1

GERIATRIC BALANCE AND FALL PREVENTION

Theresa A. Schmidt, DPT,MS,OCS,LMT,CEAS

www.educise.com

Allied Health Education

Copyright 2016 by Educise Resources Inc. All Rights reserved.1

Provider Disclaimer

• Allied Health Education and the presenter of this

webinar do not have any financial or other

associations with the manufacturers of any products or suppliers of commercial services that may be

discussed or displayed in this presentation.

• There was no commercial support for this

presentation.• The views expressed in this presentation are the

views and opinions of the presenter.

• Participants must use discretion when using the

information contained in this presentation.

Instructor: Theresa A. Schmidt, DPT,MS,OCS,LMT,CEAS,DD

Physical therapist specializing in orthopedic rehab, muscle energy,

joint mobs, myofascial release, craniosacral & visceral

manipulation, precision exercise, medical massage, bioenergy,

functional training and evidence-based integrative medicine.

Owner of Flex Physical Therapy and

Educise Resources Inc, Northport, NY.

www.educise.com3

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Introduction

Who hasn’t heard the commercial in which an elderly person exclaims:

“I’ve fallen and I can’t get up!”

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Falling is Part of Life

Unfortunately, it may also result in death or injury.

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Adequate Balance

Many mechanisms in the body contribute to

postural control in order to maintain

equilibrium and prevent or recover from falls

The ability to maintain the center of gravity over

the base of support is the essence of balance

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What is Balance?A state of equilibrium:

“Adequate postural control requires keeping the center of gravity over at the base of support

during both static and dynamic situations. The

body must be able to respond to translations of

the center of gravity voluntarily imposed, e.g.,

intentional movement, and in voluntarily or

unexpectedly opposed, e.g., slip, trip.”

(Guccione, AA, p. 282)7

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Postural Reflexes

• To maintain equilibrium, the center of gravity is

stabilized to allow for postural changes and

movement, either in response to (unexpected) or

in anticipation of (expected) positional changes:

a displacement of the C of G (center of gravity)

• Automatic postural responses attempt to make

corrections when the C of G is perturbed away

from the BOS (base of support)(Guccioine, p. 283)

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4

Balance Physiology: Three Systems

• Sensory System: proprioceptors

detect body’s relative position in space and respond accordingly to changes in position and

trajectory

• Central Processing System: brain

determines response to perturbation

• Effector System: muscles

Perform the movements to effect a response(Guccione, p. 282)

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Sensory System

• Somatosensory

• Vestibular

• Visual

• All three contribute input to central processing

of positional information for response

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Sensory: Somatosensory

• Proprioceptors

– in joints, muscles, tendons

– detect changes in length and velocity of motions

Strength and flexibility are reduced in aging

Perception of position may be altered by peripheral

neuropathy, injury, biomechanical faults or disease

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5

Sensory: Vestibular

Vestibular Labyrinth: inner ear senses head motion and position from two sources:

- Semicircular canals: 3 fluid-filled structures sense direction and velocity of rotary motion as fluid moves

-Otoliths: utricle and saccule-

detect linear acceleration (straight line motion),

as head moves, otoconia (calcium stones) move over the hairs lining the organ

(From: http://www.betterbalance fall prevention.com/images/ResearchArticle. Accessed 2/21/13)

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Vestibular Disorders

• Symptoms: dizziness, lightheadness,

disorientation, sense of spinning (vertigo),

floating, blurry vision, nausea, feel like falling

• Types:

– Peripheral vestibular- labyrinth problem

– Central vestibular-CNS disorder

– Systemic- in the body

– Cardiovascular- circulatory disorder(From: http://www.betterbalance fall prevention.com/images/ResearchArticle. Accessed

2/21/13)

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Vestibular Diagnoses• BPPV: benign paroxysmal positional vertigo-

specific head motions cause sudden, temporary vertigo, no known cause

• Menieres disease- fluid balance disorder in inner ear with tinnitus, loss of hearing, vertigo, full feeling in the ear, no known cause

• Perilymph fistula- fluid leakage from inner to middle ear, may be due to injury

• Vestibular neuritis- infection of vestibular nerve

• Labyrinthitis- inner ear infection(From: http://www.betterbalance fall prevention.com/images/ResearchArticle. Accessed 2/21/13)

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6

Sensory: Visual

• Depth perception- 3-D distance perception

• Visual acuity- sharpness of shapes

• Contrast sensitivity- detect difference in patterns

and shading

-Loss in aging correlates with fall risk in elderly (Lord,

(SR, Clark, RD, Webster, pp. 175-181)

• Peripheral vision- lateral vision while looking

forward

(Guccione, pp. 282-283)

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Central Processing

• Postural response is preprogrammed by CNS

• “the CNS receives sensory information provided by the visual, vestibular, and somatosensory

systems;

• processes it in the context of previously learned

responses; and

• executes a corrective automatic postural

response that is guided by or expressed through

the mechanical structure in which it sits.”(Guccione, p. 283)

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Nashner’s Postural Response Model

Normal postural control reaction to outside perturbations uses 3 mechanisms:

• Ankle Strategy

• Hip Strategy

• Stepping Strategy

• C of G = center of gravity

• BOS= base of support

(Guccione, p. 283) 18

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Ankle Strategy

• Works in response to minimal displacement of

C of G over BOS in ant/post directions

• A corrective motion occurs primarily about the

ankle joint, with the upper body more rigid

• Normal adult latency: 100-120 msecs.

• Normal sequence: LE muscles recruited from

distal to proximal

• (i.e. tibialis anterior> quads; or gastroc>hams

activation sequence) (Guccione, p. 283)

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Hip Strategy

• Acts in response to greater displacement of

in A/P directions

• Corrective motion occurs primarily about the hip

joint, with the upper body more rigid

• Normal adult latency: 100-120 msecs.

• Normal sequence: LE muscles recruited from

proximal to distal

• (i.e. glutes>hams>gastrocs) (Guccione, p. 283)

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Stepping Strategy

• In response to perturbation taking the C of G

beyond the BOS

• Response involves patient

stumbling or stepping

to restore balance

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8

Other Balance Response Strategies

• Taking extra lateral steps

• Excess trunk and arm motions, grabbing a

handrail or swinging arms

• Patterns of response and response timing varies

between individuals

• In aging adults, there is a higher incidence of

antagonist muscle co-contraction and proximal

to distal activation than in normal adults

(Guccione, p. 284)

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Timing Delays Increase Fall Risks

• “Studenski and colleagues reported evidence of

delayed latency in older fallers when compared

with age-matched nonfallers.

• Latencies are not only delayed in the healthy

older adult but are even further delayed in the

older person with a history of unexplained falls.” (Guccione, p. 284)

• It’s interesting how research portrays information.

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Effectors: Musculoskeletal• Posture- malalignment shifts weight

• Range of Motion- poor flexibility contributes to lack of corrective strategies to restore balance (LE, cervical, trunk)

• Strength/ power- inadequate strength and slow response times contribute to ineffectiveness in returning to prior position (dynamometer: hip/knee/ankle)

• Endurance- Fatigue contributes to inability to remain in equilibrium over time (use 6 min. walk test: distance covered in 6 minutes)

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AGING AND BALANCE

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The Problem of Falling

Most falls are not very dramatic; as a matter of

fact, everyone falls at some point in life.

Unfortunately, the consequences of falling are

considerably worse as one ages.

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Epidemiology

Incidence, Morbidity and Mortality

• One-third of adults over 65 fall annually

• Falls are the most common cause of hospital

admission and injury death in adults over 65.

• Falls cause the most fractures in adults over 65,

95% of hip fractures are due to falls

• Women who fall have more than double the risk

of fracture than men

(From: http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. Accessed 2/25/12.)28

Nursing Home Residents Fall Stats

• “nursing home residents account for about 20% of deaths from falls” in adults over 65”

• Annually there are 100-200 falls reported in

100-bed nursing homes

• 50 to 75% of residents fall annually

• Residents experience about 2.6 falls each year.

(from: http://www.cdc.gov/HomeandRecreationalSafety/Falls/nursing.html. Accessed 2/25/12)

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Risk Factors in Aging

• Musculoskeletal:

-joint and myofascial stiffness

-muscle weakness

-postural asymmetry

“Muscle weakness and walking or gait

problems are the most common causes of

falls among nursing home residents.”

