COMPS:Posture and Falls Flashcards
Fall death rates in US inc ___% from 2007 to 2016 for older adults
30%
- 1/5 falls cause serious injury
- 3mil tx’d in ER/year
- 800,000+ pts hospitalized for falls
- head inj
- hip fx
- >95% hip fx caused by falling
- *Rule of Thirds
Examination
*Important Exam Considerations…
- Strength AND mm performance
- ex. dual tasking
- flex
- posture
- functional mob & abilities
- locomotion/gait analysis
- environ/equip set ups
- skin integrity
- sensation
- tone/motor control
- cognitive/mental status
- PMH, social hx
- pain assess.
Strength, Flex, Strategies
STRENGTH
- MMT/Dynamom
- hip Exts, knee Exts, DF/PF
- NOTE: PF MOST FORGOTTEN
-
what mm is KEY for one leg stance?
- glute med, PF’s!!!
- hip Exts, knee Exts, DF/PF
- 5x sts
- heel rise test
Strength, Flex, Strategies
Flexibility
- Ankle DF and Great Toe Ext
- NOTE: DF not usually culprit
- *look @ hip flexors and knee flexors
-
Shoulder ROM
- ex. if using an AD→ we want flexion
- Cervical ROM
- NOTE: DF not usually culprit
Strength, Flex, Strategies
Strategies (think for balance)
- Impaired balance strats
- ankle, hip, step
- Righting rxns
Literature: Resistance Training Interventions
see pics
Note resistance training, overload principle for TRUE DIFFs
How do you START Strength Training?
1RM in Older Adults
- Direct assess. NOT advised
- Determining 1RM:
- # of reps that completed w/ good form and NO substitution
- Reps and % of 1RM (ACSM)*****
- 90%→ 4-5reps
- 80%→ 8-9reps
- 70%→ 12-13reps
- 60%→ 16-20reps (Start HERE for most***)
- NOTE: Do NOT predetermine #reps during tx
- NOTE: not much diff bw 1-3sets→ set up circuit style training
Literature: Resistance Training Interventions
see pics
NOTE: Progression (high intensity 12 wk resistance progressing intervents), ankle DF ROM (strength usually OK, ROM not)
Interventions: HIIT
AMRAP
- AMRAP→ w/in specified time frame
- Track progress→ by how many reps pt can get in time frame
- NOTE: stop pt when form starts to break
Interventions: HIIT
EMOM
- Specified # of reps, whatever time is left over is rest time
- i.e. 10 reps
- if takes 30s to do 10 reps, 30s rest
Interventions: HIIT
Guidelines/Goals
- Exercises should be based off of physical exam findings/goals
- Goal: safely overload mm’s
Interventions: HIIT
AMRAP Ex.
- 4 moves: S2S, Tandem walk, Lunge, Farm walks
- 2 min for ea. exercise
- tabata apps
- Document: cues provided, reps or laps performed, any LOB, vitals***
- Ways to Progress: inc resistance, add dual tasks for walking balance, plyos
Interventions: HIIT
EMOM Ex.
- 4 moves: Squats, Heel raises, Step ups, Toe raises
- 8 reps for ea. ex.→ strengthening ex.
- Document: cues, amt of rest, vitals***
- Ways to Progress: Repeat circuit #x, inc resist, progress to power (lower reps)
Postural Examination
*losing EXT
- FHP
- Kyphosis
- Scoliosis
- L/S stenosis
- Rounded shoulders
- NOTE: if you FIX IT→ maintaining can be diff, sometimes fixing makes it WORSE→ Clinical Decision Making
Postural Examination
- FHP, kyphotic, rounded shoulders, DEC lumbar lordosis, INC hip/knee flex
-
FHP INCd risk of falls
- Influence of FHP on balance in Community Dwelling Women Age 60+
-
FHP INCd risk of falls
- REEDCO posture scoring sheet (see pics)
Postural Examination Techs
2 Most Used:
- Wall-Occiput Distance (common, doesnt tell you problem, but good start)
- Rib-Pelvis Distance (looks @ L/S)
Postural Examination
Wall-Occiput Distance
- <4cm= risk for t/s vertebral fx
- Pt stands straight w/ back against wall and heels touching wall. The dist bw the occipital prominence and wall is quantified using a tape measure.
