Balance and Mobility Screening

Tri-County RehabilitationCanfield’s Little Clinic with BIG Results Bruce Weston PT, DPT, OCS

Purpose

In accordance with American Geriatric Societyrecommendations:• Provide an ongoing screening tool to monitor fall risk

and level of mobility for older adults in our community.• Determine those older adults in need of a more

extensive multifactorial fall risk assessment.• Recognize those older adults in need of specific

interventions to decrease their fall risk and improve their ADL mobility and safety.

Criteria for screening

• Individuals 65 and older, referred to Tri-County Rehabilitation for any condition will be offered a complimentary screen of their balance and mobility. A summary will be forwarded to their PCP, with their permission.• Other individuals 65 and older may be screened at a

$20.00 charge with results forwarded to their PCP.

Components of the screen

1. Short Physical Performance Battery (SPPB)2. Gait Speed3. Activity-Specific Balance Confidence (ABC) Scale

1. ) Short Physical Performance Battery (SPPB)• A short screen of balance, gait speed, and lower

extremity strength. • The total possible score is 12. • Scores < 10 are predictive of fall risk in older adults.

2.) Gait Speed

• Computed over a 4 meter to 15 foot (4.57 meter) course.• Shown to be a predictor of life expectancy and nursing

home admission.• Slower times are sensitive and specific for predicting

falls in alder adults, with a cut off of 0.57 m/sec for recurrent falls

Gait Speed and Life ExpectancyStudenski S, et al. Gait Speed and Survival in Older Adults. JAMA. 2011, January 5; 305 (1):50-58

3.) Activity-Specific Balance Confidence (ABC) Scale• Consists of questions regarding an older person’s

confidence in performing sixteen different ADL activities.• Each activity is scored on a scale from 0% to 100%

confidence.• An average score is computed with scores < 67%

predictive of fall risk in older adults.

The Activities-specific Balance Confidence (ABC) ScaleFor each of the following activities, please indicate your level of self-confidence by choosing a corresponding number from the following rating scale:

0% 10 20 30 40 50 60 70 80 90 100%no confidence completely confident

How confident are you that you will not lose your balance or become unsteady when you……walk around the house? ____%…walk up or down stairs? ____%…bend over and pick up a slipper from the front of a closet floor ____%…reach for a small can off a shelf at eye level? ____%…stand on your tiptoes and reach for something above your head? ____%…stand on a chair and reach for something? ____%…sweep the floor? ____%…walk outside the house to a car parked in the driveway? ____%…get into or out of a car? ____%…walk across a parking lot to the mall? ____%…walk up or down a ramp? ____%…walk in a crowded mall where people rapidly walk past you? ____%…are bumped into by people as you walk through the mall?____%… step onto or off an escalator while you are holding onto a railing? ____%… step onto or off an escalator while holding onto parcels such that you cannot hold onto the railing? ____%…walk outside on icy sidewalks? ____%

Documentation• A summary is faxed to each individual’s PCP with copies

maintained at Tri-County Rehabilitation.• Reassessment is performed at subsequent referrals for

physical therapy or at intervals determined by the PCP.• Reassessment is also performed at the request of the

individual.

Case Report• 79 y/o female who tripped and fell walking into her garage,

09/21/12.• Denied prior falls or problems on intake form.• PMH: R TKA (10/11/10), atrial fib with pacemaker (May,

2012).• Referred with diagnosis of OA of the knees and left knee pain.• PT evaluation revealed tendonitis of the left pes anserine,

patellar tendon, and IT band insertion.

Case Report• As part of her evaluation a balance and mobility screen was also

performed.• SPPB

• Balance:• Feet together = 10 sec = 1 point• Semi-tandem = 10 sec = 1 point• Full-tandem = 1.9 sec = 0 point

• Gait (4 m) = 4.72 sec = 4 points• Chair Stand = 5x in 20.8 sec = 1 point • Total score = 7/12 (low level of function, scores <10/12 are predictive of

fall risk)• Gait speed = 4 m / 4.72 sec = 0.83 m/sec (moderate level of

function, gait speed of 0.56m/sec and less are predictive of recurrent falls)

• ABC = 64% confidence (moderate level of confidence, scores < 67% are predictive of fall risk)

Name: _Ann B___________________ DOB: ____10/31/32 (79)______ PCP: _______Charles W MD___________

Tri-County Rehabilitation, Inc. Balance and Mobility Summary Sheet

Date ABC High

Funct Mod. Funct.