(From:http://www.cdc.gov/HomeandRecreationalSafety/Falls/nursing.html. Accessed

2/25/13)

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Risk Factors in Aging

• Altered vestibular sensitivity

• Motor planning deficits

• Reduced perceptual cues: low or poor vision or

attending to incorrect environmental cues

(depth perception, focus, attention)

• Delayed or altered recruitment patterns

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Risk Factors in Aging

• Poor coordination memory

• Cognitive and memory impairment

• Dementia

• Psychological confusion

• Fear: “ptophobia”= fear of falling (Lewis, p. 108)

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Risk Factors in Aging

• Cardiovascular: dizziness from

– orthostatic hypotension

– vertebral artery compromise

*If falling is frequent, consider cardiovascular or

neuromuscular compromise (Lewis, p. 110)

• Peripheral neuropathy: loss of sensation,

inability to feel changes in surfaces and joint

motions, proprioceptive loss(Lewis, p. 107)

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Risk Factors in AgingPolypharmacy- taking more than 4 drugs

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Medication Hazards

• “Medications can increase the risk of falls and fall-related injuries. Drugs that affect the central

nervous system, such as sedatives and anti-

anxiety drugs, are of particular concern.

• Fall risk is significantly elevated during the three

days following any change in these types of

medications.”

(From: http://www.cdc.gov/HomeandRecreationalSafety/Falls/nursing.html. Accessed 2/25/13)35

Drugs in the Elderly

• Drug metabolism and distribution decrease

with age, liver and kidneys are less efficient,

• Drugs may stay in their system longer

• No one knows the interactions of multiple

drugs in the body, most studies are of one or

few drug combinations

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Environmental Risk Factors• Loose rugs, slippery or wet floors

• Uneven surfaces

• Improper footwear, walking in socks

• Dim lighting, poor contrast

• Obstacles

(From: http://www.cdc.gov/HomeandRecreationalSafety/Falls/nursing.html. Accessed 2/25/13)

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Environmental Risk Factors

• Poor fitting of ambulation aids/wheelchairs

• Improper bed or toilet height

• Lack of assistive aids (grab bars)

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Medical Risk Factors

• Cardiovascular: hypoxemia, dizziness,

Low blood volume

• Electrolyte imbalances

• Neuromuscular disease: MS, Parkinson’s• CNS injury or disease, stroke, brain tumors,

• Foot problems

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Personal Implications of Falling

• Loss of independence

• Limited ADLs

• Loss of confidence

• Limited social interaction

• Fear of additional falls

(Guccione. p. 280)

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BREAK

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Balance Examination Tools

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Best Places To Find Exams

https://www.cdc.gov/steadi/

http://geriatrictoolkit.missouri.edu/

WWW.REHABMEASURES.ORG

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Written Tools

Questionnaires

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Falls Efficacy Scale (FES)

Psychological Aspects of Balance

• “On a scale from 1 to 10, • with 1 being very confident and

• 10 not being confident at all, how confident are

you that you do the following activities without

falling?...

• A score of greater than 70 indicates that the

person has a fear of falling” and avoids activities

(Falls Efficacy Scale, in Lewis, p. 236.) (Tinetti, Richman and Powell 1980)

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Falls Efficacy Scale Activities Score 1-10

1. “Take a bath or shower2. Reach in to cabinets or closets

3. Walk around the house

4. Prepare meals not requiring carrying heavy or hot objects

5. Get in or out of bed

6. Answer the door or telephone

7. Get in or out of a chair

8. Getting dressed and undressed

9. Personal grooming (i.e. washing your face)

10. Getting on and off the toilet

• Score 1 very confident 10 not confident at all

• Total Score” (Falls Efficacy Scale, in Lewis, p. 236)46

ABC: Activities Specific Balance

Confidence Scale

• Informs if client has confidence in ability to do ADLs without falling

• 16 item questionnaire, 0-100% confidence

• reliability .81-.98

• “How confident are you that you will not lose your balance or become unsteady when you…”

• GET THE ABC at:

• www.pro-pt.net/files/pdf/Outcome%20Measures/

ABC_Scale-Final.pdf

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ABC SCALE

• Includes ADLs:

• walk around house, up/down stairs, pick up shoe, reach a shelf, stand on toes or chair to reach,

• sweep floor, walk to driveway, enter/exit car,

• walk across shopping lot, up/down ramp, walk crowded mall, bumped by others,

• use escalator, use escalator holding items without handrail,

• walk on ice

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Objective Tools

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Posture Evaluation

• Normal static standing alignment :

• lateral view: plumbline goes through:

• middle ear, acromion,

• greater trochanter, posterior patella,

• anterior lateral malleolus.

• Aging postural changes: forward head, thoracic

kyphosis, protracted shoulders, lumbar lordosis

(or flattening), and increased hip and knee

flexion. (Lewis, p. 65)

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POSTURE Affects Balance

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Positioning Exams

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Position Screening: Blood Pressure

• Ask patient to move from lying to sitting,

sitting to standing

• Ask if he becomes dizzy during positional

changes, document it

• Examiner may check blood pressure in various

positions and the change in BP to assess

orthostatic hypotension

• Is it vestibular or orthostatic?

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Assessing Orthostatic Blood Pressure

• To test, ask the client to lie down 5 mins.

While you measure BP

• Ask client to stand, measure BP again after 1

minute and after 3 minutes

• If Systolic BP drops >/= 20mmHg, or

• If diastolic BP drops >/= 10 mmHg, or

• Client is dizzy or lightheaded

• Positive for orthostatic hypotension

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Is it Vertebral Artery Syndrome?

• With patient supine, examiner passively moves

his neck into rotation with extension

• Positive if nystagmus, unilateral pupillary dilation

or constriction, dizziness, nausea or vomiting

occurs: refer to Physician

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Is it Vestibular?

56

• There are special tests for vestibular

involvement which are beyond the scope of

this course.

• Caloric testing, Dix-Hallpike maneuver, and

other tests can help rule out or rule in

vestibular nerve impairment

STANDING, SITTING AND WALKING

BALANCE TESTS

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ROMBERG TEST

• Client stands with feet parallel, close together

• Client remains in place with eyes open

• Test again with eyes closed 30 secs.

• assess body sway

• Abnormal if loss of balance, eyes open or

• Client steps to catch self: a positive test

• Romberg/Tandem Romberg

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ROMBERG VIDEO

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Tandem Romberg

• Tandem or sharpened Romberg: stand heel to toe with arms folded on chest for 60 secs., eyes closed

• Sharpened Romberg Norms: ages 60-69: 56 sec, 70-74: 48 sec., 75-79: 39 sec, 80-86: 45 sec.

• 60-69= 56, 70-74=48,

• 75-79=39, 80-86= 45

• (Briggs et al, 1989)

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21

TANDEM ROMBERG VIDEO

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Single Leg Stance Test: Eyes Open/ Closed

• AKA: Unilateral leg stance test (SLST)

Ask client to cross arms and

lift favored leg

• Shoes on, average of 3 trials

• Result: High risk of falls/injury if below 5 seconds

• Disqualify if elevated foot hits ground, arms uncross, stance leg moves, or trunk tilts >45 degrees

• Repeat with eyes closed(Lewis, p. 113)

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MEANS FOR ONE-LEGGED STANCE

TEST (from Bohannan, et al 1984)

AGE 20-29 30-39 40-49 50-59 60-69 70-79

OPEN

eyes

30.0 30.0 29.7 29.4 22.5 14.2

CLOSED

eyes

28.8 27.8 24.2 21.0 10.2 4.3

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MEANS FOR TIMED UNIPEDAL STANCE

TEST, right foot (El-Kashlan, 1998)

AGE 20-49

Yrs.

50-59 60-69 70-79

OPEN

eyes

28.8

Sec.

24.2 27.1 18.2

CLOSED

eyes

20.7

Sec.

6.1 2.0 1.0

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SINGLE LEG STANCE TEST VIDEO

eyes open

65

SINGLE LEG STANCE TEST VIDEO

eyes closed

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Functional Reach Test (FRT) Standing

• Patient standing, reaches forward as far as possible with hands along a tape measure on the wall, shoulder flexed 90, closed fist, feet on floor

• Measure excursion of reach without falling

• “Duncan and colleagues have shown that frail persons with reaches less than 6 inches have 4 times the likelihood of falling than persons with a reach greater that 10 inches”.

