Article Test

Introduction.
Complaints of people by the general practitioner that their walking and balance performance was altering and they couldn’t find why. An group of general practitioners[ hold an record what was happen with this group, that complaints over the walking and balance performance and they find that this were the first symptoms of an possibility of an form of dementia. The second important finding was that the period was long about 8- 10 years and that could be a sign that dementia can be faster be found and with the possibilities to treat. Now in 2023 start the Uni of Rotterdam Erasmus University with an investigation to search for walking problems as an first sign, that there could be an neurological disease become manifest that is called dementia. There are an lot of forms of dementia and some differences are certainly there, but still now no investigation had makes this differences, therefore must we do with the determination that it could count for all forms of dementia.

Get we search in the literature that we see that people has investigated people with MCI ( Mild Cognitive Impairment) that there was an great loss on  movement  especially  walking.  Is this an sign that this complaints has also another behaviour? 4 5

An example of the adaptation of elderly that copy with the decreasing length and form of their attitude is known and looking at the change of this attitude makes it understandable that balance must also recovered to counter this changed attitude. Figure 3 let see what the impact is when the spine is going in a kyphosis and therefore the mid line is altering.

Knowing that the body is change is an sign of that adaptation, but what we see by people that loss their cognitive abilities is something different Here we see that their body perception is alter and isnt correctable through them and they arent aware of this change of body perception. This is one of the first differences that people with dementia have as we them compare with elderly without dementia.

Thus that elderly with dementia has problems with their walking and balance must be have an direct relation with this neurological disease and it is very important to find this most common reason because than is treatment and slowing down of the effects of this disease on walking and balance possible. 

What is changing in the beginning of this disease?
An researchs done with people that was coming to relieve their love-ones give us material that could be help to find more out why the balance and walking was so difficult. Of course the amount of 35 participant is low. This group was walking with an aid, 33 with an rollator frame and two with an stick. This aid was given to them through the family and not through professionals. The reason therefore was often that family say that the balance but especially the walking capacity wasnt optimal and therefore they search for an aid. To get it clear where this need lay, we started with an assessmenti131 and measurements as the Berg Balance Test (B.B.S.), Tinetti balance TestI15I, Statiek tesf16.17.18I to measure the balance level and search for the missing link but we start with the test that Rikli and Jonesuclhas developed around 2000 (Senior Fitness Test) for elderly to determinate what men and woman should performed on an certain age because we want to know or this people were capable to hold the level that belong by their age.

This 7 test were; 1. 30 second sit and stand test. In 30 seconds standup from an normal chair without using the hands. 2. Arm curl, the power of the elbow flexor. 3. 6 minute walk test, the distance that in 6 minute was done as fast as possible.  - 4. 2 minute step test, lifting one knee at the level of a stripe on the wall as fast as possible in 2 minute. - 5. Chair sit-and -reach, mobility test to touch the toes. - 6. Back Scratch, mobility test to reach on the back. - 7. 8 foot up and go, or the Up and Go- test with standing up, walk and turn.

Now we could determinate or this persons with dementia perform according their age or that there were differences and where. When she has the level that belong with their age, than this was called normal. When she perform better thus better as the range that was given than this was better. Below the border was called border and when it was firm below than was this called worse.

Conclusion of this investigation by 35 people with the diagnosis dementia. (Regrettable was their no further diagnostic specification of what kind of dementia they suffer.) All participants had troubles with the items as speed, selectivity and dexterity and the items that asked for mobility or a sitting performance and move (the arm curl) than was their performance almost equal  with people of the same age. But walking and especially fast walking, stand on one leg and lift the other, standing up and the Up and Go-test and then especially doing this (ast was the greatest problem.

The balance test (B.B.S. or Tinetti) were also not optimal but almost all could perform on the border or little worse from the point that fall danger was present. But again was observe that the problem was speed and especially dexterity and selectivity. Thus the reason that they had a walking/balance aid was present but what was the greatest functional disorder that could explain this outcome.

