beyond balance: evidence based practice enhancing quality of life in the geriatric patient

04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 11

Beyond Balance:Beyond Balance: Evidence Based Practice Enhancing Quali Evidence Based Practice Enhancing Quality of Life in the Geriatric Patientty of Life in the Geriatric Patient

Jenny Zimney, MPT, GCSJenny Zimney, MPT, GCS

[email protected]@northwestrehab.com

Northwest Rehabilitation AssociatesNorthwest Rehabilitation Associates1380 Liberty St. SE1380 Liberty St. SESalem, OR 97302Salem, OR 97302(503) 371-0779(503) 371-0779

http://northwestrehab.com/course-balance.html





Beyond Balance: Beyond Balance: What factors What factors

create safety and create safety and balance?balance?

Can I really Can I really impact the impact the frequent faller?frequent faller?

Can fear of falling Can fear of falling be overcome?be overcome?


Course Objectives:Course Objectives:Following today’s session you will be able to:Following today’s session you will be able to:1.1. Choose and implement the appropriate Choose and implement the appropriate

functional scale for their patient status and functional scale for their patient status and setting. setting.

2.2. Develop objective measurable treatment Develop objective measurable treatment interventions and goals based on the functional interventions and goals based on the functional scales used. scales used.

3.3. Discuss the rationale and purpose for each Discuss the rationale and purpose for each functional scale presented. functional scale presented.


Course Objectives cont’d:Course Objectives cont’d:4.4. Quantify a geriatric patients balance, Quantify a geriatric patients balance,

fear of falling and fall risk using the fear of falling and fall risk using the functional scales presented. functional scales presented.

5.5. Identify reliable reimbursement and Identify reliable reimbursement and marketing options for fall prevention marketing options for fall prevention programs in your community. programs in your community.

6.6. Make a greater impact on reducing falls Make a greater impact on reducing falls in your community!in your community!


Systems of BalanceSystems of Balance


Balance and Motor Planning:Balance and Motor Planning: What is my plan/objective?What is my plan/objective? What am I feeling?What am I feeling? What am I going to do about it?What am I going to do about it? Was this successful last time?Was this successful last time? What is my plan this time?What is my plan this time? Can my body do this (or) do this in Can my body do this (or) do this in

time?time?


Allum et al 2002 J PhysAllum et al 2002 J PhysChanges in Postural Control with AgeChanges in Postural Control with AgeResults:Results:

With perturbation on sway boardWith perturbation on sway boardYounger = Trunk rolls toward Younger = Trunk rolls toward from from perturbation (uphill)perturbation (uphill)

Older = Trunk rolls away from Older = Trunk rolls away from perturbation (downhill)perturbation (downhill)


Sensory SystemsSensory SystemsVision

VestibularVestibularSomatosensorSomatosensoryy


Age Related Changes: Age Related Changes: VisionVision

↓↓ visual acuityvisual acuity Impaired dark adaptationImpaired dark adaptation ↓ ↓ response to peripheral field visual response to peripheral field visual

stimulistimuli ↓↓ contrast sensitivitycontrast sensitivity Difficulties with accommodationDifficulties with accommodation Abnormal visual perceptionAbnormal visual perception


Age Related Changes: Age Related Changes: VestibularVestibular

Loss of hair cells in semicircular Loss of hair cells in semicircular canalscanals

Calcification in cupulaCalcification in cupula

““Thinning” of vestibular afferent Thinning” of vestibular afferent axonsaxons


Age-Related Changes: Age-Related Changes: SomatosensorySomatosensory

10-15% 10-15% ↓↓ nerve conduction velocity nerve conduction velocity

↑ ↑ Sensory detection thresholdsSensory detection thresholds

↑↑ Central processing timeCentral processing time

↑ ↑ latency of automatic postural responseslatency of automatic postural responses


Age related changes: Age related changes: Efferent SystemEfferent System

↑ ↑ Active muscle stiffnessActive muscle stiffness ↓ ↓ Muscle force and power generation Muscle force and power generation

capacitycapacity ↑ ↑ Variability of contraction amplitudes Variability of contraction amplitudes

for proximal/distal muscles of a for proximal/distal muscles of a synergysynergy

↑ ↑ of trials to adapt strategy for of trials to adapt strategy for perturbationperturbation


Age Related Changes: Age Related Changes: EtiologyEtiology

Normal changes associated w/ agingNormal changes associated w/ aging Decrease in physical Decrease in physical

activity/stimulationactivity/stimulation Disease states: Diabetes, PVD, CVA, Disease states: Diabetes, PVD, CVA,

vestibular dysfunctions, macular vestibular dysfunctions, macular degenerationdegeneration