(Guccione, p. 288)

•May be done in standing or sitting, use average of the last 2 scores of 3 trials

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MEANS FOR FUNCTIONAL REACH TEST (from Isles, et al, p. 1370, 2004)

AGE 20-29 30-39 40-49 50-59 60-69 70-79

Isles

Mean

in cm.

42.71

cm

41.01

cm

40.37

cm

38.08

cm

36.85

cm

34.13

cm

Others

Duncan

Brauer

37.08 35.05 35.05 35.05

29.6

26.67

29.6

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FUNCTIONAL REACH TEST VIDEO

standing

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Modified FRT Sitting

• Patient sitting with hips, knees and ankles at

90, sitting against the chairback, feet on floor

• Initial reach with shoulder at 90 forward

• Do 1 trial with uninvolved side near wall,

reaching forward, , one with sitting with back

to the wall, leaning R, and one with sitting

back to the wall leaning L

• 3 trials are used, scores average of last 2 trials

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Sitting FRT Means (Thompson and Medley, 2007)

AGE

Yrs.

21-39 40-59 65-93

Lateral reach in

sitting, cm.

44.9 42.3 32.9

Forward reach

in sitting, cm.

29.5 26.7 20.3

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FUNCTIONAL REACH TEST VIDEO

sitting

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5 TIMES SIT TO STAND TEST

• Measures functional limb strength

• Patient sits with arms across chest in standard

chair of 43 cm height, 47.5 cm depth

• Rises sit to stand as quickly as possible 5 times

• Normal healthy adults can do in 8.2 seconds

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FTSST Results (#seconds for 5 stands)

Whitney, 2005 Whitney,

2005

Bohannon,

2006

Bohanno

n, 2006

Young controls

23-57 yrs.

8.2 11.4 60-69 yrs

Young with balance

issues 14-59 yrs

15.3 12.6 70-79

Older control

63-84 yrs

13.4 12.7 80-89

Older with balance

issues 61-90 yrs

16.4

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5 TIMES SIT TO STAND TEST VIDEO

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Five Times Sit to Stand Test (FTSST)

Whitney et al studied the FTSST in n=81 without

balance issues and n=93 with balance problems

• FTSST: subject stands up from a 43 cm. chair 5X

rapidly

• Compared to DGI and ABC scales

• Each test identified a % of persons with balance

deficits:

FTSST: 65%, ABC 80%, DGI 78%(Whitney, SL, Wrisley, DM, Marchetti, GF, Gee, MA, Redfern, MS, and Furman, JM, Clinical

Measurement of Sit-to-Stand Performance in people with Balance disorders: Validity of

Data for the Five-times-Sit-To- Stand Test. Phys Ther 2005;85(10):1034-1035)76

STEP TEST

• Measure the times a person can step with one

foot completely on and off a 7.5cm block

quickly in 15 seconds

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MEANS FOR STEP TEST (# in 15 seconds)

(from Isles, et al, p. 1370, 2004)

AGE 20-29 30-39 40-49 50-59 60-69 70-79

Isles:

mean #

of

steps

20.72 20.17 18.77 17.13 15.59 13.73

Others:

Hill

Brauer

17.67

16

15.6

17.67

16

15.678

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WHAT ABOUT BEDRIDDEN

PATIENTS?

Test using the Function in Sitting Test

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FUNCTION IN SITTING TEST- FIST• 14 functional sitting items used for patients to

be used bedside under 10 minutes

• Need stopwatch and tape measure, pen, stool

and chair

• Position: Patient sitting on edge of bed, hands in

lap, neutral hip ab/ad/rot. Hips flexed 90, half

femur on bed, feet flat on floor or stool

• Explain test to patient, sitting with best posture

and balance, reaching and scooting, withstanding

some pushes, without using hands80

FIST SCORING

• 0 = Dependent- requires complete physical assist

to perform, dependent

• 1 = Needs physical assistance, document

amount of assist required:

min A (25% or less effort by therapist)

mod A (26-74% effort by therapist)

max A (75% or more effort by therapist)

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FIST SCORING• 2 = Upper extremity support = Must use 1 or

both arms to assist self to perform or for

balance

• 3 = Verbal cues, increased time = normal

performance but needs more time or cueing to

complete

• 4 = Independent = normal speed and safety

(Download at: www.samuelmerritt.edu/fist) used

with permission.

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FIST FUNCTION IN SITTING TEST

• Get test online at: (From: http://

www.samuelmerritt.edu/fist/documentation

• “Anterior nudge: superior sternum• Posterior nudge: between scapular spines

• Lateral nudge: to dominant side at acromion

• Static sitting: 30 seconds

• Sitting, shake ‘no’: left and right• Sitting, eyes closed: 30 seconds”

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FIST CONTINUED

• “Sitting lift foot: dominant side, lift foot 1 inch twice’

• Pick up object from behind: object at midline,

hands breadth posterior

• Forward Reach: use dominant arm, must

complete full motion

• Lateral reach: use dominant arm, clear opposite

ischial tuberosity”• (From: http:// www.samuelmerritt.edu/fist/documentation. (Accessed

12/26/13)

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FIST CONTINUED

• “Pick up object from floor: from between feet• Posterior scooting: move backwards 2 inches

• Anterior scooting: move forward 2 inches

• Lateral scooting: move to dominant side 2 inches”

TOTAL the score ____/56. Add notes or comments.

MDC= 5.63 for acute stroke (www.rehabmeasures.org)

(From: http:// www.samuelmerritt.edu/fist/documentation. (Accessed 12/26/13) with permission. Download templates and web-based training at the website for your clinic.

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Gait Exam Tests

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TIMED Up and Go Test (TUG)

• The examiner times how long it takes for patient

to

• sit in a chair,

• rise,

• stand still,

• walk towards a wall,

• turn around

• before touching the wall,

• return to the chair and sit down. 87

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TIMED UP AND GO MEANS FOR

COMMUNITY ELDERLY (from Isles et al, p.1370)

AGE RANGE yrs. TIMED GET UP AND GO (secs)

20-29 5.3

30-39 5.4

40-49 6.2

50-59 6.4

60-69 7.2

(8,8.4,13)

70-79 8.5 (8.5,8,8.4)88

TIMED UP AND GO VIDEO

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Interpreting TUG Test

• If >12 secs, they have high falls risk (https://www.cdc.gov/injury/STEADI)

• If >30 secs, they may require assistive device,

have low BBS score and are unable to walk in

community due to slowness

(https://www.atrainceu.com/course-module/1473452-69)

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BERG BALANCE SCALE

• The next 2 slides give an overview of the Berg

Balance Scale,

• The next 14 slides specify the 14 components

of the actual examination.

(All of the next 14 slides are adapted from: Berg K., in Lewis, p. 233)

•Berg is the test most often used by PTs to

document balance exam results

91

Equipment for BBS

• Chair with armrests

• Stopwatch

• Tape measure

• Step stool

• Item to lift from floor

92

BERG BALANCE VIDEO 1

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BERG BALANCE VIDEO 2

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Berg Balance Scale“1. Sitting to standing

• Instruction: Please stand up. Try not to use your hands for support.

• Grading: Please mark the lowest category that applies.

• (4) Able to stand, no hands and stabilize independently

• (3) Able to stand independently using hands

• (2) Able to stand using hands after several tries

• (1)Needs minimal aide to stand or to stabilize

• (0)Needs moderate or maximal assist to stand”(Lewis, p. 233)

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Berg Balance Scale“2. Standing UnsupportedInstruction: Stand for two minutes without holding.

Grading: Please mark the lowest category that applies.

(4) Able to stand safely for 2 minutes

(3) Able to stand 2 minutes with supervision

(2)Able to stand 30 seconds unsupported

(1)Needs several tries to stand 30 seconds unsupported

(0)Unable to stand 30 seconds unassisted” (Lewis, p. 233)

96

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Berg Balance Scale“IF SUBJECT IS ABLE TO STAND 2 MINUTES UNSUPPORTED, SCORE

FULL MARKS FOR SITTING UNSUPPORTED. PROCEED TO ITEM #4.