The next test was de Statiek- test[^7, an test that invest the possibilities that someone have when he must react on little pressure on hip and/or shoulder  height to the back, to the front and sideways. This pressure asked for an immediately response that is equal with the pressure and that the whole body participate. Thus we feel the action but also see what the feet and trunk do, to prevent a fall movement.

All the participant has difficulties to react on this Statiek test as people should react of their age. The difficulties were; to react so fast and enough power as necessary to resist that little pressure. Often had participants problems to get the reaction on a continue level and must they every time again build up an equal pressure. Increasing the pressure gave the same problems, they were unable to react on the right level.

The conclusion of the Statiek test was therefore that there control over the body weight shifting wasn’t optimal and that pointed for an changing body perception[ 2 22! and/or not the selectivity in the muscles pattern that take care for this control of body weight shifting and that means that the brace when they came on the edge of their balance wasn’t optimal and therefore had often too little time to make an good step strategy to restore balance.

The difference with this group people with dementia and the same group of that age without dementia was not that some muscle were low in power but that there was no possibility to adapt on this pressure situation and that pointed for an lack of selectivity. That means that we must search for a pathological neurological tone because than are the use of pathological synergy present and that would explain this lack on adaptation. Remarkable detail by almost all participants when they walk without an walking aid under supervision where;

1. Walking not in the mid of the corridor but often at the side near the railing, some with slight touch and the people that  walk in the mid where afraid walking through the square at the end of the corridor or, as love ones told, walking outside without an aid or contact with someone.
2. The rigidity of the head and upper trunk movements and the lack of expression on the face and “no interest” in the environment, only when the stood still. That give an attitude where the elbow were bended as a sign of some high tension.

Tone investigation.
The last part of the assessment is the investigation of the tone. The literature gives clear signs that in the beginning of the disease there is often a tone increase. This tone is invest and called paratonia[*5. The thesis of Dr. H. Hobbelen has given us an picture what this neurological pathological hypertonus differs from other hypertonus by other neurological disorders.

The occurrence of that paratonia is invest through the group around H. Hobbelen and others have also see that people in the beginning of the disease has often a tone that is higher than normal. The tone is tested with a test called the MAS-P and is invest by others to get it of a good value. This give us an instrument that is equal with the tone measurements for person after an stroke[30 3!

The tone measurement by the people in table 1 give the following results; - The tone of the elbow and knee and then especially of the elbow flexors and the knee extensors was higher as also, but, lesser the antagonist.

This higher tone in the agonist as in the antagonist is one of the remarkable differences of paratonia comparing with spasrr1241, but often was the speed that is needed by this assessment so low that there isnt resistance to feel and that this only occur when the speed get higher as invest through Tardie1.1311 and colleges. Of the 35 persons this was the case by almost 20 persons but the differences where great. There were also differences by some persons that has no tone increase but the next day was there a resistance in the same movement and by the same speed.

This results where obtain when the person was in a sitting position and never directly after a walking performance and therefore was the hypothesis that the tone has decrease because the difficulty and gravity was changed. - Therefore we started to do the test directly after the walking performance and when it was allowed when they stand still, but often was this difficult and was it almost impossible to feel or this was paratonia or higher tone to control the attitude.

But directly after an walking performance gave an better picture, now was the tone by all persons higher, certainly when we increase the movement-speedn than was there always an resistance. - Conclusion of this test was that direct after a walking performance, the tone was higher as normal and when this person sit longer than was the decrease clear greater. Thus the walking/balance performance and the gravity asked from the damaged brain an higher pathological tone to control all freedom degrees134 and asked therefore an lot of all brain functions.

This other picture of the problems that people with dementia have with movements and especially walking and balance what asked for selectivity, dexterity and speed directly after the performance compared with the investigations that are done in sitting-relax position. The arm curl was such an example where there were no clear differences that where there on all walking or balance performances. Thus must the tone measurement also occur when they move? This was difficult and as a solution we measure directly after but maybe with the Myotron-prowl device, we get the opportunity to measure when people performed.

