1	Getting a Foot Up on Fall Prevention: Balance Retraining-What Works Cindy Rankin, PT IHCA September 2005
2	FALLS and the Elderly “STAGGERING STATISTICS” 1 in 3 Elderly fall EVERY year Falls account for ½ of accidental deaths in Elderly 75% of ER visits by Elderly are due to a fall Cost of falls is $10 Billion per year 50% of elders over 75 who fall & fracture a hip will die within 1 year of injury The fear of falling discourage elders from being active which then increases their fall risk
3	Falls/Balance Assessment Identifying the fall risk is only 1 component of prevention and balance rehabilitation. Fall screens and risk assessment merely tag those who need further evaluation There are a number of clinical tests used to identify balance impairments
4	Balance Assessments You should use an approach which identifies intrinsic and extrinsic factors which contribute to falls The tools used should vary with the level of physical functioning. A thorough understanding of balance and mobility is needed
5	Extrinsic Risk Factors The floor: rugs, slippery floors, cords, wires, clutter, unrepaired surfaces Furniture: clutter, unstable, low chairs, low/high beds, low/high cabinets Lighting: glare, dimly lit, no night-lights Bathroom: low seats, no bars, unsafe bathing Home entry/exit Ground surfaces: wet leaves, snow, ice, rocks
6	Intrinsic Risk Factors Age: > 80 Medical Conditions & Diseases: Postural hypotension Foot problems Parkinson & other neuromuscular diseases TIA, CVA Arthritis DM Urinary Incontinence Heart Disease Acute Illness
7	More Intrinsic Factors Visual impairments Mental impairments: depression, poor judgment or dementia Walking speed Sensation & impaired reflexes Functional abilities: use of walker, cane History of falls Strength and overall mobility
8	"MEDICATIONS:" MEDICATIONS: Benzodiaxepams (antianxiety including Xanax, Valium, Ativan, Restoril,etc) Cardiac meds Diuretics Antihypertensives Alcohol Antiparkinson drugs Antipsychotics Sedatives ( Restoril, Trazodone, Phenobarbital) Antidepressants (Elavil, Prozac, Paxil, Zoloft) Medications to control dizziness (Meclizine, Phenergan, Valium)
9	The Components of Balance Posture and maintaining upright position normal sway & static posture Postural control strategies: Ankle Hip Step Flexibility & strength of ankles, knees, hips, spine Sensory systems
10	Sensory Systems N Eyes- Vision Feet-Somatosensory: spatial location, touch, vibration, pain O Inner Ear- Vestibular: movements of the head These systems work together to tell us who is moving- us or the environment.
11	Sensory Systems These systems are CRITICAL to successful balance training They are under- assessed Assess each individually & collectively
12	Changes with Age All systems continue to operate –though not as “sharp” or quick Combined with medical conditions & side effects of medication(s) --- maintaining balance becomes much more difficult
13	Fall Screens Nursing performs fall risk assessment as part of admission & with quarterly MDS Multidisciplinary team to perform fall investigation Assessment important whether part of assisted living, ICF, SNF, or in community housing. Those individuals at risk need further assessment to identify impairments & reduce fall risk.
14	Balance Assessment Tools Use different tools depending on the level of physical functioning. A complete listing of intrinsic risk factors should be included as well as a fall history. Thorough understanding of balance is the foundation for balance testing and successful rehabilitation. MUST include review of medications which are known to effect balance & dizziness
15	Clinical Balance Tools Easy to learn- just practice These scales which will guide proper therapy interventions Make it a standard of practice Read the directions- score alike Use the test items that the person “failed” to outline your balance retraining program Perform barefooted UNLESS they have orthotics
16	The Tests Functional Reach- Multidirectional Modified Clinical Test for Sensory Integration in Balance (M-CTSIB) Tinetti Berg Balance Scale, Dynamic Gait Index, Fullerton Timed Get-up-n-Go Balance Efficacy Scale Dizziness Handicap Inventory Oculomotor Screen
17	Multidirectional Functional Reach - MDFR Expanded version of the Forward Functional Reach- quick and easy to administer Evidence based Tests how far a person can reach by leaning Good practical safety applications for mobility & ADLs Looks at control of COG as a combination of flexibility, strength, sensory integration & fear.
18	MDFR
19	Modified CTSIB Perform up to 3 trials with each task Screening tool to guide the clinician to thorough testing of sensation, low vision evaluation, &/or vestibular testing. The test: 2 positions: 1. Standing with arms folded on chest & feet together---- eyes open then closed 2. Standing on foam with arms folded on chest & feet together--- eyes open then closed.
20	Tinetti Assesses both static balance & gait Use for lower functioning people As the person improves, use a different tool. Not predictive of fall when score is over 19/28 Read the instructions to ensure proper scoring Do not use ½ points Cannot perform if patient is non-weight bearing.