3. Sitting with back unsupported but feet supported on floor or on a stool

Instruction: Sit with arms folded for two minutes.

Grading: Please mark the lowest category that applies.

(4)Able to sit safely and securely 2 minutes

(3) Able to sit 2 minutes under supervision

(2) Able to sit 30 seconds

(1)Able to sit 10 seconds

(0)Unable to sit without support 10 seconds” (Lewis, p. 233)

97

Berg Balance Scale

“4. Standing to sittingInstruction: Please sit down.

Grading: Please mark the lowest category that

applies.

(4) Sits safely without use of hands

(3) Controls descent by using hands

(2)Uses back of legs against chair to control descent

(1)Sits independently but has uncontrolled descent

(0)Needs assistance to sit” (Lewis, p. 233)

98

Berg Balance Scale“5. TransfersInstruction: Please move from this chair (chair with arm

rests) to this chair (chair without arm rests) and back again. (Both directions)

Grading: Please mark the lowest category that applies.

(4) Able to transfer safely without use of hands

(3) Able to transfer safely with definite need of hands

(2) Able to transfer with verbal cueing and/or supervision

(1)Needs one person to assist

(0)Needs two people to assist or supervise to be safe”(Lewis, p. 233)

99

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Berg Balance Scale

“6. Standing unsupported with eyes closedInstruction: close your eyes and stand still for 10

sec.

Grading: Please mark the lowest category that applies.

(4) Able to stand 10 seconds safely

(3) Able to stand 10 seconds with supervision

(2) Able to stand 3 seconds

(1)Unable to keep eyes closed 3 seconds but stays steady

(0)Needs help to keep from falling” (Lewis, p. 233)

100

Berg Balance Scale“7. Standing unsupported with feet together.Instruction: Place your feet together and stand without

holding onto any external support.

Grading: Please mark the lowest category that applies.

(4) Able to place feet together independently and stand 1 minute safely

(3) Able to place feet together independently and for 1 minute with supervision

(2) Able to place feet together independently but unable to hold for 30 seconds

(1) Needs help to attain position but able to stand 15 seconds feet together

(0)Needs help to attain position and unable to hold for 15

seconds” (Lewis, p. 233) 101

Berg Balance Scale“THE FOLLOWING ITEMS ARE TO BE PERFORMED WHILE STANDING

UNSUPPORTED

8. Reaching forward with outstretched arm

Instruction: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. Examiner places a ruler at end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward. The recorded measure is the distance forward that the fingers reach while the subject is in the most forward lean position.

Grading: Please mark the lowest category that applies.

(4) Can reach forward confidently>10 inches

(3) Can reach forward>5 inches safely

(2) Can reach forward>2 inches safely

(1)Reaches forward but needs supervision

(0)Needs help to keep from falling” (Lewis, p. 233)

102

35

Berg Balance Scale“9. Pick up object from the floorInstruction: Pick up the shoe/slipper that is placed in

front of your feet.

Grading: Please mark the lowest category that applies.

(4) Able to pick up slipper safely and easily

(3) Able to pick up slipper but need supervision

(2)Unable to pick up but reaches 1-2 inches from slipper and keeps balance indep.

(1)Unable to pick up and needs supervision while trying

(0)Unable to try; needs assist to keep from falling”(Lewis, p. 233)

103

Berg Balance Scale

“10. Turning to look behind/over left and right shoulders.

Instruction: Turn to look behind you over/toward left shoulder. Repeat to the right.

Grading: Please mark the lowest category that applies.

(4) Looks behind from both sides and weight shifts well

(3) Looks behind one side only; other side shows less weight shift

(2) Turns sideways only but maintains balance

(1)Needs supervision when turning

(0)Needs assist to keep from falling” (Lewis, p. 233)

104

Berg Balance Scale“11. Turn 360 degreesInstruction: Turn completely around in a full circle.

Pause. Then turn a full circle in the other direction.

Grading: Please mark the lowest category that

applies.

(4) Able to turn 360 safely in <4 sec each side

(3) Able to turn 360 safely one side only in <4 sec

(2) Able to turn 360 safely but slowly

(1) Needs close supervision or verbal cueing

(0)Needs assistance while turning” (Lewis, p. 233)

105

36

Berg Balance Scale

“DYNAMIC WEIGHT SHIFTING WHILE STANDING UNSUPPORTED

12. Stool touch Instruction: Place each foot alternately on the stool. Continue until each foot has touched the stool four times for a total of eight times.

Grading: Please mark the lowest category that applies.

(4) Able to stand independently and safely and complete 8 step in 20 seconds

(3) Able to stand independently and complete 8 steps >20 seconds

(2) Able to complete 4 steps without aid with supervision

(1)Able to complete>2 steps, needs minimal assist

(0)Needs assistance to keep from falling/unable to try”

(Lewis, p. 233) 106

Berg Balance Scale“13. Standing unsupported, one foot in front. Instruction:

(Demonstrate to subject) Place one foot directly in front of the other. If you feel that you cannot place your foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot. (To score 3 points, the length of the step should exceed the length of the other foot and the width of the stance should approximate the subject’s normal stride width.)

Grading: Please mark the lowest category that applies.

(4) Able to place foot tandem independently and hold 30 seconds

(3) Able to place foot ahead of other independently and hold 30 seconds

(2) Able to take small step independently and hold 30 seconds

(1)Needs help to step but can hold 15 seconds

(0)Loses balance while stepping or standing” (Lewis, p. 233) 107

Berg Balance Scale“14. Standing on one legInstruction: Stand on one leg as long as you can without

holding onto external support.

Grading: Please mark the lowest category that applies.

(4) Able to lift leg independently and hold >10 seconds

(3) Able to lift leg independently and hold 5-10 seconds

(2) Able to lift leg independently and hold up to 3 seconds

(1)Tries to lift leg; unable to hold 3 sec but remains standing independently

(0)Unable to try or needs assist to prevent fallTOTAL SCORE ___________/_____56__”

(Lewis, p. 233)

108

37

Interpreting Berg Balance Scale

MDC: minimal detectable change: tells us if

significant change has really occurred

If initial BBS score is:

0-24, MDC = 5

25-34, MDC = 7

35-44, MDC = 5

45-56, MDC = 4

(Download Berg Scale: www.rehabmeasures.org)

109

Interpreting Berg Balance Scale

• Specificity= 90% predicts one will not fall

• Sensitivity= 64% predicts people who fall

• People must have a score of at least 45/56 for independent ambulation in safety (Riddle and

Stratford, 1999)

• Uses minimal equipment in a small clinic space

• Ceiling effect for higher functioning people

• NO ambulation items on the test

• Most common functional exam post-stroke

110

Low Berg Score Predicts Falls

Shumway-Cook and Woollacott (1997, 2012)

reported as Berg scores declined,

risk of falls increased, with a change of 1 pt.

• BBS 56-54 increased falls risk of 3-4%

• BBS 54-46 increased falls risk of 6-8%

• BBS scores <36, 100% increased falls risk

(From https://www.atrainceu.com/course-module/1473452-69)

111

38

Statistics for BBS Studies: adults in community(From: http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=888

GENDER AGE IN YEARS MEAN SCORE

MALE 60-69 55

FEMALE 60-69 55

MALE 70-79 54

FEMALE 70-79 53

MALE 80-89 53

FEMALE 80-89 50

112

BBS MINIMAL DETECTABLE CHANGE

ELDERLY: Donohue study:

Initial Score and MDC:

• 0-24 = 4.6

• 25-34 = 6.3

• 35-44 = 4.9

• 45-56 = 3.3(Donohue, et al, 2009,

(From: http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=888

• Romero, et al, 2011: reported MDC = 6.5113

TINETTI BALANCE TOOL

Performance Oriented Assessment of

Balance & Gait Scale

• 7 gait (12 points) and

• 9 balance tests (16 pts)

Scored from 0-2:

• 0 = greatest impairment

• 2= independent

114

39

Tinetti Assessment Tool: GaitExaminer observes gait at a normal and a rapid pace;

rated from 0-1.

