk of falling

Balance, gait and eye movement problems in PSP:
* Bradykinesia (slow body movements): slower walking, slower preparatory movement to overcome obstacles and slower reactive movement
* Axial rigidity (limited flexibility, especially trunk): limits size of preparatory and reactive movements
* Vertical gaze palsy (slow eye movements, especially vertical): slower saccades compromise tasks that need visual input such as walking, avoiding obstacles, turning, stepping up/down (stairs, curbs)

Rehabilitation in PSP:
* Very little research on this topic
* Before our study, only 3 research studies done (1986, 1993, 2003). All were case reports (1 or 2 patients). All focused on gait or balance rehab; there was NO eye movement training.
* Our study was the first involving a group of patients (ie, small clinical trial) and involving eye movement training as part of the rehabilitation program in PSP.

Optometrist world is separated from the physical therapy world and the neurology world. We tried to bring these worlds together.

This was a first step. It’s necessary to study these techniques in hundreds of patients before we can say there’s an effect.

About the study:
* 20 PSP subjects: moderate impairments on clinical exam; able to walk short distances independently; corrected visual acuity 20/70; no recent eye surgery; no neurological problems other than PSP; no acute orthopedic problems
* Divided into two groups: one group received eye plus balance training; the other got balance training only. Eye+balance training group: 5 males/5 female, 71 years old (average). Balance training group: 5 males/4 females, 67 years old (average).

Exercises – where, how, when:
* At the University of Minnesota PT Dept.
* Individual sessions delivered by trained researchers. Subjects were supervised for safety.
* One hour, 3 times a week, for 4 weeks

Eye movement training included two items:
* Computer-based saccade training. Subjects sat in front of a computer screen. An arrow pointing in some direction was shown. Subjects had to move their eyes in the direction of the arrow. The exercise focused on pushing the eyes to move. Software from www.visionbuilder.no A free sample can be downloaded.
* Biofeedback training. Subjects wore a BIRO (binocular infrared recording system).

Eye movement/balance training included two items:
* Scanning environment to identify hidden objects
* Platform limb cue training. Have to pay attention to arrow and sound to make the right choice about whether there’s a step in front of them.

Balance training included four items for those in the eye/balance training group:
* Romberg: stand with feet close together; eyes open and eyes closed; with eyes closed, the subject must rely on the VOR and somatosensory system for balance
* Turning
* Sit-to-stand. The trick is to lean forward as much as possible to stand up.
* Compensatory stepping

The balance training only group got the above four items once a week. The other two days a week, they got this balance training:
* Alternate knee touch
* Side step: 5 steps to each side
* Heel-to-toe walk: need more balance for this
* Toe lifts
* Heel lifts
* Single leg stands
* Leg lifts (to the side): helps strengthen the glutious
* Leg swings (front and back)
* Step ups: this was not associated with eye movement.

Testing – when, what, how:
* Before and after the program of exercises
* Measured walking speed; walking stance time; walking step length; timed Up and Go test; eye movements (eye only movements, eyes plus head downward movements)
* Used motion analysis sensors (sensors on head and legs, when walking) and infra-red eye sensors

Up and Go test:
* stand up from a chair, walk 3 meters, turn around, walk back to the chair, sit down
* how long does it take to do this?
* the amount of time is related to risk of falling

The VOR cannot be suppressed.

Statistically significant results for the eye+balance group: (in order of largest effect)
Increase in vertical eye movements
Increase in walking speed
Decrease in walking stance time
Decrease in timed Up and Go time

Statistically significant results for the balance only group:
Increase in walking step length. The exercises incorporate range of motion

* Balance and eye movement training might be effective to improve gait and eye-body coordination in patients with moderate PSP
* Potential way to change circuits in brain that control eye movement and walking in PSP

We all know how hard it is to diagnose PSP. And how hard it is to bring patients to a study. And how hard it is to convince patients that this is worth a try.

[These are Dr. Zampieri’s own questions and answers! This was part of her presentation.]

Q: Can we generalize the results to other patients with PSP?
A: We need larger clinical trials before we can say it’s effective training.

Q: What parts of the intervention were responsible for the improvements?
A: The training included many components. All we can say is that the whole package worked together.

Q: Is there a retention of the benefits after training stops?
A: Another study has to be done for this.

Q: What patients respond better to rehab – early, moderate, or advanced?
A: All we can say is that moderate patients improved.

Q: Would more/less therapy have led to the same results?
A: We don’t know. More studies have to be done.

Q: How does rehab impact risk for falling?
A: It’s tricky to measure falls.

Two papers were published on the study:
Zampieri, et al. Physical Therapy 2008.
Zampieri, et al. Archives of Physical Medicine & Rehabilitation 2009.

[This is the open Q&A, with questions from the audience. Unless indicated, the answers were given by Dr. Zampieri. Janet Edmunson, Chair of the CurePSP Board, answered some questions. I’ve re-organized the Q&A, and have deleted the irrelevant questions.]


Q: Can I get this eye and balance training in south Florida?

A: The whole program is not totally available in a clinic.

We put the biofeedback together ourselves. We built the device there so it’s not available.

PTs wouldn’t have access to that part. But, yes, the software is available. PTs know the exercises. Other items can be incorporated by PTs.

Q: Does exercise/therapy have any effect on balance or eye movement in PSP patients? So far, we haven’t found any medication, activity, or treatment that has made any improvement.

A: This was the focus of the study. There is nothing out there. My study showed eye and balance training showed a benefit.

We all should be exercising. Exercise is never bad. Use it or lose it.

Q: What exercises should be done (and how often) when the disease becomes a serious balance problem?

A: The same things we did.