ORORLearned non-useLearned non-use


TaskRequirements

AmbientConditions

Medications

Somatosensory

ROMHx of

Balance ReactionsTemporal

FactorsPhysical

Load

Comorbidities

MuscularPower/

Endurance

Attention/Cognition

Vestibular

EnvironmentalTerrain

ReactionTime

Vision

The EquilibriumOf

Balance


Common medications related Common medications related to falls:to falls:

Benzodiazapines (Valium, Ativan)Benzodiazapines (Valium, Ativan) Sedatives (Benadryl, Buspar)Sedatives (Benadryl, Buspar) Hypnotics (Xanax)Hypnotics (Xanax) Antipsychotics (Thorazine, Haldol)Antipsychotics (Thorazine, Haldol) Antidepressants (Elavil)Antidepressants (Elavil) Antihypertensives (Lopressor, Catapress)Antihypertensives (Lopressor, Catapress) Antianxiety (Librium)Antianxiety (Librium) Diuretics (Lasix, Diuril)Diuretics (Lasix, Diuril)


Balance Review: More Balance Review: More thoughts…thoughts…

Environmental DemandsEnvironmental Demands

Cognition/Attentional Demands Cognition/Attentional Demands

Self-Efficacy/Fear of FallingSelf-Efficacy/Fear of Falling


Environmental Demands and Environmental Demands and Balance/MobilityBalance/Mobility

36 older adults self reported trip log and 36 older adults self reported trip log and videotaped weekly (tracking 8 environ videotaped weekly (tracking 8 environ

dimensions) dimensions) Results: Temporal (speed), physical Results: Temporal (speed), physical

load, terrain and postural transitions load, terrain and postural transitions (head mvmt) distinguished those w/ (head mvmt) distinguished those w/ disabilities, 1/2 as many activities disabilities, 1/2 as many activities and had to be accompanied.and had to be accompanied.

(Shumway-Cook A, et al. Phys Ther. 2002;82:670-681)(Shumway-Cook A, et al. Phys Ther. 2002;82:670-681)


Attentional Demands:Attentional Demands:Static vs. Dynamic EquilibriumStatic vs. Dynamic Equilibrium6 healthy young subjects (20-30 yo)6 healthy young subjects (20-30 yo)Tested reaction time to auditory cue with Tested reaction time to auditory cue with

sitting, standing upright (broad and narrow sitting, standing upright (broad and narrow base, walking (SLS and DLS)base, walking (SLS and DLS)

Standing > sitting; Walking > sit or stand; Standing > sitting; Walking > sit or stand; SLS > DLSSLS > DLS

Conclusion: Balance control w/in gait is not Conclusion: Balance control w/in gait is not automatic.automatic.

Lojoie, Teasdale, Bard, Fleury. Exp Brain Res. 1993;97:139-144.Lojoie, Teasdale, Bard, Fleury. Exp Brain Res. 1993;97:139-144.


Attentional Demands of Attentional Demands of Obstacle NegotitationObstacle Negotitation

15 older adults vs. 15 younger adults15 older adults vs. 15 younger adults Testing reaction time to auditory cue Testing reaction time to auditory cue

with walking level and over foam with walking level and over foam block when in SLSblock when in SLS

Results: Pre-crossing and Crossing Results: Pre-crossing and Crossing were = in older adults were = in older adults

Brown, McKenzie, Doan. J Geron. 2005;60A(7):924-927Brown, McKenzie, Doan. J Geron. 2005;60A(7):924-927


Attentional Demands:Attentional Demands:Dual-task Methodology:Dual-task Methodology:1.1. Limited Central Processing CapacityLimited Central Processing Capacity2.2. Task performance requires part the Task performance requires part the

limited capacity within the CNSlimited capacity within the CNS3.3. If performing 2 tasks and that If performing 2 tasks and that

capacity is exceeded, 1 or both capacity is exceeded, 1 or both tasks can be disturbed.tasks can be disturbed.


