FALL PREVENTION. Looking At Falls From The Inside Out

Transcription

1 FALL PREVENTION Looking At Falls From The Inside Out Objectives 1.The learner will demonstrate an understanding of the basis of underlying impairments that lead to the falls, and understand how to choose assessment that address those impairments. 2.The learner will understand how to assess the components of an assessment, and understand the impact of an assessment on creating an appropriate plan of care to address underlying impairments leading to fall risks. 3.the learner will understand how to effectively use assessment data to create a treatment protocol. 4.the learner will demonstrate understanding of how an objective assessment can drive positive outcome measures. 1

2 Fall Statistics 1 out of 3 persons 65 years and older falls each year, most never tell their doctors 2.5 million are treated each year in the ER for fall-related injury At least 700,000 are hospitalized each year as a result of a fall, most with fractures or head injuries Direct medical costs for falls are $34 billion annually. At least ⅔ are hospital costs. At least 95% of hip fractures are due to falls. Falls are the most common cause of traumatic brain injuries Falls Falls are generally multifactor in nature resulting from several factors. Determining the Root Cause of a fall requires practitioners to assess for all risk factors that were instrumental in the fall. 2

3 Risk Factor Model for Falls in Older AGe Balance Balance- Ability to control the center of gravity over the base of support in a given sensory environment Center of Gravity- an imaginary point in space about which the sum of the forces and moments equals Zero equilibrium Sensory Environment-The conditions which exist or are perceived to exist in the real world around us that impact balance. 3

4 Postural Control 3 Major components of Postural Control Sensory Input Central Integration Process Motor Output t Dynamic Systems Model Sensory Determine Body Position Motor Choice of Body Movement Compare, Select and Combine Senses Visual, Vestibular, Somatosensory Select and Adjust Muscle Contractions Trunk, LE, UE, Eyes, Head Environmental Interaction Generation of Body Movement 4

5 Assessment Assessment/History of Falls Medication Review Visual Acuity Test Gait and Balance assessment Functional Assessment Physical Exam Environmental assessment Laboratory Testing Assessment Assessment/History of Falls Post fall assessment Activity at time of fall setting of fall time of day of fall frequency of falls equipment symptoms at the time of fall previous injuries and consequences 5

6 Assessment Medication Review Older adults taking more than 3 or 4 drugs were at increased risk of recurrent falls Medications associated with falls Nonsteriodal anti-inflammatory drugs Cardiac drugs diuretics antihypertensive agents B blockers Psychotropic drugs sedative/hypnotic antidepressants neuroleptics and antipsychotics Benzoidiazepines Narcotics/Opoids Assessment Visual Acuity Testing Visual Acuity Testing- Snellan Chart Clock Drawing- Visual Spatial Random dot stereotest-depth Perception Contrast Sensitivity-differentiate between finer increments of light versus dark Color Blind Testing 1. Visual factors should be assessed in older people presenting with falls or hip fractures; Age and Aging 2003;32: Copyright 2003, British Geriatric Society; Abdelhafiz, Ahmed; Austin, Christopher; 2. Screening for visual impairment in elderly patients with hip fracture; validating bedside test: J Eye (2005) 19, doi: /sj.eye Published online 7 May 2004.;Squirrell D, Kenny J, Mawer N, Gupta M, West J, Currie Z, Pepper I, Austin C: 6

7 Assessment Prior level of function Standardized Test Berg Get Up and Go Functional Reach Romberg ROM/Flexibility Contracture Measurements Functional mobility Neurological reflexes Digestive Pain Strength Gait analysis assistive device w/c management/positioning Response to position change Balance Firm surface Compliant surface Sitting Standing Cardiopulmonary Status Cognitive status SLUM Mini mental Allen cognitive disability Assessment Posture Center of gravity Over base of Support Trunk alignment Pelvic mobility Visual Perception Spatial Perception Communication Skin Integrity Bowel/ Bladder Incontinence sensation Risk of Falls Stepping strategy Hip strategy Ankle strategy Restraint use ADLs-self care Muscle Tone Vertigo Patient and family goals coordination endurance 7

8 ROM Decreased ROM of ankle joints limits ability of body to shift weight forward during transfers and gait. Hyperextension or limited extension of the knee joint prevents the knee from stabilizing during stance and supporting the weight of the upper body Limited Hip flexion creates increased difficulty with forward weight shift on a sit to stand transfer. Limited Hip extension creates an unstable seat for the pelvis and causes a shifting of the center of gravity Tightness of the hip adductors can cause a decrease in the base of support ROM Phys Ther Oct;80(10): Balance and ankle range of motion in community-dwelling women aged 64 to 87 years: a correlational study. Mecagni C1, Smith JP, Roberts KE, O'Sullivan SB. Subjects with less ankle ROM had worse test scores with functional reach and POMA gait assessment. 8

