balance and fall

Question 1

common risk factors for falls

Answer 1

impaired balance, gait, weakness
multiple medications (FRIDS)
vision
environemental hazards
postural/orthostatic hypotension
feet/footwear
(listed in order of importance)

Question 1

highest risk meds

Answer 1

psycotropic meds
- sedatives.hypnotics
- anti-psychotics
- anti-depressants
- narcotics

Question 2

how to balance needs of falls prevention for impatient environment

Answer 2

mitigation strategies include fall prevention plans, safe handling strategies, and early mobility

unintended consequence - increased zero fall environment, culture of mobility decreases

Question 3

why over implemention of fall prevention strategies be an issue

Answer 3

multisystem organ involvement, susceptibility to infection/disease, immobility, deconditioning, functional decline

Question 4

LOW RISK individualized fall interventions

Answer 4

educate patient
vitamin D +/- calcium
refer for strength and balance exercise (community exercise or fall prevention program)

Question 5

LOW RISK for falls - STEADI

Answer 5

patient scores >/= 4 on the stay independent brochur

evaluate gait, strength, and balance
TUG - recommended

Question 6

MODERATE RISK individualized fall interventions

Answer 6

educate patient
vitamin D +/- calcium
refer to PT to improve gait, strength, and balance
OR
refer to a community fall prevention program

Question 7

HIGH RISK individualized fall interventions

Answer 7

educate patient
vitamin D +/- calcium
refer to PT to enhance functional mobility and improve strength and balance
manage and monitor hypotension
manage medications
address foot problems
optimize vision
optimize home safety
FOLLOW UP WITHIN 30 DAYS
- review care plan
- assess and encourage fall risk reduction behaviors
- discuss and address barriers to adherence

Question 8

physical screening for fall risk
CDC STEADI Recommendations

Answer 8

30 seconds chair stand test
4 stage balance trst
TUG
Orthostatic hypotension test

Question 9

30 second chair stand test

Answer 9

biomechanical constraints/ MSK determinants (strength)

anticipatory postural adjustments/postural movement strategies

Question 10

4 stage balance test

Answer 10

biomechanical constraints/ MSK determinants (BOS)

anticipatory postural adjustments/postural movement strategies

Question 11

timed up and go

Answer 11

anticipatory postural adjustments/postural movement strategies (STS)

stability in gait
observation of walk and turn

Question 12

screening guidelines

Answer 12

ask every patient over 65 and older about history of falls

have you fallen in the lasy year
- if yes - ask about frequency and circumstances
- if no - ask any difficulties w walking or balance or unsteadiness
- if no to both - no fall risk assessment unless other red flags
- if yes to either - multifactorial fall risk assessment need to be done to screen for balance or mobility deficits

Question 13

6 systems of postural control

Answer 13

biomechanical, stability limits/verticality, anticipatory postural adjustments, reactive postural adjustments, sensory orientation, stability in gait

Question 14

test and measures for biomechanical system

Answer 14

goniometry, manual muscle test, 5x sit to stand, 30 second chair stand

example: ROM, strength, posture

Question 15

test and measures for stability limits/verticality

Answer 15

seated/standing psoture and perceived vertical, functional reach tset; part of BERG

examples- reaching, contraversion or ipsiversion pushin

Question 16

test and measure for anticipatory postural adjustments

Answer 16

parts of Tinetti, Berg (sit to stand, stand on one foot, alternating toe tap), 5c sit to stand, miniBEST

example: step initiation, going up/down curbs/staits

Question 17

test and measures reactive postural adjustments

Answer 17

parts of Tinetti (sternal bridge), retropulsion test (pull test), miniBEST

example; unexpected pertubations

Question 18

test and measures sensory orientation

Answer 18

sensation testing, vision testing, mCTSIB (part of miniBEST), Berg/Tinetti components with eyes closed

example’ instability on compliant surfaces or with eyes closed

Question 19

test and measures stability in gait

Answer 19

DGI, FGA, TUG and TUG-cog, miniBEST

example gait instability with head turns, pbstacle negotiation

Question 20

miniBEST and BESTTest

Answer 20

miniBEST examines 4 areas (not biomechanical or stability limits)
BESTTest examines all 6 areas

Question 21

PT balance interventions

Answer 21

individually tailored multifactoral exercise program
strengthening/resistance exercise (avoid under dosing, primary focus of intervention for those at high risk of falls)
targeted balance challenges
ROM and flexibility exercise
endurance
home modifications

Question 22

Treatment

Answer 22

exercise must provide a moderate or high challenge to balance
balance exercise must be of a sufficient dose to have an affect - 50 HOURS
ongoing exercise is necessary
programs without walking were MORE effectice (38% reduction in falls compared to 21% with)
strength training may be included

Question 23

balance exercise prescription

Answer 23

must provide moderate to high challenge to balance
- standing w little to no UE support
- reducing BOS
- altering COG
must be progressive and ongoing
2-3HRS/WK FOR A MIN OF 12 WEEKS
can be group or home based
other guiding principles (multidimensional stepping>walking)

