Gerontology Module 7 - Balance and Falls

Predictive value (ideally want both to be high):

(+) predictive value is how well the tool predicted falls compared to the actual number of falls (-) predictive value is how well a (-) test correctly predicts the absence of falls

Flexibility exercises:

-Ankle flexibility important for proprioceptive efficiency ankle joint receptors

Altered sensory conditions during balance activities:

-Bare feet -Eyes open / closed -Labile Surfaces -Head Movement

2nd Motor response: (70-120 ms) Brainstem > facilitates co-contraction

-Bilateral > SLS > Eyes open > eyes closed -Stable > unstable > Head turning

Downfall of mCTSIB?

-Cannot discern the specific patterns of sensory dysfunction -Does not predict falls in active community-dwelling adults

Extrinsic risk factors for falling:

-Contribute to up to 36.9% of all falls -Affect more mobile older adults -Make up ~ ½ of falls that require medical assistance -Environment i.e. dim light, floor coverings, pets, footwear -Institutional risk factors include time of day, staffing levels on nursing floor, room distance from nurses' station

Modified Clinical Test of Sensory Interaction on Balance (mCTSIB)

-Designed to assess how well an individual is able to balance when 1 or more of their balance-related sensory inputs are compromised -Test individuals stands on both feet under 4 different and progressively more difficult conditions 1. on solid, level surface with EO 2. on solid, level surface with EC 3. on foam with EO 4. on foam with EC Score = times for each of 4 conditions are totaled and used as balance score

Component of motor function controlled by vestibular system input is muscle activity:

-During erect posture it initiates transitory muscular contractions and controls muscle tone -Assists in stabilizing gaze during head and body movements by generating conjugate smooth eye movements opposite in direction and ~ equal velocity to head movements

Psychological Impact of Falls "Fear of Falling"

-Falls and near falls can generate fear, anxiety, and loss of confidence -Tinetti defined FOF "lasting concern about falling that leads to an individual avoiding activities that the person remains capable of performing"

Intrinsic risk factors for falling:

-Frail, Alzheimer's disease, Parkinson's Disease, stroke, depression, Rheumatoid Arthritis, hip fracture, LE amputation -Weakness (most common), altered vision, fear of falling -Changes in stride length variability that increases over time as disease progresses

Fall prevention program and safety education:

-Identify fall risks -Safety in the home and environmental adaptations -Allow for plenty of time for functional activities • Avoid rushing -Dizziness during postural changes test for postural hypotension • Educate on changing positions slowly and wait for BP to stabilize

Precautions:

-Isometric exercises for OA -Avoid valsalva maneuver i.e. count out loud -Monitor heart rate, blood pressure

Hip Strategy Proximal (Type I mechanoreceptors Ruffini)

-Larger perturbations -Hip works with ankle and trunk to maintain COG over BOS

Integrated Neurosensory System impact on balance:

-Mobility of neck, thoracic, lumbar spine may be limited • Older adults have limitations in cervical rotation and extension • Muscles may be weak and inflexible • Joints may be restricted or contracted -Dehydration impact on vestibular system • Self-restricting fluids to prevent incontinence • Medical restriction of fluids related to diuretics • Medications may cause dehydration -Gait Patterns • May be slow, limited foot clearance, inaccurate foot placement

Berg Balance Scale

-Monitor performance during balance activities -Screen for individuals who would benefit from a PT referral -Predict multiple falls in community-dwelling and institutionalized older adults • BBS consists of 14 tasks, takes ~15 minutes to administer -14 items are scored on a 5-point ordinal scale -Based on ability to complete task and time for completion -Scores on 14 items are combined for a total score • Scoring 0-20, wheelchair bound 21-40, walking with assistance 41-56, independent

Tinetti study found number of persons falling increased from 8% with no risk factors to 78% with 4 or more risk factors:

-Muscle weakness followed by history of falls > gait deficit > balance deficit > use of an AD for ambulation -Use of 4 or more prescription medications • Increases risk for falls by 30% -Depressive symptoms, postural hypotension, arthritis

Assessment of vitals:

-Perform a supine BP and sitting BP •Person supine for 5 minutes then measure BP and HR •Measure BP and HR again immediately standing, and again within 3 minutes after standing -Must include a medication history

1st Motor Response (< 50 ms): Spinal Cord > automatic reflexes

-Proprioception and neuromuscular control react unconsciously -Impulse Technique Isometric Stabilization (ITIS) • Use medicine ball, Perturbations -Oscillating Technique Isometric Stabilization (OTIS) • Use band resistance, Body blade