21	Berg Balance Scale Scores in a number of balance tasks with top score of 56. Gait is not assessed A score of 45 or below is associated with HIGH fall risk. Justifies skilled intervention Useful tool but there is a ceiling Again, read the directions for proper scoring The test is to be done WITHOUT an assistive device. Whenever the UEs are used , scoring is effected.
22	Dynamic Gait Index Reliable Useful for who score > 45 with Berg Assesses higher level gait skills: -With head turns -With pivoting -Stepping over an obstacle -Stepping around an obstacle -Steps/stairs
23	Timed Get Up and Go Time how long it takes to stand up from a chair without arms, walk 10 feet, turn around, walk back and sit down. Normal: 10 seconds or less Mild Fall Risk: 11-20 seconds AT Risk: 21-30 seconds HIGH Fall Risk: over 30 seconds
24	Fullerton Advanced Balance Scale Higher level skills Incorporates components of other tests 10 skills assessed: -mCTSIB -reaching -360 turn -step up and over -1 leg stance -2 footed jump -walk with head turns -reactive postural control
25	Balance Efficacy Scale Underutilized Rates self confidence with balance related skills 18 questions The fear of falling can be just as limiting as physical impairment
26	Dizziness Handicap Inventory List of 25 questions about the person’s complaints of dizziness or unsteadiness Triggers need for further Vestibular testing
27	NOW That We Have Identified the Impairments
28	Medication Reduction After thorough assessment work to REDUCE medications that suppresses or impairs the sensory system Consider this: Walking with sensory system suppressed is like trying to knit in the dark with mittens on.
29	General Principles Widen the base of support rather than automatically giving an assistive device The Evidence: several recent studies had good outcomes with fewer focused exercises 2 times per week for 12-25 weeks. Consider this: If you have a limp-you can walk 10 miles per day and still limp
30	General Principles Exercise Progression is very important 1^st Stability 2^nd Mobility 3^rd Multitasking Must work on symptom management of dizziness/vertigo
31	"THE ANKLE" THE ANKLE 58 % of balance comes from the ankle Evidence based: best stretch 1 repetition, standing calf stretch for 10 minutes Fast and slow strengthening Evidence based: best strengthening standing, multidirectional Evidence based: best reaction training: standing on foam or disc, multitask training with eyes open, closed and distracted FLAT heeled shoes, flexible sole Mobilize the ankle and toes Assess painful foot and ankle. Pain is not part of aging!
32	Balance Retraining -Flexibility & Strengthening The Hip Cannot stand upright if hips won’t extend Weakness in gluteals: 1^st to go –last to be treated. KEY in trunk stabilization in standing Assess function without assistive device The Evidence– BEST way to strengthen prone, keep knee flex (actively or passively) then lift leg into extension
33	Balance Retraining –Flexibility & Strengthening The Spine: Upright posture and postural control 1^st STRETCH –STRETCH-STRETCH start with upper body and neck The evidence: poor postural stability caused inaccurate perceptions of true vertical which leads to abnormal posturing. Work or seated posture & balance Wheelchair positioning is important to reinforce therapy
34	Final word on Strengthening The Evidence: therapists tend to not push the elderly- use more resistance Unless medically unsafe, follow the 1 repetition max testing and train at 80% or 8 rep max. Need power and endurance workouts Train the muscle specific to the task Recent studies support fewer but more focused exercises--
35	Sensory Training-Eyes, Ears, Feet The Central Nervous System is retrainable BUT it must be appropriately stimulated thru adaptation and habituation Consider this: You can’t break in a pair of shoes by wearing all the other pairs in the closet.
36	Sensory Training Train/stimulate the systems that are working to compensate for the one(s) that is permanently impaired Exercise should be designed to focus on 1 system & then systematically advanced as the level of recovery improves
37	Postural Strategies-Center of Gravity Drills On firm surface with eyes open (EO) On firm surface with eyes closed (EC) On semi stable surface with EO On semi stable surface with EC On dynamic surface with EO On dynamic surface with EC Add movement on each surface Add resisted movement on each surface
38	Dynamic Center of Gravity Drills Equipment – varies the surface for increase challenge Rocker board Sit-o-disc Foam Theraball Weight shifting- forward, back, left and right Lunges: forward, back, left and right Theraband Weighted ball Lifting and carrying Pushing and pulling
39	Gait Training Teach compensatory/protective strategies Practice WITHOUT the device Get Restorative Nursing going ASAP Widen the base of support Walk barefooted and with shoes
40	Closing Remarks If you don’t use it, you lose it. Functional Maintenance activity/exercise are critical For those impairments that can’t be “fixed”, training should focus on compensation and protection Thorough analysis will guide you to good intervention Focus on prevention of future falls
41	Successful Balance Training Starts with comprehensive assessment Uses this information to design an exercise program Incorporates multi-aspect training Applies this training to life skills Invokes physical and psychological confidence
42	Thank you Handout available on the Professional Therapy Services, Inc website: ptsinc.org