Voluntary Step and Cognitive Voluntary Step and Cognitive TaskTask

66 healthy elderly vs. healthy young adults66 healthy elderly vs. healthy young adults Tested voluntary stepping on force plate Tested voluntary stepping on force plate

single task and w/ modified Stroop testsingle task and w/ modified Stroop testResults: Older adults withResults: Older adults withSingle task: 42-52% slower step initiationSingle task: 42-52% slower step initiationDual task: 190-256% slower, 41% no reaction Dual task: 190-256% slower, 41% no reaction Melzer, Oddsson. JAGS. 2004;58(8):1255-1262Melzer, Oddsson. JAGS. 2004;58(8):1255-1262


Fear of Falling Influences Fear of Falling Influences GaitGait

95 com-dwell older adults95 com-dwell older adults Gait parameters: speed, stride length, Gait parameters: speed, stride length,

step width, double limb support timestep width, double limb support time In fearful group, speed was slower, stride In fearful group, speed was slower, stride

shorter, step width larger and double shorter, step width larger and double limb support time was 6% longer.limb support time was 6% longer.

Chamberlin ME, Fulwider BD, Sanders SL, Medeiros JM. J Geron: Med Sci. 2005;60A:9:1163-1167Chamberlin ME, Fulwider BD, Sanders SL, Medeiros JM. J Geron: Med Sci. 2005;60A:9:1163-1167


Fear of Falling: Fear of Falling: Predisposing FactorsPredisposing Factors

6. No Emotional Support6. No Emotional Support5. Sedentary Lifestyle 5. Sedentary Lifestyle 4. Chronic Dizziness4. Chronic Dizziness3. Fall history w/ in previous year3. Fall history w/ in previous year2. Vision > 50% impaired2. Vision > 50% impaired1: Age > 80 Anxiety Trait 1: Age > 80 Anxiety Trait Murphy, Dubin, Gill. J Geron 2003;58A(10):M943-947.Murphy, Dubin, Gill. J Geron 2003;58A(10):M943-947.


Assessing Balance: Falls Assessing Balance: Falls HistoryHistory

How often do you lose your balance, How often do you lose your balance, i.e. slip, trip or stumble?i.e. slip, trip or stumble?

When was your most recent fall?When was your most recent fall? Did the fall occur inside or outside?Did the fall occur inside or outside? How did the fall occur?How did the fall occur? Were you injured?Were you injured? Were you dizzy when you fell?Were you dizzy when you fell?


Why use Functional Testing?Why use Functional Testing? Evidence-basedEvidence-based Demonstrate skillDemonstrate skill Establish GoalsEstablish Goals Guide to treatmentGuide to treatment Objective measure Objective measure

of progressof progress Prediction of future Prediction of future

eventsevents


Types of ReportingTypes of Reporting Self-Report**Self-Report** Clinician observation Clinician observation

and rating**and rating** Equipment-based Equipment-based

testingtesting

**Focus of Functional Test presented**Focus of Functional Test presented


Which is best?Which is best?

Self-Report

Clinical Observation

Proxy-Report


The Activities-specific Balance The Activities-specific Balance Confidence Scale (ABC)Confidence Scale (ABC)

Developed by Powell and Myers with input from Developed by Powell and Myers with input from 15 clinicians and 12 older outpatients to 15 clinicians and 12 older outpatients to quantify fear of falling quantify fear of falling

Type of Information:Type of Information: Self Report Self Report

Components:Components: 16 items of varying difficulty 16 items of varying difficulty rated on 0-100% scalerated on 0-100% scale Equipment needed:Equipment needed: Paper and pencil Paper and pencil

Time to Complete Test:Time to Complete Test: 5-10 minutes 5-10 minutes



Scoring:Scoring:> 80 = high functioning > 80 = high functioning older adult (I com. older adult (I com. Dwelling)Dwelling)50-80 = moderate level of 50-80 = moderate level of functioning (Chronic Health functioning (Chronic Health Conditions or ALF)Conditions or ALF)< 50 = low physical < 50 = low physical functioning (Home care)functioning (Home care)

Myers AM et al, Myers AM et al, J of Gerontol:Medical Sci, 1998J of Gerontol:Medical Sci, 1998



Strengths:Strengths: InexpensiveInexpensive Self TestingSelf Testing Examines Examines

community mobilitycommunity mobility Variety of situations Variety of situations

and environments and environments assists in treatment assists in treatment and goal settingand goal setting

Weaknesses:Weaknesses: Cannot use w/ Cannot use w/

significant cognitive significant cognitive impairmentimpairment

Imagination needed Imagination needed if not regularly if not regularly performedperformed

Very high ceilingVery high ceiling Nearly no floor Nearly no floor

effectseffects


Modified Falls Efficacy Scale Modified Falls Efficacy Scale (mFES)(mFES)

Adapted from Tinetti’s FES to quantify fear of Adapted from Tinetti’s FES to quantify fear of falling falling

