Property of Horn & Neely. Not to be distributed or used without permission of the authors.

Transcription

1 Prac%cal Interven%ons For Balance Impairments In Older Adults Linda B. Horn, PT, DScPT, MHS, GCS, NCS Laurie Neely, PT, DPT University of Maryland School of Medicine Physical Therapy and Rehabilita%on Science Disclosure No relevant financial rela%onship or conflict of interest exists Combined Sec%ons Mee%ng 2016 Anaheim, CA February 17-20, 2016 Session Learning Objec%ves Iden%fy interven%ons that are specifically designed to address one or more balance impairments Describe components of an interven%on program based on the results of the PT examina%on Develop comprehensive balance interven%ons that are pa%ent- centered 79- year- old female Sustained a fall in her yard 6 weeks ago. She reports no injury and her husband needed to help her get up. PMH: COPD (stopped smoking 20 years ago), OA bilateral hips, mild thoracic kyphosis, osteopenia, and hypertension. Social hx: Lives with her husband in a 2 story home with 12 steps inside with rail and 6 steps with rail to enter/exit home. Prior level of func%on: Independent in all ac%vi%es and ambulated with no assis%ve device. CC: Fear of falling, mild dizziness when ge]ng OOB Medica%ons Symbicort (budesonide/formoterol) 2 puffs bid ProAir (atenolol sulfate) 2 puffs q 4-6 hrs as needed Calcium/vitamin D Vitamin D 2000 IU daily Fosamax (alendronate) 1 tab weekly Lisinopril 10 mg, 1 tab daily PT exam Mental Status: Alert & oriented x3 AROM/PROM: Grossly WNL except ankle dorsiflexion to neutral bilaterally (ac%ve and passive) Posture: Mild thoracic kyphosis Extensibility: decreased bilateral gastrocs and pectoralis the authors. 1

2 PT exam Strength UE: 5/5 throughout LE Bilat hip flex 4/5, ext 3/5, abd 3/5 Bilat knee flex & ext 4/5 Bilat ankle dorsiflex 4/5 in available range & plantarflex 3/5 Oculomotor exam: Saccades, smooth pursuit & VOR normal all direc%ons; posi%onal tes%ng nega%ve bilaterally Sensa%on: Light touch & propriocep%on intact bilat LEs Vital signs stable Modified CTSIB Firm surface EO & EC: 30 sec Foam surface EO 10 sec EC 0 sec DGI: 18/24 Bed mobility & transfers Independent sit to stand using arms Independent rolling in bed and supine sit Gait Ambulates 100 independently in clinic with a cane due to fear of falling, step length bilat Gait velocity: 0.70 m/sec TUG: 20 sec with cane THERAPEUTIC EXERCISE Hamstring Flexibility Bandy, y/o without LE orthopedic condi%ons One 30 sec stretch was just as effec%ve as >1 stretch and/or a 60 sec. compared to no stretching Feland, y/o (mean = 65 y/o) par%cipa%ng in the 1999 Senior Games Significant increase with one 32 sec sta%c stretch in subjects 65 yrs or older the authors. 2

3 Plantar Flexor Flexibility Tight gastroc and/or soleus may result in poor gait Knight, y/o without LE pathology Runner s Stretch done for 20 sec with a 10 sec rest 4x at each session; 3x/wk x 6 wks AROM & PROM using stretching, ac%ve heel rises, MH, & US Greatest in US group Trunk Rota%on Axial trunk rota%on important when older adult takes crossover step in response to perturba%on Hilliard, 2008 Knight, 2001 Strength LE weakness has been correlated with fall risk in normal elderly subjects Hip flexors, extensors, abductors Knee flexors, extensors Ankle dorsi- & plantar- flexors Desired % 1 RM STRENGTH TRAINING # Repe::ons 100% 1 95% 2 93% 3 90% 4 87% 5 85% 6 83% 7 80% 8 77% 9 75% 10 67% 12 65% 15 Gold standard - % of 1 RM 60% of 1 RM is lowest to induce strengthening On- line calculators hqp:// OneRepMax.html Strength Training Ankle dorsiflexion Tie Thera- Band around a phone book or heavy board. Pa%ent places foot under band on book and performs dorsiflexion. May need hold down edge of book with other foot Core Stabiliza%on using foam rolls Supine on whole roll or flat end of 1/2 roll for trunk stabiliza%on Property and of Horn & coordina%on Neely. Not to be exercises Toe Exercises Toe grasp exercises Gather a towel with the toes; a weight can be added as able Grasp the bean bag with the toes and move from one place to another These exercises were done 10 min, 3x/wk for 8 wks Results: Improved postural sway in exercise group Kobayashi, 1999 the authors. 3