Loss of Balance:

-Protective responses -Extension of limbs -Stepping strategy

Strengthening exercises to prevent falls:

-Provide adequate force production of LE and trunk -Improve postural muscles and balance control

Perturbations:

-Provoke postural adjustment that brings COG back over BOS -Push on shoulders or sternum small backward force stimulate ankle DF and hip flexors -Forward push from back facilitates ankle PF and hip extensors

Stepping Strategy (commonly used in Older Adults)

-Re-aligns BOS under the COM

Ambulation:

-Requires weight shifting -Requires interaction variety of support surfaces • Practice on even surfaces and level ground, uneven surfaces, inclines, stairs -Lighting and background noise

FOF is independently associated with slow-timed physical performance and depressive symptoms:

-Results in inactivity -Individual may have suffered a fall -Individual did not fall but knew someone that had fallen -Limit activities or are guarded during activities • May grab on to furniture or supportive structure during ambulation -Fear alters gait habits and activities

Ankle Strategy (Type II Pacinian mechanoreceptors)

-Small movements occur at ankle -Maintains center of gravity (COG) over base of support (BOS) -Weakness / limited ROM affect ankle strategy

4 Basic Domains of Fall Assessment:

1. Specific patterns and injuries 2. Physical function and functional activity level 3. Psychological consequences i.e. fear of falling, activity restrictions 4. Health related quality of life

Fall Assessment Includes:

1. Systems review, Tests and Measure: -Posture, CV status, balance, strength, sensation, vision, cognition, equipment needs, family dynamics, co-morbidities, current diagnosis, motivation, etc. 2. Screening Tools -Need to consider multifactorial nature of falls -Use a screen tool that is valid and developed for setting and population • Institutionalized vs. community dwelling • TGUG for frail elderly or Morse Fall Scale for a new patient

> __ of those 65 and older experience a fall related incident / year

1/3

_ months exercise program improved LE strength, walking endurance, function

3; appropriate for older adults at risk for disability, addition of resistance permits for increased loading and improved balance and weight shifting

FGA can be used to predict falls within the subsequent _ months.

6

Optimal control of balance is maintained up until age?

60

Rate of falls for those > age __ rises with aging in both sexes, and across all racial groups.

60

Person will be dependent on one or more ADLs with a gait speed:

< 1.0 mph

3 levels of FOF:

Absence of fear, fearful but still active, fearful to the point of decreasing activity

Dynamic Gait Index (DGI)

DGI focuses specifically on postural stability during walking activities and evaluates a person's ability to modify gait in response to changing tasks -DGI rates 8 aspects of gait performance that includes walking, variable-speed walking, stairs, walking and turning, walking around obstacles and high level skills -Each item is rated 0 = severe impairment, 3 = normal -Score: High risk for fall = <24 -Reliability is good and tool is used for evaluating effectiveness of intervention for community dwelling adults and vestibular disorders

Falls and morbidity

Difficulty getting off the floor or ground after a fall is associated with substantial morbidity • Study on rising ability may differ based on initial body position and with or without use of a AD • Takes 2 to 3 times longer to get off floor after a fall vs. younger person

Psychological Assessment tools:

FES MFES SAFE ABC

T/F Falls are an inevitable consequence of aging.

False; may be due physical dysfunction, medications, environmental hazards -History of falls increases risk for subsequent falls

T/F Vestibular system plays a major role in control of COG position when somatosensory and visual information are adequate.

False; minor role, only dominant when conflict between visual and somatosensory during ambulation

Other Risk factors:

Functional impact may predispose to ↑ risk for fall -Poor health status -Impaired mobility from inactivity or chronic illness -Postural changes or instability affects the COG • Kyphotic posture contributes to propensity to fall in osteoporotic individuals -Limitations in ROM and joint mobility -Coordination problems -Gait deviations

Studies show resisted Lateral Stepping (around ankles) effective frontal plane strengthening for?

