07/04/22 07/04/22 J Zimney MPT, GCS J Zimney MPT, GCS 1 Beyond Balance: Beyond Balance: Evidence Based Practice Enhancing Evidence Based Practice Enhancing Quality of Life in the Geriatric Pa Quality of Life in the Geriatric Pa tient tient Jenny Zimney, MPT, GCS Jenny Zimney, MPT, GCS [email protected][email protected]Northwest Rehabilitation Associates Northwest Rehabilitation Associates 1380 Liberty St. SE 1380 Liberty St. SE Salem, OR 97302 Salem, OR 97302 (503) 371-0779 (503) 371-0779
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Beyond Balance: Evidence Based Practice Enhancing Quality of Life in the Geriatric Patient
Beyond Balance: Evidence Based Practice Enhancing Quality of Life in the Geriatric Patient. Jenny Zimney, MPT, GCS [email protected] Northwest Rehabilitation Associates 1380 Liberty St. SE Salem, OR 97302 (503) 371-0779. Beyond Balance: . What factors create safety and balance? - PowerPoint PPT Presentation
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Beyond Balance:Beyond Balance: Evidence Based Practice Enhancing Quali Evidence Based Practice Enhancing Quality of Life in the Geriatric Patientty of Life in the Geriatric Patient
Northwest Rehabilitation AssociatesNorthwest Rehabilitation Associates1380 Liberty St. SE1380 Liberty St. SESalem, OR 97302Salem, OR 97302(503) 371-0779(503) 371-0779
Course Objectives:Course Objectives:Following today’s session you will be able to:Following today’s session you will be able to:1.1. Choose and implement the appropriate Choose and implement the appropriate
functional scale for their patient status and functional scale for their patient status and setting. setting.
2.2. Develop objective measurable treatment Develop objective measurable treatment interventions and goals based on the functional interventions and goals based on the functional scales used. scales used.
3.3. Discuss the rationale and purpose for each Discuss the rationale and purpose for each functional scale presented. functional scale presented.
Course Objectives cont’d:Course Objectives cont’d:4.4. Quantify a geriatric patients balance, Quantify a geriatric patients balance,
fear of falling and fall risk using the fear of falling and fall risk using the functional scales presented. functional scales presented.
5.5. Identify reliable reimbursement and Identify reliable reimbursement and marketing options for fall prevention marketing options for fall prevention programs in your community. programs in your community.
6.6. Make a greater impact on reducing falls Make a greater impact on reducing falls in your community!in your community!
Balance and Motor Planning:Balance and Motor Planning: What is my plan/objective?What is my plan/objective? What am I feeling?What am I feeling? What am I going to do about it?What am I going to do about it? Was this successful last time?Was this successful last time? What is my plan this time?What is my plan this time? Can my body do this (or) do this in Can my body do this (or) do this in
Allum et al 2002 J PhysAllum et al 2002 J PhysChanges in Postural Control with AgeChanges in Postural Control with AgeResults:Results:
With perturbation on sway boardWith perturbation on sway boardYounger = Trunk rolls toward Younger = Trunk rolls toward from from perturbation (uphill)perturbation (uphill)
Older = Trunk rolls away from Older = Trunk rolls away from perturbation (downhill)perturbation (downhill)
Age Related Changes: Age Related Changes: VisionVision
↓↓ visual acuityvisual acuity Impaired dark adaptationImpaired dark adaptation ↓ ↓ response to peripheral field visual response to peripheral field visual
stimulistimuli ↓↓ contrast sensitivitycontrast sensitivity Difficulties with accommodationDifficulties with accommodation Abnormal visual perceptionAbnormal visual perception
load, terrain and postural transitions load, terrain and postural transitions (head mvmt) distinguished those w/ (head mvmt) distinguished those w/ disabilities, 1/2 as many activities disabilities, 1/2 as many activities and had to be accompanied.and had to be accompanied.
(Shumway-Cook A, et al. Phys Ther. 2002;82:670-681)(Shumway-Cook A, et al. Phys Ther. 2002;82:670-681)
Attentional Demands:Attentional Demands:Static vs. Dynamic EquilibriumStatic vs. Dynamic Equilibrium6 healthy young subjects (20-30 yo)6 healthy young subjects (20-30 yo)Tested reaction time to auditory cue with Tested reaction time to auditory cue with
sitting, standing upright (broad and narrow sitting, standing upright (broad and narrow base, walking (SLS and DLS)base, walking (SLS and DLS)
Standing > sitting; Walking > sit or stand; Standing > sitting; Walking > sit or stand; SLS > DLSSLS > DLS
Conclusion: Balance control w/in gait is not Conclusion: Balance control w/in gait is not automatic.automatic.