9 Strength Muscle weakness and reduced physical fitness, particularly to the lower body, are one of the most common intrinsic risk factors for falling. A panel of the American Geriatrics Society, British Geriatrics Society and American Academy of Orthopedic Surgeons(1) found it to be the most important risk factor, increasing risk of a fall by four to five times. 1.American Geriatrics Society; British Geriatrics Society and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. Journal of the American geriatrics society, Vol. 49, 2001, pp World Health Organization; Biological, Medical and Behavioral Risk Factors on Falls Dr. Nabil Kronfol Strength J Gerontol A Biol Sci Med Sci May;58(5):M The positive effects of negative work: increased muscle strength and decreased fall risk in a frail elderly population. These data demonstrate that lower extremity resistance exercise can improve muscle structure and function in those with limited exercise tolerance. The greater strength increase following negative work training resulted in improved balance, stair descent, and fall risk only in the ECC group 9

10 Assessment Functional Assessment Limitations with ADLs KATZ Index of Independent Activities of Daily Living Barthel Index of Activities of Daily Living Instrumental Activities of Daily Living Assessment Environmental Assessment Equipment Time of day Lighting Flooring Obstacles/clutter Footwear distractions height of bed/chair arrangement of furniture ease of movement of furniture adaptive equipment 10

11 Assessment Balance and Gait Assessment Gait exam Dynamic balance Movement over the base of support Functional Reach (Test limits of stability) Functional Test Berg Get up and Go BESTest Static balance Rhomberg Strength, Balance, Environment, 11

12 Gait Assessment Gait deviations can cause increased risk for falls. Most therapists use informal gait assessment. Use of timed gait tests, measures of stride length and width of base of support allow therapists to gain improved understanding of deviations and allow objective measures for creating treatment and goals. Deviations can vary based on diagnosis, most deviations can impair the patient s ability to correct with loss of balance. Berg Balance Assessment Berg Balance Scale Description: 14-item scale designed to measure balance of the older adult in a clinical setting. Equipment needed: Yardstick, 2 standard chairs (one with arm rests, one without), Footstool or step, Stopwatch or wristwatch, 15 ft walkway Scoring: A five-point ordinal scale, ranging from indicates the lowest level of function and 4 the highest level of function. Score the LOWEST performance. Total Score = 56 Interpretation: = independent = walking with assistance 0 20 = wheelchair bound Berg K, Wood-Dauphinee S, Williams JI, Maki, B (1992). Measuring balance in the elderly: validation of an instrument. Can. J. Pub. Health July/August supplement 2:S

13 Berg Balance Assessment Cut Off Scores: Score of < 45 indicates individuals may be at greater risk of falling (Berg, 1992) Berg K, Wood-Dauphinee S, Williams JI, Maki, B. (1992). Measuring balance in the elderly: validation of an instrument. Can. J. Pub. Health July/August supplement 2:S7-11 History of falls and BBS < 51, or no history of falls and BBS < 42 is predictive of falls (91% sensitivity, 82% specificity) (Shumway-Cook, 1997) Score of < 40 on BBS associated with almost 100% fall risk (Shumway-Cook, 1997) (n = 44, mean age = 74.6 (5.4) years for non-fallers, 77.6 (7.8) for fallers) Shumway-Cook, A., Baldwin, M., et al. (1997). Predicting the probability for falls in communitydwelling older adults. Physical Therapy 77(8): Retrieved from Rehab Measures Database. Comments: items Potential ceiling effect with higher level patients. Scale does not include gait Minimal Detectable Change: A change of 4 points is needed to be 95% confident that true change has occurred if a patient scores within initially, 5 points if they score within 35-44, 7 points if they score within and, finally, 5 points if their initial score is within 0-24 on the Berg Balance Scale. Donoghue D; Physiotherapy Research and Older People (PROP) group, Stokes EK. (2009). How much change is true change? The minimum detectable change of the Berg Balance Scale in elderly people. J Rehabil Med. 41(5): Norms: Activity Possible Impairment Possible Treatment Sitting to Stand Standing Unsupported Standing to sit Lower body or upper body weakness Poor dynamic center of gravity control Abnormal weight distribution Poor use of somatosensory input, impaired vision fear of falling Lower body weakness Lower and upper body weakness Decreased vision Decreased ROM Upper and lower body strengthening exercises with resistance (quads, biceps, triceps, hip abductor, hip adductors) Seated and standing balance activities emphasizing forward weight shifts Transfer training with first 45% of transfer trunk and hip flexion and second 55% of transfer trunk and hip extension Standing balance activities with eyes closed (controlled sway in A-P and lateral directions) Seated and standing balance activities with eyes closed Lower body exercises with resistance Lower and upper body exercises with resistance Compensation training of somatosensory and vestibular systems ROM of exercises and joint mobility 13