Gluteus Medius • During gait, gluteus medius fires rapidly during mid-stance and must develop an adequate level of force in milliseconds while producing an isometric-eccentric contraction

Excessive FOF accompanied by activity limitation which can contribute to falls:

May result in loss of mobility, decreased social stimulation, and loss of strength and function

Balance Terms-Postural Control System (PCS)

PCS receives information from receptors in proprioceptive, visual, and vestibular systems which must be intact for optimum balance control

Balance exercises:

Postural control or response to perturbations Weight shifting Anticipatory adjustments to limb movements -Incorporated into functional exercises • Sit <> stand -Voluntary weight shifting • Sitting > standing • Shifting trunk Anterior-Posterior, laterally, rotation

Proprioception:

Static awareness of joint position Kinesthetic awareness Closed-loop efferent reflex response required for regulation of muscle tone and activity

Cardiovascular disorders may contribute to a fall:

Syncope: Patient with symptoms of sweatiness, nausea, cold, lightheadedness, and clamminess prior to fall suggests cardiac syncope Orthostatic hypotension: Patient falls as a result of change in position, dizziness

This uses a set of movements that stresses balance, controlled movement, synchronized breath control, and awareness of body alignment.

Tai Chi

Downfall of Morse Fall Scale?

Test does not take in to account medications that may increase fall risk

T/F 85% of falls occur at home.

True

T/F Falls are the leading cause of injury death and disability for those over age 65.

True

Researchers found that older adults with physical impairments exhibited pronounced reductions in _____ power output during walking?

ankle; generated more energy from hip and low back as compensation for reduced plantarflexorpower output

Falls Efficacy Scale (FES)

assess fear of falling for elderly in long-term care

What is the cornerstone of management of balance disorders?

balance re-organizing strategies

Patient's with arthritic conditions may have ______ deficits affecting performance in transfer and ambulatory tasks: -Significant challenges to _____ mobility / stability

balance; lateral

Medications most commonly associated with falls by community-dwelling older adults:

benzodiazepines, beta-blockers, and diuretics

Increased/Decreased step width variability is associated with sensory impairment?

decreased

Modified FES (MFES)

for community dwelling older adults

Placing band around the _____ was selective enhancement of gluteal muscles versus TFL by adding an ER effort to hips.

forefoot

About how many patients who sustain a hip fracture who were independent prior to the injury never regain their former independence?

half

More than 95% of this type of injury are caused by falling.

hip fx

Increased/Decreased stance time variability is associated with CNS impairment?

increased

Specificity:

is the ability to correctly identify the absence of falls -Higher specificity, fewer people are incorrectly classified as fallers who do not go on to fall (false positives)

Sensitivity:

is the ability to detect falls when they are present -Higher sensitivity, fewer people are incorrectly classified as non-fallers who go on to fall (false negatives)

Fear of falling =

low perceived self-confidence in avoiding falls during essential, non-hazardous activities -Fall efficacy influences functional ability with respect to balance and physical functioning

Recommend a _______ review is one of the strongest fall prevention interventions.

medication

Intervention should promote?

orientation gaze stabilization postural realignment muscle strength joint mobility

Kinesthesia

perception of motion and joint position sensibility or perception

Feedforward:

preparation for voluntary movement which requires balance adjustment, anticipating center of mass (COM) change from previous experience

Goal of Treatment in rehabilitation is?

prevention of impairments by optimizing function

Feedback:

reaction to a specific stimulus, mechanoreceptor detection of altered support surface

Gait changes include:

shorter stride length ↑ BOS width prolonged double limb support time slower gait speed

PCS Sensory Sources:

somatosensory vestibular visual

Oscillating Technique Isometric Stabilization (OTIS)

stimulates mechanoreceptor and muscle spindle activity, also facilitates increased joint stability and automatic reflexes by using short, rapid pulling of bands in an oscillation manner, leg is stabilized and does not move, it reacts to weight shifting generated by the arms increasing proprioception

Impulse Technique Isometric Stabilization (ITIS)

uses quick and repetitive loading and unloading, or impulses by tossing a med ball, this facilitates the mechanoreceptors which stimulate joint proprioceptors and reflex adaptation

ABC:

• ABC Scale is a reliable and valid self-report measure of balance confidence • 16-item scale rated from 0% (no confidence) to 100% (complete confidence) during ADLs -< 50 indicate a low level of functioning -> 50 -80 indicate a medium level of functioning -> 80 indicate a high level of functioning -ABC discriminates better than Falls Efficacy Scale (FES) scores of high versus low mobility participants

Falls: Treatment Interventions

• Bipedal, tandem, uni-pedal activities, Wide BOS > Narrow BOS • Eyes Open (EO) > EC • Speed: Slow to fast • Stable > Unstable Environment i.e. AirXPad, Foam Roll, Wobble Board, Gel Cushion, BOSU • Perturbations various directions, Direction: Known to unknown, • Static standing > Dynamic standing i.e. Head moving, UE / LE reaches • Tandem Walks > Lateral Stepping > Carioca • Step-over 6"-12" hurdles Forward / Lateral • Agility activities, obstacle negotiation, shuttle walks vs. shuttle runs