• Gait initiation

• Step height and length- swing of each foot

-symmetry of steps

-continuity- stops or continues walking

• Path deviation- marked or straight

• Trunk motion- swaying, flexion

• Walking stance- heel distance between heels, BOS( Tinetti, ME, in Lewis, p. 229, Tinetti, ME, pp. 42-49) 115

Tinetti POMA modified (Tinetti, 1986)

1. Sitting balance

0= leans, slides

1= safe, steady

2. Rise from chair

0= unable without assist

1= able using hands

2= independent, not using hands

116

Tinetti POMA: modified for lab (Tinetti, 1986)

3. Attempt to rise

0= unable

1=rises with > one try

2= rises on first try

4. Immediate standing balance

0= moves feet, not steady

1= uses support to steady self

2= Independent without aids

117

40

Tinetti POMA: modified for lab (Tinetti, 1986)

5. Balance standing

0= unsteady

1= wide base, over 4 “, gait aid2= independent without support

6. Sternal nudge

0= starts falling

1= grabs, catches self, staggers

2= independent, steady

118

Tinetti POMA: modified for lab (Tinetti, 1986)

7. Stand with eyes closed

0= not steady

1= steady

8. Turn around in a circle

0= discontinuous steps

1= continuous

0= grabs, unsteady, swaggering

1= independent, steady

119

Tinetti POMA: modified for lab (Tinetti, 1986)

9. Stand to sitting down

0= not safe

1= not smooth, uses hands

2= safe, independent

10-Starts walk

0=hesitant or 1 try, 1= not hesitant

120

41

Tinetti POMA: modified for lab (Tinetti, 1986)

11- Step length and height

0= R swing leg fails to pass

1= R swing passes L

0= R fails to clear floor

1= R clears floor

Repeat for L side and include score of 0 or 1 for

each for a total of 4 possible points

121

Tinetti POMA: modified for lab (Tinetti, 1986)

12. Foot Clearance

0= foot drop

1= L foot clears floor

1= R foot clears floor

122

Tinetti POMA modified for lab

13- Symmetry of steps

0= unequal step lengrth

1= equal step length

14- Continuity of steps

0= discontinuous

1= continuous

123

42

Tinetti POMA modified for lab

15- Ambulate 10 ft. path

0= significant deviation from straight

1= uses gait device or has min/mod

deviation

2= ambulates straight path

16- Trunk motion 0= sways or uses gait aid

1= spreads arms, flexes knees or trunk

2= No aid, sway or flexion of knees, trunk

124

Tinetti POMA: modified for lab (Tinetti, 1986)

Walking heels spaced apart

0=Heels apart (base of support wide)

1= Heels almost touching while walking

(base of support normal, 2-4” wide)

125

Tinetti Score Predicts Falls Risk

• Normal = 28

• Low risk = 25-27

• High risk = 20-23

• Very high risk = <20

Download at www.rehabmeasures.org(Tinetti, 1986)

126

43

Dynamic Gait Index (DGI)

• Assesses changes in gait with task

performance

• Scores impairments from 0-3 points per

task

• Predicts falls likelihood increases 2.58

times for scores under 19 points (Whitney, 2000)

• Romero reported MDC for DGI in adults >65

yrs = 2.9 points (Romero, 2011)

127

Dynamic Gait Index (DGI)

• Examiner observes gait: scores 8 gait activities from 0-3 points each:

• 0 = severe impairment, 1= moderate impairment 2=mild, 3 =normal

– on level surface,

– with speed changes,

– during horizontal head rotation,

– with vertical head turns,

– pivot turn,

– stepping over shoe box obstacle,

– stepping around 2 cones each 6’ apart, and – stair climbing up/down

128

Dynamic Gait Index

Access tool download at:

www.rehabmeasures.org

Need: 20 ft. walkway, 15” wide, shoebox, 2 cones,

stairs

Score of < or = 19/24: predicts falls in elders

Score of >22/24: may walk safely in community

129

44

DYNAMIC GAIT INDEX VIDEO

130

Dynamic Gait Index (DGI) Reliability

Marchetti et al performed 3 trials of the DGI in 47 subjects 24-90 yrs. Divided into group 1: normal control and group 2: people with balance or vestibular disorders.

They compared differences in gait parameters from the DGI for both groups.

Results: The DGI demonstrated differences between involved and control groups for dynamic gait parameters.

The study showed fair to excellent reliability between trials.

(Marchetti, GF, et al., pp. 640-651) 131

DGI statistics

• Cutoff point = 19/24 predicts elderly falls risk

• MCID= minimally clinically important difference

for DGI= 1.9 in community dwelling elders

• MDC:

– Comm. dwelling elders= 2.9

– MS = 4.19-5.54

– Chronic stroke = 4

– Parkinsons = 2.9

– Vestibular = 3.2

(From: www.rehabmeasures.org, accessed 2/7/14) 132

45

Normative Values for DGI (Vereech et al)

AGE AVERAGE DGI SCORE

30-49 24

50-69 23.9

70-79 23.2

80-89 22

133

134

BESTest Balance Evaluation Systems Test

Fay Horak designed BESTest to evaluate 6 balance systems for a %-age score of 108 total points:

• Biomechanical constraints

• Stability Limits/ verticality

• Postural Responses, reactive

• Sensory Orientation

• Transitions/Anticipatory Postural Adjustments

• Gait stability

• Cognitive effects

(Horak, p. 2, http://www.bestest.us. Accessed Aug. 27, 2013)

135

46

BESTest

The BESTest is a copyright protected

• To learn the BESTest, visit Dr. Horak’swebsite at

http://www.ohsu.edu/horak

Test copies available at:

• FullBESTest.pdf

• MiniBEST.pdf (revised 3/08/13)

136

BESTest Tools Needed

• Tape measure, stopwatch

• Medium density Foam block 2x2ft by 4” high• 2 shoe boxes

• Incline ramp at 10 degrees, min. 2x2 ft.

• 6 inch stair step (15cm)

• 5 pound free weight (2.5kg)

• Masking tape

• Armchair and floor marked with tape 3m away

(Horak, p. 1 BESTest)

137

BREAK

138

47

Mini-BESTest: 14 components

Anticipatory

1. SIT TO STAND arms crossed

2. RISE TO TOES feet apart, hands on hips, hold 3 s.

3. STAND ON ONE LEG hands on hips, lift leg back

139

Mini-BESTestReactive Postural Control:

stand, feet apart, arms at sides, leans on

examiner’s hands and ex. releases to assess how they attempt to regain balance

4. COMPENSATORY STEPPING CORRECTION-

FORWARD, lean fwd on examiner’s hands5. COMPENSATORY STEPPING CORRECTION-

BACKWARD, lean bkwd against examiner’s hands6. COMPENSATORY STEPPING CORRECTION-

LATERAL, lean laterally against examiner’s hands 140

Mini-BESTest

Sensory Orientation

Stand, feet together, hands on hips, stand still (note

30 secs + or -)

7. STANCE (FEET TOGETHER); EYES OPEN, FIRM

SURFACE,

8. STANCE (FEET TOGETHER); EYES CLOSED, FOAM

SURFACE

9. INCLINE- EYES CLOSED, stand still on ramp with

toes facing the higher side

141

48

Mini-BESTestDynamic gait: Begin walking normal speed, then

as commanded perform:

10. CHANGE IN GAIT SPEED, walk fast or slow

11. WALK WITH HORIZONTAL HEAD TURNS –,

walk and turn head R/L

12. WALK WITH PIVOT TURNS, Turn 180 degrees,

and stop rapidly, feet close together as you stop

142

Mini-BESTest13. STEP OVER OBSTACLES, walk normal pace, step

over the 9” box 10 ft away

14. TIMED UP & GO WITH DUAL TASK [3 m WALK]

Stand from chair, walk normal speed to tape, stop, turn and return to sit in the chair

(can modify #14 by asking pt. to count backward by threes as you walk from/to the chair)

(From: http://www.bestest.us/files/7413/6380/7277/MiniBEST_revised_final_3_8_13.pdf. Accessed 09/09/13)

143

Mini-BESTest“Clarifications on Scoring and Total Scoring:• The Mini-BESTest should be scored out of 28

points to include 14 items that are scored from 0 to 2.

• For Item 3 (single-leg stance) and Item 6(compensatory lateral stepping), when compiling total score, use only the worst score.