Attentional Demands:Attentional Demands:Dual-task Methodology:Dual-task Methodology:1.1. Limited Central Processing CapacityLimited Central Processing Capacity2.2. Task performance requires part the Task performance requires part the
limited capacity within the CNSlimited capacity within the CNS3.3. If performing 2 tasks and that If performing 2 tasks and that
capacity is exceeded, 1 or both capacity is exceeded, 1 or both tasks can be disturbed.tasks can be disturbed.
Voluntary Step and Cognitive Voluntary Step and Cognitive TaskTask
66 healthy elderly vs. healthy young adults66 healthy elderly vs. healthy young adults Tested voluntary stepping on force plate Tested voluntary stepping on force plate
single task and w/ modified Stroop testsingle task and w/ modified Stroop testResults: Older adults withResults: Older adults withSingle task: 42-52% slower step initiationSingle task: 42-52% slower step initiationDual task: 190-256% slower, 41% no reaction Dual task: 190-256% slower, 41% no reaction Melzer, Oddsson. JAGS. 2004;58(8):1255-1262Melzer, Oddsson. JAGS. 2004;58(8):1255-1262
step width, double limb support timestep width, double limb support time In fearful group, speed was slower, stride In fearful group, speed was slower, stride
shorter, step width larger and double shorter, step width larger and double limb support time was 6% longer.limb support time was 6% longer.
Chamberlin ME, Fulwider BD, Sanders SL, Medeiros JM. J Geron: Med Sci. 2005;60A:9:1163-1167Chamberlin ME, Fulwider BD, Sanders SL, Medeiros JM. J Geron: Med Sci. 2005;60A:9:1163-1167
How often do you lose your balance, How often do you lose your balance, i.e. slip, trip or stumble?i.e. slip, trip or stumble?
When was your most recent fall?When was your most recent fall? Did the fall occur inside or outside?Did the fall occur inside or outside? How did the fall occur?How did the fall occur? Were you injured?Were you injured? Were you dizzy when you fell?Were you dizzy when you fell?
The Activities-specific Balance The Activities-specific Balance Confidence Scale (ABC)Confidence Scale (ABC)
Developed by Powell and Myers with input from Developed by Powell and Myers with input from 15 clinicians and 12 older outpatients to 15 clinicians and 12 older outpatients to quantify fear of falling quantify fear of falling
Type of Information:Type of Information: Self Report Self Report
Components:Components: 16 items of varying difficulty 16 items of varying difficulty rated on 0-100% scalerated on 0-100% scale Equipment needed:Equipment needed: Paper and pencil Paper and pencil
Time to Complete Test:Time to Complete Test: 5-10 minutes 5-10 minutes
Scoring:Scoring:Items are scored from 0 to 10.Items are scored from 0 to 10.Total the ratings (possible range = 0 Total the ratings (possible range = 0 – 140) and divide by 14 to get each – 140) and divide by 14 to get each subject’s mFES score. subject’s mFES score. Scores of < 8 indicate fear of falling, Scores of < 8 indicate fear of falling, 8 or greater indicate lack of fear.8 or greater indicate lack of fear.
Timed “Up and Go”Timed “Up and Go”Developed by Richardson and Podsiadlo to Developed by Richardson and Podsiadlo to
assess basic mobility skills in older adults assess basic mobility skills in older adults Type of Information:Type of Information: Clinician Observation and Clinician Observation and ratingrating Components:Components: One Item- stand, walk 10 ft, turn One Item- stand, walk 10 ft, turn
Timed “Up and Go”Timed “Up and Go”Scoring:Scoring: >30 sec people that are more >30 sec people that are more
dependent, unable to climb stairs, dependent, unable to climb stairs, require AD, help with transfers, require AD, help with transfers, dependent in most activitiesdependent in most activities
<10 sec freely independent<10 sec freely independent <20 sec( I) transfers, I toilet, able to <20 sec( I) transfers, I toilet, able to
climb most stairs, go out alone climb most stairs, go out alone
Normal Values of Balance Normal Values of Balance Tests in Women Aged 20-80Tests in Women Aged 20-80
456 women in 6 age cohorts456 women in 6 age cohortsTests: TUG, Step, FR, LRTests: TUG, Step, FR, LRResults: Results:
Linear change with Step and TUGLinear change with Step and TUGFR started to decline in 40’sFR started to decline in 40’sLR started to decline in 30’s!!!!!LR started to decline in 30’s!!!!!
