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Creating Closed-Chain Environments for Successful Mobility

This photo taken June 12, 2013 shows Alberta Hough, center, who suffers from Parkinson's disease, assisted by her daughter Gloria Hawks, left, and occupational therapist Ally Evelyn-Gustave, right, as she uses a walker to get to a powered scooter in her home in Baltimore. Hough struggles to feed herself a snack, her arms shaking badly from Parkinson's disease. Days earlier, the 84-year-old fell while eating, sliding off her kitchen chair. The rest of Houghâ AP PHOTO/PATRICK SEMANSKY

AP PHOTO/PATRICK SEMANSKY

“I don’t need a walker.”  Said every older adult ever.

And sometimes they’re right.

I have always been of the school of thought that when I see an older adult bracing himself on walls and furniture as he moves throughout the house that it’s time to intervene.  The need for additional support is obvious. Furniture walking just isn’t safe, and by most assessments, it is a red-flag risk of falls.

Or so I thought.

What I have come to understand more and more about the human nervous system, particularly the sensory-motor feedback loop, is that furniture walking may not be so much about physical support for weakened muscles and joints as it is for sensory feedback for body awareness.

Picture this… you’re standing on one foot. You start to sway and realize you’re about to lose your balance. But just touch a fingertip to something stable (the wall or countertop) and your body immediately corrects itself.  It’s not that your tiny fingertip is keeping your body weight from falling over, it’s the sensory awareness of where you need to adjust in relation to the environment.

This phenomenon is most apparent in the world of Parkinson’s disease, where proprioception and movement patterns are altered by a lack of dopamine.  People with Parkinson’s disease have a hard time finding their balance without extrinsic sensory input.  They tend to lean backward and can’t seem to find “the middle” without touching something stable and adjusting to that input.  People with Parkinson’s disease are also natural “pullers”- pull to stand, pull to sit up- and accordingly modify their environments with props that help them move. They clearly use walls and tables as points of contact as they walk along, and we spectators- caregivers and therapists- shudder at the dysfunction.

So we do the right thing- and we rock their world.  We remove the permanent surfaces that they use to pull and stabilize themselves.  We move the furniture.  We widen the environment. We give them lots of open space.  We teach them to push to stand, and then we give them a walker- a non-fixed surface to help them find their center of gravity.  We teach them to move “normally”.   And this feels absolutely terrifying to the person we are trying to help.

We replace a closed-chain environment with an open-chained one.  For someone who needs tactile input for stabilization, that is a flawed approach.

The problem is, we haven’t fixed their dopamine shortage.  What may seem like a successful intervention with direct supervision and coaching, fails miserably when the person is left to their own devices.  We have removed every opportunity for them to use the sensory and motor patterns that are “normal” for someone with an abnormal brain.  We’ve taken away the things that they naturally seek- stable surfaces to touch (sensory) and pull on (motor).

And, given our example of neurotypical you and I standing on one foot, it’s not just Parkinson’s patients that need tactile cues from the environment to right our balance.  Any sensory impairment (diabetes, stroke) , physical impairment (weak muscles and joints), or even aged sensory organs (skin, brain) may benefit from stable objects in the environment to improve mobility.  Walkers are not stable.  They are extensions of our limbs, and for some people, that just compounds the problem.

I keep going back to a man I met early in my career.  He was a retired physician with severe Parkinson’s and an unstoppable desire to move.  He created a “pull-along” system throughout his home that even led out the door and to his garage.  He installed grab bars along the walls arm-distance apart.  He could walk- briskly and safely- from bar to bar in and out of each room of his house.  His movement pattern was difficult to watch- his lower extremities seemed to lag behind the swinging motion of his arms.

I adamantly opposed his techniques.  He needed a walker.  He needed to learn to push and not pull.  He needed to rely on his own body, not fixed external devices, for mobility. He needed to relearn normal movement patterns.  He was agreeable to neuromuscular re-education for the sake of improving the quality of his motor skills, but not to the change in his day to day techniques.  And as hard as I pushed him to change, to use the “normal” movement patterns we’d been working on, he had his own successful devices.

I have to admit… man he was quick.  He zoomed from room to room.   And he never fell- that is until he reached his garage and ran out of monkey-bar real estate.  Once he shifted to the walker he kept outside, his strategies no longer worked.  Every time he fell, it happened outdoors.

So the question is this: Should we work to design environments that cater to successful mobility for adults with aging sensory-motor systems, or should we continue to implement our ideas of “normal” onto their natural preferences?

If I were an older adult facing fear, falls, and life in a wheelchair because someone took my props away, I know how I would answer.

I wrestle with the rehabilitate vs. compensate dichotomy, but I’m leaning toward creating environments that facilitate safe movement based on a person’s existing skill set, instead of an unrealistic ideal.  I am re-thinking the “monkey-bar” approach.  And I think I like it.

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One comment

  1. Great blog, thanks for sharing! Safe mobility in the home is so important for the elderly so that you can stay at your home as long as possible, and stay safe as well. There are so many things you can do to increase security from ramps to personal safety alarms, they can make a substantial difference to quality of life and peace of mind.

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