Center for Epidemiological Studies Depression Scale (CES-D)

• CES-D is a short, self-report scale used to assess general psychological impairments i.e. depression -Not used to make a diagnosis -CES-D has 20 statements reflect patients' feelings from previous week -Maximum score = 60 -Score = >22 indicates a probable major depression 5-21 indicating mild to moderate depression < 15 indicating absence of depression

Functional Reach Test

• Consists of measuring distance that an individual can reach forward without moving feet • Study comparing individuals who were able to reach 25.4 cm or more -Reach is < 25.4 cm were twice as likely to fall -Reach < 15.2 cm were 4 times more likely to fall -People who were unable to reach were 8 times more likely to fall

Morse Fall Scale

• Currently used in VA facilities and acute care settings -Short, simple, valid takes less 3 minutes -History of falls, AD, gait / transfer status, mental status -Total score of 125 • No risk 0 -24 • Low to moderate risk 25 -45 • High risk 46 + • Sensitivity = 72% (-) Predictive Value = 81%, (+) Predictive Value = 38% -Has a low ceiling effect and over estimates potential fallers

FES:

• FES assess fear of falling for elderly in long-term care -Valid, and reliable self-report screening instrument for Fear of falling • Each of 10 ADLs i.e. taking bath or shower, or getting dressed, is scored 1 (totally confident) to 10 (no confidence at all) -Individual item scores are totaled and averaged for a final score average • Score >7 is considered indicative of FOF

Geriatric Depression Scale (GDS)

• GDS Long Form 30-item questionnaire -Patients answer yes or no in reference to how they felt over the past week -Takes about ~ 5 to 7 minutes to complete • Short Form GDS consisting of 15 questions was developed in 1986 -Questions from Long Form GDS which had highest correlation with depressive symptoms in validation studies were selected for Short Form • Scores of 0-4 are considered normal, 5-8 indicate mild depression; 9-11 indicate moderate depression; and 12-15 indicate severe depression

MFES:

• MFES reliable, valid self-report scale, 4 outdoor activities added to FES to make the tool more useful for Community Dwelling older adults: -Uses a visual analog scale -Items are scored from 0-10 with 0 = not confident / not sure at all to 5 = fairly confident / sure, 10 = completely confident / sure • Ratings are totaled 0-140 and divided by 14 -Score of < 8 indicates a FOF and scores >8 indicate lack of fear

Timed Single Legged Stance

• Measures 1 legged stance balance endurance -Excellent screen tool for Community-Dwellers -Inability to maintain SLS position strong predictor of fall risk -Quick, simple, requires only a stopwatch • Maintain ability to SLS for 10 seconds (norm) with Eyes Open (EO) -Norms: 10 seconds = 89% community dwellers, 45% for nursing home residents • Sensitive to clinical interventions

SAFE:

• SAFE scale consists of 11 items that represent ADLs and IADL's -Social and higher cognitive aspects of ADLs that relate to fear of falling -Activity level subscale scores range from 0 = no, 1 = yes, fear of falling subscale 0 = not at all worried, 3 = very worried across 11 activities • Higher total SAFE scores indicate more fear of falling • SAFE demonstrated strong reliability and validity

Mini-Mental State Exam (MMSE)

• Tests for memory or recall, orientation, attention, language, and visual-spatial skills -Test is relatively easy to administer -Takes between 5 to 10 minutes • Maximum score on the MMSE is 30, and a score below 24 indicates cognitive decline

1st Motor Response Training

• The main objective of the training is to facilitate the unconscious process of interpreting and integrating peripheral sensations received by CNS into appropriate motor responses • Stimulating the joint receptors involves afferent info synapsing directly on alpha motor neurons with programmed response from efferents(reflex stabilization) • The neuronal circuits mediate automatic / stereotyped reflexes • Mechanoreceptor fire increase muscle co-contraction stabilizing the joint

Functional Gait Assessment (FGA)

• improves reliability and reduces the ceiling effect seen in DGI • 10 items of FGA e.g. gait on a level surface, change in gait speed, gait with horizontal and vertical head turns, pivot turn, step over obstacle, narrow BOS, eyes closed, ambulating backward, and steps • Each item is scored on an ordinal scale (0 -3) = Maximum total score is 30 -Higher score represents better balance and gait ability • Good construct validity in patients with PD