Q: Is it worth focusing on balance and eye gaze when the patient can no longer stand or straighten his head to see?

A: I don’t know. Maybe.


Q: Vision Builder has many selections. Which one should we use?
Q: Is the saccade practice the critical one for PSP?

A: Look for saccade training.

Q: Can you define what you mean by the disease being moderate?

A: Clinicians have a scale that is a list of symptoms that are frequently observed in PSP. Clinicians can grade 0 to 4 the severity of symptoms. The PSP Rating Scale includes saccades, postural instability (pull back test), bradykinesia (opening and closing hands), etc. The composite score tells clinicians if the patient is mild, moderate, or severe.

Q: Many medications have dizziness as a side effect. Were patients required to not have any medication changes prior to and during the study?

A: Many medications do have an effect on balance. We did not change medications in the study. Most of our subjects were not taking medications that would effect balance. Some did.


Q: Is the balance problem caused by the eyes not looking up or down?

A: In part. It’s also caused by bradykinesia and rigidity.

Q: What vestibular issues do PSP patients have?

A: They have problems suppressing VOR. PSP patients may move their heads but their eyes go in a different direction (often opposite).

Q: Could you address the differences in the visual disturbances between PSP and CBD? Falls play a very significant role in these disorders. I am interested in treatment strategies to assist with management.

A: I haven’t treated patients with CBD. I have read about it.

In PSP, eye movements are slow. In CBD, the start of the movement is slow (the latency is slow). The involvement in walking and balance are the same.

Q: Is there anything that can be done to prevent nystagmus, which is an uncontrolled movement of the eyes, usually from side to side, but sometimes the eyes swing up and down or even in a circular movement.

A: Our therapy was not designed to treat nystagmus. It was designed to treat the slowness of eye movement. The biofeedback part of the intervention was related to nystagmus.

Find out about vision therapy from an optometrist.

Looking for things (such as at a grocery store) is a good exercise anyone can do — without software or special equipment.


Q: Why does PSP cause the patient to run into walls and doorways, even when being guided?

A: Two components there — motor (bradykinesia, rigidity, slow eye movement) and thinking. My presentation was about motor issues.

In terms of thinking issues… There may be impulsive behavior related to the frontal area of the brain. This relates to judgment. Also, the person may realize too slowly there’s something in the way.

Q: What is the difference between exercise and PT?

A: PT uses exercise as a therapeutic approach. PT controls the exercises and adapts them to someone with motor problems. PT is controlled exercise. There is an objective to the exercise. The PT knows what exercise is effective for specific problems.

Q: Interested in efficacy of therapy — physical and speech.

A: Anything is good.

Q: My mother is dragging her leg. Any recommendations on strengthening?

A: I would need to see the patient to say. Talk to the neurologist and the physical therapist. Many things cause someone to drag a leg. (Could be lack of strength, rigidity, bradykinesia, anything.)

Q: I have been struggling with PSP for 6 years. I have fallen all the way down over 1200 times. Now my home caregiver has decided I no longer need physical therapy.

A: The objectives of PT have to be adjusted to what the patient is presenting. If it were me, I would be active as long as I could be.

A by Janet Edmunson: There are ways to be safe while exercising. It is important to avoid falling.

A by audience member: Most insurance companies will only pay for PT if there’s demonstrated improvement.

Q: If the outcome is going to be the same — namely, loss of life — is PT mainly for patient comfort?

A: I wouldn’t say this. I think it’s important to be active for as long as possible.

It depends on the stage of the disease. If we are looking at final stage with respiratory problems, then, yes, for comfort. But while activity is still possible, it should be sought.

Q: Does PT for PSP patients prolong their life at all?

A: I don’t know if anyone can answer this question.

Research is showing that exercise is so beneficial that if we could give a pill of exercise it would be the best pill ever. Exercise is important for neuro-plasticity.

Rats that have been modified to have Parkinson’s Disease that are active, experience delayed progression of PD than rats that are not active.

I’m an exercise advocate!

Q: When should PT be terminated?

A: This is a broad question. The answer is not black and white.

Range of motion is important.


Q: When my husband with PSP sleeps over 12 hours, his balance is much better. Is there any relationship between balance and hours slept? Do most PSP patients sleep so many hours?

A: If this is working, that’s great! The brain must be getting rest.

Q: My husband has MSA-C. He starts the day out with better balance than the evening time. The change is drastic. Can you tell me why the degree of balance changes throughout the same day, not only from stage to stage, of the disease?

A: I don’t have experience with MSA. I don’t remember seeing this drastic change with PSP. I can’t answer this question.


Q: The eye movement interferes with ability to read text. Can eye exercise help a CBD patient with this problem?

A: Look into optometric vision therapy. There are lots of exercises for kids that improve reading a great deal.

Find this sort of therapy through optometric societies.

Q: What does a PSP patient see?

A: There’s a difference between vision and eye movement. Eye movement is about the ability to use your vision.

Q: Is there any type of eyeglass lens that will help to focus things that are below the fixed eyeball?

A: Again, there’s a difference between eye movement and vision. Glasses won’t help you look down. They just help you see better what you are looking at. Prisms are a type of eyeglass that might help.

Q: I have pain above my eyes. Is this due to muscle problems? My left eye does not open all the way.

A: This brings to mind blepharospasm. Talk to your neurologist about this.

A couple of our subjects had blepharospasm. One touched his forehead to encourage the eye lid to open. The other just waited until the eye lid opened.

A by Janet Edmunson: You might consider speaking with your neurologist about botox.


Q: Do you recommend massage therapy?

A: Massage helps muscles relax. It helps you feel better. It’s valuable. This is a personal opinion.

A by Janet Edmunson: Range of motion exercise is a good thing to do.