Innovations in assessing and training balance reactions

Transcription

1 Innovations in assessing and training balance reactions Speakers Cynthia Danells PT, MSc; Clinical Resource Specialist and Clinical Research Coordinator, Toronto Rehabilitation Institute, University Health Network Avril Mansfield R.Kin, PhD; Scientist, Toronto Rehabilitation Institute, University Health Network; Affiliate Scientist, Evaluative Clinical Sciences, Hurvitz Brain Sciences Program, Sunnybrook Research Institute; Associate Professor (status only), Department of Physical Therapy, University of Toronto Janelle Unger PT, MSc; PhD candidate, Rehabilitation Sciences Institute, University of Toronto Learning objectives 1. Understand the components of balance control, specifically reactive balance control; 2. Be able to assess reactive balance control and underlying impairments; and 3. Be able to develop a person-specific reactive balance training program. A refresher on balance: definitions of terms and concepts Balance = ability to move without falling. You are either balanced or you are not; the opposite of balance is falling. Postural control = ability to control body position. Anticipatory balance control = ability to make appropriate adjustments before or during movement in anticipation of possible loss of balance (e.g., when moving from double support to single support at initiation of walking). A [postural] = sudden unexpected loss of balance. If you do not react appropriately to the, you will fall. Stability = ability to resist s. Reactive balance control = ability to react to stop a fall after a (i.e., hip or ankle strategy, taking a step, or reaching to grab something). The terms balance, stability and postural control are often used interchangeably, but are not strictly the same. Models of balance & falling Falls occur due to interaction between the individual, task and environment. 1 An individual with good balance can still fall when completing a challenging task and/or in a challenging environment (e.g., ice skating). Conversely, a person with bad balance might fall doing a very routine task in a relatively safe environment (e.g., walking on an even surface). 1

2 Another model of balance and falls considers the different tasks, and the movement strategies and physiological or biomechanical impairments that underlie balance control. 2 The overall goal is to complete various movement tasks (e.g., walking or other voluntary movements) without falling. Movement strategies can be implemented in anticipation of instability caused by falling, or as a reaction to a sudden unexpected postural. Various sensory, perceptual, cognitive, or biomechanical problems can lead to difficulty maintaining balance during movement. Alternatively, we can think about falls as happening due to loss of balance and a failure to recover from a loss of balance (i.e., due to poor reactive balance control). When people who have poor postural control and/or poor anticipatory balance control are mobile and physically active, they increase the risk of losing balance. Underlying sensorimotor and cognitive impairments (e.g., due 2

3 to aging or neurological disease) can lead to poor balance control, but can also lead to difficulty walking, which reduces people s mobility and the amount of physical activity they do. Over time, reduced physical activity can cause further declines in balance control. Falls can lead to physical injury, which can cause further impairments (e.g., due to head injury). Falls can also lead to fear of falling, which leads to further reductions in physical activity. 3 Clinical balance assessment The Berg Balance scale is the most frequently-used tool for assessing balance in clinical practice. 4-6 It is particularly frequently used in neurology and geriatrics. How do you use the Berg Balance Scale (or any similar performance-based rating scales) in your practice? Do you use the overall score? Or do you observe how your client performs a series of progressively more challenging tasks? The Berg Balance Scale does not assess reactive balance control, and few clinical scales do. For this reason, reactive balance control is not often assessed in clinical practice. 6,7 Reactive balance assessment The Balance Evaluation Systems Test (BEST) 8 is one of the few clinical assessment tools that includes assessment of reactive balance control. The BEST also assesses other domains of balance and fall risk from Horak s model described earlier. The instructions for the reactive control assessment included in the BEST provide a method to deliver a standardized and controlled that is repeatable. The assessment is feasible in clinical practice as it does not require any special equipment. To improve safety of the therapist and client, we recommend adding a safety harness to the assessment. We also recommend video recording the assessment so that you can go back and view the clients response, which can often be very quick, to catch anything you might have missed in the moment. Reactive balance training Reactive balance training (sometimes called -based balance training ) involves clients intentionally experiencing postural s so that they can practice and improve control of balance reactions. We believe it is important that they experience an actual /loss of balance in order to improve these reactions, although no study has determined if training the movements alone (e.g., voluntary stepping movements) can improve control of balance reactions. Previous research studies on reactive balance training have included older adults with multiple conditions, and people with Parkinson s disease and stroke. Reactive balance training can improve reactive balance control. 9 Improvements in reactive balance control can be seen with very little reactive balance training (e.g., just a training single session 10 ) and can be retained in the long-term (e.g., several months to a year) with little or no training in between. 10,11 There is evidence that reactive balance training can reduce the risk of falling in daily life. 12 3

4 Eligibility criteria for reactive balance training Clinical judgement will prevail, but please consider the following and when in doubt consult colleagues/md or err on the side of caution for self and patient. ** This table was developed based on criteria used in previous research studies and clinical practice at Toronto Rehab. You should use your clinical judgement with respect to patient & therapy related goals. Patients/therapists may choose not participate in reactive balance training if it is not relevant to the plan of care, despite being eligible for reactive balance training. General exclusion criterion: Illness, injury, or condition that may be exacerbated by repeated exposure to postural s or that would prevent wearing a safety harness. Contraindications Musculoskeletal * : -Lower extremity amputation -Weight bearing restrictions in lower extremity -Recent trauma, hip or knee arthroplasty or other surgery, fractures, soft tissue injury -Severe instability in hips, knees, ankles (could be MSK or neuro in origin) -Acute low back or lower limb pain -Halo -Aspen collar -History of lower extremity fragility fracture/severe osteopenia/osteoporosis -Contractures that prevent neutral hip or ankle Cardio-respiratory/vascular * : -Cardiac event or surgery where activity restrictions are still in effect -Abnormal or unstable cardiovascular responses to exercise -Arterial dissection Neurological * : -Missing bone flap without a helmet -Severe spasticity in the legs Precautions - consult with MD/healthcare team Musculoskeletal * : -Weight bearing restrictions in the upper extremity 2 -Osteoarthritis -Rheumatoid arthritis -Instability in hips, knees, ankles (could be MSK or neuro in origin) ** Cardio-respiratory/vascular * : -Tracheostomy -Postural hypotension/low blood pressure -Hypertension Neurological * : -Shoulder subluxation with sling ** -Missing bone flap with helmet -History of seizures -Epilepsy -Chronic subdural hemorrhage -Dizziness/vertigo -Poor sensation/proprioception 4