Berg Balance ScaleBerg Balance ScaleScoring:Scoring: 41-56 low fall risk41-56 low fall risk 21-40 medium fall risk21-40 medium fall risk 0-20 high fall risk0-20 high fall riskAdditionally Additionally > 45 safe, > 45 safe,
Physical Performance TestPhysical Performance TestDeveloped to assess function in community dwelling Developed to assess function in community dwelling
older adultsolder adults Type of Information: Clinician observation and ratingClinician observation and rating Components: 3 Versions (7,8,9 item tests) rated on 3 Versions (7,8,9 item tests) rated on
0-4 scale0-4 scale Equipment needed: Stopwatch, paper & pen, bowl Stopwatch, paper & pen, bowl
and 5 kidney beans, spoon, coffee can, heavy and 5 kidney beans, spoon, coffee can, heavy book, jacket or sweater, penny, 25-foot walkway, book, jacket or sweater, penny, 25-foot walkway, flight of stairsflight of stairs
Time to Complete Test: 15-20 minutes 15-20 minutesReuben, Siu. JAGS 1990;38(10):1105-1112Reuben, Siu. JAGS 1990;38(10):1105-1112
Physical Performance TestPhysical Performance Test Schmidt et al: Schmidt et al:
Predictive of frail elderly dropout rates Predictive of frail elderly dropout rates in exercise program in exercise program (JAGS 2000;48(8):952-960)(JAGS 2000;48(8):952-960)
Brown et al:Brown et al: Differentiates Mild to Moderate Frailty Differentiates Mild to Moderate Frailty
Dynamic Gait IndexDynamic Gait IndexDeveloped by Shumway-Cook and Wollacott to Developed by Shumway-Cook and Wollacott to
assess likelihood of falling in older adultsassess likelihood of falling in older adults Type of Information: Clinician observation and Clinician observation and
ratingrating Components: 8 facets of gait, 0-3 scale 8 facets of gait, 0-3 scale Equipment needed: box, 2 cones, stairs, at box, 2 cones, stairs, at
least 25 ft walkwayleast 25 ft walkway Time to Complete Test: 15 minutes 15 minutesShumway-Cook A, Woollacott A, Motor Control Theory and Practical Applications. Williams Shumway-Cook A, Woollacott A, Motor Control Theory and Practical Applications. Williams
Specifics of the test:Specifics of the test: Test gait at different speedsTest gait at different speeds Stepping over and around Stepping over and around
obstaclesobstacles Gait w/ head turns (horizontal Gait w/ head turns (horizontal
Studied 247 patients with Studied 247 patients with vestibular disorders and found:vestibular disorders and found:
DGI effective to ID fall risk with DGI effective to ID fall risk with older and younger adults with older and younger adults with vestibular disordersvestibular disorders
J Vest Research 2000;10(2):99-105J Vest Research 2000;10(2):99-105
Kristjansdottir et al 2004Kristjansdottir et al 2004Compared 6-MWT to Limited Graded Compared 6-MWT to Limited Graded
Exercise Test:Exercise Test:6-MWT effectively identified 6-MWT effectively identified cardiopulmonary concerns as did cardiopulmonary concerns as did graded test. graded test.
Conclusion: Good test for Conclusion: Good test for cardiopulmonary cardiopulmonary rehab…….Conditioning????rehab…….Conditioning????
Timed StandsTimed StandsScoring: 30 second timed Scoring: 30 second timed
standsstands
Jones CJ, Rikli RE, Beam W. Res Q Exerc Sport. 1999;70:113-119
Normal Normal Range *Range * 60-64 65-69 70-74 75-79 80-84 85-89 90-94
Men 14-19 12-18 12-17 11-17 10-15 8-14 7-12
Women 12-17 11-16 10-15 10-15 9-14 8-13 4-11
*Normal range of scores is defined as the middle 50 percent of each age group. Scores above the range would be considered “above average” for the age group and those below the range would be “below average”.
Chair Stands as a Measure of Chair Stands as a Measure of LE Strength in Sexagenarian LE Strength in Sexagenarian
WomenWomen 47 women performed 5STS, 30STS, Isokinetic 47 women performed 5STS, 30STS, Isokinetic
testing of hip, knee and ankletesting of hip, knee and ankle Results:Results:
5STS: Ankle PF, Hip Flex & Knee Ext. 5STS: Ankle PF, Hip Flex & Knee Ext. 30STS: Ankle PF 30STS: Ankle PF But both only moderate predictors of LE strength.But both only moderate predictors of LE strength. Other factors: sensorimotor, balance, psychologicalOther factors: sensorimotor, balance, psychological
McCarthy et al. J Geron. 2004;59A(11):1207-1212.McCarthy et al. J Geron. 2004;59A(11):1207-1212.