Important!!
To know what is happen with the tone when people with dementia move is essential when we want to treat this people. Treatment of people with dementia is still, now, only possible through movement that increase the blood circulation of the brain and slower down this diseas€133.34.35,30. Aerobic treatment with a good amount of intensity will increase the blood circulation and has effects on several brain elements as the hippocampus and also anaerobe treatment has an good effect but we must be careful or this can have an effect on the balance performance.

Walking as training.
Thus that means that walking performance can be trained by people with dementia but there is a border. The border is the paratonia that will increase when people increase their speed and/or when they walk longer and the fatigue increase. Than is the amount of effort that is necessary must larger than people with no increase of an pathological tone and the danger that the balance is decrease is increasing. The problem to get the right level of intensity[3^ to get an positive reaction in the brain is than difficult or maybe impossible to achieve.

Balance performances.
The limit for balance training is through the increasing of the pathological neurological tone also difficult, because to train this, the person must train in an position that need an balance reaction and asked for the speed to react with an body reaction that give time to make an foot free, to make an step-strategy and that will be slowing down through the paratonia. That means that all fall prevention programs will have less positive effects and will this person give no benefit, but the therapists that do this fall-prevention program are often the first that see what the reaction is and could be through tone measurement search for an clear sign that can be helpful for an fast diagnosis and thus an early treatment.

The signal that people cannot participate because the increase of the paratonia make it impossible, should be important sign that people with dementia has through that problems with all kinds of movements and then must we search and invest other treatment forms.

Other treatment form.
Knowing that the pathological tone is one of the reason that the functioning level is decreasing, was the reason to chanpe of the therapy-intensity by people after an stroke, Parkinson and dementia[ 38 . That intensity increase the tone and make movements for all participants more difficult. Decreasing the intensity/heaviness level, was it possible the negative effects of the this treatment in the period before to reduce and one of the pillars
was hydrotherapy[39,40,41]

Hydrotherapy.
Hydrotherapy is an form of therapy that is capable to chanpe elements that occur in diseases with brain damape and make it possible to move on better level than on la nd  .[ 42t43t44 45.4d.] The sensorics input will be increase and the tone will be decrease and this two elements will give the damage brain the possibility to do more with the residual power. Furthermore will the water stimulate the aerobe and the anaerobe activity?

That means that the blood circulation in the brain will be increase but also the balance training can be done on an task specific[ 4 way with the possibility to give resistance and the balance reaction can be done in the water because the fall will be through the water be safe. The transfer of the training in water on land is positive[ 48 but still, will there be an increase of tone by people with dementia through the gravity.

Conclusion.
The possible reason that the walking and balance performance by people with dementia is often so fast negative changing, even before the disease is diagnosed, is a source for investigation over an long period. Still there are clear signals that the pathological increase tone is an very important factor but the measurements of that tone increase is till now done in an relax, sitting position and it would be very important that  this  measurements are done when people are walking or doing balance movements. When this tone is the factor that makes walking and balance difficult than must the therapy be so that this dont lead to a tone increase and till now is all the therapy that is given, including the fall-prevention, a tone increasing exercise.

Thus must the therapy be done in an environment that decrease the tone and also stimulate the aerobe and anaerobe activity to slow done the disease but have also an positive slowing down effect on the walking/balance performances. And that treatment must be give on a regular base and should be an issue for further investigation what the best treatment is for the disease dementia.

Corresponding Author:
Jan van de Rakt
Physical Therapist NDT teacher IBITA,Course Leader and teacher on the DutCh, Institute for Allied Health Sciences. Nursing Home Waelwick in Ewijk, The Netherlands

Conflicts of Interest Statement None 

Funding Statement: None
Email: [email protected]
 
Acknowledgement None

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