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Geriatric PT > COMPS:Posture and Falls > Flashcards

COMPS:Posture and Falls Flashcards

1
Q

Fall death rates in US inc ___% from 2007 to 2016 for older adults

A

30%

  • 1/5 falls cause serious injury
  • 3mil tx’d in ER/year
  • 800,000+ pts hospitalized for falls
    • head inj
    • hip fx
  • >95% hip fx caused by falling
    • *Rule of Thirds
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2
Q

Examination

*Important Exam Considerations…

A
  • Strength AND mm performance
    • ex. dual tasking
  • flex
  • posture
  • functional mob & abilities
  • locomotion/gait analysis
  • environ/equip set ups
  • skin integrity
  • sensation
  • tone/motor control
  • cognitive/mental status
  • PMH, social hx
  • pain assess.
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3
Q

Strength, Flex, Strategies

STRENGTH

A
  • MMT/Dynamom
    • hip Exts, knee Exts, DF/PF
      • NOTE: PF MOST FORGOTTEN
    • what mm is KEY for one leg stance?
      • glute med, PF’s!!!
  • 5x sts
  • heel rise test
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4
Q

Strength, Flex, Strategies

Flexibility

A
  • Ankle DF and Great Toe Ext
    • NOTE: DF not usually culprit
      • *look @ hip flexors and knee flexors
    • Shoulder ROM
      • ex. if using an AD→ we want flexion
    • Cervical ROM
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5
Q

Strength, Flex, Strategies

Strategies (think for balance)

A
  • Impaired balance strats
    • ankle, hip, step
    • Righting rxns
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6
Q

Literature: Resistance Training Interventions

A

see pics

Note resistance training, overload principle for TRUE DIFFs

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7
Q

How do you START Strength Training?

1RM in Older Adults

A
  • Direct assess. NOT advised
  • Determining 1RM:
    • # of reps that completed w/ good form and NO substitution
    • Reps and % of 1RM (ACSM)*****
      • 90%→ 4-5reps
      • 80%→ 8-9reps
      • 70%→ 12-13reps
      • 60%→ 16-20reps (Start HERE for most***)
    • NOTE: Do NOT predetermine #reps during tx
    • NOTE: not much diff bw 1-3sets→ set up circuit style training
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8
Q

Literature: Resistance Training Interventions

A

see pics

NOTE: Progression (high intensity 12 wk resistance progressing intervents), ankle DF ROM (strength usually OK, ROM not)

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9
Q

Interventions: HIIT

AMRAP

A
  • AMRAP→ w/in specified time frame
  • Track progress→ by how many reps pt can get in time frame
    • NOTE: stop pt when form starts to break
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10
Q

Interventions: HIIT

EMOM

A
  • Specified # of reps, whatever time is left over is rest time
  • i.e. 10 reps
    • if takes 30s to do 10 reps, 30s rest
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11
Q

Interventions: HIIT

Guidelines/Goals

A
  • Exercises should be based off of physical exam findings/goals
  • Goal: safely overload mm’s
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12
Q

Interventions: HIIT

AMRAP Ex.

A
  • 4 moves: S2S, Tandem walk, Lunge, Farm walks
  • 2 min for ea. exercise
    • tabata apps
  • Document: cues provided, reps or laps performed, any LOB, vitals***
  • Ways to Progress: inc resistance, add dual tasks for walking balance, plyos
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13
Q

Interventions: HIIT

EMOM Ex.

A
  • 4 moves: Squats, Heel raises, Step ups, Toe raises
  • 8 reps for ea. ex.→ strengthening ex.
  • Document: cues, amt of rest, vitals***
  • Ways to Progress: Repeat circuit #x, inc resist, progress to power (lower reps)
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14
Q

Postural Examination

*losing EXT

A
  • FHP
  • Kyphosis
  • Scoliosis
  • L/S stenosis
  • Rounded shoulders
  • NOTE: if you FIX IT→ maintaining can be diff, sometimes fixing makes it WORSE→ Clinical Decision Making
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15
Q

