fall risk reduction program grading the task module #4 shelley thomas, mpt, mba dara coburn, m.s.,...
TRANSCRIPT
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
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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 randomlyWhole body movements to beat, hands on assistance, increased proprioceptive input in time to beat, visual mode
Hit opposite of beatHands 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
www.interactivemetronome.com/index.php/fall-risk-coaching
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