4 Scapular adduc%on Chin tucks Trunk extension Posture Exercises NEUROMUSCULAR RE- EDUCATION Balance Treatment Ideas General Progression of Balance Exercises Sit stand Feet apart together semi- tandem tandem single limb stance Firm surface compliant/unstable surface Visually simple complex/conflic%ng Eyes open closed Single task dual task BALANCE TREATMENT IDEAS Sensory Re- Weigh%ng To force use of the visual system, work on compliant surfaces with eyes open To force use of ves%bular system, work on compliant surfaces with eyes closed or visually complex area/background To force use of somatosensory system, work on firm surface with eyes closed or visually complex area/background Ves%bular Exercises Older adults with c/o dizziness and nega%ve ves%bular func%on tests 90% of the group that performed gaze stabiliza%on exercises showed a clinically significant improvement in fall risk compared to 50% of the control group First study to show greater reduc%on in fall risk by adding adapta%on & subs%tu%on exercise to a balance rehab program Hall, 2010 BALANCE TREATMENT IDEAS Limits of Stability (LOS) Low tech Clip a headlamp on the waistband Weight shirs with the goal of pu]ng the light beam on the designated target. Can be performed standing on foam Use theraband around trunk to provide resistance Small wedge placed under the toes/forefoot will help stretch ankle plantar flexors with anterior weight shir the authors. 4

5 Reac%ve Postural Control Yungher, 2012 Number of protec%ve steps decreased with repeated exposure to lateral perturba%ons Treatment ideas Perturba%ons (shoulders, pelvis) Lean & release Cable with harness aqachment Other Balance Treatment Ideas Kick ball - alternate or random paqern Play catch Nerf ball, beach ball, Koosh ball, etc ; throw at various heights & loca%on Pop bubbles; can vary how far pa%ent has to reach as well as direc%on (watch for wet floor) Other Balance Treatment Ideas Lunges Stand and reach with UEs Four Square Step Test canes/pvc pipe Single limb support Side stepping Side stepping with ant or post crossover Braiding Twister board Other Balance Treatment Ideas Sway exercises- all direc%ons Rapid loading and unloading in lateral direc%on March in place Walking backwards/retrowalking Other Balance Treatment Ideas: Tai Chi Benefits Decrease fall risk and fear of falling: Wolf, 1996; Vouketalas, 2007; Gillespie, 2009 Inconclusive Unable to make defini%ve statement: Wu, 2002 No change Unable to show decreased fall risk: Logghe, 2009 Balance Training Task Specificity most studies have shown that balance ac%vi%es improve balance and gait ac%vi%es improve gait Rose, 2000 showed improvement in gait speed and func%on with a high intensity balance training program the authors. 5

6 FUNCTIONAL MOBILITY & ACTIVITIES Gait Training Gait training Different surfaces: firm, compliant, uneven, stairs, ramps Light vs. dark Least restric%ve assis%ve device Dual Task Head movement Changing direc%ons Func%onal ac%vi%es Gait Training Community ambula%on (Shumway- Cook, 2002) To perform IADL (shopping, doctor visit), older individuals walk an average 900-1,000 Considera%ons Need to be able to manage stairs (one flight), curbs, slopes, and uneven surfaces Aqen%onal demands need to be able to mul%- task (walk and talk especially if accompanied by another person on trips, find way in unfamiliar surroundings, etc) Interac%on with physical loads such as carrying packages, etc involves muscle force and an%cipatory postural control Gait Training Community ambula%on (Shumway- Cook, 2002) Considera%ons Gait speed especially if need to cross street Ambient condi%ons: light level and weather condi%ons Postural transi%ons including stopping, star%ng, changing direc%ons, reaching for objects Traffic density WALKING IS THE VERY BEST EXERCISE. HABITUATE YOURSELF TO WALK VERY FAR.. Thomas Jefferson, 1785 Func%onal Training Func%onal training can produce greater improvements in performing daily tasks than strength training alone Func%onal tasks Transi%oning from supine- sit- stand Walking at different speeds and with different tasks Walking in different direc%ons Stooping/squa]ng Krebs, 2007; devreede, 2005 the authors. 6