Postural Examination

A
  • FHP, kyphotic, rounded shoulders, DEC lumbar lordosis, INC hip/knee flex
    • FHP INCd risk of falls
      • Influence of FHP on balance in Community Dwelling Women Age 60+
  • REEDCO posture scoring sheet (see pics)
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16
Q

Postural Examination Techs

2 Most Used:

A
  1. Wall-Occiput Distance (common, doesnt tell you problem, but good start)
  2. Rib-Pelvis Distance (looks @ L/S)
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17
Q

Postural Examination

Wall-Occiput Distance

A
  • <4cm= risk for t/s vertebral fx
  • Pt stands straight w/ back against wall and heels touching wall. The dist bw the occipital prominence and wall is quantified using a tape measure.
  • POSITIVE FINDING: inability to touch wall w/ back of head
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18
Q

Postural Examination:

Rib-Pelvis Distance

*looks @ L/S

A
  • <2 finger breadth= risk for vertebral fx
  • Distance bw inferior margin of 12th rib and ASIS of pelvis
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19
Q

Flexicurve

A
  • Osteoporotic curve
    • see slide 14
  • Index of Kyphosis*=> (TW/TL)x100
    • see pics for norms
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20
Q

Impact of Falls

Stats

Most important***

A
  • ¼ (25%) older people fall yearly,
  • 20-30% older adults who fall suffer mod→ severe inj’s
    • hip fx or head trauma
    • inc risk of premature death
  • Costly $$$
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21
Q

Literature: Interventions for Osteoporosis

A

See pics

  • NOTE: Sinarki’s landmark study clearly demo’d
    • EXT ex’s significantly reduced incidence of fx reoccurence
    • FLEX ex’s INCd risk
      • Flex ex’s→ 89% fx
      • EXT ex’s→ 16% fx***
      • Flex + Ext→ 53%
      • No Ex→ 59% fx
  • NOTE: NO KTC ex’s, work on stability and EXT***
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22
Q

Literature: Interventions for Osteoporosis

A
  • Special assess/exercises?
    • FRAX score
    • Meeks Method
    • Spinomed
  • Safe ADL practices
    • Moving safely
    • Proper posture
      • chair hts, head pos’s
    • Hip hinge for push, pull, squat
    • Log roll in bed
    • Posture relief in sitting
    • NO curl ups, no manipulations***
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23
Q

Literature: Interventions for Osteoporosis

A
  • Phys activity generally regarded as an important stimulus for bone modeling/remodeling***
  • Wolff’s Law
    • Bone adapts to loads placed on it**
    • ***Load has to be thru long axis
      • LAQ*
      • Aquatic Tx*
      • Pilates*
      • Walking*
      • Running
      • Squats
      • Push press
      • Power clean
      • Plyos
  • NOTE: *’s=GOOD
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24
Q

Literature: Interventions for Osteoporosis

A
  • Special ex considerations include indiv programs of:
    • Stretching
    • Manual Tx
    • Low wts+more reps to min. stress on jts