• For Item 14, if a person's gait slows greater than 10% between the TUG with and without a dual task, the score should be decreased by a point. “

• (Quoted from Horak, F, and King, L, On the Mini-BESTest: Scoring and the Reporting of Total Scores Physical Therapy 2013;93(4): 571-575, in http://ptjournal.apta.org/content/93/4/571.full?sid=da3957b8-1a85-473e-97e1-976998d82501, Accessed 09/09/2013)

144

49

SCORING MINI-BESTEST14 Items from 0 to 2 points each of 28 total:

Sit to stand:

– 2= normal, stands without hands independently

– 1= moderate, uses hands, one try’– 0= severe, unable or multiple tries using hands

Rise on toes:

-2= nml, stands on toes 3 seconds

-1= mod, heels up, partial ROM or loses balance

-0= sev, </= 3 secs.145

SCORING CONTINUEDStand on 1 leg

-2= nml, 20 secs.

-1= mod, <20 secs

-0= sev, unable

Compensatory stepping forward, feet shldr apart, lean forward on examiners hands

-2= nml, recovers balance with 1 step

-1= mod, > 1 step to recover

-0= falls or fails to step

146

SCORING CONTINUED

Compensatory stepping backward, feet shldr apart, lean backward on examiners hands

-2= nml, recovers balance with 1 step

-1= mod, > 1 step to recover

-0= falls or fails to step

Compensatory stepping lateral, feet together, lean sideways on examiners hands

-2= nml, recovers balance with 1 step

-1= mod, > 1 step to recover

-0= falls or fails to step

147

50

SCORING CONTINUED

Stand, eyes open, feet together, stay still on firm

-2=nml, 30 secs.

-1= mod, <30 s

-0= sev, unable

Stand, eyes closed, feet together, on foam

-2=nml, 30 secs.

-1= mod, <30 s

-0= sev, unable

148

SCORING CONTINUEDIncline- eyes open, feet shldr width apart, uphill

-2= nml, 30 secs aligns with ramp

-1= mod, stands < 30 secs, aligns with ramp

-0= sev, unable

Gait speed change- on command walk usual pace, then fast, then slow

-2=nml, changes pace without losing balance

-1= mod, cannot alter pace without imbalance or change of pace

-0=unable to maintain balance or alter pace

149

SCORING CONTINUEDObstacles- walk nml pace, step over box and continue:

-2=nml, steps over box, good balance, pace

-1=mod, slows or touches box

-0= steps around box or unable

Dual-task TUG- Usual TUG and second try with counting back by 3’s:

-2=nml, no obvious difference with dual

-1= mod, task affects gait or math by 10%+

-0=sev, stops walk or counting

150

51

151

BUT WE ARE IN A HURRY

Brief-BESTest: 8 items• Hip abduction

• Functional reach forward

• Single leg stance, (L and R)

• Compensatory stepping (L and R), lateral push

and release

• Stand with eyes closed on foam

• Timed Up and Go Test (Padgett, et al , p. 1202)

152

BEStest, MiniBESTest, Brief BESTest

Padgett, et al rated n=20 people with or without a

neuro dx. using all 3 tests

Results: Reliability for all versions was ICC >.98

Accuracy to ID people with or without neuro dx.=

• BESTest 78%

• MiniBESTest or brief BESTest 72%

All 3 tests specificity to ID nonfallers was 95-100%(Padgett, et al, 2012)

153

52

3 BESTest Versions: Accurate to ID

Repeat Fallers with Parkinsons

Duncan et al tested n=80 patients with ParkinsonsDisease with prior falls using the 3 BESTestevaluations after 0, 6 and 12 months

Result: Correlation betw. Brief and Mini r=.94 and with BESTest r=.95

Brief BESTest retrospective accuracy in predicting falls =.82,

Sensitivity in predicting falls =.76; Specificity=.84

(Duncan, et al, 2013)

154

Mini-BESTest and Berg Balance Similar

Godi et al compared Mini-BEStest and Berg Balance

Scale in N=90 patients with balance deficits

Results for test-retest reliability :

Mini-BESTest ICC=.96; MDC=3.5 points

BBS ICC=.92; MDC= 6.2 points

MDC -minimal detectable change

Mini-BEStest has lower ceiling effect and more

accuracy to indicate balance improvement than BBS(Godi, et al, 2013)

155

Mini-BESTest for People with Stroke

Tsang, et al measured validity and reliability of Mini

with n= 106 chronic stroke patients

Results:

• Internal consistency= Chronbach=.89-.94

• Interrater reliability ICC= .96,

• Intrarater reliability ICC= .97

• MDC= 3 points

• Use Mini-BESTest for patients with chronic stroke

(Tseng, et al, 2013)156

53

Use Brief-BESTest to save time!

ONE MAY RELY ON THE BRIEF VERSION

(Duncan, et al, 2013)

Validity, Reliability of Balance Tests

• Prospective study: Lin et al. compared responsiveness,

validity, and reliability of balance tests in subjects > 65

yrs

• Counted # of falls every 3 months for 1 yr.

• Assessed 4 balance measures and ADLs

• Results: Tinetti was considered the best performance

measure followed by the Timed Up And Go.

• Excellent test - retest reliability for all 4 tests

(Lin, et al) 158

Reliability with Dementia Patients

• Blankevoort, et al tested reliability of 6 perf. tests

• 6-m walk test (6WMT), Fig. of 8 Walk test (F8W),

• TUG, Chair Rise test, (CRT) Jamar dynamometer,

on n=58 pts. with dementia aged 70-92y/o

• Reliability ICC=.90-.95 for F8W, TUG and Jamar

• ICC= .79-.86 for 6MWT, CRT

• (Blankevoort, et al, 2013)

159

54

Normative Values for Balance Tests

• Isles produced normative data for the timed up and

go task, functional reach test, lateral reach test, and

step test in 456 indep. females 20-80 yrs.

• Results: a significant effect for each test indicated

progressive decline in balance over time.

• Normative data was published

• Showed high test-retest reliability (ICC= .95-.97) and

a decline in scores for all tests with advancing age.

(Isles, et al, 2004)

160

BALANCE TEST MEANS PUBLISHED FOR

COMMUNITY ELDERLY (Modified from Isles et al, p.1370)

AGE RANGE FUNCTIONAL

REACH TEST (cm)

LATERAL REACH

TEST (cm)

TIMED GET UP

AND GO (s)

STEP TEST (#)

20-29 YEARS 43

(37)

23 5.3 21

30-39 41 23 5.4 20

40-49 40

(35)

19 6.2 19

50-59 38

(35)

18 6.4 17

60-69 37

(35,30)

17

(20)

7.2

(8,8.4,13)

16

(17.6,16,15.6)

70-79 34

(26.7,29.6)

16

(20)

8.5 (8.5,8,8.4) 14

(17.8,16,15.6)

161

Clinical Tests have High Reliability

• Steffen at al collected data on 4 clinical tests in

96 independent people 61-89 years old .

• Six minute walk test, Berg Balance Scale, Timed

Up And Go, and comfortable and rapid gait

speeds.

• Results: High test-retest reliability of all 4 tests,

with age-related declines in performance

Authors gave age and gender referenced data

(Steffen, TM, et al. pp. 128-137)

162

55

Values for 6MWT, BBS, TUG & Gait

Speed

Steffen, et al studied n=96 independent elders 61-89 y/o in the community for 4 tests:

• 6MWT, Berg (BBS), TUG, and comfortable and fast gait speeds (CGS,FGS)

• High test-retest reliability for all (ICC=.95-.97)

• All performances declined with age

(Steffen, TM, Hacker, TA, Mollinger, L, Age and Gender-Related Test performance in Community-Dwelling Elderly People: Six-Minute Walk Test,

Berg Balance Scale, timed Up and Go Test, and Gait Speeds. Phys Ther.2002;82:128-137.)163

Balance Tests Means in Elders 61-89y/o (Modified from Steffen, p. 133)

AGE 6MWT (meters) BBS TUG

60-69 M 572 55 8

60-69 F 538 55 8

70-79 M 527 54 9

70-79 F 471 53 9

80-89 M 417 53 10

80-89 F 392 50 11164

HIGHER LEVEL BALANCE TESTS

165

56

FOUR STEP SQUARE TEST

• Need stopwatch and 4 canes or tape on the floor.