- POSITIVE FINDING: inability to touch wall w/ back of head
Postural Examination:
Rib-Pelvis Distance
*looks @ L/S
- <2 finger breadth= risk for vertebral fx
- Distance bw inferior margin of 12th rib and ASIS of pelvis
Flexicurve
- Osteoporotic curve
- see slide 14
-
Index of Kyphosis*=> (TW/TL)x100
- see pics for norms
Impact of Falls
Stats
Most important***
- ¼ (25%) older people fall yearly,
- 20-30% older adults who fall suffer mod→ severe inj’s
- hip fx or head trauma
- inc risk of premature death
- Costly $$$
Literature: Interventions for Osteoporosis
See pics
- NOTE: Sinarki’s landmark study clearly demo’d
- EXT ex’s significantly reduced incidence of fx reoccurence
-
FLEX ex’s INCd risk
- Flex ex’s→ 89% fx
- EXT ex’s→ 16% fx***
- Flex + Ext→ 53%
- No Ex→ 59% fx
- NOTE: NO KTC ex’s, work on stability and EXT***
Literature: Interventions for Osteoporosis
- Special assess/exercises?
- FRAX score
- Meeks Method
- Spinomed
-
Safe ADL practices
- Moving safely
- Proper posture
- chair hts, head pos’s
- Hip hinge for push, pull, squat
- Log roll in bed
- Posture relief in sitting
- NO curl ups, no manipulations***
Literature: Interventions for Osteoporosis
- Phys activity generally regarded as an important stimulus for bone modeling/remodeling***
-
Wolff’s Law
- Bone adapts to loads placed on it**
- ***Load has to be thru long axis
- LAQ*
- Aquatic Tx*
- Pilates*
- Walking*
- Running
- Squats
- Push press
- Power clean
- Plyos
- NOTE: *’s=GOOD
Literature: Interventions for Osteoporosis
- Special ex considerations include indiv programs of:
- Stretching
- Manual Tx
- Low wts+more reps to min. stress on jts
*See pics for Studies
Literature: Interventions for Osteoarthritis (OA)
*not a focus of test
see pics
Screening Fall Risk: STEADI
Stopping Elderly Accidents, Deaths, Injuries
-
Assessment→ More physically based
-
Algorithm
- screening ?’s
- TUG (Reqd)
- (+)→ >/=12s
- 30s Chair Rise (Optional)
- (+)→ below avg score
- 4 Stage Balance Test (optional)
- (+)→ Full tandem <10s
- # of falls
- Inj vs. no inj
-
Algorithm
-
Intervention:
-
Algorithm
- Not @risk vs @risk
- Individualized plan
- Follow-up in 30-90d
-
Algorithm
STEADI Algorithm for Fall Risk Screening, Assessment, and Intervention
*GOLD STANDARD
GOLD STANDARD***
Other Risk Factors for Falls
See pics
NOTE: FOF→ considered red flag → assess right away
Evaluation:
Balance
-
Subjective:
- hx of falls?
- For ea recent fall:
- Where
- When
- Activity
- Time of Day
- Symptoms?
- Strength/ROM
- Cognition/Executive functioning
- Modified CTSIB
- Vision, Vestib, Somatosensory
Evaluation: FOMs
what do we want to do w/ them in general?
Purposefully select tests that eval areas specific to ea. individual
Evaluation: FOMs
Sitting Balance
Sitting Balance Test
Eval: FOMs
Static Balance
Functional Reach
4 Stage Balance Test
One Leg Stance Test
Eval: FOMs
Dynamic Balance
- Gait Speed
- TUG
- Berg
- Four Square Step Test
- Tinnetti
- DGI
- Mini BEST→ reactive balance control
- Fullerton Advanced Balance
Eval: FOMs
Fear of Falling (FOF)
ABC Balance Confidence
Falls Efficacy Scale-International
*NOTE: non-billable
Eval: FOMs
Strength
30s or 5xSTS
Heel Rise Test
What CAN be done about Falls?
Literature says…
“Effective strategies to prevent falls have been IDd, BUT are underutilized….dissemination of evidence, coupled w/ interventions to change clinical practice could reduce fall rates !!!
-Tinnetti, 2008
Rehab Dosage: Balance
IMPORTANT SLIDE!!! KNOW IT!!!!
******
- FOMs
- Good for screening and may be specific for a given condition
- MAY NOT TELL YOU WHERE DEFICITS LIE****
- App of motor learning principles
- see neuro cards
- GET THEM UP!!!
- Aim for Success about 75% of the time
- relate it back to motor learning→ something specific they’ve learned→ other 25% they actually fall and you catch them (pushing limits!!!)
- Needs to be MORE than strengthening or walking
-
50 hrs to truly reduce risk/optimize balance
- May be @ higher risk if <50hrs
- reqs client engagement outside of skilled care
Literature: Avin et al 2015
*Recommendations based on AGS/BGS CPG and National Institute for Health and Care Excellence (NICE) CPG
- HIGH qual study (first clinical practice statement (CPS))
- CPS is summary of CPGs
-
Screening
- Older adults in contact w/ HC provider should be asked whether they have fallen in prev year or are concerned about falls
- If yes, they should be screened for balance/mobility impairs
-
Assess/Intervention
- Positive Screen: PT/OT should use targeted multifactorial assess and intervents
Interventions according to AGS/BGS & NICE study
- Indiv’d intervents addressing specific impairs or risk factors
- Strength training
- Balance training (duration from Sherrington study→ Success 75% of time)
- Gait training
- Correct environ.
