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Geriatric PT > COMPS:Posture and Falls > Flashcards

COMPS:Posture and Falls Flashcards

1
Q

Fall death rates in US inc ___% from 2007 to 2016 for older adults

A

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
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2
Q

Examination

*Important Exam Considerations…

A
  • 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.
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3
Q

Strength, Flex, Strategies

STRENGTH

A
  • MMT/Dynamom
    • hip Exts, knee Exts, DF/PF
      • NOTE: PF MOST FORGOTTEN
    • what mm is KEY for one leg stance?
      • glute med, PF’s!!!
  • 5x sts
  • heel rise test
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4
Q

Strength, Flex, Strategies

Flexibility

A
  • 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
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5
Q

Strength, Flex, Strategies

Strategies (think for balance)

A
  • Impaired balance strats
    • ankle, hip, step
    • Righting rxns
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6
Q

Literature: Resistance Training Interventions

A

see pics

Note resistance training, overload principle for TRUE DIFFs

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7
Q

How do you START Strength Training?

1RM in Older Adults

A
  • 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
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8
Q

Literature: Resistance Training Interventions

A

see pics

NOTE: Progression (high intensity 12 wk resistance progressing intervents), ankle DF ROM (strength usually OK, ROM not)

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9
Q

Interventions: HIIT

AMRAP

A
  • 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
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10
Q

Interventions: HIIT

EMOM

A
  • Specified # of reps, whatever time is left over is rest time
  • i.e. 10 reps
    • if takes 30s to do 10 reps, 30s rest
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11
Q

Interventions: HIIT

Guidelines/Goals

A
  • Exercises should be based off of physical exam findings/goals
  • Goal: safely overload mm’s
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12
Q

Interventions: HIIT

AMRAP Ex.

A
  • 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
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13
Q

Interventions: HIIT

EMOM Ex.

A
  • 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)
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14
Q

Postural Examination

*losing EXT

A
  • 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
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15
Q

Postural Examination

A
  • 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+
  • REEDCO posture scoring sheet (see pics)
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16
Q

Postural Examination Techs

2 Most Used:

A
  1. Wall-Occiput Distance (common, doesnt tell you problem, but good start)
  2. Rib-Pelvis Distance (looks @ L/S)
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17
Q

Postural Examination

Wall-Occiput Distance

A
  • <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
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18
Q

Postural Examination:

Rib-Pelvis Distance

*looks @ L/S

A
  • <2 finger breadth= risk for vertebral fx
  • Distance bw inferior margin of 12th rib and ASIS of pelvis
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19
Q

Flexicurve

A
  • Osteoporotic curve
    • see slide 14
  • Index of Kyphosis*=> (TW/TL)x100
    • see pics for norms
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20
Q

Impact of Falls

Stats

Most important***

A
  • 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 $$$
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21
Q

Literature: Interventions for Osteoporosis

A

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***
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22
Q

Literature: Interventions for Osteoporosis

A
  • 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***
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23
Q

Literature: Interventions for Osteoporosis

A
  • 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
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24
Q

Literature: Interventions for Osteoporosis

A
  • Special ex considerations include indiv programs of:
    • Stretching
    • Manual Tx
    • Low wts+more reps to min. stress on jts

*See pics for Studies

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25
Q

Literature: Interventions for Osteoarthritis (OA)

*not a focus of test

A

see pics

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26
Q

Screening Fall Risk: STEADI

Stopping Elderly Accidents, Deaths, Injuries

A
  • 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
  • Intervention:
    • Algorithm
      • Not @risk vs @risk
      • Individualized plan
      • Follow-up in 30-90d
27
Q

STEADI Algorithm for Fall Risk Screening, Assessment, and Intervention

*GOLD STANDARD

A

GOLD STANDARD***

28
Q

Other Risk Factors for Falls

A

See pics

NOTE: FOF→ considered red flag → assess right away

29
Q

Evaluation:

Balance

A
  • 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
30
Q

Evaluation: FOMs

what do we want to do w/ them in general?