• Draw a square cross on the floor using canes or

tape, number the square from 1 to 4 clockwise

beginning at 10 o’clock to 2:00 to 4:00 to 8:00.• Patient stands in box 1, ask him to face box 2 and

step as quickly as possible into boxes 2, 3, 4, 1,

THEN 4, 3, 2, and 1. Keep facing same direction.

• Use 2 trials, best score is used, time when 1st foot

contacts floor of box 2

• (Dite and Temple, 2002)(www.rehabmeasures.org)166

FOUR SQUARE STEP TEST

1 →

↓↓

2↓

←←

4↑

→→

←3

↑↑167

FOUR SQUARE STEP TEST VIDEO

168

57

Y BALANCE TEST (YBT)

• Tests risk for injury in sports

• Used for upper and lower quarter

• Based on STAR

• Client stands on 1 leg and reaches other leg in

3 different positions

• Measure the length of client’s reach: anterior, posteromedial and posterolateral

• Great for re-evaluation to show progress

169

STAR EXCURSION BALANCE TEST

• Setup: 4 pieces of tape on floor in shape of a +

and x overlapping in the center, like a star

• Client stands on 1 foot in center, reaches other

foot around the star in 8 directions

• Measure distance of each reach,

• Directions: reach L CW first, R CCW

• Differences in posteromedial reach identifies

ankle instability

170

Y & STAR EXCURSION TESTS VIDEO

171

58

BREAK

172

Interventions to Promote Balance

and Prevent Falls

Balance Rehabilitation:

“Identify and Treat modifiable deficitsIdentify and compensate for fixed deficits”

Maximize independence

(Guccione, p. 290)

173

Balance Exercises- basic

• May be performed lying to start, and progress to sitting and standing:

• Shoulder shrugs

• Shoulder retraction

• Neck rotation

• Quad sets

• Glut sets

(Lewis, pp. 198-202)

174

59

Balance Exercises- basic

Performed in standing:

• Chin tucks (lying, sitting or standing)

• Leg lifts

• Hip circles

• Runners stretch

• Heel raises, toe raises

(Lewis, pp. 198-202)175

Balance Exercises

• Single leg stance, look in all directions

• Double leg stance, with neck rotation

176

Balance Exercises

• Standing Romberg, feet parallel: do with eyes

open, and with eyes closed

• Standing tandem Romberg

• Walking on a straight line: forward/backward

• Lateral stepping

• Heel and Toe walking

177

60

Balance Exercises

• Marching steps

• Braiding steps

• Walking at various speeds

• Walking, turning, changing direction

• Stepping in different directions (STAR, 4-step

box)

• Balance Beam walking, forward and backward

178

More Balance Exercises

• Jumping, hopping

• Walk across variety of surfaces, eyes open/closed

• Standing on unstable surface: foam mat, rocker

board, half-moon foam roller, full round foam

roller, BOSU ball, double or single leg stance

• Therapeutic ball/ physioball programs using a

variety of positions and activities while

maintaining stability on the ball

179

More Balance Activities

• Functional activities

• Reach in all different directions for objects at

various heights

• Get up and down out of a chair

• Rise and lower self to the floor

• Transferring to a variety of surfaces at different

heights

• Curb and stair climbing

• Walking up/ down ramps or inclines180

61

Functional Balance Activities

• Walk while carrying a variety of typical items in

the home: book, plate of food, shopping bag,

box, cup of water, pot

• Place objects on shelves of various heights

• Step over different obstacles

• Step around different obstacles

• Step over or walk around a moving obstacle (pet)

181

Community Balance Activities; FUN!

• Tai Chi / Chi Kung

• Wii balance and exercise programs

• Functional activities

• Yoga

• Dancing

• Hiking in the woods or on the beach

• BETTER COMPLIANCE WHEN HAVING FUN!

• Be sure patient has assistance if needed for guarding or balancing during community activities until independent

182

183

TAI CHI FOR BALANCE TRAINING

62

TAI CHI RESEARCH

Taylor et al: RCT of 3 interventions in

n=684 community adults with 1+ falls risk factor

(avg age 75y/o):

• tai chi 1/wk or 2/wk or control of low level exercise

class 1/wk for 20 wks

• Falls rate reduced 58% in all groups significantly,

continued for 12 months followup

• Balance and strength improved significantly

• No difference between groups

• 65% TC patients continued after the study ended184

TAI CHI FOR PEOPLE WITH DEMENTIA

Yao, et al did pre-post test design in n=22 comm. dwelling Alzheimers-caregiver dyads

• Measured unipedal stance time (UST) and TUG

• 16 wks of “Positive Emotion Motivated Tai Chi Protocol” with caregiver

• UST improved wk #4 from 4.0-5.1, wk#16 to 5.6sec.

• TUG improved wk#4 from 13.2-11.6, wk#16 to 11.6

(Yao, et al, 2012)

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SYSTEMATIC REVIEW and TAI CHI

Gillespie et al reviewed 159 trials on balance:

6 trials of 1625 patients using Tai Chi,

• Reported Tai Chi significantly reduced fall risk

• RR 0.71, 95% CI

(Gillespie, et al, 2012)

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Evidence-Based Outcomes on Exercise

and Balance Interventions

Improvements in balance and reduction of falls

has been demonstrated in the research.

The next slides offer samples of evidence-based

research, primarily from systematic reviews

and RCTs demonstrating the effects of

interventions discussed in this seminar.

187

Targeted Exercise Intervention Improves

Balance• Yang et al RCT of n=165 comm. dwelling elders

with mild balance dysfnctn

• 2 groups, 1 Otago Exercise Program, Visual Health

Info Balance & Vestibular Kit, vs. 1 control

• After 6 mo., exercise group had significant

improvement in Functional Reach (mean 2.95cm)

Step Test (2.10 steps/15 secs), gait step width

(2.17cm), hip abductor strength (0.020 in

kg/body wt)• Yang, et al, 2012)

188

Otago Home Program Exercises• Warmups of head, neck, trunk, back and ankle

movements

• Strengthening 10 reps quads, hams, abductors, calf and toe raises

• Balance ex: walk/turn (2x), retro walk, sideways walk (4x10 steps), knee bends (10), heel-toe walk 10 steps, heel-toe stand 10 s., 1-leg stand 10s., heel walk/toe walk (4x10steps), retro heel-toe walk 10 steps, sit to stand 5-10x, stair walk as tol., and

• 30min walk

• About 20 mins exercise over 5x/wk x 6 months

(Yang. Et al, p. 28, and http://www.acc.co.nz)189

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EFFECT OF CORE TRAINING ON

BALANCE AND FUNCTIONAL MOBILITY

Granacher, et al studied n=32 older adults who did

9 wk progressive core stability strength training

exercise vs. control

Results: measured 10 m. walk, spinal mobility,

Functional Reach Test and TUG

Exercise group improved in

spinal mobility 11%, stride velocity 9%, FRT 20%,

and TUG 4% (p<.05) (Granacher, et al, 2013)

190

Home Care Falls Prevention Program

Effect on BalanceWhitney, et al studied charts of 11,667 patients

with fall risk, over 65y/o, who had PT, OT, ST, or nursing services at home

Reviewed database of PT outcome data:

• Berg Balance BBS,

• Performance Oriented Measurement Assessment POMA,

• Dynamic Gait Index DGI, and

• modified Clinical Test of Sensory Integration and Balance, mCTSIB

191

MEANINGFUL CLINICAL GAINS

• Minimal detectable change MDC 95% was

measured for each, with result of mean

improvement in:

• BBS: 12 points (SD8)

• Tinetti POMA 8 points (SD4)

• DGI 7 points (SD4)

(Whitney, et al, 2012)

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BALANCE EXERCISE IMPROVES

FUNCTION AFTER TKA

• Piva et al did pilot dbl. blind RCT with n=43 pts.