*See pics for Studies

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25
Literature: **Interventions for Osteoarthritis (OA)** ## Footnote **\*not a focus of test**
see pics
26
Screening Fall Risk: **STEADI** ## Footnote **Stopping Elderly Accidents, Deaths, Injuries**
* **Assessment→** More _physically based_ * **Algorithm** * screening ?'s * TUG (**Reqd)** * **(+)→ \>/=12s** * 30s Chair Rise (**Optional)** * **(+)→ below avg score** * 4 Stage Balance Test (**optional)** * **(+)→ Full tandem \<10s** * # of falls * Inj vs. no inj * **Intervention:** * **Algorithm** * Not @risk vs @risk * Individualized plan * Follow-up in 30-90d
27
**STEADI Algorithm for Fall Risk Screening, Assessment, and Intervention** **\*GOLD STANDARD**
GOLD STANDARD\*\*\*
28
Other Risk Factors for Falls
See pics NOTE: **FOF→ considered _red flag_ → assess right away**
29
Evaluation: ## Footnote **Balance**
* **Subjective:** * hx of falls? * For ea recent fall: * Where * When * Activity * Time of Day * Symptoms? * Strength/ROM * Cognition/Executive functioning * Modified CTSIB * Vision, Vestib, Somatosensory
30
Evaluation: **FOMs** ## Footnote **what do we want to do w/ them in general?**
_Purposefully_ select tests that eval areas **specific to ea. individual**
31
Evaluation: FOMs ## Footnote **Sitting Balance**
Sitting Balance Test
32
Eval: FOMs ## Footnote **Static Balance**
Functional Reach 4 Stage Balance Test One Leg Stance Test
33
Eval: FOMs ## Footnote **Dynamic Balance**
* Gait Speed * TUG * Berg * Four Square Step Test * Tinnetti * DGI * Mini BEST→ reactive balance control * Fullerton Advanced Balance
34
Eval: FOMs ## Footnote **Fear of Falling (FOF)**
ABC Balance Confidence Falls Efficacy Scale-International \***NOTE: non-billable**
35
Eval: FOMs ## Footnote **Strength**
30s or 5xSTS Heel Rise Test
36
What CAN be done about Falls? Literature says…
"Effective strategies to prevent falls have been IDd, **BUT are _underutilized_….**dissemination of **evidence, coupled w/ interventions** to change clinical practice *could reduce fall rates !!!* *-Tinnetti, 2008*
37
Rehab Dosage: Balance ## Footnote **IMPORTANT SLIDE!!! KNOW IT!!!!** **\*\*\*\*\*\***
* FOMs * Good for **screening** and may be **specific for a given condition** * **MAY NOT TELL YOU WHERE DEFICITS LIE\*\*\*\*** * App of **motor learning principles** * see neuro cards * **GET THEM UP!!!** * Aim for Success about 75% of the time * relate it back to motor learning→ something specific they've learned→ **other 25% they _actually fall and you catch them_ (pushing limits!!!)** * Needs to be MORE than strengthening or walking * **50 hrs to _truly reduce risk/optimize balance_** * May be @ higher risk if \<50hrs * reqs **client engagement _outside of skilled care_**
38
Literature: **Avin et al 2015** ## Footnote **\*Recommendations based on AGS/BGS CPG and National Institute for Health and Care Excellence (NICE) CPG**
* HIGH qual study (first clinical practice statement (CPS)) * **CPS is _summary of CPGs_** * **Screening** * Older adults in contact w/ HC provider _should be asked_ whether they have fallen in prev year or are concerned about falls * **If yes,** they should be screened for balance/mobility impairs * **Assess/Intervention** * **Positive Screen:** PT/OT should use targeted multifactorial assess and intervents
39
Interventions according to AGS/BGS & NICE study
* Indiv'd intervents addressing **specific impairs or risk factors** * Strength training * Balance training (duration from Sherrington study→ **Success 75% of time)** * Gait training * Correct environ. * Correct footwear * ADs * Added Pt of contact for enhanced **proprioception & stability** * **\*Proactive approach when client has dementia!! (prior to Lvl 4)** * **Tactile cue from AD**
40
Interventions: AGS/BGS & NICE study ## Footnote **NOT ADVISED\*\***
NOT ADVISED\*\* * Walking as a single intervention * Non-specific or Low-intensity ex. or balance training * Providing info w/out approp. follow-up * Hip protectors * Vit. D supps * **Will NOT _reduce_ fall risk, only helps you _not get hurt_\*\*\*\*\***
41
Literature: **Sherrington et al _2008/2011_**