Type of Information:Type of Information: Self Report Self Report

Components:Components: 16 items of varying difficulty 16 items of varying difficulty rated on 0-100% rated on 0-100%

scalescale Equipment needed:Equipment needed: Paper and pencil Paper and pencil




Scoring:Scoring:Items are scored from 0 to 10.Items are scored from 0 to 10.Total the ratings (possible range = 0 Total the ratings (possible range = 0 – 140) and divide by 14 to get each – 140) and divide by 14 to get each subject’s mFES score. subject’s mFES score. Scores of < 8 indicate fear of falling, Scores of < 8 indicate fear of falling, 8 or greater indicate lack of fear.8 or greater indicate lack of fear.



Strengths:Strengths: InexpensiveInexpensive Self TestingSelf Testing Assesses indoor and Assesses indoor and

outdoor situationsoutdoor situations More realistic More realistic

activities then ABCactivities then ABC

Weaknesses:Weaknesses: Cannot be used w/ Cannot be used w/ significant cognitive significant cognitive impairmentimpairment


ABC mFESVS


Timed “Up and Go”Timed “Up and Go”Developed by Richardson and Podsiadlo to Developed by Richardson and Podsiadlo to

assess basic mobility skills in older adults assess basic mobility skills in older adults Type of Information:Type of Information: Clinician Observation and Clinician Observation and ratingrating Components:Components: One Item- stand, walk 10 ft, turn One Item- stand, walk 10 ft, turn

come back and sit down.come back and sit down.

Equipment needed:Equipment needed: Stopwatch, Chair (46cm)w/ Stopwatch, Chair (46cm)w/ arms (65 cm)arms (65 cm)



Timed “Up and Go”Timed “Up and Go”Scoring:Scoring: >30 sec people that are more >30 sec people that are more

dependent, unable to climb stairs, dependent, unable to climb stairs, require AD, help with transfers, require AD, help with transfers, dependent in most activitiesdependent in most activities

<10 sec freely independent<10 sec freely independent <20 sec( I) transfers, I toilet, able to <20 sec( I) transfers, I toilet, able to

climb most stairs, go out alone climb most stairs, go out alone


Timed “Up and Go”Timed “Up and Go”Strengths:Strengths: Can use assistive Can use assistive

devicedevice Quick, easy, Quick, easy,

inexpensiveinexpensive Incorporates most Incorporates most

aspects of mobilityaspects of mobility Sensitive to changeSensitive to change Not diagnosis Not diagnosis

dependentdependent

Weaknesses:Weaknesses: Not usable for non-Not usable for non-

ambulatory patientsambulatory patients Ceiling – not Ceiling – not

challenging for challenging for community dwellerscommunity dwellers

Must be able to Must be able to follow directionsfollow directions

Only a few aspects Only a few aspects of balance are of balance are challengedchallenged


Normal Values of Balance Normal Values of Balance Tests in Women Aged 20-80Tests in Women Aged 20-80

456 women in 6 age cohorts456 women in 6 age cohortsTests: TUG, Step, FR, LRTests: TUG, Step, FR, LRResults: Results:

Linear change with Step and TUGLinear change with Step and TUGFR started to decline in 40’sFR started to decline in 40’sLR started to decline in 30’s!!!!!LR started to decline in 30’s!!!!!

Isles, Choy, Steer, Nitz JAGS 2004;52(8):1367-1372.Isles, Choy, Steer, Nitz JAGS 2004;52(8):1367-1372.


Berg Balance ScaleBerg Balance ScaleDeveloped to measure balance of the older Developed to measure balance of the older

adult in a clinical settingadult in a clinical setting Type of Information: Clinician observation Clinician observation

Components: 14 items of everyday tasks 14 items of everyday tasks rated on 0-4 scalerated on 0-4 scale Equipment needed: Ruler, Watch, 2 Ruler, Watch, 2

standard chairs, footstool or step, objectstandard chairs, footstool or step, object Time to Complete Test: 15-20 minutes 15-20 minutes


Berg Balance ScaleBerg Balance ScaleSpecifics of testing:Specifics of testing: No assistive device No assistive device

can be usedcan be used Must be able to Must be able to

stand unsupportedstand unsupported Forward reach w/ Forward reach w/

fingers fingers outstretched (36% outstretched (36% cannot do this)cannot do this)