A

Purposefully select tests that eval areas specific to ea. individual

31
Q

Evaluation: FOMs

Sitting Balance

A

Sitting Balance Test

32
Q

Eval: FOMs

Static Balance

A

Functional Reach

4 Stage Balance Test

One Leg Stance Test

33
Q

Eval: FOMs

Dynamic Balance

A
  • Gait Speed
  • TUG
  • Berg
  • Four Square Step Test
  • Tinnetti
  • DGI
  • Mini BEST→ reactive balance control
  • Fullerton Advanced Balance
34
Q

Eval: FOMs

Fear of Falling (FOF)

A

ABC Balance Confidence

Falls Efficacy Scale-International

*NOTE: non-billable

35
Q

Eval: FOMs

Strength

A

30s or 5xSTS

Heel Rise Test

36
Q

What CAN be done about Falls?

Literature says…

A

“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

37
Q

Rehab Dosage: Balance

IMPORTANT SLIDE!!! KNOW IT!!!!

******

A
  • 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
38
Q

Literature: Avin et al 2015

*Recommendations based on AGS/BGS CPG and National Institute for Health and Care Excellence (NICE) CPG

A
  • 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
39
Q

Interventions according to AGS/BGS & NICE study

A
  • 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
40
Q

Interventions: AGS/BGS & NICE study

NOT ADVISED**

A

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*****
41
Q

Literature: Sherrington et al 2008/2011

A
  • 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
    • 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
42
Q

Literature: Sherrington et al 2017

A
  • 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
43
Q

Interventions: Progressions

Ways to reduce UE support:

A
  • Palms up or Hands on higher surface/wall
  • Finger tips
  • One hand
  • One had palm up
  • One hand finger tips
44
Q

Interventions: Progressions

Ways to reduce BOS:

A
  • Split stance
  • Semi tandem
  • Tandem
  • Single leg***
45
Q

Interventions: Progressions

@ Ea stage progress w/:

A

Foam

Vertical and Horiz head mvmts

Eyes closed

46
Q

Interventions: Progressions

Cognitive Dual Task

A

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
47
Q

Interventions: Progressions

Motor Dual Tasks

A
  • 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
48
Q

Interventions: Agility Drills

*Treat them like athletes! Same principles!

A

see pics

Cone work

49
Q

Clock Yourself App

A

see pics READ!!!

50
Q

Literature: SUNBEAM PROGRAM

A

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

51
Q

Literature: SUNBEAM PROGRAM

A

USED HUR health/fitness equipment

Logs/tracks progress

52
Q

Literature: SUNBEAM

BALANCE EXERCISES

A

SEE PICS

53
Q

Literature: Reykjavik Model

NOT ON TEST

A

see pics have gen. understanding

54
Q

Literature: Reykjavik Model

Proprioceptive Training

A

EO then w/ EC

see pics

55
Q

Literature: Reykjavik Model

Vestibular and Eye Control

A

see pics

56
Q

Literature: Reykjavik Model

Proprioceptive and Vestibular Tx

A

see pics

57
Q

Literature: Reykjavik Model

Fall Reaction Training

A

see pics

58
Q

Preventative Strategies: At Home

In general…

A
  • 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 *****
59
Q

Preventative Strategies: At Home

When Assigning an HEP

Consider:

A
  • 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
60
Q

Preventative Strategies: At Home

Otago Exercise Program

A
  • Reimbursable thru Medicare Part B (outpatient), and endorsed by CDC
  • Reduces fall risk by 35%***
61
Q

Preventative Strategies: Group Programs

In general…

A

Research shows that home-based OR group settings are approp

62
Q

Preventative Strategies: Group Programs

2 Groups endorsed by CDC:

A
  1. Tai Chi: Move for Better Balance
  2. Stepping On
63
Q

Preventative Strategies: Group Programs

Tai Chi: Moving for Better Balance

A
  • 8 forms
  • emphasizes SLS/DLS, posture, breathing
  • 1hr, 3x/week for 6mos
  • Fall reduction of 55%***
64
Q

Preventative Strategies: Group Programs

Stepping On

A
  • Designed of OTs
  • 7 2hr/week sessions
  • Follow-up home visit
  • 3mo booster session
  • Fall rate reduction 35%, almost 60% in Men

Geriatric PT (7 decks)

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