Fall Risk Reduction Program

Grading the TaskModule #4

Shelley Thomas, MPT, MBADara Coburn, M.S., CCC-SLP

Fall Risk Reduction Program: Review of Modules 1 -3

In the first module we reviewed the premise of the Fall Risk Reduction Program, including the inclusion criteria for patient selection

The second module reviewed patient assessment Identifying patients at risk of falling Evaluating patients in a dual task condition to

simulate “real life” situations The third module covered how to determine

which systems of balance were weakest and develop an exercise program for those systems

Module 4: Agenda

What IM scores mean

How to advance patient by modifying domains of challenge

Reassessment to gauge progress

IM Scores: Task Average Average number of milliseconds off the beat Lower task average indicates improved motor

planning and sequencing Short and Long Form Assessments will

provide a baseline task average. Repeat these assessments on regular basis to monitor progress. Don’t use task average of exercises performed to

determine if patient is improving because exercise difficulty can influence task average.

IM Scores: Variability Average

Average number of milliseconds from one hit to the next; is a measure of precision.

Lower variability indicates more precise, calculated motor control Variability average is comparing the patient

to him or herself, rather than the reference tone

IM Scores: Other Data% Super-Right-On

Highest-In-A-Row

Burst All these measures indicate

consistency of hits and can be correlated with improved motor control and sequencing

Fall Risk Reduction Program: Exercise Difficulty

In Module 3 we reviewed exercises that target each balance domain

Exercises can be made more or less difficult. Find that “sweet spot” for success – exercise is hard enough to challenge balance systems but doesn’t overly frustrate the patient? Exercise should be performed at one “level” more difficult than

person can perform safely or independently. Can also use task and variability average as a guide.

• Example: Patient clap hands rhythmically while seated but not standing, as indicated by task and variability average; Exercise difficulty should be focused on standing activities.

• Example: Patient can successfully perform IM if not distracted; Exercise difficulty can be increased by providing distractions (dual tasking)

Phase 1-3 Activities Reminder: Patient needs to

spend time in Phase 1-3 learning IM basics. Amount of time spend in these

phases dependent on patient’s learning curve.

Is the time they learn the “game”(i.e. when to hit trigger, what is the beat, what do guide sounds mean, etc.)

Begin IM exercises specific to balance systems in Phase 4

Advancing the Exercises

Utilize that IM scores to determine how to grade the exercises Task and variability average on Short Form Test or Long

Form Assessment more important than scores on exercises Difficulty of exercise can have significant impact on score

Use patient’s response to therapy to determine when and how to grade the task. Frustration level Success level Amount of cuing needed Retention of previous session

Domains of Challenge

Computer Challenge

Extremity Challenge

Postural

Challenge

Cognitive/Linguistic Challenge

Environmental Challenge

Domains of Challenge

Can manipulate five domains of challenge to make exercises more or less difficult

Rule of thumb - alter one domain at a time

Computer Challenge – Make an exercise easier or harder by adjusting . . .

Tempo speed Volume of repetitions Difficulty level Volume Guide Sounds Burst goal(s) Feedback

Extremity Challenge – Make an exercise easier or harder by adjusting . . .

Trigger placement Triggers placed closed to center of mass are

easier to hit than triggers placed further away• Increase difficulty even more by requiring weight

shift to reach, add weights or resistance bands Trigger sequence

Hitting one trigger is easier than hitting multiple triggers

• Increase difficulty by creating patterns that incorporate both sides of body, cross midline, or alternate between hand and foot taps

Postural Challenge – Make an exercise easier or harder by adjusting . . . .

Amount of postural support Postural variations:

Supine Sitting with back support Sitting without back support Sitting on unstable surface (physioball) Standing Standing on unstable surface (on floor mat,

balance board) Tandem stance on stable or unstable surface Unilateral stance on stable or unstable

surface

Cognitive/Linguistic Challenge – Make an exercise easier or harder by . . .

Combining a cognitive and IM task. Hit trigger while: Naming objects Digit recall Answering questions Mathematic manipulation

Environmental Challenge – Make an exercise easier or harder by adjusting . . . .

Complexity of the environment Quiet room Dark room Door open In busy hallway Outside On sidewalk next to traffic With background noise

Timing Tendency Strategy to Improve Performance

Consistently VERY early (task average is 200-400 ms range)

Increase tempo initially to go with patient’s timing tendency, then reduce over time, place distance between patient and trigger to build in distance and effectively delay hit.

Consistently VERY late (task average is 200-400 ms range)

Decrease tempo initially to go with patient’s timing tendency, then increase over time, hands on assistance, quiet environment to minimize cognitive distractions. Is it a movement issue or cognitive processing issue? If movement, is trigger within zone of available range of motion and strength?

Hit randomly Whole body movements to beat, hands on assistance, increased proprioceptive input in time to beat, visual mode

Hit opposite of beat Hands on assistance, modeling, visual mode to provide visual representation of the beat

Score significantly worse with guide sounds

Adjust difficulty level to easier setting, decrease volume of guide sounds, visual mode with guide sounds off (visual mode only), introduce guide sounds gradually by putting volume of some to zero.

Difficulty focusing or participating Shorter exercises in the beginning then gradually lengthen.

Applying Domains of Challenge

Computer: Easier or Harder -Increase or

decrease tempo Extremity

Easier -Use only one mat Easier -Place both mats in front

(harder to step backwards) Harder – Don’t allow a “dead beat”

when changing to other foot Posture:

Easier -Cane for balance Harder – Perform with eyes closed

Applying Domains of Challenge

Computer: Easier or Harder -Increase or

decrease tempo Extremity

Easier –Place colored targets closer to center of mass

Posture: Harder – Perform standing or

on sitting on physioball Cognition

Harder – Verbalize color of paper as patient taps

Applying Domains of Challenge

Computer: Easier or Harder -Increase or decrease

tempo Extremity

Easier –Place numbers on table instead of wall

Harder – Place higher on wall so reaching overhead

Posture: Harder – Patient stands farther away from

targets so greater weight shift is required Cognition

Harder – Verbalize number that is being tapped

Environment Harder – Perform in busy hallway or gym

Exercise Intensity & Frequency Repetition and frequent trainings are

necessary for progress Recommend IM training 3-4 times per week,

minimum of 1200 “hits” per session. • Typically takes about 30 minutes, including rest

breaks• IM Reports – General Reports – Total

Minutes/Repetitions If patient is unable to participate with this

intensity, gains will take longer

Sample Exercise Program

Link provided to a sample plan on the Materials Page

Sample treatment plan module 4.pdf

Reassessment to determine progress

Administer Short Form Test weekly Administer Long Form Assessment every 2-3 weeks Administer other standardized tests as appropriate Is the patient demonstrating improvement on

assessments? Report less falls? Report more confidence with balance? Can take 6-8 sessions to note changes in balance, motor planning, timing, and sequencing.

What is the patients tolerance for therapy? Do you need to increase the exercise challenge?

Homework

Complete worksheet provided on materials page to design exercise plan at appropriate challenge level for your patient. Use the same patient as in module #2 and #3. worksheet module 4.pdf

Post-test

Complete post-test to receive link for Module # 5 of 6

Materials Page This video

PowerPoint

Sample treatment plan

Module 4 worksheet

Post test

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