14 Activity Possible Impairments Possible Treatments Stand with eyes closed Poor use of somatosensory input, visual dependency, or fear of falling Seated and standing balance activities with eyes closed Lower body weakness Lower body exercises with resistance Transfers Lower extremity weakness Lower extremity strengthening exercises Standing and reaching forward with outstretched arm Decreased ROM Decreased proprioception Hip weakness Postural deviations Vestibular dysfunction Fear ROM and flexibility exercises to trunk and lower extremity Proprioception exercises Progressive resistive exercises for the hip and core musculature Postural symmetry treatment, posture training, and progressive resistive exercises for trunk Vestibular exercises Activities that require movement in multiple directions. Activity Possible Impairments Possible Treatments Turn 360º Poor dynamic control of the center of gravity Standing weight transfer activities, gait pattern enhancements ( turning and directional changes) Dynamic and static balance training Possible vestibular Exercises coordinating head and eye movements impairments Lower body weakness Decreased trunk and neck ROM Lower body exercises with resistance that emphasize hip and knee flexion and hip abduction and adduction ROM activities for the trunk and the neck both combined and separately Standing on one leg Ankle weakness Plantar flexion and dorsiflexion PREs Decreased ankle ROM Hip and knee weakness Decreased sensory input Vestibular dysfunction ROM and stretching exercises Lower extremity progressive resistive exercises Sensory exercises Vestibular activities 14

15 Balance Evaluation Systems Test: BESTest (Horak, et al. 2009) The original BESTest contains 36 performance test items that are categorized into 6 underlying systems that t may contribute t to balance impairment: i 1.Biomechanical Constraints 2.Stability Limits and Verticality 3.Anticipatory Postural Adjustments, Transitions 4.Reactive Postural Responses 5.Sensory Orientation 6.Dynamic Balance during Gait and Cognitive Effects. Horak FB, Wrisley DM, Frank J. (2009). The Balance Evaluation Systems Test (BESTest) to Differentiate Balance Deficits. Phys Ther. 89(5): Hass CJ, Bloem BR, Okun MS. (2008). Pushing or pulling to predict falls in Parkinson disease? Nature clinical practice neurology 4(10): BESTest: Biomechanical Constraints - Foot deformities - Center of Mass alignment - Ankle Strength and Range - Hip and trunk lateral strength - Stand up from floor 15

16 BESTest: Stability Limits/Verticality - Seated Lateral Lean: eyes closed - Standing Forward Reach - Standing Lateral Reach BESTest: Anticipatory/Postural Adjustments Tests actions that require changes in posture that require the body to anticipate the motion Sit to stand Single leg stance Tandem Stance Postural Adjusting Postural Adjusting Endurance Raising arms overhead 16

17 BESTest: Reactive Responses The patient leans into the tester until a position of instability bl is reach. The tester then will let go Assesses how many steps the patient must take to regain balance. Tester must be prepared to catch the patient. BESTest: Gait Stability - Timed Gait Speed - Changes in Gait Speed - Head Turns - Directional Changes - Stepping over obstacles - Timed Up and Go - Dual task Up and Go 17

18 Modified Clinical Test of Sensory Interaction in Balance -MCTSiB Description: The CTSIB was developed as a clinical version of the Sensory Organization Test to assess sensory contributions to postural control. The CTSIB involves the observation of a patient's attempt to maintain balance in various sensory conditions. The test provides the clinician with a means to quantify postural control under various sensory conditions. Equipment: Stopwatch (CTSIB / mctsib) x x 7.62 cm piece of medium density foam (upholstery foam, or high density foam) (CTSIB / mctsib) Modified Clinical Test of Sensory Interaction in Balance -MCTSiB Patients stand with their hands at their sides, feet together and perform the following 4 sensory conditions: 1. Stand on firm surface, eyes open 2. Stand on firm surface, eyes closed 3. Stand on foam surface, eyes open 4. Stand on foam surface, eyes closed The patient performance is timed for 30 seconds. Test is terminated when a subject's arms or feet change position. If a patient in unable to maintain the position for 30 seconds they are provided with 2 additional attempts. The scores of the 3 trials are averages Horak, F. B. (1987). "Clinical measurement of postural control in adults." Physical Therapy 67(12): ; Shumway-Cook, A. and Horak, F. B. (1986). "Assessing the influence of sensory integration on balance. Suggestions from the field." Physical Therapy 66:

19 Modified Clinical Test of Sensory Interaction in Balance -MCTSiB The subject is asked to perform 4 test conditions standing in a quiet stance with arms folded across chest. The therapist score the test on the amount of time the subject is able to maintain balance and the amount of sway demonstrated compared to eyes open on a firm surface. Test position Impairment Treatment Eyes closed on a firm surface (loss of visual cues) Impaired ability to integrate the somatosensory cues to maintain balance Stimulate the somatosensory by decreasing the visual input Eyes open on a compliant Impaired ability to integrate Stimulate the vision by surface (decrease the visual cues to maintain decreasing the somatosensory cues) balance somatosensory input Eyes closed on a compliant surface (loss of visual and decreased somatosensory cues) Impaired ability to integrate the vestibular cues to maintain the balance Stimulate the vestibular system by decreasing the visual and somatosensory input. Functional Strength Testing: 30 second timed sit to stand test Moderately Active Older Adults: Rikli and Jones, 2013; n = 2140 moderately active older adults Criterion fitness standards to maintain physical independence Age Women Men

20 Functional Strength Testing: Heel Raises Grading: 5/5 (N): Patient successfully raises heel from floor through range of motion of plantar flexion. Pt. should completes minimum i of 20 times in good form and without apparent fatigue. The tibialis posterior and the peroneus longus and brevis muscles must be 5/5 or 4/5 to stabilize the forefoot and provide counter pressure against the floor. (Note: Twenty heel rises represent over 60 percent of maximum electromyographic activity of the plantar flexors. 4/5 (G): A grade 4/5 is given if pt. can complete full range of motion between times and then has difficulty in completing the movement. Functional Strength Testing: Heel Raises Grading: 3/5 (F): 1-9 times 2+/5 (P): patient can just clear the heel from the floor and cannot get up on the toes for the end of test position There is no Grade 2 from the standing position Prone 2+/5 (P +): Pt. Position: prone with feet off end of table, patient able to plantar flex through available range of motion against maximal resistance 2/Poor patient completes plantar flexion range but tolerates no resistance 2-/Poor - patient completes only a partial range of motion 20

21 6 minute walk test Allows a therapist to determine if a patient can walk community distances Gait speed is a factor in fall risk Can see if endurance is a factor in fall risk Treatment How to develop an appropriate treatment Give the impaired system(s) the best environment in which to function Use slight challenges to the system Avoid exercises/activities too difficult. Want patient to succeed Provide safe exercise surroundings (corners) Vary the task Add challenges as the patient improves Input from other systems add concurrent task i.e. reaching for items while on a compliant surface Provide resistance as indicated 21

22 Treatments Should be based on specific assessment findings. - Pain - Range of motion: Stretching, joint mobilization, modalities - Strength: Power and Strength treatment - Balance: progressive static and dynamic activities - Footwear - Home Modifications - Vestibular Treatment: Power Generation Quick Sit to stand from low surface (14 inches) Step ups onto high step (14 inches) Hopping/jumping Monster walk--can use resistance band 22

23 Treatment: Strength Training Typically, strength (resistance) training aiming for hypertrophy is done at least 3 times a week for 8 to 12 weeks; a longer training period increases a more sustained effect. A classic training program consists of 3 to 4 sets with about 10 repetitions per muscle group, at an intensity of about 80% of the one repetition maximum. This recommendation does not differ from that for young people, but a lower one repetitionmaximum can be assumed. Treatment: Static Balance Narrow base of support stance, tandem stance, single leg stance. Progression can include reduced external support, medium density foam, cognitive secondary tasks, motor secondary tasks Wobble board treatments have been found effective in improving static balance 23

24 Treatment: Dynamic Balance Progression of tasks Single leg stance with non weight bearing foot on wall behind you eyes open eye movement head turns arm circles eyes closed head turns Treatment: Dynamic Balance Bilateral stance on foam eyes open head turns (horizontal and vertical) Arm circles Figure 8 s thumb marching place (increased space) eyes closed head turns count backwards by twos or threes 24