Question 24

assistive devices

Answer 24

as a SINGLE intervention, does not reduce the number of falls or fallers - no adverse effects tho - used as part of multifaceted intervention proves effect for fall reduction increase base of support provide tactile cues about ground can provide support

Question 25

intervention recommendations from AGPT CPG

Answer 25

strength and balance (tai chi) walking program (no sufficient evidence of reducing falls) gait ADL Environmental and Home Hazards (after being hospitalized) Footwear (low heel hight and high backs)

Question 26

summary

Answer 26

fall risk is a chronic condition and should be monitored on an ongoing basis can be exaccerbated during a hospitalization can be reduced by as much as 30% by applying a simple, evidence-based intervention fall risk assessment is a multifactoral problem no simple solution all PTs should be screening older adults a combo of medical, physical, and enviromental strategies is more effective than one participating in various programs will help improve physical function, reduce fall risks, prevent falls

Question 27

In Horak’s Systems Framework for Postural Control, she discusses 6 systems that control balance. Which of the following is an example of a Biomechanical Constraint?

Answer 27

limited ankle ROM

Question 28

In Horak’s Systems Framework for Postural Control, she discusses 6 systems that control balance. Which of the following is an example of a problem in Sensory Orientation?

Answer 28

visual deficits

Question 29

Bending the knees during standing or ambulation for the purpose of maintaining a stable position during a perturbation is an example of a(n)

Answer 29

suspensory strategy

Question 30

Which 2 core tasks provide insight into a patient’s steady state postural control?

Answer 30

sitting and standing

Question 31

The ability to generate postural adjustments prior to the onset of and during voluntary movement” describes which control strategy for balance?

Answer 31

anticipatory postural control

Question 32

The appropriate use of an ankle, hip, or stepping strategy indicates adequate

Answer 32

postural responses/reactive control

Question 33

You ask a patient to stand on one leg and observe for appropriate weight shift prior to raising the contralateral limb. This evaluate

Answer 33

anticipatory postural adjustments/control

Question 34

The purpose of the CDC’s STEADI program is to

Answer 34

screen older adults for fall risk

Question 35

outcome measures

Answer 35

BEST Berg Dual task - cognitive Four square step test (FSST) functional gait assessment gait speed sensory organization test (SOT) TUG TUG-COG

Question 36

Berg Balance Scale BBS interpretation

Answer 36

for non vestibular balance assessment. measures functional balance and fall risk in adults 0-20 = wheelchair user 21-40 walking w assistance 41-56 = independent lower the score = greater fall risk 56=functional balance <45 greater risk <40 100% risk of fallinf <51 and history of falls <42 and no h/o falls <47 and in nursing home = indicates patient is at risk of falls

Question 37

BBS

Answer 37

used to assess functional balance - static and dynamic highly reliable and valid used for lower performing community dwellers and lower functioning older adults approx. 20 mins

Question 38

balance interventions - reactive postural control

Answer 38

ankle, hip, knee, stepping strategy weight shifts pertubations

Question 39

balance interventions - stability limits

Answer 39

reaching activities functional activities

Question 40

balance interventions - anticipatory postural control

Answer 40

expected changes and learned experience - functional activities - dynamic activities

Question 41

balance interventions - sensory orientation

Answer 41

surface changes functional activities eyes open/closed

Question 42

falls efficacy scale - international

Answer 42

individuals are instructed to rate each activity on a four point scale depending on how concerned they are that they might fall or if they can actually perform the activity 1 = not at all concerned 2 = somewhat concered 3 - fairly concerned 4 - very concered scores range 16-64 higher the score greater fear of falling

Question 43

activities - specific balance confidence scale

Answer 43

self reported measure in which patients rate their balance confidence for perfoming activities rated on scale 0-100 score of 0 represents no confidence and 100 represents complete confidence

Question 44

minimental status exam

Answer 44

Mini-Mental Status Exam MMSE: * One of the most frequently used cognitive screenings in older adults * < 5 minutes to administer * Quick screen to determine if there is cognitive impairments * Does NOT provide information to cause of cognitive impairment Scores: 0-30 with lower scores indicating poorer cognitive status, Folstein et al 1975: overall scores of 23 and lower are indicative of cognitive impairment * 24-30 identify individuals cognitively intact * 18-23 mild cognitive impairment * 0-17 severe cognitive impairment

Question 45

montreal cognitive assessment - MoCA

Answer 45

* 10 minute screen exam to assist in detection of MCI in multiple different conditions * Some stronger properties than MMSE in detecting MCI * Multiple languages Components * Attention and concentration * Executive function * Language * Conceptual thinking * Calculations * Orientation * Alternative trial making visuoconstructional skills: rectangle * Visuoconstructional skills clock * Naming memory attention * Sentence repetition * Verbal fluency * Abstraction * Delayed recall * Scoring: sum subscores listed on right hand side, add 1 point for fewer than 12 years education, 26/30 Norm Psychometrics: Nasserddina et al 2005: detects 90% subjects w/MCI, 100% sensitivity in Alzheimers, Smith et al 2007: in pts already dx w/ MCI helps identify those at risk of developing dementia at 6 mos