7 Func%onal Training Floor to sit/stand transfers Low Tech Balance Equipment Foam pads Swiss balls, air filled pads Tilt boards, wobble boards BOSU ball Foam rolls Many op%ons EXERCISE PRESCRIPTION FOR OLDER ADULTS Those who think they have not %me for bodily exercise will sooner or later have to find %me for illness. The Earl of Derby, 1873 Warm- Up For Older Adults 5-15 minutes Stretching is not a subs%tute for warming- up muscles for exercise muscle temperature by engaging in low- intensity movement similar to exercise preparing to perform External methods such as use of heat and non- specific movements may not be an adequate warm- up Exercise Prescrip%on Aerobic Ac%vity Frequency & Intensity Minimum of: Moderate intensity (5-6) 5 days per week; OR Vigorous intensity (7-8) 3 days per week; OR Combina%on of moderate & vigorous intensity 3-5 days per week Time: Moderate intensity min, vigorous intensity min; can be in 10 min increments Type: Walking, aqua%c exercise, sta%onary cycle ACSM, 2009 the authors. 7

8 Measurement of Aerobic Exercise Intensity Subjec%ve: Borg RPE on 20- point scale or 3-5 on 10- point scale = 60%- 80% ACSM for most individuals ( somewhat hard to hard ) if on beta blockers Talk Test (Persinger, 2004): Cardiac adapta%on occurs when pa%ent can just barely respond in conversa%on Measurement of Aerobic Exercise Intensity Objec%ve: Heart rate Target: 60%- 80% predicted max HR Calcula%ng max HR Max HR = 220- age May underes%mate max HR Karvonen method HRR (heart rate reserve) HRR = (220 age res%ng HR) + res%ng HR Exercise Prescrip%on Flexibility Frequency: at least 2 days per week Intensity: 5-6=moderate ac%vity Time: No recommenda%on Type: Any that consists of a sustained stretch of each major muscle group Exercise Prescrip%on Strength Training Frequency: at least 2 days per week Intensity using a perceived physical exer%on ra%ng 5-6=moderate ac%vity, to 7-8=vigorous ac%vity Time: NA Type: PRE (major muscle groups, reps), stair climbing and other ac%vi%es that use major muscle groups ACSM, 2009 Exercise Prescrip%on Cool Down For Older Adults Neuromuscular Training Frequency: 2-3 days per week Intensity: No recommenda%on Time: No recommenda%on Type: Progressively difficult postures changing BOS, dynamic movements that perturb COG (ie. tandem walk), stressing postural muscles (ie. heel & toe stands), reducing sensory input (stand EC), & tai chi 5-10 minutes Gradual in exercise intensity to Prevent blood pooling in LE risk of orthosta%c hypotension, dizziness, lightheadness, syncope, cardiac arrhythmias ACSM, 2009 the authors. 8