Berg Balance ScaleBerg Balance ScaleScoring:Scoring: 41-56 low fall risk41-56 low fall risk 21-40 medium fall risk21-40 medium fall risk 0-20 high fall risk0-20 high fall riskAdditionally Additionally > 45 safe, > 45 safe,

independent independent ambulatorambulator

< 36 fall risk near < 36 fall risk near 100%100%


Berg Balance ScaleBerg Balance ScaleStrengths:Strengths: Challenging for Challenging for

healthy, Com. healthy, Com. DwellerDweller

Wide range of Wide range of difficulty and difficulty and patientspatients

Reliable for PD or Reliable for PD or CVACVA

Weaknesses:Weaknesses: Cannot use Cannot use

assistive deviceassistive device Ceiling effect for Ceiling effect for

high level high level functioningfunctioning


Physical Performance TestPhysical Performance TestDeveloped to assess function in community dwelling Developed to assess function in community dwelling

older adultsolder adults Type of Information: Clinician observation and ratingClinician observation and rating Components: 3 Versions (7,8,9 item tests) rated on 3 Versions (7,8,9 item tests) rated on

0-4 scale0-4 scale Equipment needed: Stopwatch, paper & pen, bowl Stopwatch, paper & pen, bowl

and 5 kidney beans, spoon, coffee can, heavy and 5 kidney beans, spoon, coffee can, heavy book, jacket or sweater, penny, 25-foot walkway, book, jacket or sweater, penny, 25-foot walkway, flight of stairsflight of stairs

Time to Complete Test: 15-20 minutes 15-20 minutesReuben, Siu. JAGS 1990;38(10):1105-1112Reuben, Siu. JAGS 1990;38(10):1105-1112


Physical Performance TestPhysical Performance TestSpecifics of testing:Specifics of testing: Timing is from the Timing is from the

word “Go”word “Go” Incorporates stair Incorporates stair

climbingclimbing


Physical Performance TestPhysical Performance TestScoring:Scoring: < 15 predictor of < 15 predictor of

recurrent fallsrecurrent falls

**Treatments, goals **Treatments, goals and other referrals and other referrals can be designed can be designed from each item.from each item.


Physical Performance TestPhysical Performance TestStrengths:Strengths: Can use assistive Can use assistive

devicedevice High ceilingHigh ceiling Measure multiple Measure multiple

areas of functionareas of function Responsive to Responsive to

change w/ change w/ functional trainingfunctional training

Weaknesses:Weaknesses: Requires equipmentRequires equipment Scale is ordinal- Scale is ordinal-

decreased decreased sensitivity to changesensitivity to change

May fail to challenge May fail to challenge multiple facets of multiple facets of balancebalance


Physical Performance TestPhysical Performance Test Schmidt et al: Schmidt et al:

Predictive of frail elderly dropout rates Predictive of frail elderly dropout rates in exercise program in exercise program (JAGS 2000;48(8):952-960)(JAGS 2000;48(8):952-960)

Brown et al:Brown et al: Differentiates Mild to Moderate Frailty Differentiates Mild to Moderate Frailty

(J Geron 2000;55A(6):M350-(J Geron 2000;55A(6):M350-355.)355.)


Dynamic Gait IndexDynamic Gait IndexDeveloped by Shumway-Cook and Wollacott to Developed by Shumway-Cook and Wollacott to

assess likelihood of falling in older adultsassess likelihood of falling in older adults Type of Information: Clinician observation and Clinician observation and

ratingrating Components: 8 facets of gait, 0-3 scale 8 facets of gait, 0-3 scale Equipment needed: box, 2 cones, stairs, at box, 2 cones, stairs, at

least 25 ft walkwayleast 25 ft walkway Time to Complete Test: 15 minutes 15 minutesShumway-Cook A, Woollacott A, Motor Control Theory and Practical Applications. Williams Shumway-Cook A, Woollacott A, Motor Control Theory and Practical Applications. Williams

& Wilkins, 1995& Wilkins, 1995


Dynamic Gait IndexDynamic Gait Index

Specifics of the test:Specifics of the test: Test gait at different speedsTest gait at different speeds Stepping over and around Stepping over and around

obstaclesobstacles Gait w/ head turns (horizontal Gait w/ head turns (horizontal

and vertical)and vertical)


Dynamic Gait IndexDynamic Gait Index

Scoring:Scoring:< 19 related to falls< 19 related to falls > 22 safe> 22 safe


Dynamic Gait IndexDynamic Gait IndexStrengths:Strengths: Can use assistive Can use assistive

devicedevice Examines 8 Examines 8

facets of gait facets of gait including speed, including speed, head turns and head turns and over obstaclesover obstacles