25 Posture assessment and treatment Postural Strategies hip strategy have patient stand in parallel bars and sway forward and backward with increased distance and speed. This will automatically pull in the hip strategy. progress by standing on a compliant surface or a surface that is not as wide as their feet i.e. a half roll and begin to sway. The more unstable the surface the sooner the larger hip muscles will be recruited. If the hip strategy is not a normal response for them the patient will step off the foam or narrow surface. Have a patient reach with their upper body for an object out of their base of support or reach will help kick in the hip strategy. Using a narrow beam, foam or rocker board. Postural assessment and treatment ankle strategy-have stand in the parallel bars and sway using the ankles. strengthen anterior tibialis, wall fall practice previous exercise with the eyes closed and on a compliant surface Step Strategy- have a patient lean forward as far as they can and still feel stable and then have them move their feet forward until they feel stable again. This activity initiates the stepping strategy. Can facilitate with a push/pull, step up and down from a step, eyes closed and head turn on foam, 25

26 Center of Gravity Static surface sitting with back support Static surface sitting without back support upper trunk stable but progressing g hands on chair hands on thighs hands on chest upper trunk dynamic single arm raise double arm raise diagonal arm raise voluntary trunk movement lateral l t l trunk rotation ti trunk lean forward and backward voluntary leg movement heel lift toe lift seated balance challenges small perturbations applied to the hip region surprise perturbations Center of Gravity Standing balance activities Standing balance with altered base of support standing with feet shoulder width apart standing with feet in split stance»eyes open and if no problems eyes closed 10 to 15 seconds stand with feet in a semi tandem position -eyes open and if no problems eyes closed 10 to 15 seconds standing tandem gait position -eyes open and if no problems eyes closed 10 to 15 seconds Single stance position Standing while performing a cognitive task Standing and performing an upper body task (catching a ball) Standing and performing lower extremity task Stand in the parallel bars and do multidirectional weight shifts, front to back and then turn and do side to side 26

27 Outcomes Pay for Value CMS moving from pay for fee to pay for value Supported by objective and measurable documentation Questions 27

28 Resources Mancini M, Horak F. The relevance of clinical balance assessment tools to differentiate balance deficits. Eur J Phys Rehabil Med Jun; 46(2): Jonsson E, Henriksson M, Hirshfeld H. Does the functional reach test reflect stability limits in elderly people? J Rehabil Med. 2002; 35: Hile S, et al. Interpreting the need for initial Support to Perform Tandem Stance Tests of Balance. Phys Ther Oct; 92(10): Woocott J, Richardson K, Wiens M, Patel B, Marin J, Kahn K, Marra C. Meta-analysis of the impact of 9 medications classes on falls in elderly persons. Arch Intern Med Nov 23: 169 (21): Abdelhafiz A, Austin C. Visual factors should be assessed in older people presenting with falls or hip fractures; Age and Aging 2003;32: Squirrell D, et al. Screening for visual impairment in elderly patients with hip fracture; validating bedside test: J Eye (2005) 19, doi: /sj.eye Published online 7 May Mecagni C, Smith J, Roberts K, O Sullivan S. Balance and ankle range of motion in community-dwelling women aged 64 to 87 years: a correlational study. Phys Ther Oct;80(10): Berg K, Wood-Dauphinee S, Williams JI, Maki, B. Measuring balance in the elderly: validation of an instrument. Can J Pub Health :S Horak, F. "Clinical measurement of postural control in adults." Physical Therapy (12): Shumway-Cook, A. Horak, F. "Assessing the influence of sensory integration on balance. Suggestions from the field." Physical Therapy : Balogan J. The effects of a wobble board exercise training program on static balance performance and strength of lower extremity muscles. J Physiotherapy Canada :4, Horak FB, Wrisley DM, Frank J. The Balance Evaluation Systems Test (BESTest) to Differentiate Balance Deficits. Phys Ther (5): Hass CJ, Bloem BR, Okun MS. (2008). Pushing or pulling to predict falls in Parkinson disease? Nature clinical practice neurology 4(10): Mancini M, Horak F. The relevance of clinical balance assessment tools to differentiate balance deficits. Eur J Phys Med Rehabil Med (2): Di Carlo S, et al. The Mini-Bestest: a review of psychometric properties. Int J Rehabil Res E Pub ahead of print. Rodriguez L, et al. Reliability of the balance evaluation systems test (BESTest) and BESTest sections for adults with hemiparesis. Braz J Phys Ther (3): Horak F, Wrisley D, Frank J. The balance evaluation systems test (BESTest) to differentiate balance deficits. Phys Ther (5):