9 The key to effec%ve treatment of balance disorders is determining the type and severity of all of the impairments that are present and devising an individualized plan of care. American College of Sports Medicine. ACSM s Guidelines for Exercise Tes6ng and Prescrip6on. 9 th ed. Philadelphia, PA: Lippincoq Williams & Wilkins, Bandy WD, et al. The effect of %me and frequency of sta%c stretching on flexibility of the hamstring muscles. Phys Ther. 1997;77(10): Copeland JL, et al. Hormonal responses to endurance and resistance exercise in females aged years. J Gerontol Biolog Sci. 2002;57A(4):B158- B165. Creager CC. Therapeu6c Exercises using the Swiss Ball. Distributed by OPTP, Creager CC. Therapeu6c Exercises using Foam Rollers de Vreede PL, Samson MM, van Meeteren NLU, Duursma SA, Verhaar HJJ. Func%onal- task exercise versus resistance strength exercise to improve daily func%on in older women: A randomized, controlled trial. J Amer Geriatr Soc. 2005;53:2-10. Emilio, E. J. M. L., et al. The associa%on of flexibility, balance, and lumbar strength with balance ability: risk of falls in older adults. J Sports Sci Med. 2014;13: Feland JB, et al. Acute changes in hamstring flexibility: PNF versus sta%c stretch in senior athletes. Phys Ther in Sports. 2001;2: Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interven%ons for preven%ng falls in elderly people. Cochrane Database of Systema6c Reviews. 2003, Issue 4. Art. No.: CD DOI: / CD Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH. Interven%ons for preven%ng falls in older people living in the community. Cochrane Database of Systema6c Reviews. 2009, Issue 2. Art.No.: CD DOI: / CD pub2. Guccione A, et al. Geriatric Physical Therapy. 3 rd ed St. Louis, MO: Elsevier Mosby. Hall, C et al. Efficacy of gaze stabiliza%on exercises in older adults with dizziness. JNPT. 2010;34, Hilliard MJ, Mar%nea KM, Janssen I, Edwards B, Millie ML, Zhang Y, Rogers MR. Lateral balance factors predict future falls in community- living older adults. Arch Phys Med Rehabil. 2008;89, Hackney ME & Wolf SL. Impact of Tai Chi Chuan prac%ce on balance and mobility in older adults: an integra%ve review of 20 years of research. J Geriatr Phys Ther. 2014;37: Howe TE, Rochester L, Neil F, Skelton DA, & Ballinger C. Exercise for improving balance in older people. Cochrane Database of Systemic Reviews. 2011; Issue 11. Art. No.: CD Knight CA, et al. Effect of superficial heat, deep heat, and ac%ve exercise warm- up on the extensibility of the plantar flexors. Phys Ther. 2001;81(6): Kobayashi R, et al. Effects of toe grasp training for the aged on spontaneous postural sway. J Phys Ther Sci. 1999;11: Krebs DE, Scarborough DM, McGibbon CA. Func%onal vs. strength training in disabled elderly outpa%ents. Am J Phys Med Rehabil. 2007;86: Kressig RW, Wolf SL. Exploring guidelines for the applica%on of T ai Chi to pa%ents with stroke. Neurology Report. 2001;25(2): Li F, Fisher KJ, & Harmer P. Improving physical func%on and blood pressure in older adults through cobblestone mat walking: a randomized trial. J Amer Geriatr Soc. 2005;53: Logghe IHJ, et al. Lack of effect of Tai Chi Quan in preven%ng falls in elderly people living at home: A randomized clinical trial. J Amer Geriatr Soc. 2009; 57: Mulligan NFM, Tschoepe BA, & Smith MB. Balance retraining in community dwelling older adults. Topics in Geriatric Rehabilita6on. 2014;30(2): the authors. 9

10 Orr R., et al. Power training improves balance in healthy older adults. J Gerontol Med Sci. 2006;61(1), Persinger R, et al. Consistency of the Talk Test for exercise prescrip%on. Med Sci Sports Exer. 2004; Rose DJ, Clark S. Can the control of bodily orienta%on be significantly improved in a group of older adults with a history of falls? J Amer Geriatr Soc. 2000;48: Shubert TE. Evidence based exercise prescrip%on for balance and falls preven%on : a current review of the literature. J Geriatr Phys Ther. 2011;34(3), Shumway- Cook A. The effect of mul%dimensional exercises on balance, mobility, and fall risk in community- dwelling older adults. Phys Ther. 1997;77(1): Shumway- Cook A, et al. Environmental demands associated with community mobility in older adults with and without mobility disabili%es. Phys Ther. 2002;82(7): Voukelatas A, et al. A randomized, controlled trial of Tai Chi for the preven%on of falls: The central Sydney tai chi trial. J Amer Geriatr Soc. 2007;55: Wolf SL, et al. Reducing frailty and falls in older persons: an inves%ga%on of Tai chi and computerized balance training. J Amer Geriatr Soc. 1996; 44: Wolf S, et al. The effect of Tai Chi Quan and computerized balance training on postural stability in older subjects. Phys Ther. 1997;77: Wu G. Evalua%on of the effec%veness of Tai Chi for improving balance and preven%ng falls in the older popula%on- a review. J Amer Geriatr Soc. 2002;50: Yungher DA, Morgia J, Bair W, Inacio M, Beamer A, Preqyman MG, Rogers MR. Short- term changes in protec%ve stepping for lateral balance recovery in older adults. Clinical Biomechanics. 2012;27, the authors. 10