Weaknesses:Weaknesses: Only looks at Only looks at

gaitgait Not tested in Not tested in

many many populationspopulations


Whitney, Hudak, Marchetti Whitney, Hudak, Marchetti 20002000

Studied 247 patients with Studied 247 patients with vestibular disorders and found:vestibular disorders and found:

DGI effective to ID fall risk with DGI effective to ID fall risk with older and younger adults with older and younger adults with vestibular disordersvestibular disorders

J Vest Research 2000;10(2):99-105J Vest Research 2000;10(2):99-105


Functional Gait Assessment

DGI

=


Functional Gait Assessment Functional Gait Assessment (FGA)(FGA)

Developed by Wrisley et al. to increase Developed by Wrisley et al. to increase the sensitivity of DGI.the sensitivity of DGI.

Type of Information: Clinician observation Clinician observation and ratingand rating

Components: Equipment needed: 2 boxes, 2 cones, 2 boxes, 2 cones,

stairs, at least 25 ft walkway, stop stairs, at least 25 ft walkway, stop watchwatch

Time to Complete Test: 15 minutes 15 minutes


Functional Gait Assessment Functional Gait Assessment (FGA)(FGA)

Strengths:Strengths: Can use assistive Can use assistive

devicedevice More sensitive to More sensitive to

change than DGIchange than DGI Walking backward Walking backward Dual-taskDual-task Environmental Environmental

barrierbarrier

Weaknesses:Weaknesses: Only looks at gaitOnly looks at gait No scores No scores

published yetpublished yet


6-Minute Walk Test6-Minute Walk TestDeveloped to assess exercise tolerance in Developed to assess exercise tolerance in

cardio-pulmonary patientscardio-pulmonary patients Type of Information: Clinician observation and Clinician observation and

ratingrating

Component: Gait distance Gait distance

Equipment needed: Stopwatch, Stopwatch, sphygmomanometer, stethoscopesphygmomanometer, stethoscope

Time to Complete Test: 6-10 minutes 6-10 minutes


6-Minute Walk Test6-Minute Walk TestSpecifics of testing:Specifics of testing: Encourage patient to Encourage patient to

not talk during testnot talk during test Take vital signs pre Take vital signs pre

and postand post Patient can take Patient can take

standing restsstanding rests Termination of Termination of

testingtesting


6-Minute Walk Test6-Minute Walk TestScoring:Scoring: Few published Few published

normsnorms < 1000 ft (300m) < 1000 ft (300m)

indicative of indicative of morbidity w/in 6 morbidity w/in 6 months in heart months in heart diseasedisease

Median w/ healthy Median w/ healthy older adults older adults

Mean distance by age:

60-69 years: male 572m, female 538m




6-Minute Walk Test6-Minute Walk TestStrengths:Strengths: Can use assistive Can use assistive

devicedevice Sensitive to change w/ Sensitive to change w/

exercise trainingexercise training Safe due to patients Safe due to patients

self-limiting during self-limiting during testtest

Easy to perform, little Easy to perform, little equipment neededequipment needed

Weaknesses:Weaknesses: Must be able to Must be able to

stand and/or walk stand and/or walk 6 minutes6 minutes


Kristjansdottir et al 2004Kristjansdottir et al 2004Compared 6-MWT to Limited Graded Compared 6-MWT to Limited Graded

Exercise Test:Exercise Test:6-MWT effectively identified 6-MWT effectively identified cardiopulmonary concerns as did cardiopulmonary concerns as did graded test. graded test.

Conclusion: Good test for Conclusion: Good test for cardiopulmonary cardiopulmonary rehab…….Conditioning????rehab…….Conditioning????


Timed StandsTimed StandsDesigned to assess strength, mobility and Designed to assess strength, mobility and

enduranceendurance Type of Information: Clinician observationClinician observation

Component: Repeated standing up from Repeated standing up from seated position seated position

Equipment needed: Stopwatch, chair or matStopwatch, chair or mat

Time to Complete Test: 1-2 minutes 1-2 minutes


Timed StandsTimed StandsSpecifics of testing:Specifics of testing: Can be time to complete 5 reps, reps Can be time to complete 5 reps, reps

completed in 30 or 60 seconds.completed in 30 or 60 seconds. Patient is allowed to use any means Patient is allowed to use any means

necessary for standing up. (record necessary for standing up. (record need for UE’s)need for UE’s)


Timed StandsTimed StandsScoring: 30 second timed Scoring: 30 second timed

standsstands

Jones CJ, Rikli RE, Beam W. Res Q Exerc Sport. 1999;70:113-119

Normal Normal Range *Range * 60-64 65-69 70-74 75-79 80-84 85-89 90-94

Men 14-19 12-18 12-17 11-17 10-15 8-14 7-12

Women 12-17 11-16 10-15 10-15 9-14 8-13 4-11

*Normal range of scores is defined as the middle 50 percent of each age group. Scores above the range would be considered “above average” for the age group and those below the range would be “below average”.