- Correct footwear
- ADs
- Added Pt of contact for enhanced proprioception & stability
- *Proactive approach when client has dementia!! (prior to Lvl 4)
- Tactile cue from AD
Interventions: AGS/BGS & NICE study
NOT ADVISED**
NOT ADVISED**
- Walking as a single intervention
- Non-specific or Low-intensity ex. or balance training
- Providing info w/out approp. follow-up
- Hip protectors
- Vit. D supps
- Will NOT reduce fall risk, only helps you not get hurt*****
Literature: Sherrington et al 2008/2011
- High qual study
- community dwelling older adults >60yo
- Following req’s for effective program:
- Mod→High challenge that reduces base of support (BOS), moves center of mass (COM), reduces UE support
- Strength training of LEs
- Jelly legs THEN balance training
- *progress to standing
- Jelly legs THEN balance training
- Total dosage AT LEAST 50hrs, 2hrs/wk over 6mos
- TWO hrs/week ongoing to maintain bennies
- Walking may be included, but cannot be sole intervention
- Needs to be performed in home-based OR group setting
Literature: Sherrington et al 2017
- system review/meta analysis exercise only
- Looked @ which aspects of intervention further reduce fall rate
- Overall, reduced rate by 21%
-
Following accounted for 76% of variability in programs and further reduced fall rate:
- HIGH challenge to balance that reduces BOS, moves COM, reduces UE support
-
More than 3hrs/week of exercise
- these 2 attributes reduced fall rates by 39%!!!
- Exercise was particularly effective in those w/ PD & Cognitive decline
Interventions: Progressions
Ways to reduce UE support:
- Palms up or Hands on higher surface/wall
- Finger tips
- One hand
- One had palm up
- One hand finger tips
Interventions: Progressions
Ways to reduce BOS:
- Split stance
- Semi tandem
- Tandem
- Single leg***
Interventions: Progressions
@ Ea stage progress w/:
Foam
Vertical and Horiz head mvmts
Eyes closed
Interventions: Progressions
Cognitive Dual Task
Cognitive Dual Task
- Counting backwards by 3’s (serial 3s)
- Spelling words backwards
- Naming diff types of: plants, clothes, stores, foods, teams
- or naming things starting w/ particular letter
Interventions: Progressions
Motor Dual Tasks
- Placing ball back and forth ea hand
- Placing penny in and out ea pocket
- Tossing ball up and down
- Bouncing ball
- Throwing ball back and forth
Interventions: Agility Drills
*Treat them like athletes! Same principles!
see pics
Cone work
Clock Yourself App
see pics READ!!!
Literature: SUNBEAM PROGRAM
NOT ON TEST
see pics and have gen. idea
*Sunbeam Program found to reduce the rate of falls and improved phys perform. in residents of aged care
Literature: SUNBEAM PROGRAM
USED HUR health/fitness equipment
Logs/tracks progress
Literature: SUNBEAM
BALANCE EXERCISES
SEE PICS
Literature: Reykjavik Model
NOT ON TEST
see pics have gen. understanding
Literature: Reykjavik Model
Proprioceptive Training
EO then w/ EC
see pics
Literature: Reykjavik Model
Vestibular and Eye Control
see pics
Literature: Reykjavik Model
Proprioceptive and Vestibular Tx
see pics
Literature: Reykjavik Model
Fall Reaction Training
see pics
Preventative Strategies: At Home
In general…
- Research will show home-based or group settings are approp.
- Older adult adherence to HEP is 21%
-
Ideal # of exercises/balance activities for HEP:
- 3-4/day *****
Preventative Strategies: At Home
When Assigning an HEP
Consider:
- Use RPE!!!
- Client preferences, perceived benefit of program
- Client perceived barriers to perform.
- Being flexible in your delivery while staying as consistent as poss w/ literature
Preventative Strategies: At Home
Otago Exercise Program
- Reimbursable thru Medicare Part B (outpatient), and endorsed by CDC
- Reduces fall risk by 35%***
Preventative Strategies: Group Programs
In general…
Research shows that home-based OR group settings are approp
Preventative Strategies: Group Programs
2 Groups endorsed by CDC:
- Tai Chi: Move for Better Balance
- Stepping On
Preventative Strategies: Group Programs
Tai Chi: Moving for Better Balance
- 8 forms
- emphasizes SLS/DLS, posture, breathing
- 1hr, 3x/week for 6mos
- Fall reduction of 55%***
Preventative Strategies: Group Programs
Stepping On
- Designed of OTs
- 7 2hr/week sessions
- Follow-up home visit
- 3mo booster session
- Fall rate reduction 35%, almost 60% in Men