Low Funct.

SPPB High Funct.

Mod. Funct.

Low funct

Gait Speed High Funct

Mod. Funct.

Low Funct.

Needs Further Assessment

10/1/12 64% X 7/12 X 0.83 m/sec X X

Interpretation: Activities-Specific Balance Confidence (ABC) Scale: Short Physical Performance Battery (SPPB):

>80% = high level of physical functioning. 11/12-12/12 = high level of function

50-80% = moderate level of physical function. 8/12-10/12 = moderate level of function

<50% = low level of physical function. <8/12 = low level of function Scores< 10/12 predictive of fall risk in older adults

<67% = older adults at risk for falling (predictive) Gait Speed:

>1.1 M/sec = high level of function 0.75-1.1 M/sec = moderate level of function

<0.75 M/sec = low level of physical function (predictive of falls)

NOTE: _Referred with knee pain secondary to contusion from _fall. Screen indicates that she is a fall risk. . Will modify plan of < 0.56 m/sec predictive of recurrent falls in older adults __care to address this issue_______________________________ __________________________________________________ _ ____________________________________________________

Home Packet• A packet is provided to each individual screened containing:• A general home program of balance and mobility exercises.• Educational and home safety information.• Balance system basics: How does the balance system work?• Balance system basics: Balance strategies.• Home Safety Tips for Older Adults: from AGS foundation for

health in aging website.• Winter Safety Tips for Older Adults: from AGS website• Dealing with “persistent” Pain in Later Life: from AGS website• Fall Risk Reduction and Prevention: APTA power point

Balance System Basics• Balance comes from different systems working together to

create stability. Good balance depends on correct sensory information, proper use of that information by the brain, and the right response from the muscles. The sensory information that is needed comes from three systems:1. Visual system2. Sematosensory system3. Vestibular system

Balance System Basics (con.)• The state of your balance system is determined by how well

your central nervous system deals with the various inputs from your visual, sematosensory, and vestibular systems in order to keep your center of gravity over your base of support.

Balance System Basics (con.)• You employ voluntary and involuntary strategies to maintain

your balance and keep from falling.

Balance System Basics (con.)• Voluntary strategies are conscious and under your control.• Walking slower with shorter and wider steps in the dark.• Shuffling your feet with your knees slightly bent and arms

outstretched while walking on icy surfaces.• Taking someone's arm while walking on an uneven surface in

high heels.• Inching along a narrow beam on your bottom.

Balance System Basics (con.)• Involuntary strategies are rapid and reflexive responses to an

external stimulus or perturbation. There are four involuntary strategies that your body uses in order to maintain your balance.1. Ankle strategies2. Hip strategies3. Suspensory strategies4. Stepping strategies

Home Balance and Mobility Program• Designed to maintain/improve factors needed to successfully

employ these involuntary balance strategies.• Adequate ROM thru the trunk and lower extremities• Adequate strength thru the trunk and lower extremities• Adequate response to various sensory system inputs

• Must be simple to do and easy to understand.

Home Balance and Mobility Program• The individual is instructed to initiate exercises in a safe

manner using a kitchen counter or a secure chair to help with balance.

• As ROM, strength, and ability to respond to various sensory inputs improves, each exercise can be made gradually more challenging by:• Relying less on the chair or counter for support• Narrowing base of support• Increasing step width or length• Shifting more weight onto the stepping leg• Employing head movements• Closing eyes• Performing exercise on a thick rug• Counting backwards by 7’s

Step Backs

Toe Raises

Forward Hip Lifts

Standing Side Steps

Standing Toe Lifts

Chair Stands

Step Ups

Tall Stands

I’ve fallen and can’t get up cycle

Possible solution• A good many patients need ongoing and continued

maintenance support following discharge from skilled PT.• Mobility coaches?• PT students, nursing students, exercise science students, etc.• Paid at a fraction of that charged for a licensed therapist plus

office overhead• Trained and supervised by PT • Communication to PT or PCP if problems or decline noted• Questions

• Mechanism for payment?• Liability issues?• Outcomes?