Timed StandsTimed StandsScoring: 5 second timed standsScoring: 5 second timed stands

Lord, S.R. et al. J Gerontol A Biol Sci Med Sci. 2002; 57A(8):M539-M543.

Sit to Stand Time (Seconds) by Age and Gender

75-79 80-84 85-89 90+ Total

Men 12.1 (5.4) 12.9 (5.5) 13.7 (7.2) 17.2 (8.0) 12.8 (5.9)

Women 12.2 (4.1) 13.4 (5.6) 14.1 (6.5) 15.1 (6.5) 12.9 (5.1)

(SD) = standard deviation


Chair Stands as a Measure of Chair Stands as a Measure of LE Strength in Sexagenarian LE Strength in Sexagenarian

WomenWomen 47 women performed 5STS, 30STS, Isokinetic 47 women performed 5STS, 30STS, Isokinetic

testing of hip, knee and ankletesting of hip, knee and ankle Results:Results:

5STS: Ankle PF, Hip Flex & Knee Ext. 5STS: Ankle PF, Hip Flex & Knee Ext. 30STS: Ankle PF 30STS: Ankle PF But both only moderate predictors of LE strength.But both only moderate predictors of LE strength. Other factors: sensorimotor, balance, psychologicalOther factors: sensorimotor, balance, psychological

McCarthy et al. J Geron. 2004;59A(11):1207-1212.McCarthy et al. J Geron. 2004;59A(11):1207-1212.


Other Functional Other Functional AssessmentsAssessments

Short Physical Performance Battery – Short Physical Performance Battery – tandem stance, 5STS, gait speedtandem stance, 5STS, gait speed

(Guralnik et al. J Geron. 1994;49(2):M85-M94)(Guralnik et al. J Geron. 1994;49(2):M85-M94)

UAB Life-Space Assessment – Assesses UAB Life-Space Assessment – Assesses mobility in 5 designated environmentsmobility in 5 designated environments (Peel et al. Phys Ther. 2005;85:1008-1019)(Peel et al. Phys Ther. 2005;85:1008-1019)

NWRA Obstacle Course – UE dual task w/ NWRA Obstacle Course – UE dual task w/ gait over obstaclesgait over obstacles


Clinical Decision MakingClinical Decision MakingTests are chosen based on:Tests are chosen based on:1. Facet of gait, balance or mobility 1. Facet of gait, balance or mobility

noted to possibly be deficientnoted to possibly be deficient2. Possible need for referral2. Possible need for referral3. To support care plan, treatment, 3. To support care plan, treatment,

skilled therapy, or establish objective skilled therapy, or establish objective goalsgoals


More on More on Clinical Decision MakingClinical Decision Making

Individual patient needs guide assessment Individual patient needs guide assessment choice but setting distinctions may include:choice but setting distinctions may include:

Acute care, ALF, SNF, LTC & HH: Acute care, ALF, SNF, LTC & HH: TUG, 6MWT, Timed Stands, PPTTUG, 6MWT, Timed Stands, PPT

Outpatient: BBS, ABC, mFES, PPT, DGI, TUG, Outpatient: BBS, ABC, mFES, PPT, DGI, TUG, Timed Stands, 6MWTTimed Stands, 6MWT

Community Outreach/Screening: TUG, Timed Community Outreach/Screening: TUG, Timed Stands, ABC, mFESStands, ABC, mFES

NOTE: These are only generalities, do NOT limit the choice of NOTE: These are only generalities, do NOT limit the choice of test based on setting.test based on setting.


What do we do What do we do now?now?

What treatments work?


What therapeutic interventions What therapeutic interventions work?work?

Strength and ConditioningStrength and Conditioning FlexibilityFlexibility Speed/power trainingSpeed/power training Dual-task/attention trainingDual-task/attention training Functional trainingFunctional training Cognitive TrainingCognitive Training


Land vs. Aquatic ExerciseLand vs. Aquatic Exercise 11 older adults (ALF and outpatient) 11 older adults (ALF and outpatient)

Berg Balance Scale <47/56Berg Balance Scale <47/56 Comparable exercises on land and in Comparable exercises on land and in

water. 2x/wk x 6 weeks.water. 2x/wk x 6 weeks. Results: Significant improvements but Results: Significant improvements but

no difference between H2O and land-no difference between H2O and land-based.based.