Other Functional Other Functional AssessmentsAssessments
Short Physical Performance Battery – Short Physical Performance Battery – tandem stance, 5STS, gait speedtandem stance, 5STS, gait speed
(Guralnik et al. J Geron. 1994;49(2):M85-M94)(Guralnik et al. J Geron. 1994;49(2):M85-M94)
UAB Life-Space Assessment – Assesses UAB Life-Space Assessment – Assesses mobility in 5 designated environmentsmobility in 5 designated environments (Peel et al. Phys Ther. 2005;85:1008-1019)(Peel et al. Phys Ther. 2005;85:1008-1019)
Clinical Decision MakingClinical Decision MakingTests are chosen based on:Tests are chosen based on:1. Facet of gait, balance or mobility 1. Facet of gait, balance or mobility
noted to possibly be deficientnoted to possibly be deficient2. Possible need for referral2. Possible need for referral3. To support care plan, treatment, 3. To support care plan, treatment,
skilled therapy, or establish objective skilled therapy, or establish objective goalsgoals
Community Outreach/Screening: TUG, Timed Community Outreach/Screening: TUG, Timed Stands, ABC, mFESStands, ABC, mFES
NOTE: These are only generalities, do NOT limit the choice of NOTE: These are only generalities, do NOT limit the choice of test based on setting.test based on setting.
What therapeutic interventions What therapeutic interventions work?work?
Strength and ConditioningStrength and Conditioning FlexibilityFlexibility Speed/power trainingSpeed/power training Dual-task/attention trainingDual-task/attention training Functional trainingFunctional training Cognitive TrainingCognitive Training
Eccentric WorkEccentric WorkLaStayo et al. compared LaStayo et al. compared
cardipulmonary rehab with LE cardipulmonary rehab with LE eccentric resistance in frail elderly. eccentric resistance in frail elderly.
Results: Eccentric work group showed:Results: Eccentric work group showed:↓ ↓ in TUG (16.65 to 11.96 seconds)in TUG (16.65 to 11.96 seconds)↑ ↑ in Berg (49.7 to 53.4)in Berg (49.7 to 53.4)
LaStoya et al. J Geron. 2003;58A(5):M419-424.LaStoya et al. J Geron. 2003;58A(5):M419-424.
Innovative treatment ideas:Innovative treatment ideas: Dynadiscs (static vs. dynamic balance)Dynadiscs (static vs. dynamic balance) ? One-legged stance? One-legged stance Corner vs. CountertopCorner vs. Countertop Eyes closed or not?Eyes closed or not? Lite GaitLite Gait Dual taskingDual tasking Backward gaitBackward gait Speed trainingSpeed training Conditioning and strengtheningConditioning and strengthening
Case Study #1: EarlCase Study #1: Earl 78 yo male 5 days post prostate 78 yo male 5 days post prostate
surgery onset of LE weaknesssurgery onset of LE weakness PMH CABG, “CVA’s”, SeizuresPMH CABG, “CVA’s”, Seizures PLOF: Highly active, Lived I, Walked PLOF: Highly active, Lived I, Walked
dog in park daily, Phase III cardiac dog in park daily, Phase III cardiac rehab.rehab.
Case Study #2: JuliaCase Study #2: Julia 82 yo female fell 6/04 w/ L hip fx w/ 82 yo female fell 6/04 w/ L hip fx w/
THATHA No falls since but is “very afraid”No falls since but is “very afraid” Meds: Plendil, Diovan, LexiproMeds: Plendil, Diovan, Lexipro PMHx: CVA 11 years ago, HTNPMHx: CVA 11 years ago, HTN
Case Study #3: BillCase Study #3: Bill 75 yo male w/ hx 4-5 falls in last 6 75 yo male w/ hx 4-5 falls in last 6
mos. Latest fall, “reached to floor mos. Latest fall, “reached to floor and just rolled”.and just rolled”.
PMHx: MVA w/ TBI & R LE fx ’60, R PMHx: MVA w/ TBI & R LE fx ’60, R RTC repair, C5-6 discectomy, CABG x RTC repair, C5-6 discectomy, CABG x 4, NIDDM4, NIDDM