* High qual study * **community dwelling older adults \>60yo** * Following req's for **effective program:** * **Mod→High challenge that _reduces base of support_ (BOS), _moves center of mass (COM), reduces UE support_** * Strength training of LEs * Jelly legs THEN balance training * \*progress to standing * **Total dosage AT LEAST 50hrs, 2hrs/wk over 6mos** * **TWO hrs/week ongoing to maintain bennies** * Walking may be included, but cannot be sole intervention * Needs to be performed **in home-based OR group setting**
42
Literature: **Sherrington et al _2017_**
* system review/meta analysis **exercise only** * Looked @ which aspects of intervention further reduce fall rate * Overall, reduced rate by 21% * **Following accounted for 76% of variability in programs and further reduced fall rate:** * **HIGH challenge** to balance that reduces BOS, moves COM, reduces UE support * **More than 3hrs/week of exercise** * ***these 2 attributes reduced fall rates by 39%*****!!!** * Exercise was particularly effective in those w/ **PD & Cognitive decline**
43
Interventions: **Progressions** ## Footnote **Ways to _reduce UE support:_**
* Palms up or Hands on higher surface/wall * Finger tips * One hand * One had palm up * One hand finger tips
44
Interventions: **Progressions** ## Footnote **Ways to _reduce BOS:_**
* Split stance * Semi tandem * Tandem * Single leg\*\*\*
45
Interventions: **Progressions** ## Footnote **@ Ea stage progress w/:**
Foam Vertical and Horiz head mvmts Eyes closed
46
Interventions: **Progressions** ## Footnote **Cognitive Dual Task**
**Cognitive Dual Task** * Counting backwards by 3's (serial 3s) * Spelling words backwards * Naming diff types of: plants, clothes, stores, foods, teams * or naming things starting w/ particular letter
47
Interventions: **Progressions** ## Footnote **Motor Dual Tasks**
* Placing ball back and forth ea hand * Placing penny in and out ea pocket * Tossing ball up and down * Bouncing ball * Throwing ball back and forth
48
Interventions: **Agility Drills** ## Footnote **\*Treat them like athletes! Same principles!**
see pics Cone work
49
Clock Yourself App
see pics READ!!!
50
Literature: **SUNBEAM PROGRAM**
NOT ON TEST see pics and have gen. idea \***Sunbeam Program found to reduce the rate of falls and improved phys perform. in residents of aged care**
51
Literature: SUNBEAM PROGRAM
USED HUR health/fitness equipment Logs/tracks progress
52
Literature: **SUNBEAM** ## Footnote **BALANCE EXERCISES**
SEE PICS
53
Literature: **Reykjavik Model** ## Footnote **NOT ON TEST**
see pics have gen. understanding
54
Literature: **Reykjavik Model** ## Footnote **Proprioceptive Training**
EO then w/ EC see pics
55
Literature: **Reykjavik Model** ## Footnote **Vestibular and Eye Control**
see pics
56
Literature: **Reykjavik Model** ## Footnote **Proprioceptive and Vestibular Tx**
see pics
57
Literature: **Reykjavik Model** ## Footnote **Fall Reaction Training**
see pics
58
Preventative Strategies: **At Home** ## Footnote **In general…**
* Research will show **home-based or group settings are approp.** * Older adult adherence to HEP is 21% * **Ideal # of exercises/balance activities for HEP:** * 3-4/day \*\*\*\*\*
59
Preventative Strategies: **At Home** ## Footnote **When Assigning an HEP** **Consider:**
* Use RPE!!! * Client preferences, perceived benefit of program * Client perceived barriers to perform. * Being flexible in your delivery while staying as consistent as poss w/ literature
60
Preventative Strategies: **At Home** ## Footnote **Otago Exercise Program**
* Reimbursable thru Medicare Part B (outpatient), and endorsed by CDC * **Reduces fall risk by 35%\*\*\***
61
Preventative Strategies: **Group Programs** ## Footnote **In general…**
Research shows that **home-based OR group settings are approp**
62
Preventative Strategies: **Group Programs** ## Footnote **2 Groups endorsed by CDC:**
1. Tai Chi: Move for Better Balance 2. Stepping On
63
Preventative Strategies: **Group Programs** ## Footnote **Tai Chi: Moving for Better Balance**
* 8 forms * **emphasizes SLS/DLS, posture, breathing** * 1hr, 3x/week for 6mos * **Fall reduction of 55%\*\*\***
64
Preventative Strategies: **Group Programs** ## Footnote **Stepping On**
* Designed of OTs * 7 2hr/week sessions * **Follow-up home visit** * 3mo booster session * **Fall rate reduction 35%, almost 60% in _Men_**

Geriatric PT (7 decks)

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