Douris et al. J Ger PT. 2003;26(1):3-6.Douris et al. J Ger PT. 2003;26(1):3-6.


Eccentric WorkEccentric WorkLaStayo et al. compared LaStayo et al. compared

cardipulmonary rehab with LE cardipulmonary rehab with LE eccentric resistance in frail elderly. eccentric resistance in frail elderly.

Results: Eccentric work group showed:Results: Eccentric work group showed:↓ ↓ in TUG (16.65 to 11.96 seconds)in TUG (16.65 to 11.96 seconds)↑ ↑ in Berg (49.7 to 53.4)in Berg (49.7 to 53.4)

LaStoya et al. J Geron. 2003;58A(5):M419-424.LaStoya et al. J Geron. 2003;58A(5):M419-424.


Innovative treatment ideas:Innovative treatment ideas: Dynadiscs (static vs. dynamic balance)Dynadiscs (static vs. dynamic balance) ? One-legged stance? One-legged stance Corner vs. CountertopCorner vs. Countertop Eyes closed or not?Eyes closed or not? Lite GaitLite Gait Dual taskingDual tasking Backward gaitBackward gait Speed trainingSpeed training Conditioning and strengtheningConditioning and strengthening


Fall Prevention and You!Fall Prevention and You! Falls Free: Promoting A National Falls Falls Free: Promoting A National Falls

Prevention PlanPrevention Plan V15.88 History of Fall, new diagnosis V15.88 History of Fall, new diagnosis

codes to be implemented on October codes to be implemented on October 1, 2005 1, 2005

Falls Free ProgramFalls Free Program


Case Study #1: EarlCase Study #1: Earl 78 yo male 5 days post prostate 78 yo male 5 days post prostate

surgery onset of LE weaknesssurgery onset of LE weakness PMH CABG, “CVA’s”, SeizuresPMH CABG, “CVA’s”, Seizures PLOF: Highly active, Lived I, Walked PLOF: Highly active, Lived I, Walked

dog in park daily, Phase III cardiac dog in park daily, Phase III cardiac rehab.rehab.


Case Study #2: JuliaCase Study #2: Julia 82 yo female fell 6/04 w/ L hip fx w/ 82 yo female fell 6/04 w/ L hip fx w/

THATHA No falls since but is “very afraid”No falls since but is “very afraid” Meds: Plendil, Diovan, LexiproMeds: Plendil, Diovan, Lexipro PMHx: CVA 11 years ago, HTNPMHx: CVA 11 years ago, HTN


Case Study #3: BillCase Study #3: Bill 75 yo male w/ hx 4-5 falls in last 6 75 yo male w/ hx 4-5 falls in last 6

mos. Latest fall, “reached to floor mos. Latest fall, “reached to floor and just rolled”.and just rolled”.

PMHx: MVA w/ TBI & R LE fx ’60, R PMHx: MVA w/ TBI & R LE fx ’60, R RTC repair, C5-6 discectomy, CABG x RTC repair, C5-6 discectomy, CABG x 4, NIDDM4, NIDDM

Wife and dau assist prnWife and dau assist prn


Case Study #4: ShirleyCase Study #4: Shirley 64 yo female w/ severe onset of 64 yo female w/ severe onset of

dizziness that lasted 3-4 days, no just dizziness that lasted 3-4 days, no just “very unsteady”.“very unsteady”.

PMHx: dizziness onset 5 yrs ago, PMHx: dizziness onset 5 yrs ago, Hypothyroidism, Breast CAHypothyroidism, Breast CA

Meds: SynthroidMeds: Synthroid No Health InsuranceNo Health Insurance


Case Study #5: Myrt Case Study #5: Myrt 84 yo female 7/4/04 reaching to close 84 yo female 7/4/04 reaching to close

trunk when struck by car, fell w/ pelvic trunk when struck by car, fell w/ pelvic fx.fx.

3 weeks in nursing home3 weeks in nursing home Sister reports multiple fallsSister reports multiple falls c/o back pain, using quad cane, FWWc/o back pain, using quad cane, FWW PMHx: nothing significantPMHx: nothing significant Meds: Zetia, Multivitamin, NaproxynMeds: Zetia, Multivitamin, Naproxyn

beyond balance: evidence based practice enhancing quality of life in the geriatric patient

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