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
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, 1997 20-40 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, 2000 55-79 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
Plantar Flexor Flexibility Tight gastroc and/or soleus may result in poor gait Knight, 2001 17-50 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://www.exrx.net/calculators/ 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
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
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
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
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 30-60 min, vigorous intensity 20-30 min; can be in 10 min increments Type: Walking, aqua%c exercise, sta%onary cycle ACSM, 2009 the authors. 7
Measurement of Aerobic Exercise Intensity Subjec%ve: Borg RPE 11-15 on 20- point scale or 3-5 on 10- point scale = 60%- 80% ACSM 13-16 for most individuals ( somewhat hard to hard ) 13-15 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, 10-15 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
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