– 2-6 mo. post total knee arthroplasty

• Compared functional outcomes for 2 interventions:

– supervised functional training (FT) 2x/wk x 6 wks or

– functional training (FT+B)plus balance ex. f/by 4 mo

home ex program

Measured: gait speed, chair rise test, single-leg stance

time (SLST)

and WOMAC and LE Functional Scale, adherence, pain,

stiffness, and attrition

193

INTERVENTIONS USED FOR TKA• FT activities included exercise for warm-up,

strength, endurance, task-oriented exercises (chair

stands, stairs, walk/bicycle) and cool-down

• FT+B activities added perturbation and agility work:

side stepping, braiding, tandem walk, crossover

steps, shuttle walk, direction changes,

multidirectional balance perturbation standing on

foam mat and also on tilt board, and roller board

perturb. with 1 foot on platform, 1 on roller board

• Home programs for 4 mo 2x/wk (Piva, p. 894)

194

BALANCE EXERCISE IMPROVES

FUNCTION AFTER TKA

• Both intervention groups improved in LE function

• More improvement for the Functional Training

with Balance group than with the functional

training alone group

• Particularly in SLST and gait speed

• Not statistically significant (pilot)

(Piva, et al, 2010)

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SYSTEMATIC REVIEW OF FALL

PREVENTION INTERVENTIONS

Gillespie et al reviewed RCTs of fall reduction interventions in 159 trials with 79,193 people to assess fall rate/yr and risk of falling between control and intervention groups

Significant reduction in fall rate and risk in

• Multi-component exercise and home program groups

• Home safety assessmennt/modification groups

(Gillespie, et al, 2012)196

SYSTEMATIC REVIEW CONTINUED

Economic savings proven in:

-home based exercise for adults >80y/o

- home safety for adults with prior fall, and - --

multi-component program addressing eight risk

factors.

(Gillespie)

197

Physical Activity and Fall Related

Efficacy

• Schepens et al: Meta- analysis of 20 studies

comparing fall related efficacy to

participation/activity measures.

• Results: positive correlation between fall-related

efficacy and activity r=.53.

• There is a strong association between levels of

occupational-based and basic-ADL activity

performance and function and increased fall-

related efficacy. (Schepens, S, et al., pp. 137-148)

198

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Improvement in Balance with

Mulitfactorial Programs

• Cadore et al : systematic review of the effects of

exercise programs on balance, strength, fall risk,

and gait from 1990-2012.

• Result: multicomponent exercise programs

including balance training, endurance, and

strength shows the most positive effect on

improving gait, strength, balance and rate of

falls in older frail adults .(Cadore, 2013)

199

Validity of Studies on Exercise Effect on

Falls Risk• Systematic review of 4 databases from 2000-

2010.

• Internal validity was described by the majority

of the studies.

• There were few reports describing external

validity and therefore one cannot generalize

regarding the data on physical activity

interventions for decreasing risk of falls. (McMahon, S, And Fleury, J, pp., 2140- 2154)

200

EXERCISE IMPROVES BALANCE AND

MOBILITY TESTS

Yang, et al: RCT: n=165 adult community dwellers

> 65 yrs with balance concerns

• Treatment group, n=83 : performed 6 months

home exercise of balance and strengthening

• control group: n=82 did usual activities

(Yang, et al, 2012)

201

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Yang, Continued

• Results: significant improvements in the treatment group for step test, functional reach test, hip abductor strength test, and gait step width

• Exercises included: warm-up ROM head, neck, trunk, back, and ankle, strengthening for knee, side hip, calf and toe raises, knee bends, walking forward, sideways and backward, heel and toe walking, forward/backward, stairs and walking

(Yang, XJ, et al., pp. 24-37)

202

Balance and Strength Improves Falls Risk

Tofthagen et al did retrospective review of Pub

med and CINAHL databases in 2011: studies of

adult community dwellers.

• Evidence supports the use of balance and

strength training programs for community

dwelling adults at high risk for falls, including

patients with peripheral neuropathy.

(Tofthagen, C, et al., pp. E416-E424)

203

EFFECT OF “LIFE” TRAINING ON FALL RATE and FUNCTIONAL TESTS

Clemson et al: randomized parallel trial of subjects 70 years+ with 2+ falls or 1 fall-related injury in the past year. Three interventions:

• Group 1: Lifestyle integrated functional exercise, (LIFE) (strength /balance training and selected activities),

• Group 2: structured program of balance/ leg strength exercises 3x/wk

• Performed 5 sessions + 2 booster sessions + phone calls

204

69

FALL RATE REDUCED BY BALANCE AND

STRENGTH TRAINING

• Group 3: Sham control of gentle exercise over 3 home visits

• Results: measured rate of falls after 3, 6, and 12 months, LIFE intervention group had

• 31% significant reduction in fall rate

• improved static balance, function, ankle strength, and participation for LIFE program vs. controls

(Clemson, L, et al., From http://www.ncbi.nlm.nih.gov/PMC/articles/PMC 3413733. Accessed 2/24/13)

205

LIFE PROGRAM ACTIVITIES

• Activities are performed as part of ADLs during

the day

• Examples of LIFE program include:

• Weight shift, narrowing BOS, move to sway

limits, turn changing direction, step over

obstacles, stand on 1 leg, tandem stand, on toes,

on heels, walk sideways, up stairs, knee bends,

pickup objects from floor(Clemson, p. 2)

206

WHAT WORKS FOR BALANCE•Tai Chi reduces fall risk.

•Changing from multifocal lenses to single vision

lenses reduced falls in people who were active in

outside activities

•Fall rate was reduced by withdrawal of psychotropic

medication

•Home safety assessment and modification reduced

rate of falls and fall risk

Gillespie LD, et al., From: http://www.ncbi.nlm.nih.gov/pubmed/22972103. Accessed

2/24/13) 207

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WHAT WORKS?

Gillespie et al reviewed RCTs of fall reduction

programs for community dwelling adults:

compared fall rates between treatment and

control groups.

• Exercise was the most common intervention,

followed by multi-factorial interventions.

208

WHAT WORKS?

• Rate of falls and fall risk was reduced by

home and group exercise programs.

• Multifactorial intervention and

assessment programs reduce fall rates.

(Gillespie LD., et al., From:

http://www.ncbi.nlm.nih.gov/pubmed/22972103. Accessed 2/24/13)

209

210

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Fall Prevention Recommendations:

AGS Panel on Falls Prevention

• Use long-term balance and exercise training

• Environmental modifications

• Medication Review and Adjustment

• Assistive Devices (walker, cane, hip protector,

bed alarms)

• Education and Behavioral Interventions

(From: http://www.betterbalancefallprevention.com/images/researcharticl.Accessed 2/24/13)

211

AGS Panel on Falls Prevention:

Considerations Requiring More Evidence

• Visual Intervention

• Patient Education

• Medical management of diseases/impairments

affecting balance, cardiovascular meds

• Footwear alterations

• Restraints

(From: http://www.betterbalancefallprevention.com/images/researcharticl.Accessed 2/24/13)

212

Conclusion About Exercise and

Balance Programs

• Fall risk and incidence are reduced

• Multiple factors are improved by exercise and

balance interventions

• Many balance assessment tools are valid and

reliable

THEY WORK!

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Faculty BiographyTheresa A. Schmidt, PT,DPT,MS,OCS,LMT,CEAS is a Board-certified specialist in orthopedic physical therapy, massage therapist, personal trainer, certified ergonomic assessment specialist. She is CEO of Flex Physical Therapy & EduciseResources Inc., continuing education in Long Island, NY. She has served as faculty of Physical Therapy at Touro College in NY, PT/PTA Programs, and adjunct professor at CUNY Queens College and Nassau Community College. She presents internationally on orthopedic rehab, fitness and alternative medicine. Her programs include: myofascial release, craniosacral, positional release/strain-counterstrain, joint mobilization, muscle energy, precision exercise, Reiki and complementary therapy. She presented for: Fascia Research Congress, APTA, AMTA, Cleveland Clinic, NASA InomedicHealth, & private medical clinics. She graduated with Highest Honors from Long Island University’s Physical Therapy Program in Brooklyn, NY, and received her Doctorate in Physical Therapy from University of New England. Dr. Schmidt provides 1:1 health consultations, tutorials and seminars. (877)281-3382

Visit www.educise.com & Facebook Educise Resources Inc

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ACCESS THE BALANCE EXAMS AT

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DISCLAIMER

In the efforts to comply with the appropriate boards/associations, I declare that I do NOT have

an affiliation with or financial interest in a commercial organization that could pose a conflict

of interest with my presentation.

Theresa A. Schmidt

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