5 Functional * : -Unable to provide informed consent -Unable to stand unsupported with or without a gait aid Other * : -Acute illness vomiting, migraine, fever etc. -Bariatric patients (body weight exceeds limits of safety harness system) -Colostomy bags -Indwelling catheters -Infection Control (C-Diff) -Pressure sore on pelvis or trunk Other * : -Pregnancy -High anxiety/fear of falling -Cognitive impairments (decreased attention, impulsivity, low frustration tolerance, decreased judgement) -Communication impairments (inability to comprehend or follow instructions) -Medications affecting balance -Hypo/hyperglycemia -Hernias -Nasopharyngeal/gastrostomy tubes -Infection control (MRSA) consult with infection control and ensure appropriate precautions taken (gown, gloves, wipe down equipment) Additional notes: *When considering eligibility, also consider acuity and severity of injury. **Air Cast/sling/brace as needed if patient presents with joint instability, sensory impairment etc., for safety 5

6 Treatment planning for reactive balance training Area of dyscontrol Requires external assist to regain stability Does not step when magnitude of requires a step Has low foot clearance during step: foot slides, or shuffles Demonstrates delayed stepping reaction Is unwilling/unable to step with non-preferred limb Treatment suggestions Start with low-magnitude, increase magnitude as tolerated Consider other problems that contribute, like delayed stepping or no stepping Instruct participant to step when s/he feels unstable Start with low-magnitude s Start with predictable time/direction of Practice the step prior to Consider other problems that contribute, like unwillingness to step with paretic limb Use obstacles to force a step-over Instruct participant to step as quickly as possible Start with predictable time/direction of If delay is with non-paretic limb, have participant weight-shift to paretic limb prior to Block the preferred limb with obstacles, or hand/ foot of physiotherapist Instruct participant to step with non-preferred limb Start with predictable time/direction of Time to coincide with non-preferred leg/foot being un-weighted Additional treatment strategies/comments 6

7 Area of dyscontrol Demonstrates multi-step reactions Stands asymmetrically prior to Takes short steps Attempts to use upper extremity to regain stability Falls laterally on step termination Uses crossover steps to respond to lateral s Is unable to step equally well in all directions Treatment suggestions Instruct participant to take as few steps as possible Instruct participant to take long(er) steps Instruct participant to increase loading on the lessloaded limb Consider using video or feedback of stance symmetry Instruct participant to take longer steps Step to targets Step over obstacles Physiotherapist should stand as far away as safely possible Instruct to not use reach-tograsp reactions Have participant hold object to prevent grasping Instruct participant to take as few steps as possible Start with low-magnitude Try forward/backward s initially with a narrow base of support Instruct participant to use side-stepping strategy Place large obstacles in front and behind participant to deter cross-overs Use multi-directional s Do more s in the most challenging direction Additional treatment strategies/comments 7

8 References 1. Shumway-Cook A, Woollacott MH. Motor control: translating research into clinical practice. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; Horak FB. Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? Age Ageing. 2006;35(S2):ii7-ii Mansfield A, Inness EL, McIlroy WE. Stroke. In: Day BL, Lord SR, eds. Balance, Gait, and Falls. Vol 159: Elsevier; Jette DU, Halbert J, Iverson C, Micheli E, Shah P. Use of standardized outcome measures in physical therapist practice: perceptions and applications. Phys Ther. 2009;89(2): Sibley KM, Straus SE, Inness EL, Salbach NM, Jaglal SB. Balance assessment practices and use of standardized measures among Ontario physical therapists. Phys Ther. 2011;91(1): Oates A, Arnold C, Walker-Johnston J, et al. Balance assessment practice of Saskatchewan physiotherapists: a brief report of survey findings. Physiother Can. 2017;69(3): Gervais T, Burling N, Krull J, et al. Understanding approaches to balance assessment in physical therapy practice for elderly inpatients of a rehabilitation hospital. Physiother Can. 2014;66(1): Horak FB, Wrisley DM, Frank J. The balance evaluation systems test (BESTest) to differentiate balance deficits. Phys Ther. 2009;89: Mansfield A, Peters AL, Liu BA, Maki BE. Effect of a -based balance-training program on compensatory stepping and grasping reactions in older adults: a randomized controlled trial. Phys Ther. 2010;90(4): Pai Y-C, Yang F, Bhatt T, Wang E. Learning from laboratory-induced falling: long-term motor retention among older adults. Age. 2014;36: Mansfield A, Aqui A, Danells CJ, et al. Does -based balance training prevent falls among individuals with chronic stroke? A randomised controlled trial. BMJ Open. 2018;8:e Mansfield A, Wong JS, Bryce J, Knorr S, Patterson KK. Does -based balance training prevent falls? A review and meta-analysis of preliminary randomized controlled trials. Phys Ther. 2015;95(5):